Etiology: Abruptio Placenta Nursing Care Plan and Management

Abruptio Placenta Nursing Care Plan and Management
 Abruptio placenta is premature separation of a normally implanted placenta after the 20th week of
pregnancy, typically with severe hemorrhage.
Etiology
1. The cause of abruptio placenta is unknown.
2. Risk factors include:
 Uterine anomalies
 Multiparity
 Preeclampsia
 Previous cesarean delivery
 Renal or vascular disease
 Trauma to the abdomen
 Previous third trimester bleeding
 Abnormally large placenta
 Short umbilical cord
Pathophysiology
 The placenta detaches in whole or in par from the implantation site. This occurs in the area of the deciduas
basalis.
Assessment Findings
1. Associated findings. Severe abruption placentae may produce such complications as:
a. Renal failure
b. Disseminated intravascular coagulation
c. Maternal and fetal death
2. Common clinical manifestation include:
a. Intense, localized uterine pain, with or without vaginal bleeding.
b. Concealed or external dark red bleeding
c. Uterus firm to boardlike, with severe continuous pain
d. Uterine contractions
e. Uterine outline possibly enlarged or changing shape
f. FHR present or absent.
g. Fetal presenting part may be engaged.
3. Laboratory and diagnostic study findings.
 Ultrasound may be able to identify the extent of abruption. However, the absence of an ultrasound
finding does not rule out the presence of abruption.
Nursing Management
1. Continuously evaluate maternal and fetal physiologic status, particularly:
 Vital signs
 Bleeding
 Electronic fetal and maternal monitoring tracings
 Signs of shock-rapid pulse, pallor, cold and most skin, decrease in blood pressure
 Decreasing urine output
 Never perform a vaginal or rectal examination or take any action that would stimulate uterine activity.
2. Assess the need for immediate delivery. If the client is in active labor and bleeding cannot be stopped with
bed rest, emergency cesarean delivery may be indicated.
3. Provide appropriate management.
 On admission, place the woman on bed rest in a lateral position to prevent pressure on the vena cava.
 Insert a large gauge intravenous catheter into a large vein for fluid replacement. Obtain a blood sample
for fibrinogen level.
 Monitor the FHR externally and measure maternal vital signs every 5 to 15 minutes. Administer oxygen
to the mother by mask.
 Prepare for cesarean section, which is the method of choice for the birth.
4. Provide client and family teaching.
5. Address emotional and psychosocial needs. Outcome for the mother and fetus depends on the extent of the
separation, amount of fetal hypoxia, and amount of bleeding.
Anemia in Pregnancy
1. Hemoglobin value of less than 11 mg/dL or hematocrit value less than 33% during the second and third
trimesters
2. Mild anemia (hemoglobin value of 11 mg/dL) poses no threat but is an indication of a less than optimal
nutritional state.
3. Iron deficiency anemia is the most common anemia of pregnancy, affecting 15% to 50% of pregnant women.
It is identified as physiologic anemia of pregnancy.
Etiology
Causes of anemia include:
1. Nutritional deficiency (e.g., iron deficiency or megaloblastic anemia, which includes folic acid deficiency and
B12 deficiency).
2. Acute and chronic blood loss
3. Hemolysis (e.g., sickle cell anemia, thalassemia, or glucose-6-phosphate dehydrogenase [G-6-PD])
Pathophysiology
1. The hemoglobin level for nonpregnant women is usually 3.5 g/dL. However, the hemoglobin level during the
second trimester of pregnancy averages 11.6 g/dL as a result of the dilution of the mother’s blood from
increased plasma volume. This is called physiologic anemia and is normal during pregnancy.
2. Iron cannot be adequately supplied in the daily diet during pregnancy. Substances in the diet, such as milk,
tea, and coffee, decrease absorption of iron. During pregnancy, additional iron is required for the increase in
maternal RBCs and for transfer to the fetus for storage and production of RBCs. The fetus must store
enough iron to last 4 to 6 months after birth.
3. During the third trimester, if the woman’s intake of iron is not sufficient, her hemoglobin will not rise to a
value of 12.5 g/dL and nutritional anemia may occur. This will result in decreased transfer of iron to the
fetus.
4. Hemoglobinopathies, such as thalassemia, sickle cell disease, and G-6-PD, lead to anemia by causing
hemolysis or increased destruction of RBCs.
Assessment Findings
1. Associated findings. In clients with a hemoglobin level of 10.5 g/dL, expect complaints of excessive fatigue,
headache, and tachycardia.
2. Clinical manifestations:
 Signs of iron deficiency anemia (hemoglobin level below 10.5 g/dL) include brittle fingernails, cheilosis
(severely chapped lips), or a smooth, red, shiny tongue.
 Women with sickle cell anemia experience painful crisis episodes.
Nursing Management
1. Provide client and family teaching. Discuss using iron supplements and increasing dietary sources of iron as
indicated.
2. Prepare for blood-typing and crossmatching, and for administering packed PBCs during labor if the client
has severe anemia.
3. Provide support and management for clients with hemoglobinopathies.
 In a client who has thalassemia or who carries the trait, provide support, especially if the woman has
just learned that she is a carrier. Also assess for signs of infection throughout the pregnancy.
 In a pregnant client with sickle cell disease, assess iron and folate stores, and reticulocyte counts;
complete screening for hemolysis; provide dietary counseling and folic acid supplements; and observe
for signs of infection.
 In a pregnant client with G-6-PD, provide iron and folic acid supplementation and nutrition counseling,
and explain the need to avoid oxidizing drugs.
APGAR Scoring System
Assess 0 1 2
HEART RATE Absent Below 100 Above 100
RESPIRATION Absent Slow Good crying
MUSCLE TONE Flaccid Some flexion Active motion
REFLEX IRRITABILITY No Response Grimace Vigorous cry
COLOR Blue all over Body pink, extremities blue Pink all over
SCORE:
 7-10 Good adjustment, vigorous
 Moderately depressed infant, needs airway clearance
 Severely depressed infant, in need of resuscitation
Birth Asphyxia
 Birth asphyxia is characterized by hypoxemia (decreased PaCO2), hypercarbia (increased PaCO2), and
acidosis (lowered pH).
Etiology
1. Maternal causes include amnionitis, anemia, diabetes, pregnancy-induced hypertension, drugs, and
infection.
2. Uterine causes include prolonged labor and abnormal fetal presentations.
3. Placental causes include placenta previa, abruption placental, and placental insufficiency.
4. Umbilical causes include cord prolapsed and cord entanglement.
5. Fetal causes include cephalopelvic disproportion, congenital anomalies, and difficult delivery.
Pathophysiology
1. Unless vigorous resuscitation begins promptly, irreversible multi-organ tissue changes will occur, possibly
leading to permanent damage or death.
2. During the 24 hours after successful resuscitation, the newborn is vulnerable to post-asphyxial syndrome.
Assessment Findings
Clinical manifestations include:
1. Poor response to resuscitative efforts
2. Hypoxia
3. Hypercarbia
4. Metabolic and or respiratory acidosis
5. Minimal or absent respiratory effort
6. Seizures
7. Altered cardiac function
8. Multi-organ system failure
Nursing Management
1. Observe the newborn that has been successfully resuscitated for the following constellation of signs.
 Absence of spontaneous respirations
 Seizure activity in the first 12 hours after birth
 Decreased or increased urine output (which may indicate acute tubular necrosis or syndrome of
inappropriate antidiuretic hormone)
 Metabolic alterations (e.g., hypoglycemia and hypocalcemia)
 Increased intracranial pressure marked by decreased or absent reflexes or hypertension.
2. Decrease noxious environmental stimuli.
3. Monitor the infant’s level of responsiveness, activity, muscle tone, and posture.
4. Administer prescribed medications, which may include anticonvulsants (e.g., Phenobarbital) as prescribed.
5. Provide respiratory support.
6. Monitor for complications.
 Measure and record intake and output to evaluate renal function.
 Check every voiding for blood, protein, and specific gravity, which suggests renal injury.
 Check every stool for blood, suggesting necrotizing enterocolitis (NEC). NEC is a condition in which the bowel
develops necrotic patches that interfere with digestion and possibly cause paralytic ileus, perforation, and
peritonitis.
 Take serial blood glucose determinations to detect hypoglycemia, and monitor serum electrolytes, as ordered.
7. Administer and maintain intravenous fluids to maintain hydration and fluid and electrolyte balance.
8. Provide education and emotional support.
Cesarean Delivery
1. In this surgical procedure, the newborn is delivered through the abdomen from an incision made through
the maternal abdomen and the uterine myometrium.
2. The surgery may be preplanned (elective) or arise from an unanticipated problem.
3. Two incisions are made: one in the abdominal wall (skin incision) and the other in the uterine wall. Either of
two skin incisions is used: a midline vertical incision between the umbilicus and the symphysis or a
Pfannenstiel incision just above the symphysis (Fig. 1). Three types of uterine incisions are possible (Fig. 2):
(1) low transverse; (2) low vertical; and (3) classic, a vertical incision into the upper uterus. The low
transverse uterine incision is preferred unless a very large fetus or placenta previa in the lower uterus
prevents its use. The uterine incision does not always match the skin incision. For example, a woman may
have a vertical skin incision and a low transverse uterine incision, particularly if she is very obese.
4. In subsequent pregnancies and delivery, a trial of labor and vaginal birth is increasingly regarded as safe
and appropriate as long as cephalopelvic disproportion does not exist and the previous incision was low
transverse.
5. Elective, repeat cesarean may be performed in the absence of a specific indication for operative delivery when
either the physician or the client is unwilling to attempt vaginal delivery.
6. Anesthesia may be general, spinal, or epidural; preoperative and postoperative care will vary accordingly.
Positioning
 Supine, with a small roll under the right hip (to reduce vena cava compression); arms extended on
armboards.
Incision sites
 Classic approach, vertical (low midline).
Packs/drapes
 Extra drape sheet
 Towels
 Receiving pack for baby
Instrumentation
 C-section tray
 Delivery forceps
 Cord clamp
Supplies/ Equipment
 Basin set
 Blades
 Suction
 Neonatal receiving unit
 Self-contained oxygen
 I.D bands
 Bulb syringe
 Solutions
 Sutures
Procedure
1. Using the appropriate incisions, consistent with the estimated size of the fetus, the abdomen is opened, the
rectus muscle are separated, and the peritoneum incised (similar to an abdominal hysterectomy), exposing
the distended uterus.
2. Large vessels are clamped or cauterized, but usually no attempt to control hemostasis is made since it may
delay delivery time ( 3-5 minutes after initial incision is ideal).
3. The scrub person must be ready with suction, dry laps, and a bulb syringe.
4. The bladder is retracted downward with the bladder blade of the balfour retractor and a small incision is
made with the second knife and extended with a bandage scissors (blunt tip prevents injury to the baby’s
head).
5. The amniotic sac is entered and immediately aspirated the fluid.
6. The bladder blade is removed, and the assistant will push on the patient’s upper abdomen while the surgeon
simultaneously delivers the infant’s head in an upward position.
7. The baby’s airways are suctioned with the bulb syringe, and the baby is completely delivered and placed
upon the mother’s abdomen.
8. The umbilical cord is double clamped and cut.
9. The baby is wrapped in a sterile receiving blanket and transferred to the warming unit for immediate
assessment and care.
10. Once the bay has been safely delivered, the emergent phase of the procedure has been ended.
11. Using a nonecrushing clamp, the uterine wall is grasped for traction during closure.
12. The closure is performed in two layers with a heavy absorbable suture, using a continuous stitch, the second
overlapping the first.
13. Following closure of the uterus, the bladder flap is reperitonealized with a running suture, and the uterus is
pushed back inside the pelvic cavity.
14. The cavity is irrigated with warm saline, and closed in layers.
15. Skin is closed with the surgeon’s preference. If a tubal ligation is to be performed, it is done prior to the
abdominal closure sequence.
Perioperative Nursing Considerations
1. A C-section requires an additional uterine count of sponges, sharps, and instruments prior to its closure.
2. Oxytocin should be available for the anesthesiologist to administer I.V.
3. Once the uterus is opened, immediate suctioning is necessary.
4. A warm, portable isolette should be available to transport the infant to the newborn nursery.
Reasons For Performing A Cesarean Delivery
1. Maternal factors
a. Cephalopelvic disproportion (CPD)
b. Active genital herpes or papilloma
c. Previous cesarean birth by classic incision
d. Presence of severe disabling hypertension or heart disease
2. Placental factors
a. Placenta previa
b. Abruptio placental
3. Fetal factors
a. Transverse fetal lie
b. Extreme low birth weight
c. Fetal distress
d. Compound conditions, such as macrosomia and transverse lie.
Nursing Management
1. Perform a complete maternal and fetal assessment.
 Obtain a complete obstetric history.
 If he client presents with labor determine frequency, duration, and intensity of contractions.
 Determine the condition of the fetus through fetal heart tones, fetal monitoring strips, fetal scalp blood
sample, fetal activity changes, and presence of meconium in amniotic fluid.
2. Prepare the client for cesarean delivery in the same way whether the surgery is elective or emergency.
Depending on hospital policy:
 Shave or clip pubic hair.
 Insert a retention catheter to empty the bladder continuously.
 As prescribed, insert intravenous lines, collect specimens for laboratory analysis, and administer
preoperative medications.
 Also as prescribed, provide an antacid (to prevent vomiting and possible aspiration of gastric secretions) and
prophylactic antibiotics (to prevent endometritis).
 Assist the client to remove jewelry, dentures, and nail polish, as appropriate.
 As needed, reinforce the obstetrician’s explanation of the surgery, the expected outcome, and the
anesthesiologist’s explanation of the kind of anesthetics to be used (depending on the client’s
cardiopulmonary status).
 Make sure the client’s signed informed consent is on file.
 Continue assessing maternal and fetal vital signs in accordance with hospital policy until the client is
transported to the operating room.
 Notify other health care team members of the pending delivery.
 Modify preoperative teaching to meet the needs of planned versus emergency cesarean birth; depth and
breadth of instruction will depend on the circumstances and time available.
 If there is time, begin explaining what the client can expect postoperatively. Discuss pain relief, turning,
coughing, deep breathing, and ambulation.
 Inform the client that intraoperative and postpartum care will be performed by the surgical and obstetric
team, and that the newborn will receive care by the pediatrician and a nurse skilled in neonatal care
procedures (ie, resuscitation).
3. Facilitate a family- centered cesarean birth by including, when possible, such activities as:
 Preparing the partner for participation in the delivery.
 Reuniting the family as soon as possible following delivery.
 Providing for family time alone in the critical first hours after the mother and newborn are stabilized.
 Including the father and siblings (as possible) when demonstrating care of the newborn.
 Encouraging the mother’s support person to remain with her as much as possible. In some cases, this
person may accompany the client to the surgical suite and stay with her throughout the birth.
4. Provide physical and emotional support.
 Anticipate parental feelings of “failure” related to cesarean rather than “normal” birth. In such a situation,
provide time for them to relive and talk through the experience. Offer reassurance and support.
 Assist the family in planning for care of mother and newborn at home
Client and Family Teaching
Explain to the mother, her partner, and other family members that recovery from a surgical
cesarean delivery is slower, and often more painful, when compared with recovery from a normal
vaginal delivery. The following considerations must be taken into account:
 Need for increased rest (influenced by type of anesthesia, length of labor, and the type of
abdominal or uterine incision)
 Need for increased pain medication and other pain-relieving techniques
 Inability to climb the stairs
 Inability to drive a car
 Difficulty with breast feeding the newborn in certain positions (e.g., cradle hold).teach the
mother the best positions to use and how to use pillows to cushion the incision site.
 Difficulty with normal ADLs (e.g., dressing, bathing, toileting, and so on). Difficulty with
providing normal newborn care (e.g., lifting, carrying, bathing, and dressing the newborn) and
the need for assistance in caring for the newborn.
Circumcision
 The excision of the foreskin (prepuce).
 Circumcisions are commonly performed on the male infant at birth or shortly thereafter. However, the
uncircumcised adult may experience difficulty in retracting the prepuce from the glans of the penis because
of a stricture (phimosis), which requires surgical intervention, or circumcision may be performed to treat
recurrent balanitis or as a religious rite.
 If performed on an infant, the procedure may take place in a separate part of the newborn nursery,
aseptically suited for the procedure.
Positioning
 Supine, with legs slightly apart, or lithotomy.
 Children and infants may be placed in a frog-leg position or on a specially designed board.
Incision Site
 Circumferentially around the glans penis.
Packs/ Drapes
 Child: Pediatric Lap sheet
 Adult: Laparotomy pack
 Infant: Pediatric Lap sheet or folded towels
Instrumentation
 Infants and children: Pediatric Lap tray
 Circumcision lamp
 Adults: Minor/ very fine tray, Probe and groove director.
Supplies/ Equipments
 Basin set
 Blades
 Needle counter
 Catheter
 Gauze roll and impregnated gauze strips
 Solutions
Procedure
1. If phimosis is present, a dorsal slit is made. Adhesions are lysed.
2. A circumferential incision is made at the reflection of the foreskin, which is then excised.
3. Hemostasis is achieved, and the wound edges are approximated using absorbable suture.
4. For a very young infant, the skin edges are usually not approximated.
5. A strip of nonadherent gauze is placed around the incision and is covered with a gauze roll dressing.
6. A piece of umbilical tape may hold the gauze roll in place.
7. No other dressing is usually necessary.
1. Consider the special needs of the Jewish patient for a ritual circumcision. All female team members may be
asked to leave the room during the procedure.
2. Instruct the patient the proper way of cleansing the wound.
Cord Prolapse
1. Cord prolapse is descent of the umbilical cord into the vagina ahead of the fetal presenting part with
resulting compression of the cord between the presenting part and the maternal pelvis.
2. Cord prolapse is an emergency situation; immediate delivery will be attempted to save the fetus.
3. It occurs in 1 of 200 pregnancies.
Etiology
1. This problem occurs most frequently in prematurity, rupture of membranes with the fetal presenting part
unengaged, and shoulder or footling breech presentations.
2. It may follow rupture of the amniotic membranes because the fluid rush may carry the cord along toward the
birth canal.
Pathophysiology
 Compression of the cord results in the compromise or cessation of fetoplacental perfusion.

