Obstetrics

“Obstetrics,” or care of women during child birth, is - Health promotion and Disease prevention-
derived from the Greek word obstare, which means. protect health of generation. - MCN is a
“To keep watch.” “Pediatrics” is a word derived from challenging role.
the Greek. word pais, meaning “child.”
Family as primary unit of care essential goal
Primary Goal of MCHN because family’s functioning Family understands
individual and their effect on others.
Promotion and maintenance of optimal family health
to ensure cycles of optimal childbearing and 2 Pillars of the National Health Goals
childrearing.
1. To increase quality and years of healthy life
-No woman should die by giving birh 2. To eliminate health disparities.
Healthy families= Healthy adolescents, Healthy Core content:
adult, Healthy pregnancies, Healthy infants, healthy
children - Counseling for health promotion and disease
prevention.
“Focus not only individual but family’s health.” - Cultural diversity.
- Evaluation of health sciences literature.
1. Preconceptual health care
- Environmental health
- before getting pregnant needs to take care of
- Public health systems
health first.
- Global health
- Prevent natural tube defects is folic acid
(prepare for pregnancy) Global Health Goals
2. Care of women during trimesters of
pregnancy • End poverty
- 1st trimester (1st-3rd month) • Achieve universal primary education.
- 2nd trimester (4th-6th month) • Promote gender equality and empower
- 3rd trimester (7th-9th month) woman.
3. Care of women during puerperium • Reduce child mortality.
- Or 4th trimesters (6 weeks after childbirth) • Improve maternal health.
• Combat HIV/AIDS. Malaria, and other disease
4. Care of infants during perinatal period To ensure environmental sustainability.
- (6 weeks before conception and 6 weeks after • To develop a global partnership for
birth) development.
5. Care of children from birth to adolescence Family is the basic unit of society.
- Neonatal (28 days of life)
- Infancy (1-12 months) Framework of MCN
- Adolescence (after 18 y/o) 1. ADPIE
Philosophies of MCN 2. EBP
3. Nursing Research
- Family centered- assess both family and
4. Nursing Theory
patient.
- Community centered- health on families 4 Phases of Health Care
depends on healthy influences the health of
community. 1. Health Promotion
- Evidence based- critical knowledge in 2. Health Maintenance
research. 3. Health Rehabilitation
- Independent nursing function- teaching and 4. Health Restoration
counselling are major interventions (health
education). Trends in MCHN
- MCN nurse, advocate- protects the rights of
family members including the fetus. • Population
• Client
Obstetrics
• Advocacy- safeguarding (increased 4 out of 10 deaths are due to complications and
single parent) widespread infections.
Trends nursing implication Role of Nurse:
Inform parents of care options and back up opinion For every death, 40 more women get sick.

Increased mothers working outside home at least part 8 out of 10 births in rural areas are delivered
time 90% -Healthcare must be scheduled at times. - outside a health facility.
Discuss selection of childcare centers -
Families are more mobile. 810 women died from preventable causes related to
pregnancy and childbirth.
Good interviewing & health monitoring are necessary.
- Child and Intimate partner abuse - 94% of all maternal deaths occur in low and lower
Families are more health conscious. middle-income countries.
Statistical terms used to report MCHN
Maternal mortality ration- proportion of mothers that
Birth Rate – no. of births per 1000 population do not survive childbirth.

Fertility Rate – no. of pregnancies per 1000 women

of childbearing age

Fetal Death Rate –no. of fetal deaths weighing more

than 500 g or more per 1000 live births 4.
Neonatal Death Rate

Neonatal Period – 1st 28 days of life; Infant is called

Neonate.

No. of deaths per 1000 live births occurring in the 1st

28 days of life.

5.Perinatal Death Rate

Perinatal Period – 6 weeks before conception and 6

weeks after childbirth

No. of deaths of fetuses weighing > 500g and within

the first 28 days of life per 1000 birth.

6.Infant Mortality Rate – no. of deaths per 1000 live

births in the first 12 months of life.

6. Childhood Mortality rate – no. of deaths per 1000

population in children; 1 – 14 y/o

7. Maternal Mortality rate – no. of maternal deaths

per 100,000 live births that occur as direct result of
reproductive process.

Measuring Maternal and Child health

160 women for every 100,000 births die. Roughly

over 11 women die every day.

7 out of 10 deaths occur at childbirth or within a day

after delivery.
Obstetrics
Ethical Considerations of Practice

 Conception Issues
▪ In Vitro Fertilization
▪ Embryo Transfer
▪ Cloning
▪ Stem Cell Research
▪ Abortion
▪ Fetal rights vs rights of the Mother
▪ Use of fetal tissue for research
▪ Resuscitation
▪ No. of procedures or degree of pain that a
child should asked to achieve better health
▪ Balance between modern technology and
quality of life.

Genetics and Genetic Counselling

- Disorders are disorders that can be passed

from one generation to the next. They result
from some disorder in gene or chromosome
structure and occur in 5% to 6% of newborns.
- The study of the way such disorders occur.

CYTOGENETICS

is the study of chromosomes by light microscopy and

the method by which chromosomal aberrations are
identified.

Genetic disorders may occur:

when an ovum and sperm fuse or even earlier, in the

meiotic division phase of the gametes (ovum and
sperm).
Some genetic abnormalities are so severe past that
point.

NATURE OF INHERITANCE

Genes are the basic units of heredity that determine

both the physical and cognitive characteristics of
people.
Legal Considerations of MCN practice In humans, each cell, except for the sperm and ovum,
contains 46 chromosomes (22 pair of autosomes and
 Identifying and reporting child abuse
1 pair of sex chromosomes).
 Child can bring a lawsuit when they reach
legal age Process by which genetic information is passed on
 Informed consent for Invasive procedure and from parent to child. This is why members of the same
any risk that may harm the fetus family tend to have similar characteristics. Inheritance
 In divorced/ blended families, nurse notes the describes how genetic material is passed on from
right to give consent. parent to child.

A person’s phenotype refers to his or her outward

appearance or the expression of genes.
Obstetrics
A person’s genotype. refers to his or her actual gene The sex of the affected individual is unimportant in
composition. terms of inheritance.

A person’s genome is the complete set of genes History

present (about 50,000 to 100,000
The family history for the disorder is negative—that is,
A normal genome is abbreviated. as 46XX or 46XY no one can identify anyone else who had it (a
(designation of the total number of chromosomes plus horizontal transmission pattern).
a graphic description of the sex chromosomes
present). Ancestor

MENDELIAN INHERITANCE: DOMINANT AND A known common ancestor between the parents
RECESSIVE PATTERNS sometimes exists. This explains how both male and
came to possess a like gene for the disorder.
A person who has two like genes for a trait two
healthy genes. X-LINKED DOMINANT INHERITANCE
ex:
Dominant gene
(One from the mother and one from the father)—on
two like chromosomes is said to be homozygous for All individuals with the gene are affected.
that trait.
Affected
If the genes differ (a healthy gene from the mother
and an unhealthy gene from said to be heterozygous All female children of affected men are affected; all
for that trait. male children of affected men are unaffected.

HOMOZYGOUS DOMINANT Generation

An individual with two homozygous genes for a It appears in every generation.
dominant trait HOMOZYGOUS RECESSIVE
Homozygous/ Heterozygous
An individual with two genes for arecessive trait.
All children of homozygous affected women are
INHERITANCE OF DISEASE
affected. Fifty percent of the children of heterozygous
AUTOSOMAL DOMINANT DISORDERS affected women are affected.

One Parent X-LINKED RECESSIVE INHERETANCE

One of the parents of a child with the disorder also will
have the disorder. Males

Sex Only males in the family will have disorder.

The sex of the affected individual is unimportant in History

terms of inheritance.
A history of girls dying at birth for unknown reasons
History often exists (females who had the affected gene on
both X chromosomes).
There is usually a history of the disorder in other
family members. Unaffected
AUTOSOMAL RECESSIVE INHERITANCE Sons of an affected man are unaffected.
Both Parent
Parents
Both parents of a child with the disorder are clinically
free of the disorder The parents of affected children do not have the
disorder.
Sex
Obstetrics
MULTIFACTORIAL (POLYGENIC) INHERITANCE MOSAICISM

Abnormal condition that is present when the

- Many childhood disorders tend to have
higher- than usual incidence nondisjunction disorder occurs after fertilization of the
ovum as the structure begins mitotic division.
- Occur from multiple gene combinations
possibly combined with environmental factors. Different cells in the body will have different
- Do not follow the Mendelian laws. chromosome counts.
- No set patterns in family history
ISOCHROMOSOMES
IMPRINTING Results from chromosome accidentally dividing not by
vertical separation but by horizontal one so a new
- Refers to the differential expression of genetic chromosome with mismatched long and short arms.
material.
- Allows researchers to identify whether Genetic Counselling
chromosomal material comes from the male
or female parent. Provide concrete, accurate information about the
process of inheritance and inherited disorders.
CHROMOSOMAL ABNORMALITIES (CYTOGENIC
- Reassure people who are concerned that their
DISORDERS) child may inherit a particular disorder or that
the disorder will not occur.
- In some instances of genetic disease, the - Allow people who are affected by inherited
abnormality occurs not because of dominant disorders to make informed choice about
or recessive gene patterns but through a fault future reproduction.
in the number or structure of chromosomes
- Offer support to people who are affected by
which results in missing or distorted genes.
genetic disorders.
- When chromosomes are photographed and
displayed, the resulting arrangement is WHO SHOULD GO FOR GENETIC
termed a karyotype.
COUNSELLING?
The number of chromosomes and specific parts of
chromosomes can be identified by karyotyping or by a - Couple who has a child with congenital
process termed fluorescent in situ hybridization disorder or an inborn error of metabolism.
(FISH). - Couple whose close relatives have a child
with a genetic disorder.
NONDISJUNCTION ABNORMALITIES
- Any individual who is known balanced
Abnormalities occur if the division in uneven. translocation carrier.
- Any individual who has an inborn error or
If spermatozoon or ovum with 24 or 22 chromosomes metabolism or chromosomal disorder - A
fuses with a normal spermatozoon or ovum. The consanguineous (closely related) couple.
zygote will have either 47 or 45 chromosomes, not the - Any woman older than 35 years and any man
normal 46 chromosomes. older than 55 years.
45 Chromosomes is not compatible with life and could - Couple of ethnic backgrounds in which
specific illnesses are known to occur.
lead to abortion.
DELETION ABNORMALITIES Nursing Responsibilities

