Antepartal Complications

Maternal and Child Health Nursing
Antepartal Complication

MATERNAL and CHILD HEALTH NURSING

PREGNANCY COMPLICATION

Lecturer: Mark Fredderick R. Abejo RN, MAN
_____________________________________________________________________________

PREGNANCY COMPLICATIONS
( ANTEPARTAL )

A. Abortion
- termination of pregnancy before the fetus is viable (20 weeks or a weight of 500 g)

TYPES DEFINITION S/S NURSING INTERVENTION
1. Threatened The continuation of Bleeding or Bedrest, Restrictive activity, Sedation, Avoid coitus
the pregnancy is in spotting closed for 2 weeks following last evidence of bleeding
doubt cervix
Rhogam indicated when a young patient has a
threatened abortion in the first trimester and a
laboratory studies reveal an Rh negative and the
husband is Rh positive
2. Inevitable Threatened loss Bleeding and Save tissue fragments
that can be cervical dilation
prevented; abortive
process is going on
3. Complete Products of Minimal Continuous monitoring
conception are bleeding
totally expelled
4. Incomplete Some fragments Profuse Dilatation & Curettage;
are retained inside bleeding Use of oxytocin:
the uterine cavity Oxytocin nasal spray should be administered while
the client is sitting with her head in a vertical
position. A nasal preparation must not be
administered with the client lying down or the head
tilted back because this could cause aspiration.
Evacuation
5. Missed Retention of the Intermittent Evacuation, D & C
products of bleeding;
conception after absence of
fetal death uterine growth
6.Habitual / 3 spontaneous Provide IV, Monitor bleeding, Count perineal pads,
Recurrent abortions occurring psychological support
successively
NOTE:Because spontaneous abortion is
threatening, all perineal pads must be inspected for
the products of conception. Fluid replacement is
necessary because of blood loss

B. Ectopic Pregnancy

A pregnancy that occurs in another than uterine site, with implantation usually occurring in fallopian tubes

 A ruptured ectopic pregnancy is a medical emergency due to the large quantity of blood that may be lost in
the pelvic and abdominal cavities.
 Shock may develop from blood loss, and large quantities of I.V. fluids are needed to restore intravascular
volume until the bleeding is surgically controlled.
 Pain may be caused by a ruptured or distended fallopian tube or blood in the peritoneal cavity.

MCHN Abejo


Causes Signs and Symptoms Diagnostic Tests Management
Narrowing of  Vaginal Bleeding  Culdocentesis  Monitor amount of
tube  Knife-like abdominal pain  Culdoscopy bleeding
Pelvic  Referred pain on the right  Radioimmunoassay of  Assess vital signs
infection shoulder elevated serum  Assess abdominal
Endometriosis  Pelvic pressure of pelvic qualitative -Beta-HCG pain
Smoking fullness  Abdominal  Blood transfusion
History of  Cullen’s sign Ultrasound  Surgery:
IUD usage  Pain unilaterally, with  Blood samples of Hgb Salpingostomy
. cramping and tenderness and Hct; blood type  Administer Rhogam
 Mass in the adnexal or cul- and group for Rh (-) client
de-sac
 Slight, dark vaginal bleeding
 Profound shock if rupture
occurs
Symptoms of Shock:
decreased BP
increased RR,
fast but thready pulse.
This is the number 1
complication.

C. Hydatidiform mole / Trophoblastic Disease / Molar Disease

Gestational trophoblastic neoplasm that arise from the chorion; characterized by the proliferation and
degeneration of the chorionic or trophoblastic villi.

MCHN Abejo


A patient with Hydatidiform mole has a positive signs of pregnancy but is not pregnant.
The #1 Complication is Choriocarcinoma
The Three H of H-mole
1.Hyper - emesis gravidarum
2. increase Hcg
3. increase incidence for piH

PREDISPOSING TYPES MANIFESTATIONS DIAGNOSTIC MANAGEMENT
FACTORS TESTS
Low  Complete/  Vaginal bleeding  HCG titer  Molar evacuation
socioeconomic classical parts  Excessive N/V determination / D&C
status of the villi are  Rapid  Ultrasound  Chemotherapy
Women below affected enlargement of the  X-ray of the  Monitor HCG
18 or above 35 uterus abdomen levels
Intake of  Incomplete/  (+) Pregnancy test  Delay
Clomid partial- some  Possible PIH childbearing plans
(Clomiphene parts are  Abdominal for a year
Citrate) normal cramps  Perineal pad
Women of  Absent FHR counts
asian heritage The #1  Elevated HCG  Instruct the
Complication of titer: 1-2 million couple to have
H-mole is IU; Normal level: VAGINAL REST
choriocarcinoma 400,000 IU ( no sex) for 1
year.

