NCM 109- Care of the Mother, Child at Risk or with

Problems (Acute or Chronic)

GESTATIONAL CONDITION AFFECTING PREGNANCY

HYDATIDIFORM MOLE/ H-MOLE/

GESTATIONAL TROPHOBLASTIC DISEASE
 Bunches of grapes
 A gestational anomaly of the placenta consisting of a bunch of a clear vesicles. This
neoplasm is formed from the swelling of the chorionic villi and lost nucleus of the
fertilized egg.
 The nucleus of the sperm duplicates producing a diploid number 46XX. It grows and
enlarges the uterus very rapidly.
 Progressive degeneration of chorionic villi with unknown cause.
 Or benign growth of placental tissue/ maligancy of the uterine lining.
 
 Abnormal proliferation and then degeneration of the trophoblastic villi.
 As the cells degenerate, they become filled with fluid and appears as clear fluid-
filled, graped sized vesicles.
 The embryo fails to develop beyond a primitive start.
 Abnormal trophoblast cells must be identified because they are associated with
choriocarcinoma, a rapidly metastasizing, malignancy.
 
 Risk factors
o Increased prevalence geographically is most common in taiwan and
Philippines.
o Maternal age (>35 y/o) extreme and folate deficiency.
o The condition tends to occur in women who have a low- protein intake and
o Blood group A women who marry blood group O men.
  
ASSESSMENT
 
 EARLY SIGNS
o Most common symptoms : vesicle past thru the vagina (fluid filled)
o Hyperemesis gravidarum- due to increase HCG.
o Most common sign: Rapid increase in fundic height, absences of the fetal
heart tone.
o Vaginal Bleeding (scant or profuse)
o Most common site of distant metastasis is the lungs.
 EARLY IN PREGNANCY
o High level of HCG
o Preeclampsia at about 12 weeks
 LATE SIGN:
o HPN before 20th weeks
o Vesicle look like a snowstorm on sonogram.
o Anemia
o Abnormal cramping.
 SERIOUS LATE COMPLICATION
 NCM 109- Care of the Mother, Child at Risk or with
Problems (Acute or Chronic)

o Hyperthyrodism
o Pulmonary embolus
 
 NURSING INTERVENTION
o Prepare for D & C
o Do not give oxytocin drugs (oxytocin can cause embolism)
o TEACHING: return for pelvic exams as scheduled for one year to monitor
HCG and assessed for enlarged uterus and rising titer could be indicative of
choriocarcinoma (possible recurrence)
o Avoid pregnancy for at least 1 year and have regular exam.
o 12 to 18 months of regular monthly urine exam.
o Sex is allowed but used of condom is advice.
o No pills it will alter the result of HCG.
o Report unexpected of irregular vaginal bleeding- this could be sign of
developing CA.
o Report severe persistent headaches, cough or bloody-sputum (symptoms of
metastasis in the lungs).

.
INCOMPETENT CERVIX

 The mechanical defect of the cervix wherein there occurs painless cervical dilatation
in the 2nd trimester or early is the 3rd trimester, followed by prolapse and
ballooning of the membranes in the vagina and then, rupture of membranes (ROM)
and explosion of the fetus.
 
 Common cause of habitual abortion.

   
 CLASSIFICATION
o CONGE
NITAL








Cervix has already defect
o ACQUIRED
 Because of cervical factors - taking oral contraceptives.
 
 SIGNS AND SYMPTOMS
o 1st sign - painless vaginal bleeding accompanied by cervical dilation.
o Rupture of membranes (ROM) and passage of amniotic fluid follows cervical
dilatation, the loss of products of conception.
 NCM 109- Care of the Mother, Child at Risk or with
Problems (Acute or Chronic)

 
 MANAGEMENT
o Cervical cerclage or suturing of the cervix between 14 -16 weeks gestation
to prevent cervical dilatation.
o PREREQUISITE OF CERVICAL CERCLAGE
 Cervix is not dilated beyond 3 cm
 Intanct membranes
 No vaginal bleeding and uterine cramping.
 
 TYPES OF CERVICAL CERCLAGE
o SHIRODKAR SUTURE
 Permanent suture which is left in place for subsequent pregnancies
 Fetus is delivered via CS
o Mc Donald Suture
 Temporary suture removed at 38-39 weeks gestation.
 Fetus is delivered vaginally.
 
 NURSING MANAGEMENT
o After suturing the cervix
 Bed rest for 24 hours
 Observe for for bleeding, uterine contractions and rupture of bag
water (BOW)
 If bag of water ruptures, suture are removed.
 If uterine contractions occur - woman is given ritodrine to stop
contraction.
 Post- operative care: Restrict activities for the 2 weeks including
coitus.

  PLACENTA PREVIA
 
 
 Occurs when the placenta is improperly implanted in the cervical os.
 TOTAL PLACENTAL PREVIA
o Placenta completely covers the internal os,
o This is the most dangerous location because its potential for hemorrhage.
 
