OB Finals 1 6
OB Finals 1 6
OB Finals 1 6
NURSING PROCESS
GOAL
Collect data
Organize data
Validate data
Document data
Analyze data
Identify health problems, risks and strengths
Formulate diagnostic assessment
3. PLANNING (restore effective breathing and lung ventilation, develop
care plan)
Prioritize problems/diagnosis
Formulate goals/desired outcome
Select nursing interventions
Write nursing orders
3. BIOGRAPHIC DATA
Childhood illness
Childhood immunizations
Allergies
Accidents and injuries
Hospitalization for serious illnesses
Medications
6. LIFESTYLE
Personal habits
Diet
Sleep/rest patterns
ADL
Instrumental activities of daily living
Recreation /hobbies
7. SOCIAL DATA
8. PSYCHOLOGIC DATA
Major stressor
Usual coping pattern
Communication style (verbal expression)
All health care resources the client is currently using and has used in the
past
• PHYSICAL ASSESSMENT
1. Inspection
2. Auscultation
3. Palpation
• DIAGNOSTIC ASSESSMENT
Using of laboratory procedures to help diagnose (medical) the disease.
• Change lecture with positive sign/probable signs of pregnancy/HIGH
RISK PREGNANCY
Abnormal Obstetrics
CONTENTS
▣ Emotional support
▣ Missed Abortion
◼ Retention of all products of conception after the
death of the fetus in the uterus
S/Sx:
- No FHT
- Signs of pregnancy disappear
Management:
D&C
▣ Septic Abortion
◼ Abortion complicated by infection
S/Sx:
- Foul smelling vaginal dischrage
- Uterine cramping
- Fever
Management:
- Treat abortion
- Antibiotics
HABITUAL OR RECURRENT PREGNANCY
LOSS –SPONTANEOUS ABORTION IN
THREE OR MORE SUCCESSIVE
PREGNANCIES USUALLY DUE TO
INCOMPETENT CERVIX.
B. Induced Abortion – is an intentional loss of
pregnancy through direct stimulation either by
chemical or mechanical means.
Types of induced abortion:
1) Therapeutic abortion – to preserve the life of the
mother
2) Elective abortion
Reasons for Induced Abortion:
▣ Therapeutic – to end a pregnancy that is life
threatening to the mother
▣ To end a pregnancy of a fetus found to have severe
congenital abnormalities that may be incompatible
with life
▣ To end an unwanted pregnancy that is a result of rape
or incest
▣ To end a pregnancy because of woman’s choice not to
have a child yet
Prevention of abortion:
▣ Prepregnancy correction of maternal disorders
▣ Sepsis
▣ Rh sensitization
2. ECTOPIC PREGNANCY
- ANY PREGNANCY THAT OCCURS
OUTSIDE THE UTERINE CAVITY.
---SECOND LEADING CAUSE OF
BLEEDING IN EARLY PREGNANCY.
TYPES:
1. AMPULAR 4. CERVICAL
2. INTESTINAL 5. ABDOMINAL
3. OVARIAN
Predisposing causes:
▣ Salpingitis
▣ Peritubal adhesions
▣ Previous mole
▣ Multiple pregnancy
▣ Uterine tumor
▣ Cigarette smoking
segment
Past uterine D&C
Signs and Sxs:
▣ Painless, bright red vaginal bleeding during
the 3rd trimester
▣ Abdomen soft, non tender
▣ Infection
▣ Prematurity
** BLEEDING WITH PLACENTA PREVIA
OCCURS WHEN THE LOWER UTERINE
SEGMENT BEGINS TO DIFFERENTIATE
FROM THE UPPER SEGMENT LATE IN
PREGNANCY ( APPROXIMATELY WEEK 30
because of uterine contractions ) & THE
CERVIX BEGINS TO DILATE. THE
BLEEDING PLACES THE MOTHER AT RISK
FOR HEMORRHAGE. BECAUSE THE
PLACENTA IS LOOSENED, THE FETAL
OXYGEN MAY BE COMPROMISED”
IMMEDIATE CARE MEASURES:
** TO ENSURE AN ADEQUATE BLOOD
SUPPLY TO THE MOTHER & FETUS,
PLACE THE WOMAN ON BED REST IN A
LEFT SIDE LYING POSITION.**
2. ABRUPTIO PLACENTA
- ABRUPT SEPARATION OF AN
OTHERWISE NORMALLY IMPLANTED
PLACENTA AFTER 20 WEEKS AOG.