D. Incompetent Cervix

- Painless premature dilatation of the cervix (usually in the 16th to 20th week)

INCOMPETENT CERVIX

Synonyms  Dysfunctional cervix
Predisposing/Contributing  Repeated dilatation of the cervix,
Factors:  maternal DES ( Diethylstilbestrol) Exposure,
 Traumatic injuries to the cervix.
 Congenital anomaly
 Trauma to the cervix (surgery / birth)
1. Uterine anomaly
2. Habitual abortion
3. Pre-term labor
Initial Signs  Show (a pink-stained vaginal discharge)
 #1 Sign: Rupture of membranes and discharge of amniotic fluid
Late signs: Pressure or heaviness on the lower abdomen.

Cardinal/Pathognomonic/maj  The cervix dilates painlessly in the second trimester of pregnancy.
or sign: Bloody show
 PROM
 Painless dilatation
 Birth of dead/non-viable fetus
Screening or initial diagnostic Ultrasound
test:
Conformity test: Ultrasonography
Best major surgery: Cervical Cerclage, McDonald Cerclage
Possible surgical Sterility, rupture of the cervix premature delivery, pelvic bleeding
complication: and infection.

MCHN Abejo


Disease complication #1 Hemorrhage, Ectopic pregnancy, birth defects, viruses and
pregnancy diseases, diabetes in pregnancy, HPN

Best position before and after  Side lying position
surgery  Prone position
Best side equipment  Suction
Nursing Intervention  Pre-op: Encourage patient to maintain bed rest
 Post-op: Check for excessive vaginal discharge and severe pain.
 Bed rest in trendelenburg position
 Administer tocolytic medications as ordered Eg; Ritodrine
Hydrochloride (Yutopar): Terbutaline sulfate (Brethine):
Magnesium Sulfate, Hydroxyzine hydrochloride (Vistaril) is a
common drug ordered to counteract the effect of terbutaline
(Brethine)
 Surgery: Cervical Cerclage
 Shirodkar-Barter Technique ( internal os) permanent
suture: subsequent delivery by C/S.
 Mc Donald Procedure ( external os)-suture removed at
term with vaginal delivery

 Usually 4-6 weeks after vaginal delivery is the safe period for a
patient to resume sexual activity, when the episiotomy has healed
and the lochia had stopped
 - Monitor V/S and report HPN Monitor FHR
 Limit activities
 Observe for Ruptured BOW
 Avoid vaginal douche
 Avoid coitus

E. DIABETES MELLITUS
Gestational diabetes mellitus (pregnancy induced)

A pregnant, insulin-dependent diabetic is at risk for sudden hypoglycemia because insulin needs and metabolism
are affected b pregnancy, making sudden hypoglycemic episodes more common for diabetics.

Changes in the glucose-insulin mechanism:
o Early in pregnancy:
 A. Increase production of insulin
 B. Maternal glucose is consumed by fetus
o Late in pregnancy:
 A. Mother develops insulin resistance
 B. The presence of placental insulinase breaks down insulin rapidly

B. Description of Diabetes in Pregnancy

1. Maternal glucose crosses the placenta but insulin does not
2. During the first trimester, maternal insulin needs decrease
3. The fetus produces its own insulin and pulls glucose from the mother, which predisposes the mother to
hypoglycemic reactions
4. During the second and third trimesters, increases in placental hormones cause an insulin-resistant state,
requiring an increase in the client's insulin dose
5. Diabetes mellitus is more difficult to control during pregnancy & occurs during the second or third trimester.
Premature delivery is more frequent. The newborn infant of a diabetic mother may be large in size but will
have functions related to gestational age rather than size. The newborn infant of a diabetic mother is subject
to hypoglycemia, hyperbilirubinemia, respiratory distress syndrome, and congenital anomalies. Stillborn and
neonatal mortality rates are higher in pregnancies of a diabetic woman

NOTE: The greatest incidence of insulin coma during pregnancy occurs during the second and the third
months, the incidence of the diabetic coma during pregnancy occurs around the sixth months.