Part of the chromosomes break during cell division - Explain what procedures to undergo.
causing the affected person to have an extra portion - Explain how different genetic screening tests
of a chromosome. are done and when offered.
- Support the couple during the wait for tests
TRANSLOCATION ABNORMALITIES results.
A child gains additional chromosome through another - Assist couples in values clarification, planning,
route. and decision making based on test results.
Obstetrics
personnel, use & brands of supplies, length of
hospital stays, no. of procedures carried out,
GENETIC DISORDERS ASSESSMENT and no. of referrals while maintaining quality
of care.
1.HISTORY
• Increasing alternative settings and
- Obtain information and document diseases in styles for healthcare.
family members for a minimum of three • Increase the use of alternative
generations. treatment modalities.
- Remember to include half brothers and sisters • Increasing reliance on Home Care
or anyone related in any way as family. - • Use of technology
Document the mother’s age because • Free Birthing
some disorders increase in incidence with Legal considerations of MCN Practice
age. - Document also whether the parents
are consanguineous or related to each other. • Identifying and reporting child abuse
- Documenting the family’s ethnic background • Child can bring a lawsuit when they
can reveal risks for certain disorders that reach legal age.
occur more commonly in some ethnic groups • Informed consent for invasive
than others. If the couple seeking counseling procedure and any risk that may harm fetus.
is unfamiliar with their family history, ask them In divorced, or blended families, nurse has the right to
to talk to senior family members about other give consent.
relatives (grandparents, aunts, uncles) before
they come for an interview. Have them ask Ethical considerations of MCN Practice
specifically for instances of spontaneous
miscarriage or children in the family who died • Conception issues
at birth. • In vitro Fertilization
- Extensive prenatal history of any affected • Embryo transfer
person should be obtained to determine
• Cloning
whether environmental conditions could
account for the condition.
• Stem cell research
• Surrogate mothers
2. PHYSICAL ASSESSMENT • Abortion
• Fetal rights vs Rights of the mother
- A careful physical assessment of any family • Use of fetal tissue for research
member with a disorder, child’s siblings, and • Resuscitation
the couple seeking counseling is needed. • No. of procedure or degree of pain
- During inspection, pay particular attention to that a child should asked to achieve better health.
certain body areas, such as the space • Balance between modern technology and
between the eyes; the height, contour, and quality of life
shape of ears; the number of fingers and toes,
and the presence of webbing. High Risk Pregnancy
- Dermatoglyphics (the study of surface • Concurrent disorder, pregnancy-related
markings of he skins) complication, or external factor jeopardizes the
- Note any abnormal findings health of the woman, the fetus, or both.
- Careful inspection of newborns is often
sufficient to identify a child with a potential Maternal age- (younger than 20 years old)
chromosomal disorder. -gestational hypertension, anemia, labor
- Infants with multiple congenital anomalies, dysfunction, cephalopelvic disproportion, LBW,
those born at less than 35 weeks’ gestation, and preterm neonates.
and those whose parents have had other
children with chromosomal disorders need Older than 35 yrs. Old- Nulliparas and multiparas
extremely close assessment. (40 and older) Increased risk of placenta previa,
Trends in Health Care Environment Hydatidiform mole, Vascular, Neoplastic, and
Degenerative disease.
• Cost containment- reduce the cost of
health by closely monitoring the cost of
Obstetrics
Parity factors - Normal healthy babies should have more
than 5-6 movements in one hour. If
• 5 or more= greater risk movements are less, counting should be
• PP haemorrhage continued further in the next hour. If
• New pregnancy within 3 months normal movements felt, stop the
Medical-surgical History procedure.
- If fewer movements are felts continuously
History of previous uterine surgery and/or uterine
for 6 hours, consult your doctor.
rupture, DM, cardiac disorder, Lupus, PIH, HELLP,
DIC
Psychosocial

Maternal behaviors and adverse lifestyle that

influence health of mother/fetus.

Sociodemographic
Arise from mother and her family.

Lack of prenatal care, low income, marital status, and

ethnicity.

Environmental

Hazards in workplace and woman’s general

environment. Cardiff count to 10- assess intrauterine fetal
well-being. If the baby has moved during usual
May include chemical, synesthetic gases, and activities.
radiation. Antepartum Diagnostic Testing
10 kicks in 12 hrs. A count fewer than 3 counts
Usual schedule: in 1hr. warrants further medical evaluation.
• Every 4 weeks for the first 28-32 weeks When to Test Fetal Movement
• Every 2 weeks from 32-36 weeks
• Every week from 36-40 weeks -One hr. after breakfast, lunch and dinner.

Daily fetal movement count (DFMC) Biophysical Assessment Ultrasonography

• Used to monitor fetus in pregnancies Indications (Fetal Genetic)

complicated by conditions that may affect Fetal Ultrasound o It creates an image of the baby in
oxygenation.
the mother’s womb. o A safe way to check the health
• Also called kick counts of the unborn baby.
• Several different protocols are used for
counting. Done transabdominal/ transvaginal. o Can check
• A count of fewer than 3 counts in 1 hour for defects or other problems in the fetus. o The
warrants further evaluation by nonstress test following can be examined: Abdomen and stomach,
(NST). Arms, legs, and other body parts, Back of the neck,
• Babies have sleep cycles, and the duration of Head and brain, Heart chambers and valves, Kidneys,
sleep vary from 20-90 minutes. During sleep Placenta placement, Spine, Umbilical cord, Urinary
babies have fewer movements. bladder.
• Fetal death means absent movements.
Types of fetal ultrasound:
Conducted:
Standard ultrasound- uses sound waves to create
- Fetal movement count should be done for two-dimensional images on a computer screen.
one hour after breakfast, after lunch, and
after dinner, in lying down left lateral
position.
Obstetrics
Doppler ultrasound- shows the movement of blood Indications for use:
through the umbilical cord, in the baby’s heart, or
between the baby and the placenta. • Genetic concerns
• Fetal maturity
3-D ultrasound- shows a lifelike image of an unborn • Fetal hemolytic disease
baby.  Chorionic Villus Sampling (CVS)
• Techniques for genetic studies
During fetal ultrasound:
• Earlier diagnosis, rapid results
Transabdominal ultrasound: • Performed between 10 and 13 weeks
of gestation.
Raise shirt to expose your abdomen. • Involves removal of small tissue
specimen from fetal position of
1. A clear gel will be placed on the skin of placenta.
the abdomen.
• Trans cervically or transabdominally
2. Transducer will be moved over the area
• Catheter Inserted through vagina into
and pressed against the skin.
uterus to sample villi of placenta.
• Transvaginal ultrasound:
More fetal cells, earlier in pregnancy.
1. Remove clothes from the waist down.
2. Be given a sheet to place over legs.
• Percutaneous Umbilical Blood Sampling
3. To remove jewelry or other objects (PUBS)
4. Lie on an exam table, either on your back -Also called
or on your side. CORDOCENTESIS/FUNICENTESIS
5. Lie on your back, feet in stirrups and
knees apart. - Direct access to the fetal circulation during
6. A vaginal transducer probe will be the second and third trimesters.
covered with a sterile cover.
7. A lubricant will be put on the probe.
8. The probe will be inserted into the vagina
to capture a series of images.
9. The probe will be removed.
MRI (Magnetic Resonance Imaging)