 ASSESSMENT
o OUTSTANDING SIGN
 Frank bright red painless bleeding.
o Engagement (usually has not occurred)
o Fetal distress
o Presentation (usually abnormal)
o DIAGNOSTIC TEST: UTZ
 
 NURSING INTERVENTION
o No sex, IE , or Enema- these may lead to sudden fetal blood loss
o Bed rest
 NCM 109- Care of the Mother, Child at Risk or with
Problems (Acute or Chronic)

o Prepare to induce labor if cevix is riped or dilated.

o Administer IV fluids
o Put mother on NPO in case delivery via C-section is delivery
o Prepare for double set up (DR-OR)
o Secure consent and explanation of the procedure: The surgeon is responsible for the
signing consent and explanation of the procedure while the nurse as a witness to
the signing.
 
 TYPES OF PLACENTA PREVIA
o Low implantation
o Partial PP
o MARGIAL PP
o Total PP

 
  ABRUPTIO PLACENTA

 Premature partial or complete separation of a normally implanted placenta.

 It usually occurs after the 20th week of gestation.
 Most common cause of late pregnancy bleeding.
 
 PREDISPOSING FACTORS
o Preeclampsia and hypertensive disorders
o Illicit drugs use (especially cocaine)
o Accidents
o HX. Of placental abruption
o High multiparity
o Increasing maternal age
o Cigarette smoking
o Short cord
 
 ASSESSMENT
o Outstanding sign
 Dark red, painful vaginal bleeding
NCM 109- Care of the Mother, Child at Risk or with
Problems (Acute or Chronic)

 Dark red, painful vaginal bleeding

 Concealed hemorrhage (retroplacental) rigid board like abdomen
 Couvelaire uterus (cause by bleeding in the myometrium)
 Couvelaire uterus (also known as uteroplacental apoplexy) is a
life-threatening condition in which loosening of the placenta
(abruptio placentae) causes bleeding that penetrates into the
uterine myometrium forcing its way into the peritoneal cavity.
This condition makes the uterus very tense and rigid.

 
 Inability of the
uterus to contract
due to concealed
bleeding.
o Severe
abdominal
pain
o Drop in
coagulation
factor
 
 COMPLICATIONS
o DIC -disseminated intravascular coagulopathy
o

 
 MEDICAL MANAGEMENT
o Emergency CS if maternal and fetal jeopardy is present.
 NCM 109- Care of the Mother, Child at Risk or with
Problems (Acute or Chronic)

o Vaginal delivery if bleeding is heavy but controlled or pregnacy is greater

than 36 weeks.
o Contraceptive in-hospital observation if both mother and fetus is stable,
bleeding is minimal and contractions are lessened.
 
 NURSING INTERVENTION
o Infuse IVF as ordered
o Blood typing and cross matching
o Prepare for blood transfusion
o Monitor FHT
o Insert foley catheter
o Measure blood loss: count perineal pads
o Report s/s of DIC
o Monitor v/s for shock
o Strict I and O
 
 TYPES Of ABRUPTIO PLACENTA
o Partial abruption
o Partial abruption with hemorrhage
o Complete abruption with concealed hemorrhage.

ABORTIONS
 Termination of pregnancy before the age of viability (<20 weeks)
o
 

TYPES OF ABORTIONS
 
1. SPONTANEOUS ABORTIONS OR MISCARRIAGE
o Nature's way of expelling a defective fetus.
o Caused by chromosomal aberration, blighted ovum and germ plasma defect.
o Maternal age of >35 years old.
o Happens during 1st and 2nd trimester
 
 NCM 109- Care of the Mother, Child at Risk or with
Problems (Acute or Chronic)

TYPES OF SPONTANEOUS ABORTIONS

1. Threatened Abortion
 Sonogram finding of a viable pregnancy with vaginal bleeding but no cervical
dilation.
 Pregnancy is jeopardized by bleeding and cramping but the cervix is closed.
 CAUSE:
 Unkown: possibly chromosomal or uterine abnormalities
 ASSESSMENT:
 Vaginal spotting
 Slight cramping
 CAUTIONS:
 Caution woman not to use tampons to halt bleeding as this can lead
to infection.
 MANAGEMENT
 Observation
 No intervention is generally indicated or effective but complete bed
rest (with sedation and abstinence from intercourse)
 Administration of progesterone maybe acceptable.
 PATIENT:
 Should report increase bleeding, passage of tissue or fever.
 Passed tissue should be saved for examination.
 