MCHN Abejo


GESTATIONAL DIABETES
Definition  A type of Diabetes where only pregnant women gets where her
blood sugar rate elevates but never had a high blood sugar rate
before pregnancy.
Synonyms Diabetes during Pregnancy
Predisposing/Contributing  Hyperglycemia develops during pregnancy because of the secretion
Factors of placenta hormones such as Prolactin, Progesterone&
Corticosteroids
 Maternal age more than 35
 Previous macrosomic infant
 Previous unexplained stillbirth
 Previous pregnancy with GDM
 Family history of DM
 Obesity
 Hypertension
 FBS more than 140 mg/dl
Initial Signs 3-P’s: Polyuria, Polydipsia and Polyphagia
MATERNAL SIGNS & SYMPTOMS:
1.Excessive thirst
2. Hunger
3. Weightless
4. Blurred vision
5. Frequent urination
6. Recurrent urinary tract infections and vaginal yeast infections
7. Glycosuria and ketonuria
8. Signs of pregnancy-induced hypertension
9. Polyhydramnios
10. Fetus large for gestational age
Late signs Fatigue, weakness, sudden vision changes, tingling or numbness in
hands
Cardinal/Pathognomenic/majo Weight loss, fatigue, nausea, and vomiting excessive thirst, decrease
r sign urination

Screening or initial diagnostic 50 gms oral glucose challenge test
test
Confirmative test  3- hour glucose tolerance test will be performed to confirm
diabetes mellitus
 Glycosolated Hemoglobin less than 8%
Best diet Strict Diabetic Diet
Calories in diet should consist of 50% to 60% carbohydrates, 12% to
20% protein, and 20% to 30% fat

NOTE: Because insulin does not pass into the breast milk,
breastfeeding is not contraindicated for the mother with diabetes.
Breastfeeding is encouraged; it decreases the insulin requirements for
insulin-independent clients. Breastfeeding does not increase the risk of
maternal infection; it leads to an increased caloric demand. Infants of
diabetic mothers often display jitteriness in response to hypoglycemia
after birth
Best diet for the disease: Well-balanced Caloric Diet
Disease complication Maternal Complications: PIH, Placental disorders, stillbirth,
macrosomia, neural tube defects.

Fetal Diabetic Complications:
Macrosomia
Pre-eclampsia
Hydramnios
Congenital anomalies

NOTE:
The incidence of congenital anomalies among infants of
diabetic pregnancies is three to four times higher than that in general
population and is related to the high maternal glucose levels during the
third to sixth gestational weeks.
Best side equipment  Glucometer
 Insulin Equipment
 #1 Eternal Electronic Fetal Heart Rate monitoring

MCHN Abejo


Best drug  Insulin therapy ( don’t use Oral hypoglycemics, they are
Teratogenic)
Nature of the drug  Insulin
Nursing Diagnosis  #1 High Risk for fluid volume deficit related to polyuria and
dehydration
 Imbalanced nutrition related to imbalanced of insulin, food and
physical activity
 Potential heath care deficit related to physical improvements or
social factors..
Nursing Intervention MANAGEMENT
 Screen clients between the 24th and 28th weeks of pregnancy
 Prenatal visits bimonthly for 6 months and weekly thereafter.
 Calories in diet should consist of 50% to 60% carbohydrates, 12%
to 20% protein, and 20% to 30% fat
 Observe client closely for an insulin since a precipitous drop in
insulin required is usual
 Monitor for signs of infection or post hemorrhage
 If a pregnant diabetic is in labor, her blood glucose should be
monitored hourly.
 The preferred method of administration if insulin is required
during labor is intravenous

OTHER IMPORTANT MANAGEMENT:
Urine testing
Blood glucose determination
Insulin administration
Dietary management
Exercise
Fetal surveillance:
(* Non-stress test * contraction stress test * amniocentesis)

F. CARDIAC DISEASE

CLASSIFICATION EFFECTS MANAGEMENT
Class I Asymptomatic Retarded growth Goal is to reduce
Class II Asymptomatic at rest; Fetal distress workload of heart
symptomatic with heavy physical To relieve fetal distress let Promote rest
activity the patient lie on her side Promote a healthy diet
Class III Asymptomatic at rest; Educate regarding
symptomatic with ordinary activity Premature labor medication
Class IV Symptomatic with all You don’t have to notify Educate regarding
activity; symptomatic at rest the physician if the patient avoidance of infection
complains of a Promote reduction of
a. Class I: no limitation of activities. No “fluttering” sensation in physiologic stress
symptoms of cardiac insufficiency. her chest because of
taking terbutaline
b. Class II: slight limitation of activity, (Brethine) SQ for
Asymptomatic at rest. Ordinary premature contractions
activities causes fatigue, palpitations because it is a common
and dyspnea side effect unless vital
signs indicate stress
c. Class II: marked limitation of
activities, comfortable at rest, less
than ordinary activities causes
discomforts

d. Class IV: unable to perform any physical
activity without discomfort. May have the
symptoms during rest.