 Noninvasive radiologic technique

 Examiner can evaluate the following.
• Fetal structure, overall growth
• Placenta
• Quantity of Amniotic Fluid
• Maternal structures
• Biochemical status of tissues and
organs • Most widely used method for fetal
• Soft tissue, metabolic, or functional blood sampling and transfusion.
anomalies • Insertion of needle directly into fetal
umbilical vessel under
Biochemal Assessment ultrasonography guidance.
 Involves biologic examination and chemical Maternal Assays
determination.
Procedures used to obtain the needed  Maternal Serum Alpha-Fetoprotein (MSAFP)
specimens include amniocentesis, • Maternal serum levels used-as
screening tool for neural tube defects
percutaneous umbilical blood
(NTDS) in pregnancy.
sampling, chorionic villus sampling,
• Defects 80% to 85% of all open
and maternal sampling.
abdominal wall defects early in
 Amniocentesis: obtains amniotic fluid. pregnancy.
Obstetrics
• Screening recommended for all Antepartum Assessment Using (Electronic Fetal
pregnant women. Monitoring)
• Triple-and quad-screening to detect
autosomal trisomy’s.  Indications
• DECREASE alpha-fetoprotein= Down • Nonstress Test
Syndrome • Interpretation; reactive or non-reactive
• INCREASE alpha-fetoprotein= Neural contraction stress test
Tube Defect Detect liver cancer. • Nipple-stimulated contraction test
• Chromosomal abnormalities. • Oxytocin
• Abdominal  Nonstress Test (NST)
 Multiple Marker Screens Coomb’s Test • Most widely applied technique for
• Screening tool for RH incompatibility antepartum evaluation of the fetus.
• Detects other antibodies that may • Basis for the NST is that the normal
place fetus at risk for incompatibility fetus will produce characteristics HR
with maternal antigens. heart rate patterns in response to fetal
movement.
• Detect antibodies in RBC (no blood at
hemoglobin} • FHR recorded with a doppler
transducer, and a two dynamometer is
• 120 days-RBC lifespans
applied to detect uterine
• Reduces oxygen in blood=release contractions/fetal movements.
erythropoietin
 Vibroacoustic Stimulation 9Fetal Acoustic
Iron + Vitamin C Stimulation)
Group A B AB O • Another method of testing antepartum
FHR response and is sometimes used
AntibodyAnti None AB in conjunction with the NST.
B • Test take approximately 15 minutes to
Anti – A B antigen A&B None complete, with the fetus monitored for
Antigen Antigens 5-10 minutes before stimulation to
obtain a baseline FHR.
Negative- absent RH factor Positive- present RH
• Fetal Vaseline pattern is nonreactive.
factor
 Nipple stimulating Contraction Test
• As a result, transfusion therapy or • Apply warm moist washcloth to breast
during childbirth, a Rh-negative for several minutes.
person may be exported to Rh- • Massage 1 nipple for 10 minutes.
positive blood. • Massaging the nipples causes a
• After exposure during childbirth the release of oxytocin from the posterior
mother forms an antibody, anti-b, pituitary.
which acts against Rh antigens (Rh- • Massage the nipple for 2 minutes, rest
positive people normally have no anti- for 5 minutes, and repeat the cycle as
B) necessary to achieve adequate.
• In subsequent pregnancies the  Psychological considerations related to
mother’s anti-b antibodies can cross high-risk pregnancy.
the placenta and attach the RBCs of a • Label of high risk often increases the
fetus who is Rh-positive, thus causing patient’s sense of vulnerability.
hemolysis of the RBCs. A pregnant • May exhibit anxiety, low self-esteem,
Rh-negative won. guilt, frustration, and inability to
 Cell-free DNA screening in Maternal blood function.
Non-invasive prenatal genetic testing. • May affect parental attachment,
Provides definitive diagnosis accomplishment of the tasks of
noninvasive for fetal Rh status, fetal pregnancy, and family adaptation to
gender, and certain paternally the pregnancy.
transmitted single gene divides.  Nursing role in antepartum assessment
Provide education.
Reformed as early as 10 weeks
• Anticipatory planning
gestation.
• Counselling for family adaptation
Obstetrics
• Support person Symptomps:
Oxytocin Stimulated Contractions
-exogenous oxytocin also can be use to stimulate ▪ Progressive Dyspnea or Orthopnea
uterine contractions. ▪ Nocturnal Cough
Pre-gestational Complications ▪ Hemoptpsis
▪ Syncope
Cardiovascular Disease in Pregnancy- relatively
▪ Chest Pain
common in women of child bearing age,
complicate about 1% Clinical Findings:
Cardiac Diseases ▪ Cyanosis
▪ Rheumatic heart disease ▪ Clubbing of fingers
▪ Congential heart disease ▪ Persistent neck vein distention
▪ Hypertensive heart disease ▪ Systolic murmur grade 3/6 or greater
▪ Coronary ▪ Diastolic Murmur
▪ Thyroid ▪ Cardiomegaly
▪ Syphilitic ▪ Persistent arrhythmia
▪ Kyphoscoliotic cardiac disease ▪ Persistent split second sound
▪ Idippatic cardiomyopathy ▪ Criteria for pulmonary hypertension
▪ Corpulmonale Assessing a pregnant women with Cardiac
Disease
Physiological Condition with Heart Disease in
Pregnancy ▪ Fatigue
-First 8 weeks of pregnancy- most important changes ▪ Cough
of pregnancy occur with maximum changes at 28 ▪ Tachycardia
weeks ▪ Increased respi. Rate
▪ Poor Fetal heart tone
Decrease vascular resistance, blood pressure, heart
▪ Decrease amniotic fluid
rate, blood volume 50%
▪ Edema from poor venous return
Stroke volume increase
Diagnostic Studies
Maternal weight and basal metabolic rate also
Electrocardiography
affect COP
An average 15-degree left- axis deviation in the ECG,
-Later in pregnancy COP is higher when women is in
and mild ST changes may be seen in the inferior
the lateral recumbent position than when she is in the
leads, Atrial and ventricular premature contractions
supine.
are relatively frequent.
During Labour COP increase moderately in the first
Chest X-Ra
stage of labor and appreciably gather in the second
stage Heart silhouette normally is larger in pregnancy.
COP also increase in the immediate postpartum Echocardiography
period.
Normal changes
Heart-displaced upward and to the left with lateral
rotation on its long axis Clinical Classification

Changes in the Cardiac Sound: Class 1: Uncompromised, no limitation of physical

activity
▪ Exaggerated splitting of the first hearty sound
Class 2: Slightly compromised: slight limitation of
Diagnosis of Heart Disease physical activity.
Clinical Indicators
Obstetrics
Class 3: markedly Compromised: marked limitation Signs of Heart Failure
of physical activity
▪ Persistent Basilar Rales
Class 4: Life threatening cardiac abnormalities ▪ Nocturnal cough
can be reversed by corrective surgery and ▪ Sudden diminution in ability to carry out usual
subsequent pregnancy is less dangerous. duties
Antepartum Care ▪ Increasing Dyspnea on exertion attacks of
smothering with cough
Chief aim of management of the patient in pregnancy ▪ Hemoptysis, progressive edema and
is to keep patient with her cardiac reserve. Preferable Tachycardia
to have baseline data for her pregnancy.
Labor and Delivery
Limiting Activity
Vaginal Delivery is preferred unless there is
Helpful in severely affected women with ventricular obstetrical indication
dysfunction, left heart obstruction or class III or IV
symptomps Relief of pain with intravenous analgesics continuous
epidural analgesia is recommended for most situation,
Hospital admission by mid-second trimester may be but it’s contraindicated in patient with (intra-cardiac
advisable for some shunt, pulmonary hypertension, and aortic stenosis)
Problems should be identified early To avoid the risk of maternal Hypotension.
Beta Blockers- rather than digoxin should be used to Folic Acid-given to avoid Neural Tube Defects
control the heart rate for patients with functionally
significant mitral stenosis Postpartum Monitoring

Empiric therapy with beta-blockers is offered. Because hemodynamics do not return to baseline –
monitoring at least 72 hrs. postpartum
If possible, antiarrythmic drugs should be avoided
during first trimester because of its tetarogenic effects. ▪ Fluid balance and Antibiotic Prophylactic
▪ Semi recumbent position wit lateral tilt
Oral Therapy with warfarin is effective and logistically
▪ Closed monitoring for 3rd stage
easy.
▪ Avoid Complication of pph, anemia, infection
However, it can affect embryonic organ development, and thromboembolism
fetal intracranial bleeding is a risk ▪ Intensive medical management for any signs
of impending ventricular failure
Heparin-adjusted subcutaneous doses
▪ If pulse is more than 100, respi is more than
Peripartum Management 25
▪ Option of contraceptive is advise
Cesarean section –indicated only for the:
Prognosis
▪ Aortic dissection
▪ Marfan syndrome Favourable outcome for the mother with heart disease
depends upon the:
Positioning the patient on her left side lessens the
hemodynamic fluctuations associated with contraction ▪ Functional cardiac capacity
when the patient is supine.
Diabetes Mellitus
General Measures:
▪The disorder affects 3% to 5% of all pregnancies.
▪ Avoid contact w/ persons who have respi.
Infection ▪ Infants of diabetic women are five times more apt to
▪ Pneumococcal and influenza vaccines are be born with heart anomalies than others because of
recommenednde this threat.
▪ Cigarrete smoking is prohibited ▪ If a woman’s insulin level is insufficient, glucose
cannot be used by body cells.
Obstetrics
▪ Because of insulin insufficiency, the body cells still Impaired glucose homeostasis
cannot use the glucose, so, the serum glucose levels
continue to rise (hyperglycemia). ▪ A state between “normal” and “diabetes” in which
the body is no longer using and/or secreting
Classification of Diabetes: homeostasis insulin properly.

1. Type 1 Impaired fasting glucose: A state when fasting plasma

glucose is at least 110 but under 126 mg/dL.
Formerly known as insulin dependent diabetes
mellitus. A state characterized by the destruction of Impaired glucose tolerance: A state when results of
the beta cells in the pancreas that usually leads to the oral glucose tolerance test are at least 140 but
absolute insulin deficiency. under 200 mg/dL in the 2-hour sample.

Immune-mediated diabetes mellitus results from Risk factors for gestational diabetes:
autoimmune destruction of the beta cells.
Obesity
Idiopathic type 1 refers to forms that have no known
cause. Age over 25 years

2. Type 2 History of large babies (10 lb. or more)

Formerly known as non-insulin dependent diabetes History of unexplained fetal or perinatal loss.
mellitus. A state that usually arises because of insulin History of congenital anomalies in previous
resistance combined with a relative deficiency in the pregnancies.
production of insulin.
History of poly cystic ovary syndrome
Under normal circumstances:
Family history of diabetes (one close relative or two
▪ The food you eat is broken down into blood sugar. distant ones)
▪ Blood sugar enters your bloodstream, which signals Member of a population with a high risk for diabetes
the pancreas to release insulin. (Native American, Hispanic, Asian)
▪Insulin helps blood sugar enter the body’s cells so it Assessment
can be used for energy.
▪ A fasting plasma glucose of 126 mg/dl or above or a
▪ Insulin also signals the liver to store blood sugar for non-fasting plasma glucose of 200 mg/dl or above
later use. meets the threshold for the diagnosis of diabetes.
▪ Blood sugar enters cells, and levels in the ▪ Needs to be confirmed on a subsequent day as
bloodstream decrease, signaling insulin to decrease soon as possible. This is usually done using a 50-g
too. ▪ Lower insulin levels alert the liver to release oral glucose challenge test.
stored blood sugar, so energy is always available,
even if you haven’t eaten for a while. ▪ After the oral 50-g glucose load is ingested, a
venous blood sample is taken for glucose
▪ A lot of blood sugar enters the bloodstream. determination 60 minutes later. If the serum glucose
The pancreas pumps out more insulin to get blood level is more than 140 mg/dL, the woman is
sugar into cells. Over time, cells stop responding to all scheduled for a 100-g.
that insulin—they’ve become insulin resistant.

▪ The pancreas keeps making more insulin to try to

make cells respond. Eventually, the pancreas can’t
keep up, and blood sugar keeps rising.