2. INEVITABLE ABORTION
 Vaginal bleeding and uterine cramping leading to cervical dilatation but no products
of conception has yet to passed.
 CAUSE:
 Unknown reason but possibly poor placental attachment
 ASSESSMENT:
 Vaginal spotting
 Cramping
 Cervical dilatation
 MANAGEMENT:
 Emergency suction dilatation and curettage to prevent further blood loss
and anemia.
 The immunoglobulin (RhoGAM) is administered to Rh-Negative, unsensitized
patients to prevent isoimmunization.
 
3. COMPLETE ABORTION
 All products of conception are expelled.
 The uterus is well contracted, and the cervical os may be closed or opened.
 No need for D & C
 Supportive care
 Motional support
 CAUSE:
 Unkown: possibly chromosomal or uterine abnormalities
 ASSESSMENT:
 Vaginal Spotting
 Cramping
 NCM 109- Care of the Mother, Child at Risk or with
Problems (Acute or Chronic)

 Cervical dilatation
 Complete expulsion of uterine contents
 
4. INCOMPLETE ABORTION
 Vaginal bleeding and uterine cramping leading to cervical dilatation, with some, but
not all, products of conception having been passed.
 Placenta and membranes retained
 D & C is done to prevent further blood loss and anemia.
 CAUSE:
 Unkown: possibly chromosomal or uterine abnormalities
 ASSESSMENT:
 Vaginal Spotting
 Crampimg
 Cervical dilatation
 Incomplete expulsion of uterine contents
 CAUTIONS:
 High risk uterine infection and hemorrhage
 
5. MISSED ABORTION
 Is diagnosed when products of conception are retained after the fetus has expired.
 If products is/are retained, a severe coagulopathy with bleeding often occurs, fetus
dies.
 Should be suspected when the pregnant uterus fails to grow as expected or when
fetal heart tones disappear.
 Amennorhea may persist, intermittent vaginal bleeding, spotting or brown discharge
maybe noted.
 UTZ confirms the diagnosis
 CAUSE:
 Unknown
 ASSESSMENT:
 Vaginal spotting
 Slight cramping
 No apparent loss of pregnancy
 CAUTIONS:
 Disseminated intravascular coagulation is associated with missed abortion.
 MANAGEMENT:
 RhoGAM administration to Rh-negative unsesitized patients.
 
6. HABITUAL ABORTION
 3 or more consecutive pregnancies result abortion which is usually related to an
incompetent cervix.
 CHARACTERISTICS
 Abnormalities of the fetus; blighted ovum.
 Abnormalities of the reproductive tract
 Physical and emotional shock
 Endocrine problems
 Infectious diseases
 Maternal diseases
 Psychogenic problems
 NCM 109- Care of the Mother, Child at Risk or with
Problems (Acute or Chronic)

 MANAGEMENT
 Surgery of the cervix
 Mcdonald operation (temporary)
 Shirodkar procedure
 
2. INDUCED ABORTION
1. Therapeutic abortion
 Ensures life of a mother
 Has two-fold effect which opts for the choice of lesser evil
2. Illegal Abortion
 Unwarranted termination of pregnancy which does not put the life of
mother nor the fetus
3. Fetal demise
 Antenatal demise: occur before labor
 Intrapartum demise: occurs after the onset of labor

  PREMATURE RUPTURE OF MEMBRANE

 
 Aka Water breaking early (PROM)
(PROM)
 Rupture of fetal membranes with loss of amniotic fluid during pregnancy before 37 weeks of
gestation
 Occurs 5-10%
 Most common cause of preterm labor
 CAUSES:
o Unkown
o Associated with infection of the membranes (chorioamnnionitis)
 COMPLICATIONTS
o If the rupture occurs; possess a major threat to the uterus
o After rupture, the seal of the fetus is lost and the uterine and fetal infection may
occur
o Increase pressure form the umbilical cord from the loss of amniotic fluid, inhibiting
the fetal supply or cord prolapsed
o development of Foster-like syndrome or distorted facial features and pulmonary
hypoplasia from pressure.
 
 ASSESSMENT
o Obtain patients history
o Sudden gush of clear fluid from the vagina with continued minimal leakage
o NOTE:
 800 – 900 ml of amniotic fluid
 30 cc per hour – urine output – adult
 4- 6 hours urine time
 
 DIAGNOSIS
o Vaginal Speculum examination
o Used of nitrazine paper
 Amniotic fluid appears blue (alkaline)
 NCM 109- Care of the Mother, Child at Risk or with
Problems (Acute or Chronic)

 Urine-yellow (acidic)
o Ferning - fluid is tested in microscope if with increased estrogen fluid (amniotic fluid)
 Avoid doing digital exam in the vagina
 If mature – induced abortion (24 begin labor)
 
 NURSING DIAGNOSIS
o Risk for infection related to preterm rupture of membranes without any labor
 