MCHN Abejo


PREGNANCY INDUCED HYPERTENSION (TOXEMIA OF PREGNANCY)

NAME OF THE PRE-ECLAMPSIA ECLAMPSIA
DISEASE
MILD SEVERE
Synonym (PREGNANCY-INDUCED HYPERTENSION)
Predisposing /  Primiparas younger than age 20 years or older than 40 years
Contributing factors  women from low socioeconomic background because of poor nutrition
 women of color; women with heart disease
 diabetes with vessel or renal involvement
 essential hypertension
 poor calcium and magnesium intake
 hydatidiform mole
 multiple gestation
 polyhydramnios
 pre-existing vascular disease

Initial Sign  B≥140/90 mmGh  BP≥160/110 mmHg or  temperature rises
on at least two diastolic pressure≥110 sharply to 39.4°C or
occasion ≥ 6 hours mmHg on two 40ºC (103ºF to
apart occasions at least 6 104ºF) from
hours apart with the increased cerebral
 proteinuria of 1-2+ patient on bedrest edema; reflexes
on a random become hyperactive
sample; weight gain  proteinuria ≥5 b/24 h
over 2 lbs per week or 3+ to 4+ on  premonition that
in second trimester qualitative assessment “something is
and 1 lb per wk, (urine dipstick) happening”;
third trimester epigastric pain and
 extreme edema in nausea; urinary
 mild edema in hands and output less than 30
upper extremities or face/”puffiness” ml/h
face

Late Sign Signs of Worsening PIH  Oligauria ≤400 to 500 During pregnancy,
or Impending Seizures: ml/24h blurred vision may be a
 cerebral or visual danger sign of
 BP 160/110 mm Hg disturbances (altered preeclampsia or
or above level of consciousness eclampsia,
 headache, scotomata, complications that
 Epigastric pain
or blurred vision) require immediate
 Decreased urinary  epigastric pain or attention because they
output RUQ pain, pulmonary can cause severe
 Visual changes edema or cyanosis maternal and fetal
 Headache  impaired liver consequences.
function of unclear
etiology
 thrombocytopenia
(platelet count
<150,000);
development of
eclampsia elevated
serum creatinine > 1.2
mg/dl

Cardinal / Hypertension and proteinuria are the most significant. Edema is significant only
Pathognomonic/ Major if hypertension and proteinuria or signs of multi-organ system involvement are
Sign present.

Nursing Diagnosis and Fluid volume excess Maintaining Fluid Balance
Nursing Interventions related to 1. Control IV intake using a continuous infusion
pathophysiologic pump.
changes of PIH and 2. Monitor input and output strictly; notify health care
increased risk of fluid provider if urine output is <30 ml/h.
overload. 3. Monitor hematocrit levels to evaluate intravascular
fluid status.
4. Monitor vital signs every hour.

MCHN Abejo


5. Auscultate breath sounds every 2 hours, and report
signs of pulmonary edema (wheezing, crackles,
shortness of breath, increased pulse rate, increased
respiratory rate).

Altered tissue Promoting Adequate Tissue Perfusion
perfusion, Fetal 1. Position on side, preferably the left side to
cardiac and cereral, promote placental perfusion.
related to altered 2. Monitor fetal activity.
placental blood flow 3. Evaluate NST to determine fetal status.
caused by vasospasm 4. Increase protein intake to replace protein lost
and thombosis. through kidneys.

Risk for injury related Preventing Injury
to convulsions. 1. Instruct on the importance of reporting
headaches, visual changes, dizziness, and
Decreased cardiac epigastric pain.
output related to 2. Instruct to lie down on left side if symptoms are
decreased preload or present.
antihypertensive 3. Keep the environment quiet and as calm as
therapy. possible.
4. If patient is hospitalized, side rails should be
padded and remain up to prevent injury if seizure
occurs.

NOTE: The patient with a diagnosis of PIH should
be close to the nurses’ station because she requires
close observation. The patient also should be placed
in a room with decreased stimuli.

Maintaining Cardiac Output
1. Monitor IV intake using a continuous infusion
pump.
2. Monitor input and output strictly; notify primary
care provider if urine output is < 30 ml/h.
3. Monitor maternal vital signs; especially mean
blood pressure and respirations.
4. Assess edema status, and report pitting edema of
≥ + 2 to primary care provider.
5. Monitor oxygenation saturation levels with pulse
oximetry. Report oxygenation saturation rate of
<90% to primary care provider.