Assessment Findings
1. Associated findings
 Cord prolapse may be occult or occur at any time in the labor process, even when the amniotic membranes
are intact.
 Client reports feeling the cord within the vagina.
2. Clinical manifestations
 Fetal bradycardia with deceleration during contraction.
 The umbilical cord can be seen or felt during a vaginal examination.
Nursing Management
1. Identify prolapse cord and provide immediate intervention.
 Assess a laboring client often if the fetus is preterm or small for gestational age, if the fetal presenting part is
not engaged, and if the membranes are ruptured.
 Periodically evaluate FHR, especially right after rupture of membranes (spontaneous or surgical), and again
in 5 to 10 minutes.
 If prolapse cord is identified, notify the physician and prepare for emergency cesarean birth.
 If the client is fully dilated, the most emergent delivery route may be vaginal. In this case, encourage the
client to push and assist with the delivery as follows.
 Lower the head of the bed and elevate the client’s hips on a pillow, or place the client in the knee-chest
position to minimize pressure from the cord.
 Assess cord pulsations constantly.
 Gently wrap gauze soaked in sterile normal saline solution around the prolapsed cord.
3. Provide client and family education.
Dilation And Curettage (D&C)
 The gradual enlargement of the cervical os and the curetting (scraping) of endometrial or endocervical tissue
for histologic study.
Discussion
 The procedure is usually performed to:

1. To diagnosed cervical or uterine malignancy.
2. To control dysfunctional uterine bleeding.
3. To complete an incomplete abortion.
4. To aid in evaluating infertility.
5. To relieve dysmenorrheal.
 Fractional D&C procedures can assist in differentiating between endocervical and endometrial lesions.
Positioning
 Lithotomy; arms may be extended on armboards.
Packs/ Drapes
 Gynecologic pack
Instrumentation
 D&C tray
Supplies/ Equipment
 Padded stirrups
 Telfa
 Perineal pad
 Suction
 Lubricant
Procedure Overview
1. A weightened speculum is placed in the vaginal vault.
2. The cervix is grasped with a tenaculum.
3. A graduated sound is passed through the cervical canal into the uterine cavity to determine its depth and
angulation.
4. Using Hegar or Hank dilators, the surgeon begins to dilate the cervical opening, increasing the size of each
dilator.
5. A Telfa sponge is placed over the bill of the weighted speculum, and the uterus is gently curetted, allowing
the tissue specimen to collect on the Telfa sponge.
6. The small serrated curette is used to scrape the uterine walls again or when the D&C is performed to remove
retained placental tissue, while the large, blunt curette and forceps are used to remove the tissue.
7. If a fractional D&C is performed, endocervical curettings are obtained before the uterus is sounded, to avoid
bringing endometrial cells into the cervical os.
8. The weighted speculum is removed, and the perineum is dressed with a perineal pad.
1. Stirrups should be padded, and a coccygeal support placed on the table to protect the lower sacral area.
2. Raise and lower the legs together and slowly to prevent disturbances caused by rapid alterations in venous
return and/ or injury to the rotator hip joint.
3. Instruments are set up on the black table in order of usage, a scrub person may not be necessary during the
procedure.
4. If a fractional D&C is performed, multiple specimens may be obtained. They should be placed in separate
containers, and labeled accordingly.
Dysfunctional Labor
 Dysfunctional labor is difficult, painful, prolonged labor due to mechanical factors.
Etiology
1. Fetal factors (passenger) include unusually large fetus, fetal anomaly, malpresentation, and malposition
2. Uterine factors (powers) include hypotonic labor, hypertonic labor, precipitous labor, and prolonged labor.
3. Pelvic factors (passage) include inlet contracture, midpelvis contracture, and outlet contracture.
4. “Psyche” factors include maternal anxiety and fear and lack of preparation.
Pathophysiology
 Uterine contractions are ineffective secondary to muscle fatigue or overstretching.

Assessment Findings
 Clinical manifestations include irregular uterine contractions and ineffective uterine contractions in terms of
contractile strength and duration.
Nursing Management
1. Optimize uterine activity. Monitor uterine contractions for dysfunctional patterns; use palpation and an
electronic monitor.
2. Prevent unnecessary fatigue. Check the client’s level of fatigue and ability to cope with pain.
3. Prevent complications of labor for the client and infant.
 Assess urinary bladder; catheterize as needed.
 Assess maternal vital signs, including temperature, pulse, respiratory rates, and blood pressure.
 Check maternal urine for acetone (an indication of dehydration and exhaustion).
 Assess condition of fetus by monitoring FHR, fetal activity, and color of amniotic fluid.
 Promote relaxation through bathing and keeping the client and bed clean, back rubs, frequent position
changes (sidelying), walking (if indicated), and by keeping the environment quiet.
 Coach the client in breathing and relaxation techniques.
Early Postpartum Hemorrhage
1. Early postpartum hemorrhage is defined as blood loss of 500 mL or more during the first 24 hours after
delivery.
2. Post partum hemorrhage is the leading cause of maternal death worldwide and a common cause of excessive
blood loss during the early postpartum period.
3. Approximately 5% of women experience some type of postdelivery hemorrhage.
Etiology
1. Major causes of postpartum hemorrhage are uterine atony (responsible for at least 80% of all early
postpartum hemorrhages); laceration of cervix, vagina, or perineum; and retained placental fragments.
2. Predisposing factors include hypotonic contractions, overdistended uterus, multiparity, large newborn,
forceps delivery, and cesarean delivery.
Pathophysiology
 The uterus is unable to contract effectively and maintain hemostasis.

Assessment Findings
1. Vaginal bleeding.
2. Hypotonic uterus.
3. Excessive blood loss, which may produce hypotension, thread pulse, pallor, restlessness, dyspnea, and
chills.
Nursing Management
1. Assist with appropriate treatment to prevent complications.
 Determine the presence of uterine firmness and location and amount of vaginal bleeding immediately after
delivery.
 Measure and record serial maternal vital signs after delivery- every 5 to 15 minutes until stable; increase or
decrease the frequency of assessment relative to baseline and amount of bleeding.
 Notify the practitioner of abnormal assessment findings.
 Massage the fundus gently, taking care to support the uterus with the hand just above the symphysis pubis.
 Administer medications as prescribed.
 Keep an accurate pad count (100 mL per saturated pad).
 Assess condition of skin, urine output, and level of consciousness.
Ectopic Pregnancy Nursing Care Management
 Implantation of products of conception in a site other than the uterine cavity (e.g., fallopian tube, ovary,
cervix, or peritoneal cavity.)
Etiology
 Ectopic pregnancy can result from conditions that hinder ovum passage through the fallopian tube and into
the uterine cavity, such as:
1. Salpingitis
2. Diverticula
3. Tumors
4. Adhesions from previous surgery
5. Transmission of the ovum from one ovary to the opposite fallopian tube.
Pathophysiology
 The uterus is the only organ capable of containing and sustaining a pregnancy. When the fertilized ovum
implants in other locations the body is unable to maintain the pregnancy.
Assessment Findings
 Suspect ectopic pregnancy in a client whose history includes a missed menstrual period, spotting, or
bleeding pelvic or shoulder pain, use of intrauterine device, pelvic infections, tubal surgery, or previous
ectopic pregnancy.
 Be aware of grief and lost manifestations in the client and family.
2. Common clinical manifestations. (The client with ectopic pregnancy may report signs and symptoms of a
normal pregnancy or may have no symptoms at all.)
 Dizziness and syncope (faintness)
 Sharp abdominal pain and referred shoulder pain
 Vaginal bleeding
 Adnexal mass and tenderness
 A ruptured fallopian tube can produce life –threatening complications, such as hemorrhage, shock, and
peritonitis.
3. Laboratory and diagnostic study findings
 Blood samples for hemoglobin value, blood type, and group, and crossmatch.
 A pregnancy test reveals elevated serum quantitative beta hCG.
 Ultrasound will confirm extrauterine pregnancy.
Nursing Management
1. Ensure that appropriate physical needs are addressed and monitorfor complications. Assess vital signs,
bleeding, and pain.
2. Provide client and family teaching to relieve anxiety.
 Explain the condition and expected outcome.
 Maternal prognosis is good with early diagnosis and prompt treatment, such as laparotomy, to ligate
bleeding vessels and repair or remove the damaged fallopian tube.
 Pharmacologic agents, such as methotrexate followed by leucovorin, may be given orally when ectopic
pregnancy is diagnosed by routine sonogram before the tube has ruptured. A hysterosalpingogram
usually follows this therapy to confirm tubal patency.
 Rh-negative women must receive RhoGAM to provide protection from isoimmunization for future
pregnancies
 b. Describe self-care measures, which depend on the treatment.
3. Address emotional and psychosocial needs.
Fetal Skull
Importance of the fetal skull
1. Largest part of the fetal body.
2. Most frequent [resenting part of the fetus.
3. Least compressible of all fetal parts.
Anatomy of the Fetal Skull
Cranial Bones
The fetal skull is made up of six cranial bones which are the following:
1. Sphenoid
2. Ethmoid
3. Temporal
4. Frontal
5. Occipital
6. Parietal
The frontal, occipital and the parietal cranial bones could either be fetal presenting part if the presentation is
vertex.
Membrane Spaces
During birth, bones move and overlap with each other to allow the fetal head to fit through the birth canal which
is a process termed as molding. Molding is made possible because of the presence of the suture lines. Without
these structures a fetus’ head cannot pass through the birth canal. There are different types of sutures:
 Sagittal suture line – joins the two parietal bones.
 Coronal suture line – joins the frontal and the parietal bones.
 Lambdoid suture line – joins the occiput and the parietal bones.
Fontanelles
Fontanelle is a membrane-covered space at the junction of a main suture line.
Types of Fontanelles:
 Anterior fontanelle – diamond-shaped fontanelle. This fontanelle closes at about 12-18 months and is larger
than the other.
 Posterior fontanelle – triangular-shaped fontanelle. This fontanelle closes between 2-3 months of age and is
smaller.
Measurements of the fetal skull
Transverse diameters of the fetal skull
 Biparietal – 9.25 cm
 Bitemporal – 8 cm
 Bimastoid – 7 cm
Anteroposterior (AP) diameter
 Suboocipitobregmatic – 9.5 cm (the narrowest AP diameter). This measurement is taken from below the
occiput to the anterior fontanelle.
 Occipitofrontal – 12 cm (from the occiput to the mid-frontal bone)
 Occipitomental – 13.5 cm (the widest AP diameter). This measurement is taken from the occiput to the chin.
Which one of these diameters is presented at the birth canal depends on the degree of flexion, which is known as
the ATTITUDE, the fetal head assumes prior to delivery.
Gestational Diabetes
1. Gestational diabetes is abnormal carbohydrate, fat, and protein metabolism that is first diagnosed during
pregnancy, regardless of the severity.
2. Gestational diabetes is further classified as:
 Gestational diabetes characterized by an abnormal glucose tolerance test (GTT) without other
symptoms. Fasting glucose is normal and the diabetes is controlled by diet (A1).
 Gestational diabetes characterized by abnormal glucose tolerance test and elevated fasting glucose.
This type of gestational diabetes must be controlled by insulin (A2).
3. About 15,000 infants are born to mothers with diabetes each year. Since 1980, the International Workshop-
Conference on gestational Diabetes and the American Diabetic Association has recommended universal
screening for gestational diabetes between 24 and 28 weeks of gestation.
Etiology
 Gestational diabetes is a disorder of late pregnancy (typically), caused by the increased pancreatic
stimulation associated with pregnancy.
Pathophysiology
1. In gestational diabetes mellitus (type III, GDM), insulin antagonism by placental hormones, human placental
lactogen, progesterone, cortisol, and prolactin leads to increased blood glucose levels. The effect of these
hormones peaks at about 26 weeks’ gestation. This is called the diabetogenic effect of pregnancy.
2. The pancreatic beta cell functions are impaired in response to the increased pancreatic stimulation and
induced insulin resistance.
3. Pregnancy complicated by diabetes puts the mother at increased risk for the development of complications,
such as spontaneous abortion, hypertensive disorders, and preterm labor, infection, and birth
complications.
4. The effects of diabetes on the fetus include hypoglycemia, hyperglycemia, and ketoacidosis. Hyperglycemic
effects can include:
a. Congenital defects
b. Macrosomia
c. Intrauterine growth restriction
d. Intrauterine fetal death
e. Delayed lung maturity
f. Neonatal hypoglycemia
g. Neonatal hyperbilirubinemia
Assessment Findings
1. Associated findings include a poor obstetric history, including spontaneous abortions, unexplained stillbirth,
unexplained hydramnios, premature birth, low birth weight or birth weight exceeding 4,000 g (8lb, 13 oz),
and birth of a newborn with congenital anomalies.
2. Common clinical manifestations include:
 Glycosuria on two successive office visits
 Recurrent monilial vaginitis
 Macrosomia of the fetus on ultrasound
 Polyhydramnios
 Fasting blood sugar test will reveal elevated blood glucose levels.
 A 50-g glucose screen (blood glucose level is measured 1 hour after client ingests a 50-g glucose drink)
reveals elevated blood glucose levels. The normal plasma threshold is 135 to 140 mg/dL.
 A 3- hour oral glucose tolerance test (performed if 50-g glucose screen results are abnormal) reveals
elevated blood glucose levels. (Table 1)
 The glycosylated hemoglobin (HbA 1c) test (measures glycemic control in the 4 to 8 weeks before the
test is performed; performed on women with pre-existing diabetes) results reflect enzymatic bonding of
glucose to hemoglobin A amino acids. This is a useful indicator of overall blood glucose control. The
upper normal level of HbA1c is 6% of total hemoglobin.
 Screens for fetal (and later, neonatal) complications, including:
6.
 Maternal serum alpha-fetoprotein level to assess risk for neural tube defects in newborn.
 Ultrasonography to detect fetal structural anomalies, macrosomia, and hydramnios.
 Nonstress test (as early as 30 weeks), contraction stress test, and biophysical profile because of
risk of unexplained intrauterine fetal demise in the antepartum period.
 Lung maturity studies (by amniocentesis) to determine lecithinsphingomyelin (L/S) ratio and to
detect phosphatidylglycerol (PG); the adequacy of L/S and PG, predictor of the newborn’s ability to
avoid respiratory distress
Nursing Management
1. Establish an initial database, and maintain serial documentation of test results throughout the pregnancy.
 Assess the client’s understanding of GDM and its implications for daily life.
 As needed, explain the effects of gestational diabetes on the mother and fetus.
 Point out the need for frequent laboratory testing and follow-up for mother and fetus, for example, to prevent
infection and assess other potential complications.
 Discuss and demonstrate insulin self-injection
Table 1
Normal Glucose Tolerance Test Values
TEST TIMING VENOUS PLASMA WHOLE BLOOD PREGNANT
Fasting <105 mg/dL <90 mg/dL 105 mg/dL
1 hr <190 mg/dL <170 mg/dL 190 mg/dL
2 hr <165 mg/dL <145 mg/dL 165 mg/dL
3 hr <145 mg/dL <125 mg/dL 145 mg/dL