 THERAPEUTIC MANAGEMENT
o Bed rest
o Corticosteroid – hasten fetal lung maturity
o Antibitotic – may delay the labor and decrease risk for infection in the newborn
o Penicilling or Ampicillin
o Following endoscopic intrauterine procedures, membranes can be released by use
of fibrin base commercial sealant
o Count fetal movement – 10 per hour – most active at night (9pm onwards) –
because low sugar? Hypoglycaemia
o Good perineal hygiene
o Avoid tub bath, breast stimulation, sexual stimulation and intercourse
o Ensure adequate hydration
o CS-if with fetal distress
 
PRETERM LABOR

 Is labor that occurs after 19 weeks and before the end of 37 weeks gestation. Preterm labor
often leads to preterm birth, which accounts for 70% of neonatal morbidity and mortality.
 A woman having persistent uterine contractions, even they are mild and widely spaced,
should be considered to be in labor
 EVALUATION and the INSTITUTION OF THEREPY before rupture of membranes become
vital, as ruptured membranes make it that much more difficult to halt labor.
 Preterm labor symptoms are subtle and best recognized by the woman herself.
 
 PRETERM LABOR IS ASSOCIATED WITH:
o Dehydration
o UTI
o Peridontal Disease
o Chorioamnionitis
o Large fetal size
 
 EARLY PRETERM LABOR SYMPTOMS
o Persistent, dull, and low backache
o Vaginal spotting
o A feeling of pelvic pressure or abdominal tightening
o Menstrual-like cramp
o Increased vaginal discharge
o Uterine contraction
o Intestinal cramping
 NCM 109- Care of the Mother, Child at Risk or with
Problems (Acute or Chronic)

 
 It is possible to predict which pregnancies will end early by
o analyzing changes in the length of the cervix by ultrasound
o Analysis of vaginal mucus for presence of FETAL FIBRONECTIN (a protein produced
by tropoblast)
 Presence of fetal fibronectin in vaginal mucus = predicts that preterm
contractions are ready to occur.
 Absence of this protein = predicts that labor will not occur for atleast 14
days.
 
 SIGNS AND SYMPTOMS
o Uterine contraction, which may be painless
o Pelvic pressure
o Menstrual-like cramps
o Vaginal pain
o Low, dull backache accompanied by vaginal discharge and bleeding
o Diarrhea or intestinal cramps
o Increase or change in vaginal discharge
o The membranes may or may not be ruptured
 
RISK FACTORS

OBSTETRIC AND GYNECOLOGIC RISK FACTORS:

o Multiple gestation (twins, triplets)
o Previous preterm labor
o Exposure to DES
o More than one second-trimester abortion
o Uterine or cervical abnormalities
 Fibroid tumors
 Bicornuate uterus
 Incompetent cervix
o Preterm premature rupture of membranes
o Placenta previa
o Retained intrauterine device (IUD) – 5 to 10 years
o Short time periods (less than 6-9 months)
 
DEMOGRAPHIC AND LIFESTYLE RISK FACTOS
o Alcohol use
o Illicit drug use
o Intimate partner violence
o Lack of social support
o High levels of stress
o Long working hours with long periods of standing
 
MEDICAL RISK FACTORS
Infections causes such as:
o Bacetrial vaginosis
 NCM 109- Care of the Mother, Child at Risk or with
Problems (Acute or Chronic)

o Acute pyelonephritis
o Chorioamnionitis
o Bacteriuria
o Sexually transmitted infection
 
THERAPEUTIC MANAGEMENT
 
o Medical attempts can be made to stop labor if the;
 Fetal membranes have not ruptured
 Fetal distress is absent
 No evidence of bleeding is occuring
 Cervix is not dilated more than 4 to 5 cm
 Effacement is not more than 50%
 
o A woman who is first admitted to the hospital and placed in bedrest to relived pressure
of the fetus on the cervix.
o External and uterine contraction monitoring
o Intravenous fluid therapy to keep her well hydrated, although not documented
hydration may help to stop contractions.
 This is thought to be effective because if woman i dehydrated = pituitary gland
will activate to secrete antidiuretic hormone = this will cause the pituitary gland
to release oxytocin as well
o Vaginal and Cervical Cultures and clean catch urine sample are prescribed to rule out
infection.
 If UTI is present, the woman will be prescribed an antibiotic that is especially
effecitve for group B streptococcus as this infection can be fatal in the
newborn.
 
o DRUG ADMINISTRATION
 TOCOLYTIC AGENT
 TERBUTALINE
 is a drug approved to prevent and treat bronchospam (i.e.,
narrowing of airways) but may be used, off-label, as a tocolytic
agent.
 This drug carries "black box" warning, however, that it should not be
used for over 48 to 72 hours of therapy because a potential for
serious maternal heart problems and death.
 Should not be used in outpatient or home setting.
 
 MAGNESIUM SULFATE
 Given IV
 Traditionally given to prevent preterm labor
 However recent research does not support the use of magnesium as a
tocolytic. There is no differences seen between those women receiving not
treatment in preterm birth outcomes.
 This drug is used for fetal neuroprotection prior to 32 weeks to help
prevent cerebral palsy in premature infants.