Screening/Initial Blood pressure over 140/90, or increase of 30 mm systolic, 15 mm diastolic over
diagnostic test pre-pregnancy level.

Confirmatory Test 24-hour urine for protein of 300 mg or greater; elevated serum BUN and
creatinine; increased deep tendon reflexes and clonus; blood pressure changes
meeting criteria for diagnosis

Best Diet The woman needs a moderate to high-protein, moderate-sodium diet to
compensate for the protein she is losing.

Disease Complications Abruptio placentae (Hypertension in PIH leads to vasopasm. This in turn
causes the placenta to tear away from the uterine wall (abrupto placentae)

disseminated intravascular coagulation; HELLP syndrome; prematurity;
intrauterine growth restriction (IUGR) from decreased placental perfusion;
maternal/fetal death; hypertensive crisis; acute renal failure; hemorrhage;
cerebrovascular accident; blindness; hypoglycemia; hepatic rupture

Best Position SEVERE PRECLAMPSIA: Lateral recumbent position ECLAMPSIA: to prevent
aspiration, turn the woman on her side to allow secretions to drain from her
mouth.

Beside Equipment Infusion pump; pulse oximeter

MCHN Abejo


Best Drug Mgnesium sulfate: 4-6 loading dose of 50% give IV over 15-30 mins followed by
a maintenance dose (secondary infusion) of 1-4 g/h or IM injection or 10 g (5 g in
each buttock) as a loading dose followed by 5 g every 4 hours

Administer antihypertensives such as hydralazine (Apresoline) as prescribed, to
prevent a cerebrovascular accident

Nature of the Drug Best tocolytic agent; antihypertensive; anticonvulsant/eclampsia
#1 Complication of MgSO4 is : Respiratory Depression

PRIORITY DRUG Reflexes, respiration and urinary output are priority assessments during
ASSESSMENT: administration of magnesium sulfate therapy in patients with PIH.
SIDE EFFECT If the patient’s magnesium levels increase above the therapeutic range (4 to 8
mg/dl), the absence of reflexes is often the first indication of toxicity.
Reflexes often disappear at serum magnesium levels of 8 to 10 mg/dl.
Respiratory depression occurs at levels of 10 to 15 mg/dl, and cardiac
conduction problems occur at levels of 15 mg/dl and higher.
Urinary output of less than 30ml/hour may result in the accumulation of toxic
levels of magnesium.

Proper Assessment of Assessment Patellar Reflexes
Abnormal Reflexes
 Position the client with legs dangling over the edge of the examining table or
lying on back with legs slightly.
 Strike the patellar tendon just below the kneecap with the percussion hammer.
 Normal Response: Flexion of the arm at the elbow.

Clonus
 Position the client with legs dangling over the edge of the examining table.
 Support the leg with one hand and sharply dorsiflex the client’s foot with the
other hand.
 Maintain the dorsiflexed position for a few seconds; then release the foot.

Normal Response: (Negative Clonus Response)
 Foot will remain steady in the dorsiflexed position.
 No rhythmic oscillation of jerking of the foot will be felt.
 When released, the foot will drop to a plantar flexed position with no
oscillations.

Abnormal Response: (Positive Clonus Response)
 Rhythmic oscillations when the foot is dorsiflexed.
 Similar oscillations will be noted when the foot drops to the plantar flexed
position.

G. BLEEDING DISORDERS AFFECTING THE PLACENTA

Placenta: contains 20 cotyledons, weighs 400-600 grams. Develops on the 3rd month. Form from Chorionic
villi & deciduas basalis. Deciduas (meaning endometrial changes & growth)
Functions: Main source of nourishment & acts a transfer organ for metabolic purposes for the fetus.

Placental Problem
Placental separation is characterized by a sudden gush or trickle of blood from the vagina, further
protrusion of the umbilical cord from the vagina, a globular-shaped uterus, and an increase in fundal height. With
cervical or vaginal laceration, the nurse notes a consistent flow of bright red blood from the vagina. With postpartum
hemorrhage, usually caused by uterine atony, the uterus isn't globular. Uterine involution can't begin until the
placenta has been delivered.