 Demonstrate how to self-monitor blood glucose level. Explain that blood is generally tested daily before meals
and at bedtime.
 Explain the need to test urine for ketones, which are harmful to the fetus.
 Point out the importance of keeping daily records of blood glucose values, insulin dose, dietary intake,
periods of exercise, periods of hypoglycemia, kind and amount of treatment, and daily urine test results.
 Discuss potential complications and their management.
 Diabetic ketoacidosis is a multisystem disorder resulting from hyperglycemia in which plasma glucose
levels exceed 350 mg/dL. (Table 3)
 Hypoglycemia is a disorder caused by too much insulin, insufficient food, excess exercise, diarrhea, or
vomiting. Client and Family Teaching Table 4 list signs and symptoms of hypoglycemia and
hyperglycemia.
 (a) Discuss the management of hypoglycemia by administering 12 fluid oz of orange juice (or 20 g
of carbohydrates) and waiting 20 minutes before repeating the procedure.
 (b) Report the episode to the health care provider as soon as possible.
 Explain the need for continued evaluation during the postpartum period until blood glucose levels are within
normal limits.
3. Arrange for the client to consult with a dietitian to discuss the prescribed diabetic diet and to ensure adequate
caloric intake(Table 2)
Table 2
Generally recommended Caloric Intake for Pregnant Diabetic Women
CATEGORY KCAL/LB PER DAY TOTAL GAIN
Adult 16.4 24-30 lb
Adolescent 20.5 30 lb
Underweight 22.7 30 lb
Obese 13.6 20 lb
4. Address emotional and psychosocial needs. Intervene appropriately to allay anxiety regarding diabetes and
childbirth.
5. Prepare the client for intensive frequent intrapartum assessment, which may include:
 Fetal monitoring
 Intravenous infusion of glucose, insulin, and oxytocin
 Evaluation for diabetic ketoacidosis (signs and symptoms include altered level of consciousness, labored
breath sounds, fruity breath odor, and ketonuria)
 Intravenous fluid and electrolyte replacement therapy
 Invasive maternal cardiac monitoring
6. Identify and make referral to support groups and resources available to the client and family.
Table 3
Laboratory Values in Diabetic Ketoacidosis (DKA)
DEGREE OF DKA TOTAL CO pH
Mild 21-28mEq/L >7.30
Moderate 11-20 mEq/L 7.10-7.30
Severe <10 mEq/L <7.10

Table 4
Client and Family Teaching
HYPOGLYCEMIA HYPERGLYCEMIA
 Shakiness, dizziness
 Sweating
 Pallor, cold, clammy skin
 Disorientation, irritability
 Headache
 Hunger  Fatigue
 Blurred vision  Flushed, hot skin
 Nervousness  Dry mouth, excessive thirst
 Weakness, fatigue  Frequent urination
 Shallow respirations, but normal pulse rate  Rapid, deep respirations, fruity odor
 Urine negative for glucose and acetone  Depressed reflexes
 Blood glucose level below 60 mg/dL  Drowsiness, head
Gestational Trophoblastic Disease (Hydatidiform mole)
1. Hydatidiform mole is an alteration of early embryonic growth causing placental disruption, rapid
proliferation of abnormal cells, and destruction of the embryo.
2. There are two distinct types of hydatidiform moles-complete and partial.
 In a complete mole, the chromosomes are either 46XX or 46XY but are contributed by only one parent
and the chromosome material duplicated. This type usually leads to choriocarcinoma.
 A partial mole has 69 chromosomes. There are three chromosomes for every pair instead of two. This
type of mole rarely leads to choriocarcinoma.
Etiology
 The etiology of hydatidiform moles is unknown. Genetic, ovular, or nutritional abnormalities could possibility
be responsible for trophoblastic disease.
Pathophysiology
1. A hydatidiform mole is a placental tumor that develops after pregnancy has occurred; it may be benign or
malignant. The risk of malignancy is greater with a complete mole.
2. The embryo dies and the trophoblastic cells continue to grow, forming an invasive tumor.
3. It is characterized by ploriferation of placental villi that become edematous and form grapelike clusters. The
fluid- filled vesicles grow rapidly, causing the uterus to be larger than expected for the duration of
pregnancy.
4. Blood Vessels are absent, as are a fetus and an amniotic sac.
Assessment Findings
1. Clinical manifestation
a. Vaginal bleeding (may contain some of the edematous villi)
b. Uterus larger than expected for the duration of the pregnancy.
c. Abdominal cramping from uterine distention.
d. Signs and symptoms of preeclampsia before 20 weeks gestation
e. Severe nausea and vomiting
a. hCG serum levels are abnormally high.
b. Ultrasound reveals characteristics appearance of molar growth.
Nursing Management
1. Ensure physical well being of the client through accurate assessment and interventions.
 Review pertinent history and history of this pregnancy.
 Prepare for suction curettage evacuation of the uterus (induction of labor with oxytocic agents or
prostaglandins is not recommended because of the increased risk of hemorrhage).
 Administer intravenous fluids as prescribed.
 Ensure appropriate follow-up and self-care by explaining that frequent possibility of recurrence of the
problem or progression to choriocarcinoma. Also explain that hCG levels should be monitored for 1 year.
 Discuss the need to prevent pregnancy for at least 1 year after diagnosis and treatment.
 Inform the client that oral birth control agents are not recommended because they suppress pituitary
luteinizing hormone, which may interfere with serum hCG measurement.
 Describe and emphasize signs and symptoms that must be reported (i.e., irregular vaginal bleeding,
persistent secretion from the breast, hemoptysis, and severe persistent headaches). These symptoms may
indicate spread of the disease to other organs.
Hemolytic Disease of the Fetus and Newborn
1. Hemolytic disease of the fetus and newborn is an immune reaction of the mother’s blood against the blood
group factor on the fetus RBCs.
2. When RhoGAM (Rh immune globulin) became available in the 1960’s to treat isoimmunization in Rh-
negative women, the incidence of hemolytic disease in the fetus and newborn dropped significantly.
Etiology
1. Hemolytic disease occurs most frequently when the mother does not have the Rh factor present in her blood
but the fetus has this factor. Another common cause of hemolytic disease is ABO incompatibility. In most
cases of ABO incompatibility, the mother has blood type O and the fetus has blood type A. It may also occur
when the fetus has blood type B or AB.
2. Hemolysis is occasionally caused by maternal anemias, such as thalassemia or from other blood group
antigens (anti-D).
Pathophysiology
1. This disorder occurs when the fetus has a blood group antigen that the mother does not posses. The
mother’s body forms an antibody against that particular blood group antigen, and hemolysis begins. The
process of antibody formation is called maternal sensitization.
2. The fetus has resulting anemia from the hemolysis of blood cells. The fetus compensates by producing large
numbers of immature erythrocytes, a condition known as erythroblastosis fetalis, hemolytic disease of the
newborn, or hydrops fetalis. Hydrops refers to the edema and fetalis refers to the lethal state of the infant.
3. In Rh incompatibility, the hemolysis usually begins in utero. It may not affect the first pregnancy but all
pregnancies that follow will experience this problem. In ABO incompatibility, the hemolysis does not usually
does not usually begin until the birth of the newborn.
Assessment Findings
 The hemolytic response in ABO incompatibility usually begins at birth with a resulting newborn jaundice.
 Rh incompatibility may lead to:
 Hydramnios in the mother
 Excess bilirubin levels in the amniotic fluid.
 Varying degrees of hemolytic anemia (erythroblastosis) in the fetus. If the condition is left unmanaged,
25% of affected infants may die or suffer permanent brain damage.
 The indirect Coombs test can aid in the search for agglutination of Rh-positive RBCs to determine if
antibodies are present.
 Amniocentesis is used to determine optical density and estimate fetal hemolysis. Spectrophotometer readings
are made of the amniotic fluid collected. The readings are obtained to determine fluid density. They are
plotted on a graph and correlated with gestational age. The amount of bilirubin resulting from the hemolysis
of red blood cells can then be estimated.
 An antibody titer should be drawn at the first prenatal visit on all Rh-negative women. It should also be
drawn at 28 and 36 weeks of pregnancy and again at delivery or abortion. The normal value is 0. The result
is usually reported as a ratio; normal is 1:8. If the titer is absent or minimal (1:8), no therapy is needed. A
rising titer indicates the need for RhoGAM and vigilant monitoring of fetal well-being.
Nursing Management
1. Administer RhoGAm to the unsensitized Rh-negative client as appropriate
 Administer RhoGAM at 28 weeks’ gestation, even when titers are negative, or after any invasive procedure,
such as amniocentesis. RhoGAM protects against the effects of early transplacental hemorrhage (as
recommended by the American College of Gynecologists).
 When the Rh-negative mother is in labor, crossmatch for RhoGAM, which must given within 72 hours of
delivery of the newborn.
2. Provide management for the sensitized Rh-negative mother and Rh-positive fetus.
 Focus management of the sensitized Rh-negative mother on close monitoring of fetal well-being, as reflected
by Rh titers, amniocentesis results, and sonography.
 If there is evidence of erythroblastosis, notify the perineal team of the possibility for delivery of a
compromised newborn.
3. Provide management for ABO incompatibility.
 Phototherapy usually can resolve the newborn jaundice associated with ABO incompatibility.
 In addition, initiation of early feeding and exchange blood transfusions may be immediate measures required
to reduce indirect bilirubin levels.
 Provide client and family teaching.
Human Chorionic Gonadotropin (hCG) Pregnancy Test
 As a qualitative analysis of urine levels of human chorionic gonadotropin (hCG), this test can detect
pregnancy as early as 14 days after ovulation. A glycoprotein that is produced after conception, hCG
prevents degeneration of the corpus luteum at the end of a normal menstrual cycle.
 During the first trimester, hCG levels rise steadily and rapidly, peaking around 10 weeks’ gestation, and
subsequently taper off to less than 10% of peak levels. The most common and inexpensive method of
evaluating qualitative and quantitative hCG levels is through hemagglutination inhibition of a urine sample.
The serum hCG test (beta-subunit assay) is a more expensive alternative.
Purpose
 To detect and confirm pregnancy.
 To help diagnose hydatiform mole of hCG-secreting tumors, threatened abortion, or dead fetus.
Procedure
Patient Preparation
1. If appropriate, explain to the patient that the urine hCG test determines whether she’s pregnant or
determines the status of her pregnancy.
2. Alternatively, explain how the test functions as a screen for some types of cancer.
3. Tell the patient that she need not to restrict food but should restrict fluids for 8 hours before the test.
4. Inform the patient that the test requires a first-voided morning specimen or urine collection over a 24-hour
period, depending on whether the test is qualitative or quantitative.
5. Notify the laboratory and physician of drugs the patient is taking that may affect test results; it may be
necessary to restrict them.
Implementation
1. For verification of pregnancy (qualitative analysis), collect a first-voided morning specimen. If this isn’t
possible, collect a random specimen.
2. For quantitative analysis of hCG, collect the patient’s urine over a 24-hour period in the appropriate
container, discarding the first specimen and retaining the last.
3. Specify the date of the patient’s last menstrual period on the laboratory request.
4. Refrigerate the 24 hour specimen or keep it on ice during the collection period.
5. Be sure the test occurs at least 5 days after a missed period to avoid a false-negative result.
Nursing Interventions
1. Instruct the patient to resume her usual diet and medications.
Interpretation
Normal Results
 In a qualitative immunoassay analysis, results are negative (nonpregnant) or positive (pregnant) for hCG.
 In a qualitative analysis, urine hCG levels in the first trimester of a normal pregnancy may be as high as
500,000 IU/24 hours; in the second trimester, from 10,000 to 25,000 IU/24 hours.
 Measurable hCG levels don’t normally appear in the urine of men or nonpregnant women.
Abnormal Results
 During pregnancy, elevated urine hCG levels may indicate multiple pregnancy or erythoblastosis fetalis;
depressed urine hCG levels may indicate threatened abortion or ectopic pregnancy.
 Measurable levels of hCG in men and nonpregnant women may indicate choriocarcinoma, ovarian or
testicular tumors, melanoma, multiple myeloma, or gastric, hepatic, pancreatic or breast cancer.
Interfering Factors
 Gross proteinuria (greater than 1g/24 hours), hematuria, or an elevated erythrocyte sedimentation rate
(possible false-positive; depending on the laboratory method).
 Early pregnancy, ectopic pregnancy, or threatened abortion (possible false-positive).
 Phenothiazine (possible false negative or false positive)
Complication
 None known.
Hyperemesis Gravidarum
 Hyperemesis gravidarum is severe and excessive nausea and vomiting during pregnancy, which leads to
electrolyte, metabolic, and nutritional imbalances in the absence of the medical problems.
Etiology
 The etiology of hyperemesis gravidarum is obscure; suggested causative factors include:

1. High levels of hCG in early pregnancy
2. Metabolic or nutritional deficiencies
3. More common in unmarried white women and first pregnancies
4. Ambivalence toward the pregnancy or family-related stress
5. Thyroid dysfunction
Pathophysiology
1. Continued vomiting results in dehydration and ultimately deceases the amount of blood and nutrients
circulated to the developing fetus.
2. Hospitalization may be required for severe symptoms when the client needs intravenous hydration and
correction of metabolic imbalance.
Assessment Findings
 Signs and symptoms occur during the first 16 weeks of pregnancy and are intractable.
1. Clinical manifestations include:
 Unremitting nausea and vomiting.
 Vomitus initially containing undigested food, bile, and mucus; later containing blood and material that
resembles coffee grounds
 Weight loss
2. Other common signs and symptoms include:
 Pale, dry skin
 Rapid pulse
 Fetid, fruity breath odor from acidosis
 Central nervous system effects, such as confusion, delirium, headache, and lethargy, stupor, or coma.
Nursing Management
1. Promote resolution of the complication.
 Make sure that the client is NPO until cessation of vomiting.
 Administer intravenous fluids as prescribed; they may be given on an ambulatory basis when dehydration is
mild.
 Measure and record fluid intake and output.
 Encourage small frequent meals and snacks once vomiting has subsided.
 Administer antiemetics as prescribed.
2. Address emotional and psychosocial needs. Maintain a non judgmental atmosphere in which the client and
family can express concerns and resolve some of their fears.
Integrated Management of Childhood Illness (IMCI)
The Integrated Management of Childhood Illness or IMCI has several key points in the promotion and restoration
of health of children in the community. It has been improved to provide a more integrated approach to managing
sick children by UNICEF in cooperation with the World Health Organization.
The main objectives of IMCI involves the reduction of significantly global child mortality and morbidity associated
with the major causes of illness and as well contribute to the promotion of healthy growth and development of
children.
Its components basically encompass the improvement of several aspects of health in the community, which are:
 Skills of health workers in case management
 Health care delivery system
 Family and community health practices
The Integrated Management of Childhood Illness does not only emphasize the adjustment of curative interventions
in the community but to encourage the active involvement of family members and the community in the health
care process. Thus, health teaching/ counselling as an essential component in the improvement of health is being
utilized in IMCI.
This guide manual is being utilized by health care workers in the:
 Assessment and classification (color coded)
 Identification of appropriate treatment
 Treatment or referral
 Provision of health teaching and counselling
 Giving instructions for follow- up in the rural health unit
Case management of sick children covers those infants aged up to 2 months old and children aged 2 months old
up to 5 years. These children are assessed for any “general danger signs” which indicate the need for immediate
referral to hospital facility. In addition, the common major symptoms are also checked. The child’s nutritional and
immunization status, feeding problems, and other potential problems are also noted and dealt with.
In the new edition of Integrated Management of Childhood Illness, the health workers are not only task to provide
interventions for the sick child but also to give health teachings with regards to mother’s health and how to
express breast milk.
Furthermore, the common major health problems addressed in IMCI are: Pneumonia, Dysentery, and persistent
diarrhea, Malaria, Measles with eye or mouth complications, ear infection, feeding problem, anemia, pallor, very
low weight, and severe uncomplicated malnutrition for children aged 2 months old up to 5 years. While local
bacterial infection, jaundice, diarrhea, and feeding problem, low weight for age and thrush are being given
importance for infants aged up to 2 months old.
Incompetent Cervix
1. Incompetent cervix is characterized by a painless dilation of the cervical os without contractions of the
uterus.
2. Incompetent cervix commonly occurs at about the 20th week of pregnancy.
Etiology
1. History of traumatic birth