Gestational Diabetes Mellitus (GDM)

▪ A condition of abnormal glucose metabolism that

arises during pregnancy. ▪ Possible signal of an
increased risk for type 2 diabetes later in life.
Obstetrics
Nursing Diagnosis: THERAPEUTIC REGIMEN

▪ Deficient knowledge related to therapeutic regimen 1. Insulin

necessary during pregnancy.
▪ Women with gestational diabetes will be started on
Outcome Evaluation: insulin therapy if diet alone is unsuccessful in
regulating glucose values.
▪ Client states importance of careful attention to
nutrition, exercise, and home monitoring of glucose ▪ Short-acting insulin (regular) combined with an
levels during pregnancy; describes nutrition and intermediate type.
exercise program; states intention to keep nutrition
and exercise. Use of a very-short-acting insulin such as Lispro or
insulin as part, which have a 1-hour peak time, can
1. Education Regarding Nutrition During lead to more fluctuations in blood glucose levels
Pregnancy: than regular insulin.
▪ Women should eat almost immediately after
▪ Begin a stricter diabetic diet before she becomes injecting these short-acting insulin to prevent
pregnant. hypoglycemia before mealtimes.
▪ Women who develop gestational diabetes are ▪ Oral hypoglycemia agents are not used for
advised to begin a diabetic diet complemented by an regulation during pregnancy because, unlike
exercise program as soon as they are diagnosed. insulin, they cross the placenta and are potentially
teratogenic to a fetus.
▪ Help a woman plan her day based on the time
▪ Her diet should include a reduced amount of
saturated fats and cholesterol and an increased interval her insulin takes to reach its peak.
amount of dietary fiber. ▪ Regular insulin given before breakfast reaches its
peak just after breakfast.
▪ Intermediate insulin given in the evening reaches
▪ Urge a woman to make her final snack of the day
one of protein and complex carbohydrate to allow
its peak into the next day before breakfast.
slow digestion during the night. ▪ Evening regular insulin injection peaks after
dinner or at bedtime.
▪ Be certain a woman is using an injection
▪ No woman should reduce her intake to below 1800
technique for insulin of stretching the skin taut and
calories during pregnancy. A diet this low in
injecting at a 90-degree angle.
carbohydrates causes fat breakdown, which produces
acidosis. ▪ A woman should maintain a consistent rotating
injection routine (such as using all sites in one limb
before using another or rotating limbs) to maintain
▪ She must be extremely nutrition-conscious to
as consistent a level of absorption as possible.
maintain good control and keep her weight gain to a
suitable amount (approximately 25 to 30 lb.) in the
▪ Insulin is adjusted to keep a fasting blood glucose
hope of limiting the size of her infant and making a level below 95 to 100 mg/dL and a 2-hour
vaginal birth possible. postprandial level below 120 mg/dL.
2. Blood Glucose Monitoring
2. Education Regarding Exercise During
Pregnancy. ▪ A woman typically uses a finger stick technique,
using one of her fingertips as the site of lancet
puncture.
▪ Exercise is another mechanism that lowers the
serum glucose level and thereby the need for insulin. ▪ She places a drop of blood on a test strip. The
▪ She should begin her exercise program before strip is then inserted into a glucose meter that
pregnancy, With exercise, the blood glucose level determines the glucose level.
decreases because the muscles increase their need
▪ A fasting blood glucose level below 95 to 100
for glucose. This effect lasts for at least 12 hours after
mg/dL and a 2-hour postprandial level below 120
exercise.
mg/dL are well-adjusted values.
▪ When a woman discovers that hypoglycemia is
present, she should ingest some form of sustained
Obstetrics
carbohydrate such as a glass of milk and some ▪ Obtain a serum alpha-fetoprotein level obtained at
crackers. 15 to 17 weeks to assess for a neural tube defect

▪ If a woman discovers an elevated blood glucose ▪ An ultrasound examination performed at

level, she should assess her urine for ketones. approximately 18 to 20 weeks to detect gross
▪ Acidosis during pregnancy must be prevented abnormalities.
because maternal acidosis leads to fetal anoxia ▪ A creatinine clearance test may be ordered each
because of fetal inability to use oxygen when body trimester.
cells are acidotic.
3.Insulin Pump Therapy (Continuous ▪ Placental functioning may also be assessed by a
Subcutaneous Insulin Infusion) weekly non-stress test or biophysical profile during the
last trimester if a woman is in good control, or a daily
non-stress test if re-regulation is poor.

▪ To self-monitor fetal well-being by recording how

many movements occur an hour.

▪ Ultrasounds may be taken at week 28 and then

again at week 36 to 38 to determine fetal growth,
amniotic fluid volume, placental location, and bi-
parietal diameter
▪ Oligohydramnios
▪ Hydramnios

▪ The lecithin–sphingomyelin ratio by amniocentesis is

performed by week 36 of pregnancy to assess fetal
▪ Depending on the individual prescription, before a maturity.
snack and before a meal, a woman can dial or press a
button on the pump; the pump then pushes the ▪ Phosphatidylglycerol at amniocentesis is used to
syringe barrel forward to administer the bolus. indicate lung maturity.

▪ The site of the pump insertion is cleaned daily and 5. Timing for Birth
covered with sterile gauze; the site is changed every ▪ Cesarean birth routinely performed in pregnant
24 to 48 hours to ensure that absorption remains diabetic women at 37 weeks’ gestation.
optimal.
▪ Vaginal birth is preferred if at all possible.
▪ Several restrictions are necessary when using an
Labor may be induced by rupture of the membranes
insulin pump.
or an oxytocin infusion after measures to induce
cervical ripening.
▪ The pump must not be allowed to become wet;
when showering and remove the complete apparatus
▪ Both labor contractions and fetal heart sounds
(pump, syringe, and tubing) to bathe or swim (caution
should be monitored continuously during labor to
her not to leave it disconnected for more than 1 hour).
ensure early detection of placental dysfunction.
▪ When pump therapy first begins, she must wake at
▪ A woman’s glucose level
night and do a 2:00 AM blood glucose determination
is regulated during labor
because this is a time when she is most vulnerable for
by an intravenous.
hypoglycemia.
Infusion of regular insulin
with a blood glucose
3. Tests for Placental Function and Fetal Well- assay every hour.
Being.
Obstetrics
6. Postpartum Adjustment 2. Fetus makes more insulin to handle extra
▪ Often, she needs no insulin during the immediate glucose
postpartum period: in another few days, however, she 3. Extra Glucose gets stored as fat and fetus
will return to her prep-regnant insulin diabetic becomes larger than normal
requirements.
When a woman is diagnosed with GDM, treatment
▪ Woman with GDM demonstrates normal glucose should commence as soon sas possible:
values by 24 hours after birth and needs no further
▪ Blood glucose self-monitoring
diet or insulin therapy.
▪ Dietary Management
She requires careful observation, during the ▪ Physical Activity
immediate postpartum period because if hydramnios
was present during pregnancy, she is at risk of Obstetrical Management
hemorrhage from poor uterine contraction.
▪ Serial Us to trend fetal growth, AFI, and fetal
▪ Women with diabetes may breastfeed because anatomy
insulin is one of the few substances that does not ▪ Fetal well being monitored with kick counts,
pass into breast milk from the blood stream. NSTs, BPPs

Diet
GDM- only occur in pregnancy
Low carbohydrate diet, high fibre with caloric
Predisposing Factors:
restriction
▪ Previous pregnancy with GDM Frequent small snacks may be needed between
▪ Maternal age over 35 meals
▪ Family History
▪ Obesity Avoid starvation

Clinical Manifestation: Insulin

3 pre-meal short acting insulin (actrapid) +/-

▪ Polyuria (t loss, frequent urination)
intermediate acting insulin
▪ Polydipsia (fatigue, weakness)
▪ Polyphagia (ketonuria, tingling of hands) Oral Hypoglycemic agents

How to Diagnose DM? -implicated as teratogenic

In pregnancy, the oral glucose tolerance test should For type 2 DM patients, stop oral hypoglycemic
be performed as follows. agensts and change ti insulin

▪ In the morning after an overnight fast of Screening and Diagnosis

between 8 and 14 hrs
-Test is performed 24-28 wk
▪ Ask the patient to remain seated
▪ Administer a 75-gram oral glucose load Macrosomia (>4 kg)
▪ Measure the venous plasma glucose when
Risk is 16-29% as compared to 10% in
the patient is fasting in 30,60, 90 and 120
control.
minutes
Increase in caesarean delivery, instrumental
80-120 mg/ dl Normal Blood Glucose
deliveries (forceps/ vacuum), birth trauma…
If initial glucose tolerance test is normal but the
Fetal Morbidity
patient is thought to be at high risk repeat the
glucose tolerance test at 32 weeks of gestation. ▪ Miscarriages
EFFECT IF MOTHER HAS GDM ▪ Pre-term delivery

1. Mother’s blood brings extra glucose to the Growth Restriction

fetus -common among Type 1 diabetic mellitus
Obstetrics
Polycythermia ▪ She may not have money for supplemental vitamins
or iron preparations for the same reason.
-hyperglycemia stimulates fetal erythropoietin
production ▪ Illicit readily cross the placenta. Because this can
-Can lead to tissue ischemia and infarction lead to fetal effects, drug abuse can account for fetal
abnormalities or preterm birth
Polyhydramios
If a woman uses injected drugs, the risk for hepatitis B
-amniotic fluid volume >2000 ml or human immunodeficiency virus (HIV) infection
increases.
Maternal Mobidity

-Increased DKA due to increasingly resistant DM ▪ A woman may earn money to buy drugs through
prostitution, which increases the risk for sexually
-Increase incidence of UTI transmitted infection and poses an additional threat to
a fetus.
Substance Abuse
▪ Substance dependence is a growing health problem Common Substances Abused During Pregnancy
in women of childbearing age, so its incidence during
pregnancy is increasing.  Cocaine
-Placental Abruption, IUGR, prematurity
▪ As many as 10% to 20% of pregnant women use
illegal drugs during pregnancy. ▪ Derived from Erythroxylum coca, a plant grown
almost exclusively in South America. When sniffed
into the nose or smoked in a pipe, cocaine is
▪ Substance abuse is defined as the inability to meet absorbed across the mucousmembranes to affect the
major role obligations, an increase in legal problems central nervous system.
or risk-taking behavior, or exposure to hazardous
situations because of an addicting substance. ▪ During pregnancy there is extreme vasoconstriction
that occurs and can severely compromise placental.
circulation, leading to premature separation of the
▪ A person is substance dependent when he or she placenta, which then results in preterm labor or fetal
has withdrawal symptoms following discontinuation of death.
the substance, combined with abandonment of
important activities, spending increased time in ▪ Infants born to cocaine-dependent women may
activities related to substance use, using substances suffer the immediate effects of intracranial
for a longer time than planned, or continued use hemorrhage and a withdrawal syndrome
despite worsening problems because of substance oftremulousness, irritability, and muscle
rigidity.Cocaine use can be detected by urinalysis
use.
because the metabolites of cocaine can be detected
in urine up to 1 week after use
A mark of a woman with a substance abuse
problem is:  Amphetamines
▪ She may come late in the pregnancy for prenatal
care because she is afraid her drug use will be ▪ Methamphetamine (speed) has a pharmacologic
discovered, and she will be reported to authorities. effect similar to cocaine Ice, a rock type of
methamphetamine that is smoked, can produce high
▪ If she is using a drug that sustains her for only a few concentrations of drug in the maternal circulation.
hours, she cannot wait long at a health care facility to
be seen for an appointment. ▪ Newborns whose mothers used the drug show
jitteriness and poor feeding at birth and may be
▪ She may have difficulty following prenatal growth restricted
instructions for proper nutrition because although she
may desire to eat well, she may lack sufficient money  Marijuana & Tush
to buy both drugs and nutritious food, and choosing --widespread used among women of childbearing age
drugs over food makes her nutrition inadequate. low birth weight