MCHN Abejo


PLACENTA PREVIA

PLACENTA PREVIA
Definition  Improperly implanted placenta in the lower uterine segment near or over
the internal cervical os
 Total: the internal os is entirely covered by the placenta when cervix is
fully dilated
 Marginal: only an edge of the placenta extends to the internal os
 Low-lying placenta: implanted in the lower uterine segment but does
not reach the os

Predisposing Factor Maternal age
Parity (no. Of pregnancy)
Previous uterine surgery
Assessment . Painless
. Heavy bleeding
. Soft, non tender, relaxed uterus w/ normal tone
. Shock in proportion to observed blood loss
. Signs of fetal distress usually not present

Complication  Anemia
 #1hemorrhage
 #2shock,
 renal failure
 #3 disseminated intravascular coagulation
 cerebral ischemia, maternal and fetal death
Therapeutic Interventions > Ultrasonography to confirm the pressure of placenta previa.
> Depends on location of placenta, amount of bleeding and status of the
fetus.
> Home monitoring with repeated ultrasounds may be possible with type I-
low lying
> Control bleeding
> Replace blood loss if excessive
> Cesarean birth if necessary
> Betamethasone is indicated to increase fetal lung maturity.
Nursing Diagnosis with #1 NURSING DIAGNOSIS: Potential fluid volume deficit
Nursing Intervention
Maintain bed rest
> #1 Assessment - Monitor maternal vital signs, FHR, and fetal activity
> Assess bleeding (amount and quality)
> Monitor and treat signs of shock
> Avoid vaginal examination if bleeding is occurring
> Prepare for premature birth or cesarean section
> Administer IV fluids as ordered
> Administer iron supplements or blood transfusion as ordered (maintain
hematocrit level)
> Prepare to administer Rh immune globulin

MCHN Abejo


BESTPOSITION The patient with placenta previa should be maintained on bed rest, preferably
in a side-lying position.
Additional pressure from an upright position may cause further tearing of the
placenta from the uterine lining.
Ambulating would therefore be indicated for this patient. Performing a
vaginal examination and applying internal scalp electrode could also cause
the placenta to be further torn from the uterine lining.
Confirmatory Test > Ultrasound for placenta localization
NOTE:
 Manual pelvic examinations are contraindicated when vaginal
 bleeding is apparent in the third trimester unit a diagnosis is
 made and placenta previa is ruled out.
 Digital examination of the cervix can lead to maternal and fetal
hemorrhage.
 A diagnosis of placenta previa is made by ultrasound.
 The hemoglobin and hematocrit levels are monitored and external
electronic fetal heart rate monitoring is initiated. Electronic fetal
monitoring (external) is crucial in evaluating the status of the fetus
who is at risk for severe hypoxia.
Best Position > Left lateral position

ABRUPTIO PLACENTAE

ABRUPTIO PLACENTAE
Definition Premature separation of the placenta from the uterine wall after the 20 th
week of gestation and before the fetus is delivered (Saunders page 299-
300)
Synonyms > Placental abruption
> Premature separation of placenta
Predisposing Factor > Maternal age
> Parity
> Previous abruptio placentae, multifetal gestation
> Hypertension
NOTE:
Abruptio placentae is associated with conditions characterized by poor
uteroplacental circulation, such as hypertension, smoking and alcohol or
cocaine abuse. It is also associated with physical and mechanical factors
such as over distension of the uterus that occurs with multiple gestation
or polyhydranions. In addition, a short umbilical cord, physical trauma,
and increased maternal age and parity are risk factors.

MCHN Abejo


Pathophysiology > Spontaneous rupture of blood vessels at the placental bed may due to
lack of resiliency or to abnormal changes in uterine vasculature.
> May be complicated by hypertension or by an enlarged uterus that
can’t contract sufficiently to seal off the torn vessels
> Consequently, bleeding continues unchecked, possibly shearing off the
placenta partially or completely.

Manifestation > Painful vaginal bleeding
> Hypertonic to tetanic, enlarged uterus
> Board-like rigidity of abdomen (Cullen Sign)
> Abnormal/absent fetal heart tones
> Pallor
> Cool, moist skin
> Bloody amniotic fluid
> Rising fundal height from blood trapped behind the placenta
> Signs of shock
> Manifestation of coagulopathy

NOTE:
Uterine tenderness accompanies placental abruption, especially with a
central abruption and trapped blood behind the placenta. The abdomen
will feel hard and boardlike upon palpation as the blood penetrates the
myometrium and causes uterine irritability. Observation of the fetal
monitoring often reveals increased uterine resting tone, caused by failure
of the uterus to relax in an attempt to constrict blood vessels and control
bleeding.

Complication > Hemorrhage, shock, renal failure, disseminated intravascular
coagulation, maternal death, fetal death(Nursing Alert p.4)

Therapeutic Interventions > Replacement of blood loss.
> With moderate or severe separation or maternal or fetal distress:
emergency childbirth.