2. Repeated dilation and curettage
3. Client’s mother treated with diethylstilbestrol (DES) when pregnant with the client
4. Congenitally short cervix
5. Uterine anomalies
6. Unknown etiology
Pathophysiology
 Connective tissue structure of the cervix is not strong enough to maintain closure of the cervical os during
pregnancy.
Assessment findings
a. History of cervical trauma
b. History of repeated, spontaneous, second trimester terminations
c. Possibly spontaneous rupture of the membranes
2. A common clinical manifestation is appreciable cervical dilation with prolapsed of the membranes through the
cervix without contractions.
Nursing Management
1. Provide client and family teaching. Describe problems that must be reported immediately (ie,pink-tinged vaginal
discharge, increased pelvic pressure, and rupture of the membranes).
2. Maintain an environment to preserve the integrity of the pregnancy.
a. Prepare for cervical cerclage, if appropriate.
Maintain activity restrictions as prescribed.
c. Discuss the need for vaginal rest (ie, no intercourse or orgasm)
3. Prepare for the birth if membranes are ruptured.
Induction of Labor
1. The deliberate initiation of labor before spontaneous contractions begin may be either mechanical
(amniotomy [ie, rupture of amniotic membranes]), physiologic (ambulation and nipple stimulation), or
chemical (prostaglandins and oxytocin).
2. Artificial rupture of membranes (AROM) may be adequate stimulation to initiate contractions, or AROM may
be done after oxytocin administration establishes effective contractions.
3. Induction and AROM are initiated when the cervix is soft, partially effaced, and slightly dilated, preferably
when the fetal presenting part is engaged.
4. Oxytocin-induced labor must be done with careful, ongoing monitoring; oxytocin is a powerful drug.
Hyperstimulation of the uterus may result in tonic contractions prolonged to more than 90 seconds, which
could cause fetal compromise due to impaired uteroplacental perfusion, abruption placentae, and laceration
of the cervix, uterine rupture, and neonatal trauma.
Nursing Management
1. Monitor for safe labor and delivery process.
a. AROM
 Explain the procedure, and inform the client that labor usually follows within 6 to 8 hours of AROM.
 Monitor fetal heart tones immediately before, during, and after the procedure.
 Observe and record color, amount, and odor of amniotic fluid; time of procedure; cervical status; and
materbal temperature.
 Take and record the client’s temperature every 2 hours to assess for infection.
 Monitor for the onset of labor.
b. Medication- induced labor (see Table 1)
Table 1
Medication Used for Intrapartum Complications
Classifications Used for Selected Interventions
Suppository (prostaglandin) is inserted every 2

hours times 3.Keep the suppository cold and
bring it to room temperature before insertion.
After insertion, have the client remain dorsal
Stimulates uterine recumbent for 15-30 min.The gel is inserted
Prostaglandin smooth muscle to into the cervical os by catheter two times; 6
Dinoprostone contractInitiates hours apart.Monitor for the following side
(Prepidil, Prostin softening, effacement, effects: headache, nausea, vomiting,
E2 [suppository and dilation of the hypotension, hypertension, dyspnea, and
or gel] cervix uterine hyperstimulation.
Oxytocicn is infused at a rate of 1-2 mU/min

and increased by 1-2 mU/min every 15-30
minutes until a contraction pattern is
establishedMonitor vital signs and fetal heart
rate closely.Assess the contractile
Oxytocic pattern.Limit IV fluids to 150 mL/hour.
Oxytocin (Pitocin, Mix 10 IU oxytocin in 1000 mL Ringer’s lactate
Syntocinon and hang as a “piggy back” solution. Always
[intravenous Used for induction of use the infusion port closest to the client.
drip]) labor Monitor for water intoxication.
 Review the hospital’s policy relative to the amount, rate, and interval for increasing oxytocin or a
prostaglandin- based preparation.
 Use an infusion pump for precise regulation of the medication.
 Observe for signs of hypertonicity, such as contractions exceeding 75 mm Hg (when using the internal
pressure catheter), exceeding 90 seconds, or closer than 2 minutes. Be prepared to discontinue the
medication immediately.
 Initiate continuous internal or external fetal monitoring, and evaluate for normal range of 110 to 120 to 150
to 160 beats/ min. If there is loss of variability, late decelerations, or persistent bradycardia (fewer than 120
beats /min), discontinue medication, administer oxygen notify physician, reposition client to side lying
position, and perform a vaginal examination; fetal distress may result from rapid labor progress, descent of
fetus, or cord prolapse.
 Assess and record vital signs and fetal heart rate (FHR) every 15 to 30 minutes, depending on the stage of
labor and risk status; assess for signs of impending delivery.
Infant of a Diabetic Mother (IDM)
 May be SGA or LGA, with or without congenital anomalies and with or without birth injury.
Etiology
 IDM is caused by chronic hyperglycemia in the mother (e.g., gestational diabetes mellitus or long-term
diabetes mellitus with or without vascular changes).
Pathophysiology
1. Hyperglycemia in the mother without vascular changes causes large amounts of amino acids, free fatty
acids, and glucose to be transferred to the fetus, but maternal insulin does not cross the placenta.
 The fetal response to these transferred substances includes:
2.
 Islet cells of the pancreas enlarge (hypertrophy).
 Hypertrophic cells produce large volumes of insulin, which acts as a growth hormone, and protein
synthesis accelerates.
 Fat and glycogen are deposited in fetal tissue, and the fetus grows large (macrosomia), especially if
maternal blood glucose levels are not well controlled in the third trimester.
 Various unknown factors also may contribute to changes.
2. In maternal long-term diabetes with vascular changes, the newborn may be SGA because of compromised
placental blood flow, maternal hypertension, or pregnancy-induced hypertension, which restricts
uteroplacental blood flow.
3. Associated complications in IDM include:
 Fractures and nerve damage may occur from birth trauma if the infant is LGA.
 Congenital anomalies (e.g., heart, kidney, vertebral, and CNS) are three to five times more common,
with incidence decreasing if maternal blood glucose levels remain controlled and normal during the first
trimester.
 Risk for respiratory distress syndrome increases (high insulin levels interfere with production of
pulmonary surfactant).
 Hypoglycemia may result after birth from lack of glucose from the mother, but continued production of
insulin by the newborn.
 Hypocalcemia may result from decreased parathyroid hormone production.
 Polycythemia (ie, hematocrit exceeding 65%) may result from placental insufficiency causing chronic
fetal hypoxia and increased fetal erythropoietin production.
 Organ damage may result from decreased blood flow and renal vein thrombosis.
 Hyperbilirubinemia may result from breakdown of excess RBCs after birth.
Assessment Findings
 Congenital anomalies are more likely in IDMs who are SGA than in other SGA newborns.
 Size differences and variations are more common in IDMs who are LGA than in other LGA newborns.
 Greater size results from fat deposits and hypertrophic liver, adrenals, and heart.
 Length and head size are usually within normal range for gestational age.
 Observation reveals the characteristics appearance of a round, red face and an obese body.
 Possible signs and symptoms of hypoglycemia include jitteriness, irritability, diaphoresis, and blood glucose
level less than 45 mg/dL.
 Possible signs and symptoms of hypocalcemia include jitteriness, twitching, and a high-pitched cry.
 Blood glucose evaluation at 30 and 60 minutes and at 2,4,6, and 12 hours after birth as directed by nursery
protocol
 If results are abnormal, repeat testing every 30 to 60 minutes until newborn achieves stable level; also
test before each feeding for 24 hours.
 If reagent strips indicate blood glucose levels less than 45 mg/dL, findings should be verified by
laboratory and reported to pediatrician.
 Serum electrolyte studies may reveal hypocalcemia (total serum calcium mg/dL).
 Hematocrit level may be elevated, indicating polycythemia.
Nursing Management
1. Establish an initial database.
 Review the mother’s health history and history of the pregnancy.
 Complete an initial newborn examination and assess for birth injuries.
2. Monitor for complications.
 Monitor for signs and symptoms of hypoglycemia (see table 1)
 Measure the newborn’s glucose level according to nursery protocol.
 Feed the newborn early according to nursery protocol to prevent or treat hypoglycemia.
 If signs and symptoms continue after feeding, observe for other complications.
 Monitor for signs of hypocalcemia (see table 2)
 Obtain hematocrit value; report the findings to the physician.
 Observe for signs of respiratory distress (e.g., nasal flaring, grunting, retractions, and tachypnea).
 Initiate gavage feeding if the newborn cannot suck well or if the respiratory rate exceeds normal (30 to 60
breaths per minute).
3. Maintain a neutral thermal environment.
Table 1 Signs and Symptoms of Hypoglycemia
 Shakiness, dizziness
 Sweating
 Pallor, cold, clammy skin
 Disorientation, irritability
 Headache
 Hunger
 Blurred vision
 Nervousness
 Weakness, fatigue
 Shallow respirations, but normal pulse rate
 Urine negative for glucose and acetone
 Blood glucose level below 60 mg/dL
Table 2 Signs of Hypocalcemia

 Tetany
 Paresthesia of fingers and around the mouth
 Muscle twitching
 Cramps
 Laryngospasms
 Elevated phosphorous levels
Infections during Pregnancy
1. Maternal infections during pregnancy may contribute significantly to fetal morbidity and mortality.
2. Two of the most common groups of infections present during pregnancy are sexually transmitted infections
and TORCH infections.
Sexually transmitted infections include:
1. Chlamydia
2. Gonorrhea
3. Group B streptococcus
4. Hepatitis B
5. Human papillomavirus
6. Syphilis
7. Trichomonas
8. Candidiasis
9. Bacterial vaginosis
10. Human immunodeficiency virus (HIV)
TORCH infections include:
1. Toxoplasmosis
2. Other infections- hepatitis A, infectious hepatitis, hepatitis C, or syphilis
3. Rubella
4. Cytomegalovirus
5. Herpes simplex virus
Etiology
1. Infections in this category may be caused by various viruses. Other organisms such as bacteria, spirochetes,
protozoa, or yeast also may cause maternal infections, which are harmful to the developing fetus. Even
though the infection in the mother may be very mild, the effects on the fetus can be catastrophic.
2. The infections organism may be acquired during sexual intercourse, through the use of contaminated
articles, such as needles; from human body fluids (semen, saliva, blood, urine, cervical mucus, breast milk,
and stool); by eating undercooked meat; or by contact with infected cat feces in the litter box, sand box, or
garden soil.
3. Most organisms cross the placenta and infect the fetus, causing birth anomalies. The fetus may also acquire
the organism as it travels the birth canal during labor, causing illness after birth.
Pathophysiology
1. These infections organisms are capable of crossing the placenta and adversely affecting the development of
the fetus. Spontaneous abortion or fetal newborn abnormalities may occur.
2. In some instances, the infection can also cause infertility or sterility in the mother.
Assessment Findings For Sexually Transmitted Diseases
a. Previous history of sexually transmitted disease or pelvic inflammatory disease.
b. Numerous sexual partners
c. Use of intravenous drugs or partners who use intravenous drugs
2. Common clinical manifestations
a. PROM
b. Preterm birth
c. Systemic fetal infection
3. Laboratory and diagnostic study findings. Serologic and culture testing will reveal infection.
Assessment Findings For Torch Infections
a. Influenza-type symptoms
b. Rash
c. Lymphedema and lymphadenopathy
2. Laboratory and diagnostic study findings. Serologic and culture testing will reveal infection.
Implementation
1. Carefully screen for infections during pregnancy and treat possible infections as ordered.
 At the first prenatal visit, the pregnant woman should have a rubella titer drawn. A titer of 1:8 provides
evidence of immunity. If the titer is below 1:8, rubella vaccine is offered to the woman before discharge
postpartum. Those women who require the vaccine should be cautioned not to become pregnant for at least
3 months afterward.
 Cytomegalovirus currently has no effective therapy. This is important to remember because the highest rate
of maternal infections occurs between the ages of 15 and 35. Usually, the infection is symptomatic.
 Women who are presumed to be susceptible to varicella-zoster (chicken-pox) should have immune testing.
Varicella-zoster immune globulin should be administered to those who are susceptible or who have been
exposed. Varicella-zoster immune globulin should be administered to the exposed newborn within 72 hours
of their birth.
 All pregnant women should be screened for HbsAg, the hepatitis B surface antigen. The hepatitis B immune
globulin can prevent infection in both mother and newborn. An initial injection can be given to the newborn,
followed by doses given at 1 month and 6 months of age. Adults receive three injections that are given over a
6- to 12-month period.
2. Provide client and family teaching regarding the diagnosis of infection to promote compliance with the
treatment plan.
 Explain how maternal infections are acquired and transmitted to the developing fetus during pregnancy.
 Demonstrate proper handwashing technique, stressing that it is the single most successful means of
preventing infection.
 Discuss hygienic and dietary measures that reduce the risk of infection.
 Explain the organism, test, treatment, and fetal effects of the specific infection to the client and family.
 Include the client in planning solutions for possible fetal effects.
 Discuss “safe sex” with the client and partner.
 Seek the couple’s input for development of a plan for follow-up care.
Large-for-Gestational Age (LGA) Newborn
1. A LGA newborn is one weighs more than 4,000 g, is above the 90th percentile, or is two standard deviations
above the mean.
2. The LGA infant can be pre-term, term, or post-term.
Etiology
Predisposing factors include:
1. Genetic predisposition
2. Excessive maternal weight gain during pregnancy.
3. Poorly controlled maternal diabetes secondary to high levels of maternal glucose that cross the placenta
during pregnancy.
Pathophysiology
1. Infants who are large for gestational age have been subjected to an overproduction of growth hormone in
utero. This most frequently happens with infants of diabetic mothers who are poorly controlled. It may also
occur in multiparous pregnancies because with each pregnancy babies tend to grow larger.
2. Other associated conditions include transposition of the great vessels, Beckwith syndrome and congenital
anomalies.
Assessment Findings
1. Complications associated with maternal diabetes
2. Birth injuries due to disproportionate size of newborn to birth passageway
a. Fractured clavicle
b. Facial nerve injury
c. Erb-Duchenne palsy or brachial plexus paralysis
d. Klumpke paralysis
e. Phrenic nerve palsy
f. Possible skull fracture
Nursing Management
1. If IDM, observe for potential complications 2. Monitor for, and manage, birth injuries and complications of birth
injuries.
a. Clavicle fracture
 Confirm by x-ray.
 Assess the infant for crepitus, hematoma, or deformity over the clavicle; decreased movement of arm on the
affected side; and asymmetrical or absent. Moro reflex.
 Limit arm motion by pinning the infant’s sleeve to the shirt.
 Manage the pain
b. Facial nerve injury
 Assess for symmetry of mouth while crying.
 Wrinkles are deeper on the unaffected side.
 The paralyzed side is smooth with a swollen appearance.
 The nasiolabial fold is absent.
 If the eye is affected, protect it with patches and artificial tears.
c. Erb-Duchenne palsy and Klumpke paralysis
 Erb-Duchenne palsy. Assess for adduction of the affected arm with internal rotation and elbow extension.
The Moro reflex is absent on the affected side. The grasp reflex is intact.
 Klumpke paralysis. Assess for absent grasp on the affected side. The hand appears claw-shaped.
 Management includes:

 X-ray studies of the shoulder and upper arm to rule out bony injury
 Examination of the chest to rule out phrenic nerve injury
 Delay of passive movement to maintain range of motion of the affected joints until the nerve edema
resolves (7 to 10 days)
 Splints may be useful to prevent wrist and digit contractures on the affected side
d. Phrenic nerve palsy
 Assess for respiratory distress with diminished breath sounds.
 X-ray usually shows elevation of the diaphragm on the affected side.
 Provide pulmonary toilet to avoid pneumonia during the recovery phase (1 to 3 months).
e. Skull fracture.
 Assess for soft-tissue swelling over fracture site, visible indentation in scalp, cephalhematoma, positive skull
x-ray, and CNS signs with intracranial hemorrhage (e.g., lethargy,seizures, apnea, and hypotonia).
Mammography
 Mammography is a radiographic technique used to detect breast cysts or tumors, especially those not
palpable on physical examination. In xeromammography, a specially charged plate records the radiographic
images and transfers them to a special paper. Biopsy of suspicious areas may be required to confirm
malignancy. Although 90% to 95% of malignant breast tumors can be detected by mammography, this test
produces many false positive results. Mammography may follow such screening procedures as
ultrasonography or thermography.
Purpose
 To screen for malignant breast tumors.
 To investigate breast masses, breast pain, or nipple discharge.
 To differentiate between benign breast disease and malignant tumors.
 To monitor patients with breast cancer who are treated with breast-conserving surgery and radiation.
Procedure
Patient Preparation
1. Instruct the patient to avoid using underarm deodorant or powder the day of the exam.
2. Explain that the test takes about 15 minutes.
3. Explain to the patient that she may be asked to wait while the films are checked.
4. When scheduling the test, inform the staff if patient has breast implants.
5. Make sure the patient has signed an appropriate consent form.
6. Note and report all allergies.
Implementation
1. The patient rests one breast on a table above the X-ray cassette.
2. The compressor is placed on the breast.
3. The patient holds her breath until the X-ray is taken and she’s told to breathe again.
4. An X-ray of the cranicaudal view is taken.
5. The machine is rotated, and the breast is compressed again.
6. An X-ray of the lateral view is taken.
7. The procedure is repeated for the other breast.
8. The film is developed and checked for quality.
Nursing Intervention
1. Answer the patient’s questions about the test.
2. Encourage the patient to deep breathe to alleviate fear and anxiety.
3. Make the patient feel comfortable after the procedure.
4. Prepare to educate the patient about her diagnosis.
5. Prepare the patient for further testing or surgery, as indicated.
Interpretation
Normal Results
 The test reveals normal ducts, glandular tissue, and fat architecture.
 No abnormal masses or calcifications are present.
Abnormal Results
 Irregular, poorly outlined, opaque areas suggest malignant tumors, especially if solitary and unilateral.
 Well-outlined, regular, clear spots may be benign, especially if bilateral.
Interfering Factors
 Powders, deodorants, or salves on the breast and axilla that may cause false positive results.
 Failure to remove jewelry and clothing (possible false-positive results or poor imaging).
 Glandualr breasts that are common in patients younger than age 30, active lactation and previous breast
surgery (possible poor imaging).
 Breast implants (possible hindrance in detecting masses).
Complications
 Vasovagal reaction during compression.
Mastitis
1. Mastitis is inflammation of the breast tissue that is usually caused by infection or by statis of milk in the
ducts.
2. An epidemic mastitis infection is derived from a nosocomial source, usually S. aures, and localizes in the
lactiferous glands and ducts.
3. An endemic mastitis infection occurs randomly and localizes in the periglandular connective tissue.
4. Mastitis infections are largely preventable by prophylactic measures, such as good breast hygiene.
Etiology
 Injury to the breast is the primary predisposing factor (e.g., overdistention, stasis, or cracking of nipples).
Pathophysiology
1. The exact cause of stasis of milk in the ducts is not known.