 CORTICOSTEROID
 NCM 109- Care of the Mother, Child at Risk or with
Problems (Acute or Chronic)

 This drug is given, for reasons not clearly understood, if, in the time
between when the preterm contraction begin and preterm birth occurs.
 Betamethasone amd dexamethasone are examples of corticosteroid drug.
 Corticosteroid is given for the formation of lung surfactant to accelerate,
thus reducing the possibIlity of RDS or bronchopulmonary dysplasia
 Bronchopulmonary dysplasia (BPD) is a breathing disorder where an
infant's lungs become irritated and do not develop normally. It occurs
most often in low-weight infants born more than two months early.
Bronchopulmonary dysplasia is also known as: Chronic lung disease of
premature babies.
 During the time labor is being chemically halted, therefore, if the pregnancy is
under 34 weeks, a woman may be given;
 Two doses of 12 mg betamethasone IM 24 hours apart or four doses of 6
mg dexamethasone IM 12 hours apart
 Although the effect of betamethasone lasts for about 7 days, it takes
about 24 hours for the drug to begin its effect, so it is important labor be
halted for at least 24 hours. If the fetus is not born within the 7-day time
span, the dose of betamethasone may be repeated, but this is
controversial because any corticosteroid can interfere with glucose
regulation in the woman and potentially in the fetus.

 FETAL ASSESSMENT
 Be certain to assess overall fetal welfare in the woman who is using tocolytic therapy
to delay or prevent preterm labor by assessing FHR and activity.
 Following this initial therapy and if contraction have ceased and there is evidence
of fetal well being, women with arrested preterm labor can be safely cared at home
as long as:
 They can dependably drink enough fluid to remain well hydrated
 Strict bed rest
 Limits strenuous activity.
 
 MEDICAL MANAGEMENT
o The treatment for preterm labor is intended to improve outcomes for neonates by
prolonging the pregnancy or by affecting their adaptations to the extra uterine
environment.
o Use of tocolytic agents – to stop preterm contraction
o IV hydration and sedation – may be ordered when the client initially presents with
signs and symptoms of preterm labor

o TOCOLYSIS
 severity of fetal respiratory distress syndrome and to reduce the risk of
intrventricular haemorrhage.
o CRITERIA FOR CONSIDERING TOCOLYSIS
 If bleeding and cervical dilatation is absent or cervix is 2-3 cm
 FHT is good
 Premature uterine contraction can be stop by drugs
 Gestational age under 34 is prerequisite to inhibit labor
o CONTRAINDICATION TO TOCOLYSIS
Contraindication to labor inhibition
 NCM 109- Care of the Mother, Child at Risk or with
Problems (Acute or Chronic)

Intrauterine fetal demise

Lethal fetal anomaly
Non assuring fetal assessment
Severe IUGR
Chorionamnionitis
Maternal haemorrhage with hemodynamic instability
Severe preeclampsia and eclampsia
Inhibition of preterm labor is less effective when cervical dilation is advanced, meaning
greater than 3-4 cm.

o DRUG THERAPY
 RITODRINE HYDROCLORIDE
 MAGNESIUM S04 (BUTT TINUTUROK)
 TERBUTALINE
 NIFEDIFINE
 INDOMETHACINE
 CORTICOSTEROID THERAPY
 
 NURSING MANAGEMENT
 Monitor and assess uterine activity and FHT before, during and for 1 hour after d/c
IV therapy
 Maintain client in left position as much as possible (better blood flow to the inferior
vena cava)
 Monitor maternal and fetal v/s q 15 mins after client receiving IV dose
 Report auscultated cardiac dysrhythmias
 Auscultate breath sounds q 4 hours (Vesicular & Brochial)
 Be alert for presence of hypoglycaemia in the newborn delivered within 5 hours of
d/c yutopar (Hypoglycaemia in newborns – lethargic and shrill cry)
 Report increase of FHT greater than 180 and persistent contraction
 
 MEDICAL MANAGEMENT
o Antibiotics – to treat presumed or confirmed infections that can be a causative
factor in preterm labor.
o Corticosteroids – may be given to the client to enhance fetal lung maturity
After 24 weeks and before 34 weeks gestation. The corticosteroids is given weekly until
34 weeks.
 COMPLICATIONS
o MAGNESIUM SULFATE
 Respiratory depression or arrest
 Pulmonary edema
 Hypotension
 Cardiac arrest
 Profound hypotension
 
o BETA-ADRENERGIC (RITODINE, TERBUTALINE):
 Hyperglycaemia
 Hypokalaemia
 Hypotension
 NCM 109- Care of the Mother, Child at Risk or with
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 Arrhythmias
 Pulmonary edema / congestive heart failure – this is the most serious side
effect
 
o INDOMETHACIN (INDOCIN)
 Gastrointestinal symptoms
 Renal failure
 Hepatitis
 Premature closure of the ductus arteriosus, necrotizing enterocolitis and
intracranial haemorrhage in the fetus or neonate
 Bleeding (bruises, GI tract, gums, etc)
 
o NIFEDIPINE (PROCARDIA)
 Profound hypotension
 Possible decrease in uteroplacental perfusion
 Flushing
 Headache
 