NOTE:
The goal of management in abruption placentae is to control the
hemorrhage and deliver the fetus as soon as possible. Delivery is
the treatment of choic if the fetus is at term gestation or if the
bleeding is moderate to severe and mother or fetus is in jeopardy.

> With mild separation without fetal distress and in the presence of some
cervical effacement and dilatation: induction of labor may be
attempted
>Oxygen if necessary
> Maintenance of fluid and electrolytes balance.

Nursing Diagnosis with #1 NURSING DIAGNOSIS: Risk for fluid volume deficit
Intervention > #1 Assessment: Monitor and FHR
> Assess for vaginal bleeding, abdominal pain, and increase in fundal
height
> Maintain bed rest
> Administer oxygen as prescribed
> Monitor and report any uterine activity
> Administer IV fluid as prescribed
> Monitor I & O
> Administer blood products as prescribed
> Monitor blood studies
> Prepare for the delivery of the fetus as quickly as possible
> Monitor for signs of disseminated intravascular coagulation in the post-
partum period

Confirmatory Test > Ultrasound detects retro-placental bleeding

MCHN Abejo


VENA CAVA SYNDROME

Definition The venous return to the heart is impaired by the weight of uterus.
Synonym Supine Hypotensive Syndrome
Predisposing factors Thrombophlebitis
NOTE:
Contribute to clot formation motion include inactivity,reduced cordiac
output, compression of the viens in pelvis or legs

The most likely cause of supine hypotension is feeling dizzy, short of
breath and clammy when lying back for long periods of time in patients 6 th
month of pregnancy.
The cause of supine hypotension during pregnancy is the weight of the
uterus compresses the inferior vena cava, decreasing the return of blood
to the heart, thus decreasing cardiac output, which lowers the blood
pressure
Initial sign  Fatique
 proxymal nocturnal
 dyspnea
 orthopnea
 hypoxia
 cyanosis
Late Sign Reduce renal perfection, Decrease glomerular filtration
Cardinal sign Shock such as tachycardia
NOTE:
Caused by reduced cardiac output, respiratory distress, fatal distress
Initial / Screening test FHT monitor
NOTE:
Above 160 or below 120 beats per minutes, Fetal PH below 7.5
Confirmatory test Amniotomy:
NOTE:
Above keeping the significant other improved of the progress of care,
the fatal status would he the priority
Nursing Diagnosis  Altered tissue perfection related to decrease blood circulation
 Risk for altered Health maintenance related to insufficient knowledge
of treatments, drug therapies, home care management and prevention
of future infection
 Altered comfort related to maladaptive coping
Nursing Intervention  Closely monitor for shock and decreasing blood. Pressure,
tachycardia, coal, clammy Skin
 Maintain patient on bed rest to reduce Oxygen demands and risk for
bleeding. Monitor prescribed medication given to preserve right
Ventricular felling pressure and increase blood pressure
 Instruct patient in self – care activities Provide information about anti
smoking strategies and allow patient time to return demonstration of
treatment to the done at home
 Assess physical complaints matters of facts without emphasizing
concern. Use deep – breathing, muscle relaxation, and imagery to
relieve discomfort. Express a caring attitude
Best major Surgery Caesarian Section – note if cervix is incomplete deleted.
Best dirt for pre-operative Food and fluid are withheld before invasive procedure is not resumed until
the client is stable and free of nausea & vomiting.
Best diet for Disease Hypoallergenic Ionic diet Calcium increased
Possible Surgical Interruption of vena cava, which reduce channel size.
Complication
Complication of Disease > Bleeding as a result of treatment
NOTE:
Observation of the fetal monitoring often reveal increase uterine
rustling tone, caused by failure of the uterus to relax in an attempt to
constrict blood vesicle and control bleeding
> Respiratory failure.
Best position pre-operative Sims Position
NOTE:
Turning to the left side to shift right of the fetus off the inferior vena
cava.
Bed Side Equipment Oxygen obtain equipment for external electronic fetal heart rate
monitoring Oxygen with Cannula
History of Disease Angina, myocardial infarction

MCHN Abejo


OTHER DISEASES AND CONDITION

Name of the Disease Disseminated Intravascular Coagulation
Predisposing / Overwhelming infections particularly bacterial sepsis; #1 abruption placenta;
Contributing Factors eclampsia; amniotic fluid embolism; IUFD(Intra-uterine fetal death) or retention of
dead fetus; burn; trauma; fractures; major surgery; fat embolism; sock; hemolytic
transfusion reaction; malignancies particularly of lung, colon, stomach, and
pancreas