2. However, missed feedings, a bra that is too tight, or impaired infant suckling are contributory factors.
3. Introduction of an infections organism from either the mother’s hands following improper washing or from
the infant’s mouth is also contributory.
4. In addition, cracked, blistered nipples allow a port of entry for infectious agents.
Assessment Findings
 Because symptoms usually do not occur until the third or fourth postpartum week (or even months later),
teach the client to recognize signs and symptoms of mastitis and to report them to her nurse or physician.
1. Elevated temperature, chills, general aching, malaise, and localized pain
2. Increased pulse rate
3. Engorgement, hardness, and reddening of the breasts
4. Nipple soreness and fissures
5. Swollen and tender axillary lymph nodes
Nursing Management
1. Promote resolution of the infectious process.
 Observe for elevated temperature, chills, tachycardia, headache, pain and tenderness, firmness, and redness
of the breast.
 Administer antibiotics, and explain importance of following through with the prescribed regimen even when
symptoms subside.
 Offer comfort measures, such as small side pillows, icecaps, or heat application over localized abscess.
 Explain how to prevent infection through meticulous handwashing and prompt attention to blocked milk
ducts.
 Encourage the mother to do the following:
 Breast feed frequently
 Perform adequate breast and nipple care (e.g., adequate around-the-clock nonconstrictive support of
the breast, gentleness during care, avoidance of harsh cleansing agents and decrusting the nipple,
frequent breast pad changes, and intermittent exposure of nipples to the air)
 Recognize the signs and symptoms of infection.
Papanicolaou Test (Pap Smear)
 The Papanicolaou test (Pap smear) is a widely known cystologic test for early detection of cervical cancer. The
can also be used to detect cancerous cells of the breast, lung, stomach, and renal system. A physician or
specifically trained nurse scrapes secretions from the patient’s cervic and spreads them on a slide, which is
sent to the laboratory for cystologic analysis.
 An alternative method is to use the ThinPrep preservative solution rather than a slide. The ThinPrep was
introduced in 1996 and allows testing for malignancy cells from the cervix and shows the cell maturity,
metabolic activity, and morphology variations.
 The American Cancer Society recommends a Pap test every 3 years for women between ages 20 and 40 who
aren’t in a high-risk category and who have had negative results from three previous Pap tests. Yearly tests
(or tests at physician-recommended intervals) are advised for women older than age 40, for those in a high
risk category, and for those who had a positive test previously. If a Pap test is positive or suggest
malignancy, cervical biopsy can confirm the diagnosis.
Purpose
 To detect malignant cells.
 To detect inflammatory changes in tissue.
 To assess response to chemotherapy and radiation therapy.
 To detect viral, fungal, and occasionally, parasitic invasions.
Procedure
Patient Preparation
1. Instruct the patient to avoid intercourse for 24 hours, douching for 48 hours, and vaginal creams or
medication for 1 week.
2. Just before the test, instruct the patient to empty her bladder.
3. During the procedure, she might experience a slight discomfort but no pain from the speculum; however,
she may feel some pain when the cervix is scraped.
4. Explain the procedure takes only 5 to 10 minutes to perform.
5. Instruct the patient to disrobe from the waist down and to drape herself.
6. Ask her to lie on the examining table and to place her heels in the stirrups.
7. Tell her to slide her buttocks to the edge of the table.
Implementation
1. The patient is assisted into the lithotomy position with her feet in the stirrups.
2. An unlubricated speculum is inserted into the vagina.
3. The cervix is located.
4. Secretions from the cervix and material from the endocervical canal are collected with an endocervical brush
and wooden spatula.
5. Specimens are spread on slides and immediately immersed in fixative or sprayed with a fixative.
6. Specimens are appropriately labeled with date of last menses, collection site, and method.
7. If vaginal or vulval lesions are present, scrapings taken directly from the lesion are preferred.
8. The slides are preserved immediately.
1. Help the patient up and ask her to dress when the examination is completed.
2. Supply the patient with a sanitary napkin if cervical bleeding occurs.
3. Tell the patient when to return for her next Pap test.
Interpretation
Normal Results
 No malignant cells or abnormalities are present.
Abnormal Results
 Cells with relatively large nuclei, only small amounts of cytoplasm, abnormal nuclear chromatin patterns,
and marked variation in size, shape, and staining properties, with prominent nucleoli, suggest malignancy.
 Atypical but nonmalignant cells suggest a benign abnormality.
 Atypical cells may suggest dysplasia.
Interfering Factors
 Douching within 24 hours of testing.
 Excessive use of lubricating jelly on the slide.
 Collection of specimen during menstruation
 Delay in fixing the specimens
 Consistency of specimen too thin or too thick.
Precautions
 Preserve the slides immediately after the specimen is collected.
 Preserve the ThinPrep solution by immediately placing the lid back on the container, as exposure to air or
light can cause distortion of cells.
Complications
 Bleeding
Placenta Accreta
 Placenta accreta is an uncommon condition in which the chorionic villa adheres to the myometrium. It can
be exhibited as:
1. Placenta accreta- the placental chorionic villi adheres to the superficial layer of the uterine myometrium.
2. Placenta increta– the placental chorionic villi invade deeply into the uterine myometrium.
3. Placenta percreta– the placental chorionic villi grow through the uterine myometrium and often adhere to
abdominal structures (eg, bladder or intestine).
Etiology
 Predisposing factors are prior uterine surgery and placenta previa.

Pathophysiology
 Implantation in an area of defective endometrium with no zone separation between the placenta and the
myometrium.
Assessment Findings
1. Associated findings. Placenta accrete is usually diagnosed in the immediate post partum period when the
placenta fails to separate.
 Placenta fails to separate
 Profuse hemorrhage may result depending on the portion of placenta involved.
Nursing Management
1. Identify placenta accreta in the client. Be aware of the client’s risk status.
2. Assist with rapid treatment and intervention. Be prepared for a D&C or hysterectomy.
Placenta Previa Nursing Care Plan & Management
1. The placenta implants in the lower uterine segment, near the cervical os. The degree to which it covers the os
leads to three different classifications.
 Total placenta previa occurs when the placenta completely covers the internal os.
 Partial placenta previa occurs when the placenta partially covers the internal os.
 Low-lying or low-implantation placenta previa occurs when the placental border reaches the border of
the internal os.
2. The incidence of placenta previa is three to six per 1,000 deliveries
Etiology
Predisposing factors include:
1. Multiparity (80% of affected clients are multiparous)
2. Advanced maternal age (older than 35 years in 33% of cases)
3. Multiple gestation
4. Previous cesarean birth
5. Uterine incision
6. Prior placenta previa (incidence is 12 times greater in women with previous placenta previa)
Pathophysiology
1. Pathologic process seems to be related to the conditions that alter the normal function of the uterine
deciduas and its vascularization.
2. Bleeding, which results from tearing of the placental villi from the uterine wall as the lower uterine segment
contracts and dilates, can be slight or profuse.
Assessment Findings
1. Associated findings. In cases of suspected placenta previa, a vaginal examination is delayed until ultrasound
results are available and the client is moved to the operating room for what is termed a double-set-up
procedure. The operating room is needed because the examination can cause further tearing of the villi and
hemorrhage, which can be fatal to the client and fetus.
2. Common clinical manifestations include:
 Bright red, painless vaginal bleeding
 Soft, nontender abdomen; relaxes between contractions, if present.
 FHR stable and within normal limits.
3. Laboratory and diagnostic study findings. Transabdominal ultrasonography confirms suspicion of placenta
previa.
Nursing Management
1. Ensure the physiologic well-being of the client and fetus.
 Take and record vital signs, assess bleeding, and maintain a perineal pad count. Weigh perineal pads before
and after use to estimate blood loss.
 Observe for shock, which is characterized by a rapid pulse, pallor, cold moist skin, and a drop in blood
pressure.
 Monitor the FHR.
 Enforce strict bed rest to minimize risk to the fetus.
 Observe for additional bleeding episodes.
2. Provide client and family teaching
 Explain the condition and management options. To ensure an adequate blood supply to the mother and
fetus, place the woman at bed rest in a side-lying position. Anticipate the order for a sonogram to localize the
placenta. If the condition of mother or fetus deteriorates, a cesarean birth will be required.
 Prepare the client for ambulation and discharge (may be within 48 hours of last bleeding episode).
 Discuss the need to have transportation to the hospital available at times.
 Instruct the client to return to the hospital if bleeding recurs and to avoid intercourse until after the birth.
 Instruct the client on proper handwashing and toileting to prevent infection.
 Offer emotional support to facilitate the grieving process, if needed.
 After birth of the newborn, provide frequent visits with the newborn that mother can be certain of the
infant’s condition.
Postpartum Hemorrhage
 Postpartum hemorrhage is blood loss of more than 500 mL following the birth of a newborn.
Etiology
1. Early postpartum hemorrhage, which is usually due to uterine atony, lacerations, or retained placental
fragments, occurs in the first 24 hours after delivery.
2. Late postpartum hemorrhage occurs after the first 24 hours after delivery and is generally caused by
retained placental fragments or bleeding disorders.
Pathophysiology
 Delayed uterine atony or placental fragments prevent the uterus from contracting effectively. The uterus is
unable to form an effective clot structure and bleeding ensues or continues.
Assessment Findings
Common clinical manifestations include:
1. Vaginal bleeding is the obvious sign of postpartum hemorrhage; amount and character vary with cause.
2. Signs of impending shock include changes in skin temperature and color, and altered level of consciousness.
Nursing Management
1. Prevent excessive blood loss and resulting complications.
a. Massage the uterus, facilitate voiding, and report blood loss.
b. Monitor blood pressure and pulse rate every 5 to 15 minutes.
c. Prepare for intravenous infusion, oxytocin and blood transfusion, if needed.
d. Administer medications and oxygen as prescribed. ( Drug Chart )
e. Measure and record fluid intake and output.
f. Be prepared for possible dilation and curettage (D&C).
2. Assist the client and family to deal with physical and emotional stresses of postpartum complications.
Drug Chart Medications Used for Postpartum Complications
 Heparin IV should be administered

as a “piggy back” infusion.
 Blocks the conversion of  Heparin SQ is given deep into the
prothrombin to thrombin site (abdomen), sites are rotated,
Anticoagulants and fibrinogen to fibrin do not aspirate, apply pressure (do
Heparin sodium thus decreasing clotting not massage).
injection ability  Used to prevent and treat
(Hepalean)  Inhibits thrombus and pulmonary embolism and
Lovenox clot formation thrombosis.
 Women on anticoagulopathy
therapy should no be given
estrogen or aspirin.
 Obtain baseline coagulation
studies.
 Obtain serial coagulation studies
while the client is on therapy.
 Keep protamine sulfate readily
available in case of heparin
overdose.
 Assess client for bleeding from
nose, gums, hematuria, and blood
in stool.
 Observe color and amount of
lochia. Institute pad count.
 Avoid IM injections to avoid
formation of hematomas.
 Inform the client that this drug
does not pass into breast milk.
 Monitor for the following side
effects; hemorrhage, bruising
urticaria, and thrombocytopenia.
 Women on anticoagulant therapy
should not be given estrogen or
aspirin.
 Obtain baseline coagulation
studies while on therapy.
 Keep AquaMEPHYTON (vitamin K)
on hand in case of Coumadin
overdose.
 Assess client for bleeding from
nose, gums, hematuria, and blood
in stool.
 Interferes with hepatic  Observe color and amount of
Warfarin sodium synthesis of vitamin K – lochia. Institute a pad count.
(Coumadin, dependent clotting  Avoid IM injections to avoid
Warfilone) factors (II,VII, IX, X) formation of hematomas.
 Inform the client that this drug
passes into breast milk and its use
is contraindicated during
pregnancy. Monitor the following
side effects: hemorrhage, fever,
nausea, and cramps.
 Obtain a baseline calcium level.

 Advise the client that this
medication will cause menstrual-
like cramps.
 Assess for numb fingers and toes,
cold, chest pain, nausea, vomiting,
muscle pain, and weakness.
 May cause decreased serum
prolactin.
 IV administration is used for
emergency dosage only.
Administer at a rate of 0.2 mg over
at least 1 minute.
 Directly stimulates  DO NOT MIX THIS DRUG WITH
uterine and vascular ANY OTHER DRUG.
smooth muscle  Use solution only if it is clear and
 Promotes uterine colorless, with no precipitate. May
contraction store at room temperature for 60
 Used for prevention and days. The drug deteriorates with
Oxytoxic treatment of postpartum age.
methylergonovine or postabortion  Monitor for the following side
maleate hemorrhage caused by effects: dyspnea, palpitations,
(methergine) uterine atony or diaphoresis, chest pain,
(PO, IM, IV) subinvolution. hypotension, and headache.
Postpartum Mood Disorders
1. The Diagnostic and Statistical Manual of Mental Disorders contains official guidelines for the assessment and
diagnosis of psychiatric illness. The disorders recognized during the postpartum period are:
 Postpartum blues
 Postpartum depression without psychotic features
 Postpartum depression with psychotic features (postpartum psychosis)
2. Between 50% and 80% of all new mothers report some form of postpartum blues.
3. The incidence of moderate or major postpartum depression or postpartum bipolar disorder ranges from 30 to
200 per every 1,000 live births; the incidence of brief psychotic disorders with postpartum onset is about 1
in every 1,00 live births.
Etiology
1. Predisposing factors include a history of puerperal psychosis, bipolar (for merly manic-depressive) disorder,
delirium and hallucinations, rapid mood changes, agitation or confusion, and the potential for suicide or
infanticide.
2. Postpartum depression with and without psychosis is being studied from three perspectives.
 Biologic theories include alteration in hypothalamic function, possibly related to altered hormonal
influence.
 Psychological theories include poor support systems, psychologic stress, or poor relationship with
partner.
 Socio-cultural theories include low levels of social gratification, support, and control both at work and
in the parenting role.
Assessment Findings
 Serious postpartum depression or psychosis usually does not occur until 3 to 5 days after delivery, at which
time the client is usually discharged from the hospital or birthing center. Clinical manifestations depend on
the type of mood disorder.
1. Postpartum blues manifestations include fatigue, weeping, anxiety, mood instability with onset 1 to 10 days
postpartum and lasting 2 weeks or less.
2. Postpartum depression without psychosis manifestations include confusion, fatigue, agitation, feelings of
hopelessness and shame, and alterations in mood.
3. Postpartum depression with psychosis manifestations include symptoms of postpartum depression plus
delusions, auditory hallucinations, and hyperactivity.
Nursing Management
1. Identify postpartum mood disorders.
a. Be aware of signs and symptoms of postpartum mood disorders.
b. Teach the client and family about these disorders.
2. Support and treat the client and family.
a. Develop specific therapeutic goals.
b. Maintain the prescribed medication schedule.
c. Keep communication open with the health care providers; coordinate social services.
d. Include family participation and involvement in plans of care.
e. Make appropriate referrals.
3. Support efforts at parent-newborn bonding.
a. Provide support for the mother’s continued are of the newborn, if appropriate and safe for the newborn.
b. Plan for continuity of care for the mother, newborn, and family.
Post-term Newborn
 A post-term pregnancy is one that extends beyond 42 weeks’ gestation. The post-term infant may be LGA,
AGA, SGA, or dysmature, depending on placental function.
Etiology
 The cause of prolonged pregnancy is unknown. Factors associated with postmaturity include anencephaly
and trisomy 16 to 18.
Pathophysiolgy
1. If the placenta continues to function well, the fetus will continue to grow, which results in an LGA infant
who may manifest problems such as birth trauma and hypoglycemia.
2. If placental function decreases, the fetus may not receive adequate nutrition. The fetus will utilize its
subcutaneous fat stores for energy. Wasting of subcutaneous fat occurs, resulting in fetal dysmaturity
syndrome. There are three stages of fetal dysmaturity syndrome.
 Stage 1- Chronic placental insufficiency
2.
 Dry, cracked, peeling, loose, and wrinkled skin
 Malnourished appearance
 Open-eyed and alert baby
 Stage 2– Acute placental insufficiency
4.
 All features of stage 1 except point iii
 Meconium staining
 Perinatal depression
 Stage 3– Subacute placental insufficiency
6.
 Findings of stage 1 and 2 except point iii
 Green staining of skin, nails, cord, and placental membrane
 A higher risk of fetal inrapartum or neonatal death
3. The newborn is at increased risk for developing complications related to compromised uteroplacental
perfusion and hypoxia (e.g., meconium aspiration syndrome MAS)
4. Chronic intrauterine hypoxia causes increased fetal erythropoietin and red blood cell production resulting in
polycythemia.
5. Post-term infants are susceptible to hypoglycemia because of the rapid use of glycogen stores.
Assessment Findings
1. A long, thin newborn with wasted appearance, parchment-like skin, and meconium-stained skin, nails, and
umbilical cor. Fingernails are long and lanugo is absent.
2. Meconium aspiration syndrome is manifested by fetal hypoxia, meconium staining of amniotic fluid,
respiratory distress at delivery, and meconium-stained vocal cords.
Nursing Management
1. Manage meconium aspiration syndrome.
 Suction the infant’s mouth and nares while the head is on the perineum and before the first breath is taken
to prevent aspiration of meconium that is in the airway.
 Once the infant is dry and on the warmer, intubate with direct tracheal suctioning.
 Perform chest physiotherapy with suctioning to remove excess meconium and secretions.
 Provide supplemental oxygen and respiratory support as needed.
2. Obtain serial blood glucose measurements.
3. Provide early feeding to prevent hypoglycemia, if not contraindicated by respiratory status.
4. Maintain skin integrity.
 Keep the skin clean and dry.
 Avoid the use of powders, creams, and lotions.
 Avoid the use of tape.
Pregnancy- Induced Hypertension (PIH; preeclampsia and eclampsia)
1. Preeclampsia is a hypertensive disorder of pregnancy developing after 20 weeks’ gestation and characterized
by edema, hypertension, and proteinuria.
2. Eclampsia is an extension of preeclampsia and is characterized by the client experiencing seizures.
Etiology
1. The cause of preeclampsia is unknown.