-not clearly associated with major physical

Obstetrics
▪ Both marijuana and hashish are obtained from the ▪ Withdrawal symptoms include:nausea, vomiting,
hemp plant, cannabis. Hypertension, ShiveringAbdominal pain Insomnia
Restlessness, Muscle jerks. Diarrhea Body aches
▪ When smoked, they produce tachycardia and a
sense of well-being. ▪ Withdrawal symptoms may begin as soon as 6
hours after the last drug dose and can continue for
▪They are associated with loss of short-term memory several days.
and an increased incidence of respiratory infection in
adults.
▪ Infants of opiate-abusing women tend to be small for
gestational age and have an increased incidence of
▪A frequent user may not be able to breastfeed fetal distress and meconium aspiration.
because of reduced milk production and the risk to
the newborn from excretion of the drug in the milk.
Inhalants
▪Inhalant abuse refers to the “sniffing” or “huffing” of
 Phencyclidine aerosoldrugs.
▪ Is an animal tranquilizer that is a frequently used
street drug in polydrug abuse.
▪ frequently abused substances include airplane glue,
cooking sprays, and computer keyboard cleaner.
▪ It causes increased cardiac output and a sense of
euphoria.
▪ Most of these substances contain freon as a
propellant and can lead to severe respiratory and
▪ It has the potential for causing longterm cardiac irregularities.
hallucinations (flashback episodes). PCP tends to
leave the maternal circulation and concentrate in fetal
▪ The effect of these drugs during pregnancy is not
cells, so it may be particularly injurious to a fetus.
well documented, butthey appear to have effects
similar to alcohol abuse
 Narcotic Agonist
▪Used for the treatment of pain (e.g., morphine or ▪ The respiratory depression they can cause could be
meperidine [Demerol]) and cough suppression enough to limit the fetaloxygen supply to a serious
(codeine), are also widely abused because of their level
potent analgesic and euphoric effect.
Alcohol
▪ Heroin, a raw opiate, is the mainopiate used
▪Women are advised to drink no alcohol during
recreational
pregnancy
▪ Heroin, a raw opiate, is the main opiate used Stimulants: Effects on Fetus
recreational to the point of dependence.
▪ Preterm Labor
▪ A short-acting narcotic, heroin is inactive until it ▪ Spontaneous Abortion
crosses the blood–brain barrier (which it does more ▪ Placental Abruption
quickly than morphine). ▪ Fetal Hypertension
▪ Crack Baby Syndrome
▪ It may be administered intradermally (“skin
popping”), through inhalation (“snorting”), or Nicotine
intravenously (“shooting”).
-cigarettes, cigars pipes, “snuff”, “chew”
▪ It produces an immediate and short lived feeling of Maternal use in pregnancy affects birth weight, infant,
euphoria followed by sedation. cognition and behavior
Detoxification
▪ Pregnancy complications related to itsuse include
pregnancy-induced hypertension and, because RH sensitization during Pregnancy
narcotics are often injected with shared needles,
phlebitis, subacute bacterial endocarditis, and -occur during pregnancy if you are RH negative and
hepatitis B and HIV infection. pregnant with a fetus who has a Rh-positive blood.
Obstetrics
How is RH sensitization Diagnosed? Complications:

---Blood test during first prenatal Hydrops Fetalis

RH Incompatibility -accumulation of different cell compartments

▪ First pregnancy: Mother may become sensitized,
baby rarely affected. Anemia
-Medical condition in which the rbc (carries
haemoglobin) count or hgb is less than normal
▪ Indirect comb’s test (test for anti-RH (+) positive
antibodies in mother’s circulation) performed during -Destroy in 120 days
pregnancy at first visit and again about 28 weeks
gestation. ▪ Inadequate levels of hemoglobin in the blood less
than 12 gm/dL Causes:
▪If indirect comb’s test is negative (-) at 28 weeks, ▪ Smoking
small dose (micRhogam) is given prophylactic to
prevent sensitization in the 3rd trimester ▪ Medication
amniocentesis. ▪ Nutritional deficiency in iron and folic during
pregnancy
▪Direct Coomb’s test done on cord blood at delivery to
determine the presence of anti RH positive antibodies Iron deficiency anemia General Information:
on fetal RBCs.
▪ The most common medical complications of
pregnancy.
▪ If both direct and indirect Coomb’s test are negative,
(no formation of anti-rh-positive antibodies) and infant ▪ Most common anemia of pregnancy.
is RH (+), then RH (-) negative mother can be given
▪ A disorder of oxygen transport in which hemoglobin
Rhogam (Rho{D} human immune globulin to prevent
synthesis is deficient.
development of anti-RH-positive antibodies as a result
of sensitization from present (just terminated ▪ The woman may be asymptomatic but may tire
pregnancy) easily.

▪ In each pregnancy , an anti-RH-negative (-) Causes:

mother who carries an RH (+) fetus can receive
Rhogam to protect future pregnancies if the mother Inadequate supply supply or low intake of dietary iron.
has had indirect comb’s test and the infant has had Heavy menstrual periods.
a negative direct comb’s test (-) (DCT).
Unwise weight reducing programs
▪If mother has been sensitized (produced an anti-Rh-
When the hgb is below 12mg/dl, hct below 33%, iron
positive antibodies), Rhogam is not indicated.
deficiency is suspected.

▪ Rhogam must be injected into unsensitized mother’s Signs and symptoms:

system within 72 hours of delivery of RH (+) positive
infant.  Cheilosis (lesions corner of mouth)
 Headache
 Easy fatigability
Direct Coombs Test- Baby
 Craving to eat unusual substance (pica)
Indirect Coombs Test-Mother  Koilonychia (spoonshaped fingernails)
 Pallor of skin and mucous membranes
Phototherapy-Due to Jaundice
 A persistent or continuous noise in the ear
Cover the eves and genitalia. Check for dehydration,  Dizziness
Reposition every 3 hrs, Monitor skin when lights off.  Smooth sore tongue associated with burning
sensation
Obstetrics
ANEMIA IN PREGNANCY IRON DEFICIENCY ANEMIA

--Hemoglobin is less than 11gm/dl (or haematocrit Iron required for fetus and placenta-500 mg
<32%)
Iron required for red cell increment-500 mg
Mild anemia- 9-10.9 mg/dl
Post-Partum Loss-180 mg
Moderate anemia-7-8.9 mg/dl
Lactation for 6 months-180 mg
Severe Anemia- <7gm/dl
Total Requirement-1360 mg
Very Severe Anemia-<4gm/dl
ETIOLOGY of Fe DEFIENCY ANEMIA
Maternal effects:
▪ Diet with less Fe heavy menstrual period
▪ Infection unwise weight reduction
▪ Preeclampsia
Chronic Infections: (like malaria)
▪ Postpartal hemorrhage
▪ Tolerate poorly even minimal blood loss Repeated Pregnancies:
during birth
▪ With Interval <1 yr
▪ Healing of episiotomy is delayed.
▪ Blood loss at time of Delivery
ETIOLOGY: ▪ Multiple Pregnancy
1. Erythrocyte production: (hypo proliferative CLINICAL FEATURES
anemia)
▪ -Fe defienciency Symptomps ususally in severe anemia
▪ -Folic Acid Fatigue
▪ -Vitamin B12
Giddiness
2. RBC destruction
Breathlessness
3. RBC loss: 90% anemia in pregnancy due to Fe
defiency EFFECTS OF ANEMIA IN PREGNANCY

PHYSIOLOGICAL CHANGES IN PREGNACY Mother:

Plasma Volume 50% by 34 weeks ▪ Inadequate tissue oxygenation

▪ Predisposes to Infection
But RBC mass 25% ▪ Risk of thrombo-embolism
Results in Hemodilution: Decrease Hb, Hct, RBC ▪ Delayed general physical recovery esp
count after C Section

2-3 fold increase in Fe requirement FETUS;

COMMON ANEMIA IN PREGNANCY ▪ IUGR

▪ Preterm Birth
Common Types:
MANAGEMENT
Nutritional Deficiency Anemia
Objectives:
▪ -Iron Defiency
▪ Folate Defiency 1. Achieve a normal Hb by end of pregnancy
▪ Vit b12 defiency 2. To replenish iron stores

Hemoglobinopathies: Two ways to correct anemia:

▪ Thallasemias ▪ Iron Supplementation

▪ Blood Transfusion
Obstetrics
MANAGEMENT Women should take prenatal vitamins containing iron
60mg elemtal iron.
Recommended supplementation for non-anemic 30-
60 mg/ day of iron Women should eat green leafy vegetable, meat
legumes and fruits. - Monitor the patient’s CBC and
Anemic Gravidas 120-240 mg/ per day serum iron ferritin levels regularly.
Supplementation with folic acid + vitamin C Monitor womans vital signs esp HR noting any
Severe Anemia: (Hb<8gm/dl) tachycardia which

--IM: (Iron Sorbitol) with Z technique (to avoid Evaluate patient for s/s id decreased perfusion in vital
irritation and discoloration and promote fast organs dyspnea, chest pain, dizziness and symptoms
absorption) of neuropathy/

Side Effect of Fe Oral Therapy: Assess FHR at each visit; if hospitalized at least every
4 hours. - Provide frequent rest periods to decreased
▪ GI upset physical exhaustion - Administer oxygen as ordered to
▪ Constipation reduce hypoxia.
▪ Diarrhea
Disseminated Intravascular Coagulation DIC
Fetal Effects:
▪ Is a deficiency in clotting ability caused by
▪ Low birth weight vascular injury. It may occur in any woman in
▪ Premature/preterm birth the postpartum period, but it is usually
▪ Still birth associated with premature separation of the
▪ Neonatal death in Infants placenta, a missed early miscarriage, or fetal
death in utero.
Diagnostic/Lab Evaluation: ▪ The overactive coagulation depletes platelet
and clotting factors needed to control bleeding
▪ Low hgb (less than 10mg/dL causing excessive bleeding.
▪ Low hct (less than 33%) ▪ A coagulopathy in which the clotting and anti-
▪ Low serum iron level (less than 30mcg/dL clotting mechanisms occur at the same time.
▪ Low serum ferritin level (less than 100mg/dL) ▪ The client is at risk for both internal and
▪ Low RBC count with microcytic and external bleeding, as well as damage to
hypochromic cells organs resulting from ischemia caused by
microclottings.
Medical/Pharmacologic Treatment
Also associated with premature separation of the
Oral Iron Supplement
placenta, missed early miscarriage or fetal death in
Blood transfusion PRBC utero.