TYPES:
1. MARGINAL ( OVERT)
SEPARATION BEGINS AT THE EDGES
OF THE PLACENTA ALLOWING BLOOD
TO ESCAPE FROM THE UTERUS.
BLEEDING IS EXTERNAL.
2. CENTRAL ( COVERT)
PLACENTA SEPARATES AT THE CENTER
RESULTING IN BLOOD BEING TRAPPED
BEHIND THE PLACENTA. BLEEDING
THEN IS INTERNAL AND NOT OBVIOUS.
CAUSES:
1.MATERNAL HYPERTENSION ( CHRONIC
OR PREGNACY INDUCED)
2. ADVANCED MATERNAL AGE
3. GRAND MULTIPARITY – MORE THAN 5
PREGNANCIES
4. TRAUMA TO THE UTERUS
5. SUDDEN RELEASE OF AMNIOTIC FLUID
THAT CAUSE SUDDEN DECOMPRESSION
OF TE UTERUS.
6. SHORT UMBILICAL CORD
7. CIGARETTE SMOKING & COCAINE
ABUSE
8. PROM
S/SX:
1. SHARP PAIN IN THE FUNDAL AREA AS
THE PLACENTA SEPARATES
2.PAINFUL DARK RED VAGINAL
BLEEDING IN COVERT TYPE
3.PAINFUL BRIGHT RED VAGINAL
BLEEDING IN OVERT TYPE
4.HARD, RIGID, FIRM,BOARD-LIKE
ABDOMEN CAUSED BY ACCUMULATION
OF BLOOD BEHIND THE PLACENTA WITH
FETAL PARTS HARD TO PALPATE.
5. ABNORMAL TENDERNESS DUE TO
DISTENTION OF THE UTERUS WITH
BLOOD.
6. SIGNS OF SHOCK & FETAL DISTRESS
AS THE PLACENTA SEPARATES.
PREMATURE SEPARATION OF THE PLACENTA
CLASSIFICATION ACCORDING TO
PLACENTAL SEPARATION:
1. GRADE 0 = NO SYMPTOMS OF
PLACENTAL SEPARATION, DIAGNOSED
AFTER DELIVERY WHEN PLACENTA IS
EXAMINED & FOUNDTO HAVE DARK,
ADHERENT CLOT ON THE SURFACE.
2. GRADE 1 = SOME EXTERNAL
BLEEDING, NO FETAL DISTRESS, NO
SHOCK, SLIGHT PLACENTAL
SEPARATION
3. GRADE 2 = EXTERNAL BLEEDING,
MODERATE PLACENTAL SEPARATION,
UTERINE TENDERNESS, FETAL DISTRESS
4. GRADE 3 = INTERNAL & EXTERNAL
BLEEDING, MATERNAL SHOCK, FETAL
DEATH, DIC
MX:
1. WHEN PLACENTA ABRUPTIO IS
SUSPECTED OR DIAGNOSED,
HOSPITALIZATION IS A MUST.
2. BEDREST OR SIDE LYING POSITION
FOR OPTIMUM PLACENTAL PERFUSION.
3. MONITOR VITAL SIGNS, FHT, AMOUNT
OF BLOOD LOSS – GIVE MASK O2 IF
FETAL DISTRESS IS PRESENT.
4. DELIVERY:
** VAGINAL DELIVERY – IF THERE IS
NO SIGN OF FETAL DISTRESS, BLEEDING
IS MINIMAL & VITAL SIGNS ARE STABLE.
** CESARIAN DELIVERY – IF BLEEDING
IS SEVERE, FETAL DISTRESS IS PRESENT
& FETUS CANNOT BE DELIVERED
IMMEDIATELY WITH VAGINAL METHOD.
COMPLICATIONS:
1. COUVELAIRE UTERUS OR UTERINE
APOPLEXY – INFILTRATION OF BLOOD
INTO THE UTERINE MUSCULATURE
RESULTING IN THE UTERUS
BECOMING HARD & COPPER
COLORED.