2. Possible contributing factors include:
 Genetic or immunologic
 Primigravid status
 Conditions that create excess trophoblastic tissue, such as multiple gestation, diabetes, or hydatidiform
mole.
 Age younger than 18 or older than 35 years.
Pathophysiology
 Preeclampsia is a multisystem, vasospatic disease process characterized by hemoconcentration,

hypertension, and proteinuria.
Assessment Findings
1. Clinical manifestations of mild preeclampsia

 Blood pressure exceeding 140/90 mmHg; or increase above baseline of 30 mm Hg in systolic pressure
or 15 mmHg in diastolic pressure on two readings taken 6 hours apart.
 Generalized edema in the face, hands, and ankles (a classic sign)
 Weight gain of about 1.5 kg (3.3 lb) per month in the second trimester or more than 1.3 to 2.3 kg (3 to 5
lb) per week in the third trimester
 Proteinuria 1+ to 2+, or 300 mg/dL, in a 24 hour sample
2. Warning signs of worsening preeclampsia
 Rapid rise in blood pressure
 Rapid weight gain
 Generalized edema
 Increased proteinuria
 Epigastric pain, marked hyperreflexia, and severe headache, which usually precede convulsions in
eclampsia
 Visual disturbances
 Oliguria (<120 mL in 4 hours)
 Irritability
 Severe nausea and vomiting
3. Clinical manifestations of severe preeclampsia
 Blood pressure exceeding 160/110 mm Hg noted on two readings taken 6 hours apart with the client
on bed rest.
 Proteinuria exceeding 5 g/24 hours
 Oliguria (less than 400 mL/24 hours)
 Headache
 Blurred vision, spots before eyes, and retinal edema
 Pitting edema of the sacrum, face, and upper extremities
 Dyspnea
 Epigastric pain
 Nausea and vomiting
 Hyperreflexia
4. Eclampsia exists once the patient has experienced a grand mal seizure. The patient may progress o more
serious complications such as cerebral hemorrhage, liver rupture, and coma.
5. Laboratory and diagnostic study findings. Abdominal test results are provided in Table.
TEST FINDINGS
Blood
Hematocrit >40%
Renal Function >5.5 mg/dL

Serum uric acid >6.0 mg/dL (severe pregnancy-induced hypertension (PIH)
>1.0 mg/dL
Creatinine 2.0-3.0 mg/dL (severe PIH)
Creatinine clearance <150 mL/min
8-10 mg/dL
BUN 10-16 mg/dL (severe PIH)
Coagulation
Platelets <100,000 mL (severe PIH)
Fibrin degradation products >16 mg/mL (severe PIH)
Nursing Management
1. Monitor for, and promote the resolution of, complications.
 Monitor vital signs and FHR.
 Minimize external stimuli; promote rest and relaxation.
 Measure and record urine output, protein level, and specific gravity.
 Assess for edema of face, arms, hands, legs, ankles, and feet. Also assess for pulmonary edema.
 Weigh the client daily.
 Assess deep tendon reflexes every 4 hours.
 Assess for placental separation, headache and visual disturbance, epigastric pain, and altered level of
consciousness.
2. Provide treatment as prescribed.
 Mild preeclampsia treatment consists of bed rest in left lateral recumbent position, balanced diet with
moderate to high protein and low to moderate sodium, and administration of magnesium sulfate.
 Severe preeclampsia treatment consist of complete bed rest, balanced diet with high protein and low to
moderate sodium, administration of sulfate, fluid and electrolyte replacements, and sedative
antihypertensives, such as diazepam or Phenobarbital, or an anticonvulsant such as phenytoin.
 Eclampsia treatment consists of administration of magnesium sulfate intravenously.
3. Institute seizure precautions. Seizures may occur up to 72 hours after delivery.
Premature Rupture of Membranes (PROM)
 PROM is rupture of the chorion and amnion 1 hour or more before the onset of labor. The gestational age of
the fetus and estimates of viability affect management.
Etiology
 The precise cause and specific predisposing factors are unknown.
Pathophysiology
1. PROM is associated with malpresentation, possible weak areas in the amnion and chorion, subclinical
infection, and, possibly, incompetent cervix.
2. Basic and effective defense against the fetus contracting an infection is lost and the risk of ascending
intrauterine infection, known as chorioamnionitis, is increased.
3. The leading cause of death associated with PROM is infection.
4. When the latent period (time between rupture of membranes and onset of labor) is less than 24 hours, the
risk of infection is low.
Assessment Findings
 PROM is marked by amniotic fluid gushing from the vagina. The fluid may merely trickle or leak from the
vagina in the absence of contractions.
 Pooling of amniotic fluid in the vagina will be visualized during a speculum examination.
 Maternal fever, fetal tachycardia, and malodorous discharge may indicate infection.
2. Laboratory and diagnostic study findings. Rupture of membranes is confirmed by the following.
 Ferning is evident.
 Nitrazine test tape turns a blue-green color.
Nursing Management
1. Prevent infection and other potential complications.
 Make an early and accurate evaluation of membrane status, using sterile speculum examination and
determination of ferning. Thereafter, keep vaginal examinations to a minimum to prevent infection.
 Obtain smear specimens from vagina and rectum as prescribed to test for betahemolytic streptococci, an
organism that increases the risk to the fetus.
 Determine maternal and fetal status, including estimated gestational age. Continually assess for signs of
infection.
 Maintain the client on bed rest if the fetal head is not engaged. This method may prevent cord prolapse if
additional rupture and loss of fluid occur. Once the fetal head is engaged, ambulation can be encouraged.
 Inform the client, if the fetus is at term, that the chances of spontaneous labor beginning are excellent;
encourage the client and partner to prepare themselves for labor and birth.
 If labor does not begin or the fetus is judged to be preterm or at risk for infection, explain treatments that are
likely to be needed.
Preterm Labor
 Preterm labor is labor that begins after 20 weeks’ gestation and before 37 weeks’ gestation.
Etiology
 Among the many causes of preterm labor are:

1. PROM
2. Preeclampsia
3. Hydramnios
4. Placenta previa
5. Abruptio placentae
6. Incompetent cervix
7. Trauma
8. Uterine structural anomalies
9. Multiple gestation
10. Intrauterine infection (chorioamnionitis)
11. Congenital adrenal hyperplasia
12. Fetal death
13. Maternal factors, such as stress (physical and emotional), urinary tract infections, and dehydration.
Pathophysiology
 The uterus begins the process of contraction prior to term gestational age.
Assessment Findings
 Clinical manifestations of preterm labor are basically the signs of true labor that occur when the gestational
age of the fetus is greater than 20 and less than 37 weeks.
1. Low back pain
2. Suprapubic pressure
3. Vaginal pressure
4. Rhythmic uterine contractions
5. Cervical dilation and effacement
6. Possible rupture of membranes
7. Expulsion of the cervical mucus plug
8. Bloody show
Nursing Management
1. Assess the mother’s condition and evaluate signs of labor.
 Obtain a thorough obstetric history.
 Obtain specimens for complete blood count and urinalysis.
 Determine frequency, duration, and intensity uterine contractions.
 Determine cervical dilation and effacement.
 Assess status of membranes and bloody show.
2. Evaluate the fetus for distress, size, and maturity (sonography and lecithin-sphingomyelin ratio)
3. Perform measures to manage or stop preterm labor.
 Place the client on bed rest in the side-lying position.
 Prepare for possible ultrasonography, amniocentesis, tocolytic drug therapy, and steroid therapy.
 Administer tocolytic (contraction-inhibiting) medications as prescribed.
 Assess for side effects of tocolytic therapy (e.g., decreased maternal blood pressure, dyspnea, chest pain, and
FHR exceeding 180 beats/min).
4. Provide physical and emotional support. Provide adequate hydration.
Preterm Newborn
 A preterm newborn is one born before 37 weeks’ gestation.
Etiology
1. The etiology of preterm labor is poorly understood.
2. Possible factors include the following:
a. Multiple gestation
b. Maternal history of preterm delivery
c. Hydramnios
d. Uterine anomalies
e. More than one second trimester abortion
f. Incompetent cervix
g. Infection
h. Uterine structural anomalies
i. Premature rupture of membranes
j. Maternal substance abuse (especially cocaine).
k. Maternal age less than 18 years , poor nutrition, and lack of prenatal care
Pathophysiology
 Preterm newborns exhibit anatomic and physiologic immaturity in all body systems; this immaturity hinders
the adaptations to extrauterine life that the newborn must make.
Assessment Findings
1. Associated findings. Altered parenting as evidenced by:
 Decreased or absent parental visits
 Parental resistance or refusal to participate in newborn care
 Denial of severity of newborn illness
 Resistance or refusal to touch newborn
 Persistent verbalization of guilt
2. Clinical manifestations. There is a higher risk for the following manifestations with a younger
gestational age.
 Respiratory manifestations include tachypnea, grunting, nasal flaring, retractions, cyanosis, decreased
oxygen saturation, decreased oxygen levels, and abnormal arterial blood gas (ABG) values.
 Cardiovascular manifestations include poor tissue perfusion, hypotension, and patent ductus arteriosus.
 Gastrointestinal manifestations include feeding intolerance, gastric reflux, vomiting, and gastric residuals.
 Altered fluid status may be manifested by fluid excess or fluid deficit.
 Fluid excess is manifested by edema and congestive heart failure.
 Fluid deficit is manifested by tachycardia, poor skin turgor, decreased urine output, abnormal
electrolyte levels, and decreased blood pressure.
 Iatrogenic anemia secondary to blood sampling may be present. It is exhibited by tachycardia, pallor,
decreased blood pressure, increasing oxygen requirements, and apnea.
 Infection may occur.
 Hypoglycemia or hyperglycemia may be present.
 Ineffective temperature control may be observed, and is exhibited by an inability to maintain core body
temperature.
 Neuromuscular system manifestations include decreased suck and swallow reflex, hypotonia, and altered
state transition.
 Hyperbilirubinemia is characterized by rapid destruction of red blood cells, jaundice, and lethargy.
Kernicterus is the deposition of unconjugated bilirubin in the brain cells and is associated with mental
retardation.
Nursing Management
1. Provide respiratory support (see Drug Chart)
2. Perform the following assessments.
 Assess heart sounds for presence of murmurs.
 Assess pulse and perfusion.
 Monitor blood pressure, heart rate, and pulse pressures.
3. Provide adequate fluids and electrolytes and nutrition.
5. Prevent infection.
6. Assess for readiness for selected interventions.
 Provide stimulation when appropriate to infant state and readiness.
 Encourage flexion in the supine position by using blanket rolls.
 Provide the newborn with body boundaries through swaddling or using blanket rolls against the newborn’s
body and feet.
7. Promote parent-newborn attachment.
8. Initiate phototherapy as required.
DRUG CHART Medications Used for Postpartum Complications
 The usual dose is 4 mL/kg intratracheally in 4
doses at least 6 hours apart in the first 48
hours of life.
 Suction the infant’s airway before
administration and delay further suctioning as
long as possible.
 Restores naturally  Assess the infant’s respiratory rate, arterial
occurring lung blood gases, and color before administration.
surfactant to improve  Change the infant’s position every 2 hours to
lung compliance promote flow to both lungs.
 Used to prevent or treat  Assess the infant’s respiratory rate, color, and
Lung surfactant respiratory distress arterial blood gases after administration.
Beractant syndrome in premature  Monitor for side effects, which may include
(Survanta) infants transient bradycardia or rales.
Prolonged Pregnancy
1. A prolonged or postdate pregnancy is a pregnancy that extends past 42 weeks’ gestation.
2. The incidence of prolonged pregnancy is approximately 10%.
Etiology
 The actual physiologic cause of prolonged pregnancy is unknown. A suggested etiology is estrogen deficiency.
Pathophysiology
 Pathophysiology includes excessively large infants with resultant birth trauma or small-for-gestational-age
infants who are deprived of hydration and nutrition, because of placental aging and dysfunction and
decreased amniotic fluid.
Assessment Findings
 Weight loss and decreased uterine size (when the infant is suffering from placental dysfunction)
 Excessively large uterus
 Meconium-stained fluid
 Nonreassuring fetal heart rate patterns
2. Laboratory and diagnostic study findings. Ultrasound examination may be used to assist in determination of
fetal size.
Nursing Management
1. Carefully assess the fetus to identify risk.
a. Perform a careful risk assessment upon admission.
b. Closely monitor fetal status.
2. Prevent birth complications.
a. Assist with induction of labor
b. Prepare for a difficult delivery
c. Notify the pediatric staff of the potential for a birth-injured baby.
Puerperal Infection
1. Puerperal infection is an infection developing in the birth structures after delivery.
2. Puerperal infection is a major cause of maternal morbidity and mortality.
3. The incidence ranges from 14% and to 8% of all deliveries; there is a higher incidence in cesarean deliveries.
4. The major site of postpartum infections is the pelvic cavity; other common sites include the breast, urinary
tract, and venous system.
5. Localized infections may affect the vagina, vulva, and perineum.
6. Endometritis, localized infection of the uterine lining, occurs 48 to 72 hours after delivery.
Etiology
 Puerperal infections can be caused by poor sterile technique, delivery with significant manipulation,
cesarean birth, or overgrowth of local flora.
Pathophysiology
1. Causative organisms
 Aerobic organisms include beta-hemolytic streptococci, Escherichia coli, Klebsiella, Proteus mirabilis,
Pseudomonas, Staphylococcus aureus, and Neisseria.
 Anaerobic organisms include Bacteroides, Peptostreptococcus, Peptococcus, and Clostridium perfringens.
2. In parametritis (pelvic cellulitis), infection spreads by way of the lymphatics of the connective
tissue surrounding the uterus.
3. Puerperal infection may extend to the peritoneum by way of the lymph nodes and uterine wall.
Assessment Findings
 Puerperal morbidity is marked by a temperature of 38°C (100.4°F) or higher after the first 24 hours
postpartum on any two of the first 10 postpartum days.
 Localized vaginal, vulva, and perineal infections are marked by pain, elevated temperature, edema, redness,
firmness, and tenderness at the site of the wound; sensations of heat; burning on urination; and discharge
from the wound.
 Manifestations of endometritis include a rise in temperature for several days. In severe endometritis,
symptoms include malaise, headache, and backache, and general discomfort, loss of appetite, large tender
uterus, severe postpartum cramping, and brownish red, foul-smelling lochia.
 Parametritis (pelvic cellulitis) commonly produces elevated temperature of more than 38.6°C (102° to 104°F),
chills, abdominal pain, and sub involution of uterus, tachycardia, and lethargy.
 Signs and symptoms of peritonitis include high fever, rapid pulse, abdominal pains, nausea, vomiting, and
restlessness.
Nursing Management
1. Promote resolution of the infectious process.
 Inspect the perineum twice daily for redness, edema, ecchymosis, and discharge.
 Evaluate for abdominal pain, fever, malaise, tachycardia, and foul-smelling lochia.
 Obtain specimens for laboratory analysis; report the findings.
 Offer a balanced diet, frequent fluids, and early ambulation.
 Administer prescribed antibiotics or medications; document the client’s response.
2. Provide client and family teaching. Describe and demonstrate self-care, stressing careful perineal hygiene and
handwashing.
Rhesus (Rh) Typing
The Rhesus (Rh) system classifies blood by the presence or absence of the Rh (D) antigen on the surface of RBC’s.
In this test, a patient’s RBCs are mixed with serum containing anti-Rh (D) antibodies and are observed for
clumping. If clumping occurs, the Rh (D) antigen is present, and the patient’s blood is typed Rh positive; if
clumping doesn’t occur, the antigen is absent, and the patient’s blood is typed Rh-negative.
Purpose
 To establish blood type according to the Rh system.
 To help determine the donor’s compatibility before transfusion.
 To determine if the patient will require an Rh (D) immune globulin injection.
Procedure
Patient Preparation
1. Confirm the patient’s identity using two patient identifiers according to facility policy.
2. Explain to the patient that Rh typing determines or verifies blood group to ensure safe blood transfusions.
3. Inform the patient that he doesn’t need to restrict food and fluids for the test.
4. Tell the patient that the test requires a blood sample. Explain that he may experience slight discomfort from
the tourniquet and needle puncture.
5. Check the patient’s history for recent administration of dextran, IV contrast media, or drugs that may alter
test results.
Implementation
1. Perform a venipuncture and collect the sample in a 7-mL EDTA tube.
2. Label the sample with the patient’s name, the hospital or blood bank number, the date, and your initial.
3. If a transfusion is ordered, make sure a transfusion request form accompanies the sample to the laboratory.
1. Apply direct pressure to the venipuncture site until bleeding stops.
2. If a hematoma develops at the venipuncture site, apply direct pressure.
3. If necessary, give the pregnant patient a card identifying that she may need to receive Rh (D) injection.
Interpretation
Normal Results
 If the D antigen is present, that person is Rh positive.
 If the D antigen is absent, that person is Rh-negative.
 Antibodies to Rh antigens develop only as an immune response after a transfusion or during pregnancy.
Abnormal Results
 Rh incompatibility is the most common and severe cause of HDN, possible when Rh-negative woman and an
Rh-positive man produce an Rh positive baby.
Interfering Factors
 Unknown
Precautions
 Handle the sample gently and send it to the laboratory immediately.
Salpingo-oophorectomy
 The removal of one (unilateral) or both (bilateral) fallopian tubes and corresponding ovary.
Discussion
 This procedure may be performed in conjunction with a hysterectomy or as a separate procedure. As a
separate procedure, it is usually performed for a variety of nonmalignant diseases that include acute and
chronic infection, cysts, tumors, and hemorrhage owing to tubal pregnancy. Malignancy of a tube or ovary
will usually necessitate a hysterectomy with excision of the opposite adnexae.
Position
 Supine, with arms extended on armboards.
Instrumentation
 Major tray or abdominal hysterectomy tray.
 Internal stapling instruments.
 Self-retraining retractor.
Supplies/ Equipment
 Basin set
 Blades
 Needle counter
 Suction
 Solutions – saline, water
 Sutures
Procedure
1. The abdomen is entered through a low midline or Pfannenstiel incision, depending on the size of the patient
and the known pathologic condition.
2. The peritoneal cavity is entered and a self-retaining retractor is placed in the wound.
3. The operating table is placed in slight Trendelenberg position, and the incision is packed with moist Lap
sponges.
4. The uterus is grasped with a tenaculum or uterine elevator, and if adhesions are present, the affected tube
and ovary are isolated from surrounding organs.
5. The tube(s) are grasped with one or two Babcock clamps. Two Kelly or uterine clamps are then placed across
the ovarian vessels.
6. The tissue is divided between the clamps with a knife, dissecting scissors, or cautery pencil. Internal staples
can also be used to accomplish this task.
7. The infundibulopelvic ligament is ligated and divided, as is the broad ligament attached to the tube and
ovary. The tube and ovary are excised.
8. If internal staples are not used, a suture ligature is used to ligate the ovarian vessels.
9. This procedure is repeated on the other side (if bilateral).
10. The raw surface of the ovarian ligaments left by the dissection are reperitonealized using a running suture.
11. The wound is irrigated with warm saline, and closed in a routine fashion.
1. For bilateral surgery, a sterilization permit may be required in addition to the operative permit.
2. When the specimen is collected (if bilateral), each side should be labeled and in separate containers,
depending on hospital policy.
Shoulder Dystocia
 In shoulder dystonia, the anterior shoulder of the baby is unable to pass under the maternal pubic arch.
Etiology
 Shoulder dystocia is associated with advanced maternal age, diabetes maternal obesity, large baby
(macrosomia), postdate pregnancy, and multiparity.
Pathophysiology
 The plane of the fetal shoulders aligns perpendicular to the pubis instead of at an angle. This causes the
shoulder to become wedged under the pubic arch.
Assessment Findings
1. Associated findings. The birth process may seem unnecessarily prolonged.
 The fetal head retracts against the mother’s perineum as soon as the head is delivered. This is known as the
“turtle sign.”
 External rotation does not occur.
Nursing Management
 Identify shoulder dystocia and assist with management.