 PATHOGENESIS
o Preterm labour may be – Physiological or Pathological
o The molecular basis of initiation of labour is unclear but a number of theories have
been proposed.
o Of these – Progesterone withdraw oxytocin stimulation and Premature decidual
activation are important ones.
o As parturition nears the fetal adrenal axis becomes sensitive to ACTH and there is an
increased production of cortisol ---> This stimulates 17 hydroxylase in the
trophoblast resulting in decreased progesterone secretion ---> The reversal of
estrogen – progesterone ratio ---> Increase in prostaglandin formation
 
 Initiation of labour
o Progesterone surpresses mymotrial contractility and inhibits production of
prostaglandins by up regulating prostaglandin dehydrogenase.
 
 NURSING MANAGEMENT
o Place client on bed rest or ask to modify physical activities
o Obtain or assist in collection of laboratory specimens
o Administer prescribed medicines and therapies
o Ask client about presence of vaginal bleeding and rupture of membranes
o Client education.
 
 NURSING ASSESSMENT should include:
o Taking vital signs
o Assessing fetal heart rate
o Evaluating uterine activity
o Obtaining history of the pregnancy
 
 LABOR THAT CANNOT BE HALTED
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o When the membranes have ruptured or the cervix is more than 50% effaced and
more and more than 3-4 dilated, preterm labor cannot be halted.
o Rupture of membrane in preterm labor can be thought as "point of no return"
because if the birth is prevented there will be more increased risk in infection .
o If the fetus is very immature and the birth is cannot be halted:
 Cesarean birth can done this is to reduced pressure on the fetal head and
the possiblity of subdural hemorrhage and intraventricular hemmorhage.
 Cesarean birth can be still controversial because infants who undergone CS
birth have higher incidence of RDS.
o The first stage of labor in preterm labor is proceeds exactly as it would with a term
pregnancy.
 NOTE: first stage of labor is the longest.
o The second stage of labor in preterm labor may be shorter because a small infant
can be pushed through the dilated cervix and the birth canal more easily.
o ANALGESIC AGENT are administered with caution because:
 An immature infant will not have enough difficulty breathing at birth
without the additional burden of being sedated from a drug such as
meperidine (demerol)
o Woman who want pharmaceutical pain management for labor, an epidural is
preferable.
o Woman may feel reassured by ahaving an external fetal monitoring screen during
labor.
 be certain that if a monitor is attached, the woman rests on side to help
prevent supine hypotension syndrome or an interference with uterine
circulation.
o Episiotomy is not routine
 One may be done to relieve excessive pressure on the head and hopefully
reduced subdural hemorrhage or IVH.
o Cord is not clamp immediately to reduce preterm anemia.
 

PREGNANCY INDUCED HYPERTENSION

 
 
 GESTATIONAL HPN is a condition in which vasospasm occurs during pregnancy in
both small and large arteries.
 PREECLAMPSIA was originally called toxemia
o Because researchers pictured the symptoms as being caused by women
producing a toxin of some kind in response to foreign of protein of the
growing fetus.
 Cause: Unkown
o Although women with antiphospholipid syndrome (APS) or presence of
antiphospolipid antibodies in maternal blood are much more likely to
develop preeclampsia.
 
 PATHOPHYSIOLOGY
o Increased cardiac output required by pregnancy results in:
= vascular spasm
= injures the endothelial cells of the arteries
NCM 109- Care of the Mother, Child at Risk or with
Problems (Acute or Chronic)

= reduces the action of PROSTACYCLIN (a prostaglandin vassodilator)

= excess production of THROMBOXANE (prostaglandin vassoconstrictor)
= stimulating platelet aggregation
 
o Usually during pregnancy, blood vessels are resistant to the effects of pressor
substances such as ANGIOTENSIN and NOREPINEPHRINE as a result
= so even with increased blood supply, blood pressure remains normal
during pregnancy.
 But with GESTATIONAL HYPERTENTION, this reduced responsiveness to blood
pressure changes appears to be lost because of prostaglandin release as a result:
= Vasoconstriction occurs, and blood pressure increase dramatically.
 