2. HEMORRHAGE & SHOCK – TREATED
BY BLOOD TRANSFUSION
3. DIC – MANAGED BY FIBRINOGEN &
CRYOPRECIPITATE
3. Disseminated Intravascular Coagulation (DIC)
▣ Disorder of blood clotting
Fibrinogen levels fall below effective limits (
Hypofibrinogenemia)
▣ Symptoms
Bruising or bleeding
massive hemorrhage initiates coagulation process causing
massive numbers of clots in peripheral vessels (may result in
tissue damage from multiple thrombi), which in turn
stimulate fibrinolytic activity, resulting in decreased platelet
and fibrinogen levels
signs and symptoms of local generalized bleeding (increased
vaginal blood flow, oozing IV site, ecchymosis, hematuria,
etc)
❑ monitor PT, PTT, and Hct, protect from injury; no IM
injections
3. Disseminated Intravascular Coagulation (DIC)
SSx:
1.Excessive nausea & vomiting not relieved by
ordinary remedies persisting beyond 12 weeks
2. Signs of dehydration: thirst, dry skin, increased
pulse rate, weight loss, concentrated & scanty urine.
Management:
MX: D10NSS 3000 ML IN 24 HOURS IS THE
PRIORITY OF TREATMENT
> REST
> ANTI-EMETIC – ( EX. PLASIL)
HYPERTENSIVE DISORDERS IN
PREGNANCY:
GESTATIONAL HYPERTENSION:
- HYPERTENSION THAT DEVELOPS
DURING PREGNANCY OR DURING THE
FIRST 24 HOURS AFTER DELIVERY
WHICH IS NOT ACCOMPANIED BY
EDEMA, PROTEINURIA & CONVULSIONS
& DISAPPEARS WITHIN 10 DAYS AFTER
DELIVERY.
CHRONIC HYPERTENSION:
- THE PRESENCE OF HYPERTENSION BEFORE
PREGNANCY OR HYPERTENSION THAT DEVELOP
BEFORE 20 WEEKS GESTATION IN THE ABSENCE
OF H-MOLE & PERSIST BEYOND THE POSTPARTUM
PERIOD.
PREGNANCY INDUCED HYPERTENSION
(TOXEMIA):
- HYPERTENSION THAT DEVELOPS AFTER THE
20TH WEEK OF GESTATION TO A PREVIOUSLY
NORMOTENSIVE WOMAN.
RISK FACTORS:
1. SAID TO BE A DISEASE OF PRIMIPARAS – HIGHER
INCIDENCE IN PRIMIPARAS BELOW 17 & ABOVE 35
YEARS.
2. LOW SOCIO ECONOMIC STATUS ( LOW PROTEIN INTAKE
)
3. HISTORY OF CHRONIC HYPERTENSION ON THE MOTHER,
H-MOLE, DIABETES MELLITUS,MULTIPLE PREGNANCY,
POLYHYDRAMNIOS, RENAL DISEASE, HEART DISEASE
4. HEREDITARY – hx of preeclampsia in mothers or sisters
5. H-mole
6. Previous hx of preeclampsia
CAUSES:
1. UNKNOWN
2. PROTEIN DEFICIENCY THEORY
3. UTERINE ISCHEMIA
4. ARTERIAL VASOSPASM
TRIAD SX:
I HYPERTENSION
2. EDEMA ( INCRESE IN WEIGHT)
3. PROTEINURIA
= 2nd leading cause of maternal death
= chief causes of maternal death due to PIH:
- cerebral hemorrhage
- cardiac failure with pulmonary edema
- rena, hepatic or resp. failure
- obstetric hemorrhage assoc. with abruptio placenta
VASOSPASM – due to damge to the endothelium
VASCULAR EFFECTS KIDNEY EFFECTS INTERSTITIAL EFFECTS
▣ Headache
▣ Increased BP
▣ edema
How is HELLP diagnosed?
▣ BP measurement
⦿ Clinic Visit:
⦿ First Trimester – every month
⦿ Second Trimester – every 2 weeks
⦿ Third Trimester – every week
⦿ Nutrition – additional 300 kcal to the normal
pregnancy requirement
⦿ 6 small meals rather than 3 large meals to
decrease discomfort of a large uterus
compressing a full stomach
Labor and Delivery:
⦿ The cord is cut right after delivery of the first infant
⦿ Presentation of second infant is ascertained after
birth of first twin either by ultrasound or Leopold’s
or both
⦿ The normal interval of delivery of the first twin and
second twin is (30 minutes)
⦿ If the second twin cannot be delivered vaginally
because of abnormal position, CS is done.