1. Place the client in the McRobert’s position (ie, thighs pulled up against the abdomen with hips abducted).
 The woman flexes her thighs sharply against her abdomen, which straightens the pelvic curve. A
supported squat has a similar effect and adds gravity to her pushing efforts.
2. Apply suprapubic pressure by an assistant pushes the fetal anterior shoulder downward to displace it from
above the mother’s symphysis pubis. Fundal pressure should not be used, because it will push the anterior
shoulder more firmly against the mother’s symphysis.
Small-for-gestational –age Newborn (SGA)
1. An SGA infant is one who’s length, weight, and had circumference are below the 10th percentile of the
normal variation for gestational age as determined by neonatal examination.
2. The SGA infant may be preterm, term, or post-term.
Etiology
1. Maternal conditions associated with SGA babies include:

 Hypertension (chronic or pregnancy- induced)
 Cardiac, pulmonary, or renal disease
 Diabetes mellitus (classes D,E,F, and R)
 Poor nutrition
 Use of alcohol, tobacco, or drugs
 Age
 Multiple gestation
 Placental insufficiency
 Placental fetal abnormalities
 Pregnancy occurred at high altitudes
2. Fetal conditions associated with SGA infants include:
 Normal genetically small infant
 Chromosomal abnormality
 Malformations
 Congenital infections, especially rubella and cytomegalovirus
3. The effect of these factors upon the fetus is dependent on the stage of fetal development.
 Early gestation is a time of rapid cell proliferation. An insult at this time results in organs that contain
normal size cells, but they are fewer in number. Infants are symmetrical (their heads and bodies grew
proportionately) but their organs are smaller. Usually these infants have a poor prognosis and may
never catch up.
 Later in gestation, growth of the fetus results from an increase in cell size. An insult at this time results
in organs with a normal number of cells that are smaller in size and causes asymmetric growth. These
infants have appropriate-sized heads and body lengths, but their weight and organ sizes are decreased.
These infants usually have a better prognosis since they have an adequate number of cells. Their
growth catches up if they are provided with good nutrition postnatally.
Assessment Findings
 Soft tissue wasting and dysmaturity
 Loose, dry, and scaling skin
 Perinatal asphyxia (due to a small placenta that is less efficient in gas exchange)
 Plethora, respiratory distress, and central nervous system (CNS) aberrations (if the infant has polycythemia)
 Congenital anomalies (occurring in as many as 35% of SGA infants who suffered insults early in gestation)
 Glucose testing will reveal decreased glycogen stores, which increases the potential for hypothermia and
hypoglycemia.
 Hematocrit level may be increased (65%), which indicates polycythemia as a result of chronic fetal hypoxia.
Nursing Management
1. Provide adequate fluid and electrolytes and nutrition.

 Provide a high calorie formula for feeding (more than 20 calories per ounce) to promote steady weight
gain (15 to 30 grams per day growth plotted on curves shows a normal growth rate).
 If the infant is breast feeding, add human milk fortifier to expressed breast milk.
2. Decrease metabolic demands when possible.
 Provide small frequent feedings.
 Provide gavage feedings if the infant does not have a steady weight gain.
 Provide a neutral thermal environment.
 Decrease iatrogenic stimuli.
3. Prevent hypoglycemia
 Monitor glucose screening.
 Provide early feedings.
 Provide frequent feedings (every 2 to 3 hours)
 Administer IV glucose if blood sugar does not normalize with oral feedings.
5. Monitor serum hematocrit (normal is 45% to 65%).
 If an initial high hematocrit was obtained by heel stick capillary sample, a follow-up sample should be
done by venipuncture.
 Observe for signs, symptoms, and complications of polycythemia
3.
 Ruddy appearance
 Cyanosis
 Lethargy, jitteriness, and seizures
 Jaundice
 Provide adequate hydration to prevent hyper viscosity
6. Assess the prenatal history for possible toxoplasmosis, rubella, cytomegalovirus, and herpes simplex
infections during pregnancy. Assess maternal and infant antibody titers. Use isolation precautions when
congenital infections are suspected.
 Explain the possible causes of intrauterine growth retardation.
 Inform parents of the infant’s goal weight for discharge.
 Provide instruction on managing the infant at home.
3.
 Explain how to prepare a higher calorie formula or breast feeding.
 Explain the importance of follow-up with a developmental specialist who will screen for milestone
achievements.
Spontaneous Abortion
1. Spontaneous abortion is the expulsion of the fetus and other products of conception from the uterus before
the fetus is capable of living outside of the uterus.
2. Types of spontaneous abortions
 Threatened abortion – is characterized by cramping and vaginal bleeding in early pregnancy with no
cervical dilation. It may subside or an incomplete abortion may follow.
 Imminent or inevitable abortion – is characterized by bleeding, cramping and cervical dilation.
Termination cannot be prevented.
 Incomplete abortion – is characterized by expulsion of only part of the products of conception (usually
the fetus). Bleeding occurs with cervical dilation.
 Complete abortion – is characterized by complete expulsion of all products of conception.
 Missed abortion – is characterized by early fetal intrauterine death without expulsion of the products of
conception. The cervix is closed, and the client may report dark brown vaginal discharge. Pregnancy
test findings are negative.
 Recurrent (habitual) abortion – is spontaneous abortion of three or more consecutive pregnancies.
Etiology
 Spontaneous abortion may result from unidentified natural causes or from fetal, placental or maternal
factors.
1. Fetal Factors
a. Defective embryologic development
b. Faulty ovum implantation
c. Rejection of the ovum by the endometrium
d. Chromosomal abnormalities
2. Placental Factors
a. Premature separation of the normally implanted placenta
b. Abnormal placental implantation
c. Abnormal placental function
3. Maternal Factors
a. Infection
b. Severe malnutrition
c. Reproductive system abnormalities (eg, incompetent cervix)
d. Endocrine problems (eg, thyroid dysfunction)
e. Trauma
f. Drug ingestion
Pathophysiology
 The fetal or placental defect or the maternal condition results in the disruption of blood flow, containing
oxygen and nutrients, to the developing fetus. The fetus is compromised and subsequently expelled from the
uterus.
Assessment Findings
1. Associated findings – The client and family may exhibit a grief reaction at the loss of pregnancy, including:
a. Crying
b. Depression
c. Sustained or prolonged social isolation
d. Withdrawal
2. Clinical Manifestations – include common signs and symptoms of spontaneous abortion.
a. Vaginal bleeding in the first 20 weeks of pregnancy
b. Complaints of cramping in the lower abdomen
c. Fever, malaise or other symptoms of infection
a. Serum beta hCG levels are quantitatively low
b. Ultrasound reveals the absence of a viable fetus.
Implementation
1. Provide appropriate management and prevent complications
 Assess and record vital signs, bleeding and cramping of pain.
 Measure and record intravenous fluids and laboratory test results. In instances of heavy vaginal bleeding;
prepare for surgical intevention (D & C) if indicated.
 Prepare for PhoGAM administration to an Rh-negative mother, as prescribed. Whenever the placenta is
dislodged (birth, D & C, abruptio) some of the fetal blood may enter maternal circulation. If the woman is Rh
negative, enough Rh-positive blood cells may enter her circulation to cause isoimminization, the production
of antibodies against Rh-positive blood, thus endangering the well-being of future pregnancies. Because the
blood type of the conceptus is not known, all women with Rh-negative blood should receive RhoGAM after an
abortion.
 Recommended iron supplements and increased dietary iron as indicated to help prevent anemia.
2. Provide client and family teaching
 Offer anticipatory guidance relative to expected recovery, the need for rest and delay of another pregnancy
until the client fully recovers.
 Suggest avoiding intercourse until after the next menses or using condoms when engaging in intercourse.
 Explain that in many cases, no cause for the spontaneous abortion is ever identified.
Subinvolution
 Subinvolution is delayed return of the enlarged uterus to normal size and function.
Etiology
 Subinvolution results from retained placental fragments and membranes, endometritis, or uterine fibroid
tumor; treatment depends on the cause.
Pathophysiology
 Uterine atony or placental fragments prevent the uterus from contracting effectively.
Assessment Findings
1. Prolonged lochial discharge
2. Irregular or excessive bleeding
3. Larger than normal uterus
4. Boggy uterus (occasionally)
Nursing Management
1. Prevent excessive blood loss, infection, and other complications.
a. Massage uterus, facilitate voiding, and report blood loss.
b. Monitor blood pressure and pulse rate.
c. Administer prescribed medications. (see Drug Chart )
d. Be prepared for possible D&C.
2. Assist the client and family to deal with physical and emotional stresses of postpartum complications.
 Blocks the conversion

Anticoagulants of prothrombin to
Heparin sodium thrombin and  Heparin IV should be administered as a
injection fibrinogen to fibrin thus “piggy back” infusion.
(Hepalean) decreasing clotting  Heparin SQ is given deep into the site
Lovenox ability (abdomen), sites are rotated, do not aspirate,
 Inhibits thrombus and apply pressure (do not massage).
clot formation  Used to prevent and treat pulmonary
embolism and thrombosis.
 Women on anticoagulopathy therapy should

no be given estrogen or aspirin.
 Obtain baseline coagulation studies.
 Obtain serial coagulation studies while the
client is on therapy.
 Keep protamine sulfate readily available in
case of heparin overdose.
 Assess client for bleeding from nose, gums,
hematuria, and blood in stool.
 Observe color and amount of lochia.
Institute pad count.
 Avoid IM injections to avoid formation of
hematomas.
 Inform the client that this drug does not
pass into breast milk.
 Monitor for the following side effects;
hemorrhage, bruising urticaria, and
thrombocytopenia.
 Women on anticoagulant therapy should not
be given estrogen or aspirin.
 Obtain baseline coagulation studies while on
therapy.
 Keep AquaMEPHYTON (vitamin K) on hand
in case of Coumadin overdose.
Institute a pad count.
hematomas.
 Inform the client that this drug passes into
 Interferes with hepatic breast milk and its use is contraindicated
Warfarin sodium synthesis of vitamin K – during pregnancy. Monitor the following side
(Coumadin, dependent clotting effects: hemorrhage, fever, nausea, and
Warfilone) factors (II,VII, IX, X) cramps.