 Beginning about 20th week of pregnancy, almost all body system begin to be
affected.
o EXAMPLE: cardiac system can be easily overwhelmed because the heart is
forced to pump against rising peripheral resistance as a result this causes
reduced blood supply to organs such as
 PLACENTA = reduces fetal nutrient and oxygen supply.
 PANCREAS = Ischemia = epigastric pain and elevated amylase-
creatine ratio.
 SPASM OCCURS IN THE ARTERIES OF RETINA = vission changes
occur
 RETINAL HEMORRHAGRE= blindness
 
 VASOSPASM IN THE KIDNEY = increased blood flow resistance = There will be
Degenerative changes in the kidney glomeruli because of back pressure as a result:
= increased permeability of the glomeruli membrane (allowing
serum proteins albumin and globulin to escape into the urine
[protenuria])
= decreased glomerular filtration, so there is lowered urine output
and clearance of createnine.
 
 If increased tubular reabsorption occurs = retention of sodium begins
o Sodium retains fluid = edema
o Edema is further increased because as more protein is lost, the osmotic
pressure of the circulating blood falls and the fluid diffuses from the
circulatory system into the denser interstitial spaces to equalize the
pressure
o Extreme edema can lead to maternal cerebral and pulmonary edema and
seizures(eclmapsia)
 Arterial Spasm = causes the bulk of the blood volume in the maternal circulation to
be pooled in the venous circulation = so in assessment a woman has a deceptively
low arterial intravascular volume.
o In addition THROMBOCYTOPENIA (lowered platelet count) occurs as
platelet cluster at the site of endothelial damage.
 Measuring Hematocrit levels helps to assess the extent of plasma loss to interstitial
space or the extent of the edema.
 
 PATHOLOGICAL FINDINGS
NCM 109- Care of the Mother, Child at Risk or with
Problems (Acute or Chronic)

o Generalized vasoconstriction and arteriolar vasospasm

o Significant decrease in circulating volume
o Activation of the coagulation system
 resulting in hypertension, decreases perfusion and ischemia of
various organ particularly the brain, kidney, liver and placenta
 
 The result decreased uteroplacental perfusion impacts on the fetus
significantly and may lead to perinatal complication such as IUGR, low
birth weight, prematurity, and even mortality
 
 RISK FACTORS
o Women of color or with a multiple pregnancy, primiparas <20 years of age
or >40 years
o Women from low socioeconomic backgrounds, whose who have had 5 or
more pregnancies those who have hydramnios, or those who have
underlying disease (e.g heart disease, DM with vessel or renal involvement,
essential HPN)
o Age: extreme of age – teenager and above 35
o Super abundance of chorionic villi: H-mole
o Chronic renal and vascular disease
o Hereditary
o Past history of preeclampsia
 
 SIGNS & SYMPTOMS
o HPN – Hypertension
o Proteinuria – Protein in the Urine
o Extensive edema
o Vision Changes (Severe symptoms)
 
CLASSIFICATIONS OF PIH
 
 Gestational HPN
o (occurs only when pregnant) (No signs and symptoms)
o Sustained bp elevation of greater than or equal to 140/90 after 20 weeks
of gestation
o Increase in BP but no proteinuria or edema
o No drug therapies necessary
o Unremarkable physical findings
o No damage to the fetus
o The BP normalizes postpartum after 12 weeks
 
 Pre-Eclampsia
o Sustained BP elevation after 20 weeks of gestation in the absent of pre –
existing hypertension.
o If a seizure from preeclampsia occurs, a woman has now eclampsia, but
any status above gestational hypertension and below a point of seizures is
preeclampsia.
o Predisposing Factors to Pre – Eclampsia
NCM 109- Care of the Mother, Child at Risk or with
Problems (Acute or Chronic)

 Primapara – due to 1st exposure to chorionic villi

 Multiple pregnancy – due to increase exposure to chorionic vill
 Decreased mother’s socio – economic status
 Low intake of CHON predisposes to PIH
 H-Mole
 DM
 Age Extremes
 Chronic hypertension
 Chronic renal disease
 
 TRIAD SIGNS AND SYMPTOMS (H-E-P/A)
o H – Hypertension
o E – Edema
o P – Proteinuria
o A – Albuminuria
 
THREE TYPES OF PRE – ECLAMPSIA
 
 MILD PRE-ECLAMPSIA
o BP rises to 140/90 mmHg, taken on 2 occasions at least 6 H part
o Systolic BP >30 mmHg and diastolic pressure >15 mmHg above pre
pregnancy values
 Diastolic pressure is important to document because it is this
pressure that best indicates the degree of preripheral arterial spasm
resent
o Proteinuria (1+ or 2+ on a regeant test strip on a random sample = to 300mg
on a 24H urine collection)
 A result of 1+ or more represent a loss of 1g/L)
o 24 hour Urine collection: hindi kukunin yung ihi sa morning tas icocollect na
throughout the day
o Urine protein-createnine ration (higher or 0.3 )
o Increase in weight (10 – 12 kg or 2 lb/week [second trimester] 1lb/week
[third trimester]) because of developing edema (1st sign of pre eclampsia)
mild to mod; hand and face)
o Characterized by inability to wear or tightening of wedding ring
o Occasionally, women have orthostatic proteinuria (on long preriods of
standing, they excrete protein; on bed rest they do not)
o If there is NO HYPERTENSION, NO EDEMA, and PROTENURIA IS PRESENT
check to see when the specimen was obtained.
 Ask her to bring first morning urine sample next time as that may
reveal that orthostatic proteinemia, not preeclampsia, is the cause
of protein in her urine.
 