⦿ Cesarean delivery – delivery of choice if the
twins or one of them cannot be delivered
normally or if complications arise that necessitate
immediate delivery.
⦿ Post partum period – watch out for Hemorrhage
due to overdistention of the uterus.
Premature Labor:
▣ Is labor that occurs between 20 weeks to 37 weeks
gestation characterized by regular uterine
contraction that lasts more than 30 seconds & result
in cervical dilatation & effacement. It is the greatest
cause of neonatal mortality & morbidity.
Causes:
▣ PROM – most often associated with infection
▣ Infection of amniotic fluid –
▣ Retained IUD
▣ Fetal death
▣ History of premature labor & abortion
▣ Overdistention of the uterus – caused by multiple
pregnancy, hydramnios
▣ Abnormal placentation
▣ Uterine abnormalities
▣ Incompetent cervix
▣ Serious maternal conditions
SSx:
▣ Dx is made when there is regular uterine contractions
occuring 5-8 minutes apart accompanied by:
◼ Progressive cervical changes
◼ Cervical dilatation of more than 2 cm
◼ Cervical effacement of 80% or more
◼ Duration of at least 30 secs
◼ 10 mins apart
▣ Menstrual like cramping
▣ Watery or bloody vaginal discharge
▣ Low back pain
MX:
1. Prevention – regular prenatal check up
2. If fetus is less than 32-34 weeks, and still premature to be
delivered, labor must be arrested:
1. Bedrest on LLP to promote blood flow to the placenta
2. Hydration – IV fluids
3. Tocolytics – medications to stop uterine contractions (
relaxes smooth muscles)
1. Ritodrine Hcl
2. Terbutaline –( check pulse rate because it can
cause tachycardia)
3. Prostaglandin inhibitors ( Indomethacin)
Drugs to hasten fetal lung maturity:
- GLUCOCORTICOID therapy if labor can be
delayed for 48 hours – administration of
BETAMETHASONE accelerate fetal lung maturity &
prevents respiratory distress & hyaline membrane
disease ( most common problem of the premature
neonate).
-
MEDICAL CONDITIONS COMPLICATING
PREGNANCY
HEART DISEASE
CLASSIFICATION:
1. CLASS I = NO LIMITATION,UNCOMPROMISED
= ASYMPTOMATIC, NO DISCOMFORT
WITH ORDINARY PHYSICAL
ACTIVITY.
2. CLASS II =SLIGHT LIMITATION, SLIGHTLY
COMPROMISED, ORDINARY
ACTIVITY CAUSES DYSPNEA,
FATIGUE, CHEST PAIN &
PALPITATIONS.
3. CLASS III = MARKED LIMITATION LESS THAN
ORDINARY ACTIVITY CAUSE
EXCESSIVE FATIGUE;
PALPITATIONS, CHEST PAIN & DYSPNEA.
4. CLASS IV =SEVERE LIMITATION; PATIENT
EXPERIENCES SYMPTOMS EVEN
AT REST; UNABLE TO PERFORM ANY
PHYSICAL ACTIVITY WITHOUT
DISCOMFORT.
SIGNS & SYMPTOMS:
1.DIFFICULTY OF BREATHING – DYSPNEA,
ORTHOPNEA, NOCTURNAL DYSPNEA
2. HEMOPTYSIS
3. SYNCOPE WITH EXERTION
4. CHESTPAIN
5. CYANOSIS
7. CLUBBING OF FINGERS
8. NECK VEIN DISTENTION
9. SYSTOLIC & DIASTOLIC MURMURS
NURSE ALERT:
** REMEMBER A PREGNANT WOMAN WITH
HEART DISEASE SHOULD AVOID INFECTION,
EXCESSIVE WEIGHT GAIN, EDEMA & ANEMIA
BECAUSE THESE CONDITIONS INCREASE THE
WORKLOAD OF THE HEART.
MX:
A. PRENATAL CARE:
1. PROMOTION OF REST ( CLASS I & CLASS II)
* 8 HOURS OF SLEEP DURING THE NIGHT &
HAVE FREQUENT REST PERIODS DURING THE
DAY.
* LIGHT WORK IS ALLOWED BUT NO HEAVY
WORK, NO STAIR CLIMBING, NO EXHAUSTION.