NOTE:
Disseminated intravascular coagulation (DIC) is a state of diffuse clotting in which
clotting factors are consumed. This leads to widespread bleeding. Platelet are
decreased because they are consumed by the process, coagulation studies show no
clot formation (and are thus normal to prolonged); and fibrin plugs may clog the
microvasculature diffusely, oozing from injection sites, and presence of hematuria
are signs associated with the presence of DIC. Swelling and pain in the calf of one
leg are more likely to be associated with thrompophlebitis. (Saunders

Initial Sign Coolness and mottling of extremities; pain; dyspnea; abnormal bleeding
Late Sign Altered mental status; acute renal failure
Nursing Diagnosis & Risk for injury related Minimizing Bleeding
Intervention to bleeding due to 1. Institute Bleeding precautions
thrombocytopenia 2. Monitor pad count/amount of saturation during
menses; administer or teach self-administration of
hormones to suppress menstruation as prescribed.
3. Administer blood products as ordered. Monitor for
signs and symptoms of allergic reactions,
anaphylaxis, and volume overload.
4. Avoid dislodging costs. Apply pressure to sites of
bleeding for at least 20 mins, use topical hemostatic
agents. Use tape cautiously.
5. Maintain bed rest during bleeding episode.
6. If internal bleeding is suspected, assess bowel sounds
and abdominal girth.
7. Evaluate fluid status and bleeding by frequent
measurement fo vital signs, central venous pressure,
intake and output.

Promoting Tissue Perfusion
1. Keep patient warm
2. Avoid vasoconstrictive agents (systemic or topical).
Altered tissue perfusion 3. Change patient’s position frequently and perform
(all tissues) related to ROM exercises.
ischemia due to 4. Monitor electrocardiogram and laboratory test for
microthrombi dysfunction of vital organs casued by ischemia –
formation arrhythmias, abnormal arterial blood gases, increased
blood urea nitrogen and creatinine.
5. Monitor for signs of vascular occlusion and report
immediately.
a. Brain – decreased level of consciousness, sensory
and motor deficits, seizures, coma.
b. Eyes – Visual deficits.
c. Bone – Pain
d. Pulmonary vasculature – chest pain, shortness of
breath, tachycardia.
e. Extremities – cold, mottling, numbness.
f. Coronary arteries – chest pain, arrhythmias.
g. Bowel – pain, tenderness, decreased bowel sounds.

Screening or Initial PT; PTT; Platelet count
Diagnostic Test
Confirmative Test Decreased Fibrinogen level; increased fibrin split products; decreased anti-thrombin
III level
Beside Equipment ECG; CVP
Best Drug Heparin inhibits clotting components of DIC
Nature of the Drug Anticoagulant

MCHN Abejo


Name of the Disease Hyperemesis gravidarum

Definition Hyperemesis gravidarum is persistent, uncontrolled vomiting that begins in the first
weeks of pregnancy and may continue throughout pregnancy. Unlike “morning
sickness,” hyperemesis can have serious complications, including severe weight loss,
dehydration, and electrolyte imbalance.

NOTE: The defining factor for hyperemesis gravidarum should be the time of
occurrence – and that is the 2nd trimester, usually the 14 – 16th week. If this is
on the 1st trimester, usually this is morning sickness.

Causes  Gonadotropine production
 Psychological factors
 Trophoblastic activity

Assessment Findings  Continuous, severe nausea and vomiting
 Dehydration
 Dry skin and mucous membranes
 Electrolyte imbalance
 Metabolic acidosis
 Non-elastic skin turgor
 Oliguria

Diagnostic Result  Arterial blood gas and analysis reveals alkalosis.
 Hb level and HCT are elevated.
 Serum potassium level reveals hypokalemia
 Urine ketone levels are elevated.
 Urine specific gravity is increased.

Nursing Diagnosis  Fluid volume deficit
 Altered nutrition; less than body requirements
 Pain

Treatment  Total parenteral nutrition (TPN)
 Restoration of fluid and electrolyte balance
 Anti-emetics, as necessary for vomiting, for example Plasil , Hydroxyzine and
Prochlorperazine

Nursing Intervention  Monitor vital signs and fluid intake and output to assess for fluid volume
deficit.
 Obtain blood samples and urine specimens for laboratory tests, including Hb
level, HCT, urinalysis, and electrolyte levels.
 Provide small frequent meals to maintain adequate nutrition.
 Maintain I.V. fluid replacement and TPN to reduce fluid deficit and pH
imbalance.
 Provide em0otional support to help the patient cope with her condition.

Teaching Topics
 Using salt on foods to replace sodium lost by vomiting.

MCHN Abejo

Antepartal Complications

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