IronIV iron saccharate Management of DIC:

IV Soribitex (Jectofer)IM ▪ Correction of the cause

▪ Missed abortion- delivery of the fetus and the
Iron dextran (Inferon) must be injected deeply into a
placenta ends the production of
large muscle mass using Z tract method - Be
thromboplastin, which is fueling the process
prescribed the therapeutic levels of medications 120
to180mg iron/day( usually in the form of FESO4 or FE ▪ Blood transfusion
Gluconate. ▪ Monitor for bleeding - IV site, lab works,
nosebleeds, spontaneous bruising.
Nursing Care Management:
Given to patient to thin the blood- Heparin (to stop
Stress importance of iron rich diet and iron coagulation of blood)
supplements with vitamin C

Increase fluid intake and fibers

Obstetrics
Pseudocyesis -Antacids

Women with pseudocyesis, also known as phantom -Anti-emetics

pregnancy, think they are pregnant (when they aren’t)
and can even experience pregnancy symptoms. The Obtain Samples:
condition isn’t in any way related to miscarriage. In -Urine Test
pseudocyesis, there is no conception and no baby.
Learn more about this condition, its causes, and -Hemoglobin/ Hematocrit
treatment options.
-Electrolyte Levels
3 Theories of Pseudocyesis
ECTOPIC PREGNANCY
▪ Wish Fulfilment Theory -Abnormal implantation of the fertilize ovum
▪ Conflict Theory (want to be pregnant but has
fear to get pregnant ---causes physiologic -Outside uterine Cavity
changes) Etiology:
▪ Depression Theory (cause of major
depression) • Previous ectopic pregnancy
• Previous Surgery of the fallopian tube
GESTATIONAL CONDITIONS
• Exposure to DES (di-ethyl-stilbestrol)
Hyperemesis Gravidarum • Congenital abnormalities of the tube
(narrowing)
▪ -7-80% of all pregnant women experience • Previous Infection
some form of morning sickness during the
• Use of IUD
pregnancy
▪ Extreme Morning Sickness • Taking Hormones
▪ Persistent Uncontrolled Vommiting • Increasing Age

ETIOLOGY CLINICAL MANIFESTATIONS

▪ HCG production • Pain (localize, sharp, stabbing)

▪ Psychological factors/ disorders • Amenorrhea
▪ Tropoblastic activity • Bleeding
▪ Exact cause is not known
Signs of Ruptured Ectopic Pregnancy
CLINICAL MANIFESTATATIONS
• Between 6 and 12 weeks gestation
▪ Continued severe nausea and vomiting • Severe abdominal Tenderness
▪ Dehydration • Orthostatic Hypotension
▪ Dry skin/ mucous membrane
MANAGEMENT: EP
▪ Electrolyte Imbalance
▪ Starvation -Intact
▪ Weight loss
a. methotrexate
Interventions
b. No alcohol
 Monitor
-Ruptured
• Vital Signs
• Fluid Intake and output a. Control Bleeding
• Fluid Volume b. Salpingostomy
 Small Frequent Feedings
 Emotional Support c. Salpingectomy

--Medications-- d. Laparoscopy
Obstetrics
LABORATORY TEST

• CBC
• URINALYSIS WITH MICROSCOPIC EXAM
• BLOOD TYPE AND RHESUS
COMPLICATIONS:

• Hemorrhage
• Infection
• Loss of Reproductive Organs
• Infertility

DIFFERENTIAL DIAGNOSIS

• Appendicitis
• Threatened Abortion
• Ruptured Ovarian Cyst
• PID
• Salpingitis 3-H
• Nephrolithiasis
• Ovarian Torsion • Hyper-emesis
• Intrauterine Pregnancy • Increase HCG
• Increase Incidence of PIH
GESTATIONAL TROPHOBLASTIC DISEASE
600,000- after LMP (60 days)
Other terms:
50, 000-45-80 days
• Hydatidiform mole
• Trophoblastic disease 26,000-100 days
• Molar Disease 400,000-pregnant
Types: 800,000-H-mole

• Complete or Classical –no egg MANAGEMENT: MEDICAL

• Incomplete or Partial- has baby or fetus
• D and C
• Fluid Replacement
PREDISPOSING FACTORS: • Antibiotic
• Prevent Complication
• Inadequate Protein Intake
CHORIOCARCINOMLA
• Low Socio-Economic Status
• Age (below 18 over 35) -Not advised to be pregnant for one yr.
• Asian Heritage -Vaginal rest
• Intake of Clomid
TAHBSU-
CLINICAL MANIFESTATIONS:
TOTAL
• Positive Pregnancy Test
ABNOMINAL
• Absence of FHT
• Enlarge uterus (out of proportion from normal HYSTERECTOMY
pregnancy)
AND
• Anemia
Obstetrics
BILATERAL -complication of pregnancy, where there is placental

SALPHINGO EFFECTS ON THE MOTHER

OOPHORECTOMY A large loss of blood or haemorrhage may require

blood transfusions and intensive care after delivery
Incompetent cervix
-uterus may not contract after delivery
• -open cervix
• -painless, premature dilation of the cervix SYMPTOMPS

PREDISPOSING FACTORS • Contractions that don’t stop (and may follow

so rapidly as to seem continuous)
• Repeated dilation • Pain in the Uterus
• Trauma to cervix • Tenderness in the Abdomen
• Habitual Abortion • Pallor
• Pre-term Labor • Vaginal bleeding sometimes
CLINICAL MANIFESTATIONS • Uterus may be disproportionately enlarged

Initial Abruptions are classified according to severity

• . show RISK FACTORS

• . rupture of membranes • Pre eclampsia
Late • Maternal smoking
• Short umbilical cord
• Pressure to cervix • Prolonged rupture membranes
Cardinal

• Painless Dilatation
• Birth of a Dead Fetus
Surgery: Cerclage

• Shirodkar-barter
-Internal os

-Permanent suture

• Mc Donald
-External Os

POST SURGICAL INSTRUCTION

• Maintain bed rest

• Check for excessive vaginal discharge
• Sexual activity- 4-6 weeks
• Avoid vaginal douche
• Position: Side Lying/ Prone

Complication: Hemorrhage

PLACENTAL ABRUPTION/ ABRUPTIO

PLACENTAE (occurs when the placenta separate s
from inner wall of the uterus before birth)
Obstetrics
PREMATURE RUPTURE OF MEMBRANES (PROM)  Pregnancy Induced Hypertension
 Preeclampsia-Eclampsia
-rupture of the chorion and amnion 1 hr or more
 Preeclampsia Superimposed on chronic
before the onset of labor. The gestational age of the
HTN
fetus and estimates of viability affect the
management. --Maternal DBP >110 is associated with increased risk
of placental abruption and fetal growth restriction.
ETIOLOGY
PREGNANCY INDUCED HYPERTENSION
-precise cause and specific
 Is a condition in which vasospasm occurs
PATHOPHYSIOLOGY
during pregnancy in both small and large
-associated with malpresentation, possible weak arteries
areas in the amnion and chorion, subclinical infection  Usually mild and later in pregnancy
and possibly incompetent cervix.  No renal or other systemic development
 Resolves 12 wks postpartum
-Basic and effective defense against the fetus
contracting an infection is lost and the risk of ETIOLOGY
ascending intrauterine infection
• Unknown
ASSESSEMENT FINDINGS • Highly correlated with the antiphospholipid
syndrome or the presense of antiphospholipid
1.Clinical Manifestations
antibodies
PROM is marked by amniotic fluid gushing
Adult fluid is outside the cell.
from the vagina. The fluid may merely trickle
or leak from the vagina in the absence of Infant fluid is inside the cell
contractions
-Maternal Fever, fetal tachycardia and CLASSIGC SIGNS OF PIH
malodorous discharge may indicate infection.
• Hypertension
2. Laboratory and Diagnostic Study • Proteinuria
• Edema
 Rupture of membranes is confirmed by the ff.
Ferning is evident. CLASSIFICATIONS OF PIH
 Nitrazine test tape turns a blue-green color
 Gestational Hypertension
NURSING MANAGEMENT  Mild Pre-eclampsia
 Severe Pre-ecclampsia
 Prevent infection and other potential
 Pre-eclampsia
complications
 Determine maternal and fetal status including GESTATIONAL HYPERTENSION
estimated gestational age. Continually assess
for signs of infection Elevated blood pressure (140/90 mmhg) but has no
proteinuria or edema.
 Maintain client on bed rest if the fetal head is
not engaged. No drug therapy is necessary
 Provide client and family education
 If labor does not begin of the fetus is judged to
be preterm or at risk of infection, explain
treatment needed.