2. DIET
* HIGH IN IRON, PROTEIN,MINERALS &
VITAMINS
3. AVOID HIGH ALTITUDES, SMOKING AREAS,
UNPRESSURIZED PLANES & OVERCROWDED AREAS.
CIGARETTE SMOKING & ALCOHOLIC BEVERAGES
ARE STRICTLY PROHIBITED.
4.PREVENTION OF INFECTION
* AVOID PERSONS WITH ACTIVE INFECTIONS
(COLDS, COUGH).
* EARLY TREATMENT OF INFECTIONS
5. PROVIDE INSTRUCTIONS ON DANGER SIGNS OF
HEART FAILURE:
* COUGH WITH CRACKLES IS USUALLY THE
FIRST SIGN OF AN IMPENDING HEART FAILURE.
* INCREASING DYSPNEA, TACHYCARDIA, RALES,
EDEMA
MEDICATIONS:
>IRON SUPPLEMENTATION TO PREVENT ANEMIA
>DIGITALIS TO STRENGTHEN MYOCARDIAL
CONTRACTION AND SLOW DOWN HEART RATE
>NITROGLYCERINE TO RELIEVE CHEST PAIN
>ANTIBIOTICS TO PREVENT AND TREAT
INFECTION
>DIURETICS MAY BE PRESCRIBED IN CASE OF
HEART FAILURE
INTRAPARTAL CARE
1.EARLY HOSPITALIZATION- WOMAN IS HOSPITALIZED
BEFORE LABOR BEGINS TO PROMOTE REST, FOR
CLOSER SUPERVISION AND PREVENT INFECTION
2.WOMAN IN LABOR IS IN SEMI-FOWLER’S POSITION
OR LEFT LATERAL RECUMBENT POSITION. NO
LITHOMY POSITION.
3.VITAL SIGNS- VITAL SIGNS ARE MONITORED
CONTINUOUSLY. TACHYCARDIA AND RESPIRATORY
RATE MORE THAN 24 ARE SIGNS OF IMPENDING
CARDIAC DECOMPENSATION. DURING THE FIRST
STAGE, MONITOR VITAL SIGNS EVERY 15 MINUTES
AND MORE FREQUENTLY DURING THE SECOND STAGE
4.EPIDURAL ANESTHESIA- IS INSTITUTED FOR
PAINLESS AND PUSHLESS DELIVERY. FORCEPS IS
USED TO SHORTEN THE SECOND STAGE. PUSHING IS
CONTRAINDICATED
5. WOMEN WITH HEART DISEASE ARE POOR
CANDIDATE FOR CS DUE TO INCREASED RISK FOR
HEMORRHAGE, *INFECTION AND
THROMBOEMBOLISM
POSTPARTUM CARE
1. THE MOST DANGEROUS PERIOD IS THE IMMEDIATE
POSTPARTUM BECAUSE OF THE SUDDEN INCREASE
IN CIRCULATORY BLOOD VOLUME.
2. MONITOR VITAL SIGNS.
3. PROMOTE REST- RESTRICT VISITORS TO ALLOW
PATIENT TO REST, THE WOMAN STAYS IN THE
HOSPITAL LONGER, UNTIL CARDIAC STATUS HAS
STABILIZED.
4. EARLY BUT GRADUAL AMBULATION TO PREVENT
THROMBOPHLEBITIS.
5. MEDICATIONS
*ANTIBIOTICS
*STOOL SOFTENERS TO PREVENT STRAINING AT
STOOL CAUSED BY CONSTIPATION. SEDATIVES MAY BE
ORDERED TO PROMOTE REST.
6. BREASTFEEDING IS ALLOWED IF THERE ARE NO
SIGNS OF CARDIAC DECOMPENSATION DURING
PREGNANCY, LABOR AND PUEPERIUM.
The Anemias of Pregnancy
▣ Hemoglobin level of less than 11g/dl in the first and
third trimester and less than 10.5g/dl in the second
trimester.
Iron Deficiency Anemia
▣ Most common type of anemia during pregnancy.
Most women enter pregnancy without enough iron
reserve so that deficiency develops particularly on
the 2nd and 3rd trimester when iron requirements
increases.
Predisposing Factors:
▣ Poor diet and poor nutrition
▣ Heavy menses
▣ Sensitivity to cold
▣ Proneness to infection
▣ Dizziness