 SEVERE PRE ECLAMPSIA
o BP of 160 mmHg (systolic) and 110 mmHg (diastolic) taken on 2 occasions at
least 6 H apart at bed rest (the position in which the blood pressure is at the
lowest) or the diastolic pressure is 30 mmHg above her pre-pregnancy level
o Proteinuria (3+ or 4+ on a random urine sample or more than 5g on a 24H
sample)
NCM 109- Care of the Mother, Child at Risk or with
Problems (Acute or Chronic)

o In severe pre-eclampsia EXTREME EDEMA is most readily palpated over

bony surfaces, such as over the tibia, on the anterior leg, ulnar surface of the
forearm, and the cheekbones, where the sponginess of the fluid-filled tissue
can be palpated against bone.
o The extreme edema can be NONPITTING or PITTING
 1+ pitting edema
 2+ moderate indentation
 3+ deep indentation.
 4+ indention so deep it remains after removal of finger
o This accumulating edema will reduces woman's urine output to
approximately 400 to 600 ml/ 24 hours
o Extensive edema including cerebral- reports visual disturbances (blurred
vission), severe headache, marked hyperflexia, and ankle clonus.
o Characterized by visual disturbances, persistent headache, epigastric pain
o Epigastric pain – an aura of impeding shock
o Oliguria (<750 ml 24 hour)
o Thrombocytopenia (pasa pasa) – decreased platelets
o Elevated liver enzymes
o Cyanosis
o Pulmonary edema- woman may report feeling short of breath
o Women commonly report upper extremity upper extremity edema as
 "my rings are so tight I can't get them off"
 "When a wake up in the morning, my eyes are swollen shut"
 "My tongue is so swollen I can't talk until I walk around awhile"
 
 
 ECLAMPSIA
o A woman has passed to this stage when cerebral edema is so acute a grand
mal (tonic clonic) seizure or coma has occured
o Maternal mortality caused by - cerebral hemorrhage, circulatory collapse,
renal failure.
o Seizure or coma accompanied by signs and symptoms of preeclampsia
o Convulsion
o All sign of pre – eclampsia
o Fetal prognosis with preeclampsia is also poor because of hypoxia, possibly
caused by the seizure, with consequent fetal acidosis,
o If prem`ature separation of the placental from extreme vasospasm occurs,
the fetal prognosis becomes even graver.
 
 NURSING DIAGNOSIS
o Decreased cardiac output
o Ineffective tissue perfusion
o Fluid volume excess
o Urinary retention
o Risk for fetal injury
o Social isolation
 
 NURSING INTERVENTIONS
NCM 109- Care of the Mother, Child at Risk or with
Problems (Acute or Chronic)

o Mild
 Promote bed rest – lateral recumbent position
 Promote good nutrition – usual pregnancy diet
 Provide emotional support – instruct woman to report if symptoms
worsen, bring concerns out into the open
o Mild PIH
 Conservative treatment
 No anti hypersensitive medication or magnesium sulphate
 Delivery: indicated after 36 weeks gestation; induction with
oxytocin is used and continuous infusion of IV mgs04 (magnesium
sulfate) to prevent eclamptic seizure
o Severe
 Support bed rest – visitors restricted to support patient, darken
room, if possible, provide clear explanations of what is happening
and what is planned, allow opportunity to express feelings
 Monitor maternal well-being – monitor BP q4h (per 4 hours)
 Obtain blood studies
 Daily hematocrit levels as ordered
 Anticipate need for frequent plasma estriol levels and electrolyte
level
 Obtain daily weight and MIO (Monitoring intake and output Urine)
 Monitor fetal wellbeing – single dopper ausculatation approx 4h
interval, FHR maybe assessed with an external fetal monitor, NST or
BPP daily, O2 administration to mother
 Support a nutritious diet – moderate to high in protein and
moderate in sodium IVF line
 Administration medications to prevent eclampsia
 Hydralazine / Apresoline
 Labetalol / Normodyme
 DOC: magnesium sulfate antidote: calcium gluconate
 MgSO4 Toxicity
 B – Bp decrease
 U – U/A decrease
 R - < 12 bpm
 P – Patellar reflex absent
 

 
 
 
 
 
 
 
 
 
 
 
 
 NCM 109- Care of the Mother, Child at Risk or with
Problems (Acute or Chronic)