HYPERTENSION

-most common medical problem encountered

4 categories

 Chronic Hypertension
Obstetrics
MILD PRE-ECLAMPSIA Airway edema

cardiac renal hepatic

UPPER AIRWAY EDEMA

• Upper airway edema

• Laryngeal edema
• Airway obstruction
•
MAGNESIUM SULFATE- given to pregnant with
hypertension and eclampsia

Antidote of Magnesium sulphate is CALCIUM

GLUCONATE (prepare on bedside)

Controlling the HTN

• Hydralazine
ETIOLOGY • Labetalol
Exact mechanism not known
• Nitroglycerin
• Nifedipine
Symptoms of preeclampsia • Esmolol
• Na Nitroprusside- risk of cyanide toxicity in the
• Visual disturbances
fetus
• Headaches
• Epigastric Pain PREVENTING SEIZURES

SEVERE PRE-ECLAMPSIA • MgSO4 – Drug of choice, narrow the

therapeutic index
-Blood pressure rises to 160 mmhg systolic and 110
• Reduce >50% w/o nay serious maternal
mmhg diastolic or above on atleast two occasions 6
morbidity
hrs apart at bed rest (the position in which blood
pressure is lowest) or her diastolic • 4g IV bolus over 10 mins

SIGNS AND SYMPTOMPS MgSO4 TOXIXTY

5-10 mEq/L- prolonged PR, widened QRS

• Marked proteinuria
• Extreme Edema 11-14 mEq/l – Depressed tendon reflexes
• Acculumating edema will reduce their urine
15-24 mEq/l - SA, AV node block, respiratory
paralysis

S/S >25 mEq/l- cardiac arrest

• Severe epigastric pain and nausea and PROBLEMS OF THE PASSENGER

vomiting
• Ineffective Uterine Contraction
• Pulmonary edema
• Hypotoic Uterine Contraction
• Cerebral edema reports may be voiced of
visual disturbances -Common Active Phase
Eclampsia Cause: Weak Contraction
Most severe classification of PIH Distension of bladder
A grand-mal seizure (tonic clonic)) orcoma Analgesics
Pathophysiology
Obstetrics
Hypertonic Uterine Contraction Cause:

- intensity of contractions is increase but are of poor • CPD

quality/ ineffective • Malposition
Danger Management:
• Lack relaxation • CS-for CPD
• Less Uterine artery filling • Oxytocin- non CPD
Management Secondary Arrest of Dilatation
• Rest and Relaxation -no progress of cervical Dilatation for longer than 2
• Analgesics hrs
• No oxytocin
Management :CS
Uncoordinated Uterine Contraction
PROLONG DESCENT
-pacemaker or point of contraction started at the
-When the rate of descent is
myometrium
*1cm/hr (nullipara)
-erratic contraction
3cm/ hr (multipara
Management
Management
-Oxytocin Induction

PROLONG LATENT PHASE • IVF oxytocin

• AROM (Artificial Rupture of Membrane
-latent phase exceeds the expected
ARREST OF DESCENT
Normal
-no descent has occurred in 2 hrs
Primi-8.6 hrs
-failure of the fetus to engage
Multi -5-3 hrs
-beypnd 0 station
Prolong
Cause: CPD
Primi- 20.0 hrs
Management:
Multi- 14 hrs.
• CS
Cause: • Oxtocin
-Anesthesia ANOMALIES: PLACENTA
-Analgesia  Placenta Succenturiata
Management:  Placenta Circumvallata
 Battledore Placenta
• Hydration  Velamentous Placenta
• Help Uterus To rest  Vasa Pevia
• Decrease: noise and stimuli  Placenta: Accreta (1st degree abnormal
• Darken Room placental attachment), Increta (go beyond
myometrium)-2nd degree penetration of the
• Pain relief
placenta into the uterine wall , Percreta (-3rd
PROTACTED ACTIVE PHASE degree- which occurs when the placenta
completely penetrates through the uterine wall
-active phase that lasts for 12 hrs (nulli) and 6hrs and muscle and attaches to another adjacent
(multi) organ)
Obstetrics
ANOMALIES OF THE CORD:  Abdominal tenderness and Bleeding
 Fetus Easily Palpated
 2 vessel cord
 Unusual cord length Management: Surgical Repair

PRECIPATE DELIVERY INVERSION OF UTERUS

-Labor that is completed in fewer than 3 hrs. -Uterus turning outside out with either birth or delivery

Etiology: Types :

 Multiparity  Incomplete
 Premature or Small Fetus  Complete
 Large Bony Pelvis
Etiology:
Management:
 Cord traction
Advise to use labor graph  Relax uterus

Maternal Positioning AMNIOTIC FLUID EMBOLISM

 -Promote blood flow Etiology:

 Allows fetal oxygenation
 Abruptio Placenta
PROLONGED LABOR  Induced Labor
 Multiple Pregnancy
Etiology: History  Hydramnios
Possible Problems: Management:
 Maternal Infection  CPR
 Neonatal Infection  Oxygenation
 Maternal Exhaustion  BT as ordered
 Anxiety and Fear  Fibrinogen to correct coagulation defect
UTERINE RUPTURE UMBILICAL CORD PROLAPSE
Types: -The appearance of the umbilical cord through the
 Complete cervix or vagina
 Incomplete -when the Umbilical cord precedes fetal
 Dehiscence
Etiology: Types:
 Abnormal Gestation
 Multiple Gestation Occult-inside the vaginal canal
 Unwise Use of Oxytocin Overt-outside the vagina
 Traumatic Maneuver
Etiology:
Manifestations:
 Fetal mal-position
 Abdominal tenderness during contraction  Polyhyramnios
 Chest pain due to irritation of the  Multiple fetal Gestation
diaphragm  Abnormally Long Cord
 Hemorrhage  Placenta Previa
 FHT variability  Intra-uterine tumors
Signs of Impending Rupture  Ruptured membranes

 Sharp abdominal Pain Manifestations:

 Persistent Contractions without periods of  Appearance of the umbilical cord
relaxation
Obstetrics
 Variable FHT pattern Fetal

Management  Genetic Decfect

 Defective Ovum/ Sperm
 Depends on the cervical Condition
 Defective Implantation
 Positioning
 With sterile gloves push the fetal presenting Maternal
part
 Oxygenation  Congenital
 Monitor FHT to monitor and determine  Acquired
interruption of oxygen and nutrient flow to the
Environmental
fetus thus preventing hypoxia
 Apply Sterile, soaked towels with saline Psychological
 Amnio-infusion
Laboratory:
MULTIPLE GESTATION
 Serum HCG
-pregnancy of more than 1 fetuses  CBC
Types:  Urinalysis

 Monozygotic “identical” Nursing Management: ABORTION

 Dizygotic “fraternal”  Count perineal Pads
Manifestations:  Observe shock and other complications
 Prevent ISO immunization
 -Enlarge uterus at a rate faster than normal  Encourage Verbalization of Feelings
 Multiple Sets of heart sounds  No sexual Activity
 Flurries of fetal Movement  Assess for signs of infection/ anemia
Risks:  Vital signs monitoring

 Hydramnios Complications:
 Preterm
 Anemia
 Placenta Previa
 Infection
 Hypertension
 Uterine Perforation
 Anemia
 Postpartum Hemorrhage Viability
 Twin-twin transfusions
Weeks Rate of Survival %

ABORTION 22 0

Types: 23 25
 Spontaneous 24 55
 Therapeutic
 Inevitable 25 65
 Threatened
26 75
 Induced
 Habitual 27 90
 Septic
28 92
 Missed
 Compete Making Nursing Care Plan
 Incomplete
 Problem
Causes: Genetic or Maternal Factor  Etiology (cause of the said problem)- related to
 Sign- “as manifested by”
Obstetrics
Anomalies on the Passenger  Tumor
 Pendulous Abdomen (Relax uterus)
Normal Presentation-Vertex Presentation  Multiple Gestation
Nursing care of the ct. w/ high risk during labor and ASSESSMENT
delivery
FHT is heard on higher abdomen
Problems of the Passenger
Leopold’s manoeuvre detected different parts
Acute Pain- less than 3months
Vaginal examination- fetus may completely engaeged
Chronic Pain- bit is mistakenly detected
Vertex Presentation Tranverse Lie Position
-Baby’s chin is tucked down towards its chest. Occurs with the ff:
Occipiyo Posterior Position  Woman with pendulous abdomen
 Uterine Fibroids/ tumor
-Normal Straight
 Contraction of the pelvic brim
-Baby can be born most easily (straight occipito  Congenital abnormalities
anterior malposition  Polyhradmnous

The straight occipito posterior malposition makes Inlet Contraction

birth more difficult.
-Narrowing of the AP diameter
occipito posterior malposition-posterior
Small Pelvis (<11 cm)
presenting Head Does not fit the cervix as snugly
Cause:
-Occurs in woman with android, anthropoid or
contracted pelvis  Rickets
 Inherited Small Pelvis
Management
Outlet Contraction
 Positioning
 Squatting Narrowing of the transverse diameter
 Left lateral
 Right Lateral Shoulder Dystocia- anterior shoulder of the baby is
 Apply Counter Pressure on the sacrum unable to pass under the maternal pubic arch.
 Back Rub --Associated with advanced maternal age, diabetes
 Voiding every 2 hrs (to facilitate fetal maternal obesity, large baby (macrosomia), postdate
descent) pregnancy and multiparity.
 Apply Rebozo method/ Lunge method
 Juggling or massaging the uterus --Pathophysiology
 IVF for Hydration
The plane of the fetal shoulders aligns perpendicular
TYPES OF BREECH PRESENTATION to the pubis instead of at an angle. This causes the
shoulder to become wedged under the pubic arch.
 Complete
 Frank Assessment Findings:
 Footling
1. Associated Findings –birth process may
ETIOLOGY seem unnecessarily prolonged
2. Clinical Manifestations-fetal head retracts
 Gestational age less than 40 weeks against the mother’s perineum as soon as the
 Fetal anomaly (anencephaly or head is delivered. This is known as the “turtle
hydrocephalus) sign”
 Polyhydramnious
 Congenital Anomaly of the Brain --External Rotation does not occur--
Obstetrics
Nursing Management Types;

Identify shoulder dystocia and assist with Early- occurs during the first 24 hr after delivery
management
Late- occurs at 24-6 weeks after delivery
Place the client in the Mc Robert’s position
CAUSES:

Tone (refers to the hypotonic condition of the uterus,

inability to contract)

--Causes—

• Over-distended uterus: multiple gestation,

macrosomia, polyhydramnious
• Fatigue uterus: prolong pregnancy, use of
tocolytic drugs
• Obstructed uterus
MANIFESTATIONS:

Fundus difficult to locate

Soft and boggy uterus

-The woman flexes her thighs sharply against her
Firm (when massage), soft (massage)
abdomen, which straightens the pelvic curve. A
supported squat has a similar effect and adds gravity Excessive lochial discharges
to her pushing efforts
MANAGEMENT:
-Apply suprapubic pressure by an assistant pushes
the fetal anterior shoulder downward ro displace it • Assist in urination or if not catheterization
from above the mother’s symphysis pubis. Fundal • Administer oxytocin/ methergine as ordered to
pressure should not be used, because it will push the contract the uterus
anterior shoulder more firmly against the mother’s • Uterine Massage
symphysis. • Removal of fragments for it may interfere
Contraction
NURSING CARE OF THE HIGH RISK • Ligation of artery
POSTPARTAL CLIENT • Hysterectomy (for uncontrolled bleeding) is the
last resort to save life
• IVF
• Blood Transfusion
Trauma (refers to the inury to the tissues (Lacerations)

Lacerations

• Cervical
• Vaginal
• Perineal

Causes:

• Large Uterus
• Manual Exploration
Hemorrhage • Instrumentation (use of forceps)
• Episiotomy
-an abnormally excessive blood loss
Manifestations: Blood Discharges
-Normal: 500 ml (NSVD) and 1000-1200 ml (CS)
Obstetrics
Management: Causes:

• small clots- not a concern, blood reabsorbs • Venous Stasis

through time • Hypercoagulable Blood
• Severe Clots- incision and repair to evacuate • Injury to the Endothelial Surface
clots • Obesity
• Pre-existing varicose veins
Tissue (refers to the retained placental fragments
• History of thrombophlebitis
that prevents the uterus to contract)
• Cigarette Smoking
Causes:
Manifestations
• Accessory lobes/ variants from placenta
• Edematous Extremities
• Manual Exploration of Clots
• Fever
• Not observing signs of placental separation
• Pain and redness on the affected area
Manifestatons: Bloody Discharges • Positive Homan Sign

Management: Management : If positive for homan’s sign

• Oxytocin induction to contract the uterus • Immobility

• Dilation and evacuation to scrape out retained • Analgesics
fragments • Anticoagulant
• Thrombolytics
Medication to destroy placenta: Methotrexate • Warm Packs
Thrombosis (clotting disability) Prevention of Complication
Causes: • Avoid prolong sitting or standing
• Placental Dysfunction • Elevate legs when sitting
• DIC • Avoid Crossing of legs
Manifestations: Bloody Discharges • Exercise: Walking
Management: Treat Underlying Cause • Avoid constrictive clothing
• Maintain Hydration and prevent dehydration- to
Traction (refers to uterine inversion) prevent sluggish of blood flow
Causes: • Administer prophylactic heparin

• Uterine atony URINARY TRACT INFECTION

• Excessive traction of the umbilical cord to the (Infection of the urinary passageway)
placenta
Causes:
Management:
o Hypotonic Bladder
• Fluid Replacement o Urinary Stasis
• Oxygenation o Birth Trauma
• Vital count o Catheterization
• Pad Count o Frequent Vaginal Examination
• Psychological Support
Manifestation:
Thrombophlebitis (inflammation with formation of blood
o Dysuria
cloths)
o Urgency
Types: o Low Grade Fever
o Suprapubic Pain
• Superficial o Costovertebral angle tenderness
• Deep
Management:

o Vital Signs every 4 hrs

Obstetrics
o Encourage more intake of fluids o Multiple Fetuses
o Acidification
o Perineal Hygiene Management:
o Avoid Carbonated Drinks o Methergine Administration within 24-48 hrs
o Provides longer contraction of the uterus
ENDOMETRITIS
Psychological Mal-adaptations
-Infection of the endometrial lining and adjacent
myometrial lining Mood Disorders Onset

-also called metritis Postpartum Blues 1-10 days- 2 weeks

Onset: 24 hrs after delivery Postpartum Depression 3-5 days- 2 weeks

Causes: Postpartum Psychosis 3-5 days- 1 year

Poly Microbes: POSTPARTUM BLUES

o B-strepto Causes:
o E.coli
o Unknown
o Kleibseilla
o Emotional Let down
Manifestations: o Hormone Reduction

o Uterine enlargement and Tenderness Manifestations

o Foul odor/ purulent lochia
o Fatigue
o Malaise
o Weeping anxiety
o Fatigue
o Mood Instability
o Fever
Management
Management:
o Rest to take time for self
o Vital Signs
o Reassure patient that feelings are normal and
o Blood culture
will last for <2 weeks
Medications (As orders) o Complementary therapy (touch therapy- to help
woman to feel calm and relax)
-antibiotics, antipyretics, oxytocic
POSTPARTUM DEPRESSION
Supportive Care
Causes:
Rest
o Hormonal Fluctuations
Pain Relief
o Family History of depression, mental illness,
Comfort Measures alcoholism
o Personality characteristics
Warm Blanket o Ambivalence/ anger
o Isolation
Cold Compress
Manifestations:
Cullen Sign- superficial bruising in the subcutaneous fat
around the umbilicus. o Confusion
o Fatigue
Subinvolution (the process when involution does not
o Feelings of Hopelessness
occur)
o Appetite and Sleep Disturbance
The slower the return of the uterus than what is
Management
expected
o Psychotherapy
Causes:
o Social Support
o Retained placental Fragments o Medications: antidepressants
o Infection
Obstetrics
POSTPARTUM PSYCHOSIS S/S

Manifestations: • Small, painless round, well delineated, mobile

mass
o Depression • Soft
o Auditory Hallucinations • No retractions, dimpling
o Hyperactiviy
Mgt.
Management: Hospitalization
Excisional Biopsy
BENIGN BREAST PROBLEMS
BREASY HYPO AND HYPERPLASIA
Mastalgia (Breast Pain)
Micromastia or Breast Hypoplasia
Common: Cyclic Mastalgia
-medical term describing the post pubertal
R/t: underdevelopment of a woman’s breast tissue.
o Hormonal Sensitivity -Less than average breast size
o Trauma
o Fat Necrosis Hyperplasia
o Duct Ectasia
• -an abnormal increase in the number of cells in
2-3 days atissue
• In hyperplasia of the breast, there is an
2 Types
overgrowth of cells that line the ducts and
 Mastitis lobules of the breast
-Inflammation of the Breast • It has slightly greater risk
Etiology: • Cells are fast growing but usually look like
Staphylococcal normal breast cells
S/S • With atypical hyperplasia, the fast growing cells
• Erythema do not look like normal breast cells.
• Pain Tenderness
ATYPICAL DUCTAL HYPERPLASIA
Mgt.
• Antibiotics -overgrowth of the cells lining the ducts. Most
• Breastfeeding common form hyperplasia of the breast
 Lactational Breast Abscess
ATYPICAL LOBULAR HYPERPLASIA
Mastitis with the development of an abscess
-An overgrowth of the cells lining the lobules.
Etiology:
SIGNS AND SYMPTOMPS
Mastitis not responsive to antibiotics
• Physiological swelling and tenderness
S/S • Breast pain (not usually associated with
Redness, edematous Breast malignancy)
• Palpable breast lumps
Mgt/. • Nipple discharge
 I and D • Breast infection and inflammation-
 Antibiotics usually associated with lactation

HEAT, MASSAGE, REST –EMPTY THE BREAST Treatment Options for Atypical Hyperplasia
of the breast may include:
FIBROADENOMAS
Chemoprevention- Selective estrogen receptor
• Benign breast lumps modulators are anti estrogen drugs that the
effects of estrogen in some tissues (such as
Etilogy: breast tissue) and act like estrogen in other
tissues.
Increase estrogen sensitivity
Obstetrics
ENDOMETRIOSIS • Laser ablation
-the implantation of uterine endometrium, nodules, that have • TURP (trans urethral resection of the
spread from the interior of the uterus to locations outside the prostate)
uterus. • TUIP (trans- urethral incision of the prostate)

OVARIAN CYST
• Suprapubic prostate resection

INFERTILITY
Types:
Causes: Male
• Follicular Ovarian Cyst
• Lutein Cyst (Corpus Luteum) • Abnormal Sperm
• Theca-Lutein Cyst • Abnormal Erection
• PCOS • Abnormal Ejaculation

PCOS (Polycystic Ovarian Syndrome)

• Abnormal Seminal Fluid

Causes Female:
Causes:
• Disorders of ovulation
• not clear
• Structural Abnormalities
• Assos. Genetic component
• Hormonal Problems
Manifestations:
SUBFERTILITY
• Acne
-Inability to conceived when desired
• Weight Gain
• Trouble Losing Weight Criteria:
• Extra Hair
• Regular menses
• Irregular Periods
• Unprotected sexual activity for 1 yr
• Trouble in Getting Pregnant (infertility)
• Depression Sterility- inability to conceive because of known
condition, such as the absence of a uterus
BENIGH PROSTATIC HYPERTROPHY
ASSSITED REPRODUCTIVE TECHNIQUES
-Increase stromal tissue in the prostate gland
-If ovulation, sperm production, or sperm motility problems
-BPH (inner), Prostate CA (outer) cannot be corrected.

Etiology: --Therapeutic Insemination—

Not known -sperm are deposited next to the cervix or injected directly into
the uterine activity.
Aging Process
IN VITRO FERTILIZATION
Excessive Accumulation of dihydroxytestosterone
Steps involved
Estrogen Stimulation
A. Ovulation
S/S B. Capture of ova
C. Fertilization of ova and growth in culture medium
r/t urinary obstruction
D. Insertion of fertilized ova into uterus
Diagnostic:
ALTERNATIVES:
DRE
• Surrogate parenting
TRUS (trans-rectal ultrasound) • ART”s (advance reproductive techniques)
Mgt: non surgical • Adoption

 Stents
 Balloon dilation

Heat: TUMA (trans urethral microwave antenna)

Mgt. Surgical
Obstetrics