 Advise the client that this medication will
cause menstrual-like cramps.
 Assess for numb fingers and toes, cold,
chest pain, nausea, vomiting, muscle pain,
and weakness.
 May cause decreased serum prolactin.
 Directly stimulates  IV administration is used for emergency
uterine and vascular dosage only. Administer at a rate of 0.2 mg
smooth muscle over at least 1 minute.
 Promotes uterine  DO NOT MIX THIS DRUG WITH ANY OTHER
contraction DRUG.
 Used for prevention and  Use solution only if it is clear and colorless,
treatment of with no precipitate. May store at room
Oxytoxic postpartum or temperature for 60 days. The drug
methylergonovine postabortion deteriorates with age.
maleate hemorrhage caused by  Monitor for the following side effects:
(methergine) uterine atony or dyspnea, palpitations, diaphoresis, chest
(PO, IM, IV) subinvolution. pain, hypotension, and headache.
Thrombophlebitis and Thrombosis in Postpartum
1. Thrombophlebitis is an inflammation of the vascular endothelium with clot formation on the vessel wall.
2. A thrombus forms when blood components (platelets and fibrin) combine to form an aggregate body (clot).
3. Pulmonary embolism occurs when a clot travelling through the venous system lodges within the pulmonary
circulatory system, causing occlusion or infarction.
4. The incidence of postpartum thrombophlebitis is 0.1% to 1%, when not treated, 24% of these develop
pulmonary embolism, with a fatality rate of 15%.
Etiology
Predisposing risk factors include:
1. History of thrombophlebitis
2. Obesity
3. History of cesarean delivery
4. History of forceps delivery
5. Maternal age older than 35
6. Multiparity
7. Lactation suppression with estrogens
8. Varicosities
9. Anemia and blood dyscrasias
Pathophysiology
1. The three major causes of thrombus formation and inflammation are venous stasis, hypercoagulable blood,
and injury to the innermost layer of the blood vessel.
2. Both venous stasis (in pelvis and lower extremities) and hypercoagulable blood are present during
pregnancy.
3. The level of most coagulation factors (especially fibrinogen, and factors III, VII, and X) are increased during
pregnancy. This increase is accompanied by a decrease in plasminogen and antithrombin III, which cause
clots to disintegrate.
4. Injury to the innermost layer of the vessel is probably not contributory, in general, during pregnancy.
However, the possibility exists if the birth is by cesarean section.
Assessment Findings
 Superficial thrombophlebitis within the saphenous vein system manifests as midcalf pain, tenderness,
redness, and warmth along the vein.
 DVT symptoms include muscle pain, the presence of humans sign (ie, pain in the calf on passive dorsiflexion
of the foot, possibly caused by DVT). However, the presence of Homans sign is no longer believed to be
conclusive because the pain may result from other causes such as strained muscles or contusions.
 Pelvic thrombophlebitis, typically occurring 2 weeks after delivery, is marked by chills, fever, malaise, and
pain.
 Femoral thrombophlebitis, generally occurring 10 to 14 days after delivery, produces chills, fever, malaise,
stiffness, and pain.
 Pulmonary embolism is heralded by sudden intense chest pain with severe dyspnea followed by tachypnea,
pleuritic pain, apprehension, cough, tachycardia, hemoptysis, and temperature above 38°C (100.4°F).
 Venography accurately diagnoses DVT. There are risks associated with the radiopaque dye that is used.
 Real-time and color Doppler ultrasound will diagnose deep venous thrombosis.
 Impedance plethysmography measures changes in venous blood volume and flow.
Nursing Management
1. Promote resolution of symptoms and prevent the development of embolus.
 Assess vital signs.
 Assess extremities for signs of inflammation, swelling, and the presence of Homans sign.
 Administer anticoagulant therapy as prescribed, and observe for signs of bleeding and allergic reactions,
Note: Keep the antidote protamine sulfate available in case of a severe heparin overdose. Usually, protamine
sulfate solution is administered intravenously at a rate no greater than 50 mg every 10 minutes (see Drug
Chart)
 Caution: Do not administer estrogens for lactation suppression, because estrogens may encourage clot
formation.
 Prepare the client for diagnostic studies (ie, venography and Doppler ultrasound), as indicated.
 Implement measures to prevent complications of bed rest (e.g., bed placed in Trendelenburg position, use of
footboard, passive or active range of motion exercises, frequent shifts in position, and adequate fluid intake
and output).
 Blocks the conversion

of prothrombin to  Heparin IV should be administered as a
thrombin and “piggy back” infusion.
Anticoagulants fibrinogen to fibrin thus  Heparin SQ is given deep into the site
Heparin sodium decreasing clotting (abdomen), sites are rotated, do not aspirate,
injection ability apply pressure (do not massage).
(Hepalean)  Inhibits thrombus and  Used to prevent and treat pulmonary
Lovenox clot formation embolism and thrombosis.
 Women on anticoagulopathy therapy should

no be given estrogen or aspirin.
 Obtain baseline coagulation studies.
 Obtain serial coagulation studies while the
client is on therapy.
 Keep protamine sulfate readily available in
case of heparin overdose.
Institute pad count.
 Interferes with hepatic  Avoid IM injections to avoid formation of
Warfarin sodium synthesis of vitamin K – hematomas.
(Coumadin, dependent clotting  Inform the client that this drug does not
Warfilone) factors (II,VII, IX, X) pass into breast milk.
 Monitor for the following side effects;
hemorrhage, bruising urticaria, and
thrombocytopenia.
 Women on anticoagulant therapy should not
be given estrogen or aspirin.
 Obtain baseline coagulation studies while on
therapy.
 Keep AquaMEPHYTON (vitamin K) on hand
in case of Coumadin overdose.
Institute a pad count.
hematomas.
 Inform the client that this drug passes into
breast milk and its use is contraindicated
during pregnancy. Monitor the following side
effects: hemorrhage, fever, nausea, and
cramps.

 Advise the client that this medication will
cause menstrual-like cramps.
 Assess for numb fingers and toes, cold,
chest pain, nausea, vomiting, muscle pain,
and weakness.
 May cause decreased serum prolactin.
 Directly stimulates  IV administration is used for emergency
uterine and vascular dosage only. Administer at a rate of 0.2 mg
smooth muscle over at least 1 minute.
 Promotes uterine  DO NOT MIX THIS DRUG WITH ANY OTHER
contraction DRUG.
 Used for prevention and  Use solution only if it is clear and colorless,
treatment of with no precipitate. May store at room
Oxytoxic postpartum or temperature for 60 days. The drug
methylergonovine postabortion deteriorates with age.
maleate hemorrhage caused by  Monitor for the following side effects:
(methergine) uterine atony or dyspnea, palpitations, diaphoresis, chest
(PO, IM, IV) subinvolution. pain, hypotension, and headache.
Urinary Tract Infection in Postpartum Women
1. A UTI is indicated by more than 105 bacterial colonies/mL of urine in two consecutive clan, voided,
mistream specimens.
2. Two common types of UTIs are cystitis, inflammation of the urinary bladder, and pyelonephritis,
inflammation of the renal pelvis.
3. UTIs occur in about 5% of postpartum women; they occur in 15% of women who have undergone
postpartum catheterization.
Etiology
1. Ascending bacterial infections account for most UTIs.

2. Another cause of UTIs is retention and residual urine due to overdistention and incomplete emptying of the
bladder.
 Temporary urine retention may be due to decreased perception of the urge to void, resulting from perineal
trauma and the effects of analgesia, or anesthesia.
 Urinary stasis and residual urine provide a medium for bacterial growth, predisposing the client to cystitis
and pyelonephritis.
Pathophysiology
1. Causative organisms in cystitis and pyelonephritis include E. coli (most common), Proteus, Pseudomonas, S.
aureus, and Streptococcocus faecalis.
2. Consequences of not recognizing early symptoms of UTI include the extension of the infection upward with
subsequent permanent loss of kidney function.
Assessment Findings
Clinical manifestations depend on the type of infection.
1. Clinical manifestations include frequency, urgency, dysuria, hematuria, nocturia, temperature elevation, and
suprapubic pain.
2. Pyelonephritis manifestations include high fever, chills, flank pain, nausea, and vomiting.
Nursing Management
Recognize signs of infection and prevent the development of further complications.
1. Determine if symptoms are present and if the woman had difficulty urinating after delivery.
2. Obtain specimens, report findings, and administer antibiotics and medications as prescribed.
3. Describe self-care related to regular emptying of bladder, proper perineal cleansing, and the need for
increased fluids.
4. Insert intermittent or indwelling catheter as needed.
5. Observe and record the response to treatment.
Uterine Inversion
 The uterus turns completely or partially inside out; it occurs immediately following delivery of the placenta or
in the immediate postpartum period.
Etiology
1. Forced inversion is caused by excessive pulling of the cord or vigorous manual expression of the placenta or
clots from an atonic uterus.
2. Spontaneous inversion is due to increased abdominal pressure from bearing down, coughing, or sudden
abdominal muscle contraction,
3. Predisposing factors include straining after delivery of the placenta, vigorous kneading of the fundus to expel
the placenta, manual separation and extraction of the placenta, rapid delivery with multiple gestation, or
rapid release of excessive amniotic fluid.
Pathophysiology
1. The inverted uterus is unable to restore normal position or contract appropriately.

2. The woman is placed at increased risk for bleeding and infection.
Assessment Findings
1. Excruciating pelvic pain with a sensation of extreme fullness extending into the vagina.
2. Extrusion of the inner uterine lining into the vagina or extending past the vaginal introitus.
3. Vaginal bleeding and signs of hypovolemia.
Nursing Management
 Promptly identify and assist with the resolution of uterine inversion.

1. Recognize signs of impending inversion, and immediately notify the physician and call for assistance.
2. Immediate manual replacement of the uterus at the time of inversion will prevent cervical entrapment of the
uterus, if reinversion is not performed immediately, rapid and extreme blood loss may occur, resulting in
hypovolemic shock.
3. Take steps in order to prevent or limit hypovolemic shock.
 Insert a large gauge intravenous catheter for fluid replacement.
 Measure and record maternal vital signs every 5 to 15 minutes to establish a baseline and document
change.
 Open an established intravenous line for optimal fluid replacement.
 A fibrinogen level should be drawn to determine the risk for formation of a blood clot.
 Prepare for anesthesia as needed.
 Prepare to administer CPR, if required.
4. If manual reinversion is not successful, prepare the client and family for possible general anesthesia and
surgery.
Uterine Rupture
1. Uterine rupture is tearing of the uterus, either complete (i.e., rupture extends through entire uterine wall
and uterine contents spill into the abdominal cavity) or incomplete (ie, rupture extends through the
endometrium and myometrium, but the peritoneum surrounding the uterus remains intact).
2. Small tears may be asymptomatic and may heal spontaneously, remaining undetected until the stress and
strain of a subsequent labor.
Etiology
1. Traumatic uterine rupture may be caused by injury from obstetric instruments, such as uterine sound or
curette used in abortion.
2. Rupture also may result from obstetric intervention, such as excessive fundal pressure, forceps delivery,
violent bearing-down, tumultuous labor, and fetal shoulder dystocia.
3. Spontaneous uterine rupture is most likely to occur after previous uterine surgery, grand multiparity
combined with the use of oxytocic agents, cephalopelvic disproportion, malpresentation, or hydrocephalus.
Pathophysiology
1. The most common pathologic factor is a pre-existing scar that results in a weakened or defective
myometrium that does not stretch; this is most frequently identified in spontaneous uterine rupture.
2. Some episodes of rupture are due to traumatic disruption of the uterine surface.
3. More severe ruptures pose the risk of irreversible maternal hypovolemic shock or subsequent peritonitis,
consequent fetal anoxia, and fetal or neonatal death.
Assessment Findings
 Clinical manifestations vary from mild to severe, depending on the site and extent of the rupture, degree of
extrusion of the uterine contents, and intraperitoneal evidence or absence of spilled amniotic fluid and blood.
1. Abdominal pain
2. Vaginal bleeding (may be present but is not always)
3. Nonreassuring fetal heart pattern
4. Palpation of fetal parts under the skin
5. Signs of hypovolemic shock (with complete uterine rupture)
Nursing Management
1. Monitor for the possibility of uterine rupture.
 In the presence of predisposing factors, monitor maternal labor pattern closely for hypertonicity or signs of
weakening uterine muscle.
 Recognize signs of impending rupture, immediately notify the physician, and call for assistance.
2. Assist with rapid intervention.
 If the client has signs of possible uterine rupture, vaginal delivery is generally not attempted.
 If symptoms are not severe, an emergency cesarean delivery may be attempted and the uterine tear repaired.
 If symptoms are severe, emergency laparotomy is performed to attempt immediate delivery of the fetus and
hen establish homeostasis.
 Implement the following preparations for surgery.
 Monitor maternal blood pressure, pulse, and respirations; also monitor fetal heart tones.
 If the client has a central venous pressure catheter in place, monitor pressure to evaluate blood loss
and effects of fluid and blood replacement.
 Insert a urinary catheter for precise determinations of fluid balance.
 Obtain blood to assess possible acidosis.
 Administer oxygen, and maintain a patent airway.
3. Prevent and manage complications. Take these steps in order to prevent or limit hypovolemic shock:
 Oxygenate by providing 8 to 10 L/min using a closed mask.
 Restore circulating volume using one or more IV lines.
 Evaluate the cause, response to therapy, and fetal condition.
 Remedy the problem by preparing the client for surgery and administering antibiotics.
 Provide support for the client’s partner and family members once surgery has begun.
 Inform the partner and family how they will receive information about the mother and newborn and where to
wait.
Vasa Previa
 Vasa previa is a rare developmental disorder made up of two separate disorders.
1. First, there is a velamentous insertion of the umbilical cord. This is a condition where the umbilical blood
vessels course through the amnion and chorion and meet to form the umbilical cord a distance from the
placental surface. This places the fragile umbilical vessels at risk for tearing and hemorrhage.
2. A vasa previa is created when the fragile unprotected umbilical vessels cross the internal os and are in front
of the presenting fetal head.
Etiology
 The etiology is uncertain. However, it may be due to uneven growth of the placenta or abnormal implantation
of the blastocyte.
Pathophysiology
 The fetal vessels rupture or are compressed, leading to fetal hypoxia.

Assessment Findings
a. Vasa previa is of no danger to the mother.
b. Once the umbilical vessels rupture, fetal demise is virtually certain.
a. Vessels are occasionally palpated during a vaginal examination.
b. Minimal bright red vaginal bleeding is evident.
c. Fetal bradycardia occurs.
a. Ultrasound may reveal vasa previa.
b. Kleihauer-Betke or fetal cell blood test will confirm the presence of fetal blood cells.
Nursing Management
1. Identify, and assist with treatment of, the disorder.
a. Monitor fetal heart rate and status during labor.
b. Assist with diagnosis of the condition.
c. Anticipate and assist with emergency cesarean birth.
3. Provide client and family education. Explain emergency procedures to the client and family.
Vasectomy
 Excision of a segment of the vas deferens with ligation of distal and proximal ends.
Discussion
 This procedure is performed as an elective sterilization procedure or to prevent orchitis prior to a
prostectomy.
 It can be performed under local, regional, or general anesthesia and as an out patient procedure.
Positioning
 Supine, with legs slightly apart
Incision Site
 Scrotum
Packs/ Drapes
 Laparotomy pack or basic pack with transverse Lap sheet.
Instrumentation
 Vasectomy tray or minor tray.
Supplies/ Equipment
 Basin set
 Blades
 Suction
 Solutions
 Sutures
 Scrotal support (optional)
Procedure
1. The vas deference is palpated through the scrotum before anesthesia (local) is administered.
2. A small incision is made in the scrotum.
3. The vas is seized with an Allis or Bobcock clamp and is freed of surrounding tissue.
4. A segment of the vas is excised and the ends are ligated or cauterized.
5. The ends may be nuried within the scrotal fascia with one or two sutures.
6. The procedure is repeated on the other side, and the incision is closed in layers.
1. Local anesthesia is frequently used.
2. An ice pack may be applied to the scrotum immediately after surgery.
3. A sterilization permit may be needed in addition to the operative consent.

Etiology: Abruptio Placenta Nursing Care Plan and Management

Uploaded by

Document Informationclick to expand document information

Copyright:

Available Formats

Etiology: Abruptio Placenta Nursing Care Plan and Management

Uploaded by

Document Information

Original Description:

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Etiology: Abruptio Placenta Nursing Care Plan and Management

Uploaded by

Copyright:

Available Formats

Abruptio Placenta Nursing Care Plan and Management

HEART RATE Absent Below 100 Above 100

RESPIRATION Absent Slow Good crying

MUSCLE TONE Flaccid Some flexion Active motion

REFLEX IRRITABILITY No Response Grimace Vigorous cry

 Compression of the cord results in the compromise or cessation of fetoplacental perfusion.

 Uterine contractions are ineffective secondary to muscle fatigue or overstretching.

 The uterus is unable to contract effectively and maintain hemostasis.

Fasting <105 mg/dL <90 mg/dL 105 mg/dL

1 hr <190 mg/dL <170 mg/dL 190 mg/dL

2 hr <165 mg/dL <145 mg/dL 165 mg/dL

3 hr <145 mg/dL <125 mg/dL 145 mg/dL

Adult 16.4 24-30 lb

Mild 21-28mEq/L >7.30

Moderate 11-20 mEq/L 7.10-7.30

Severe <10 mEq/L <7.10

 The etiology of hyperemesis gravidarum is obscure; suggested causative factors include:

1. History of traumatic birth

Suppository (prostaglandin) is inserted every 2

Oxytocicn is infused at a rate of 1-2 mU/min

Table 2 Signs of Hypocalcemia

1. The exact cause of stasis of milk in the ducts is not known.

 Predisposing factors are prior uterine surgery and placenta previa.

 Heparin IV should be administered

 Obtain a baseline calcium level.

1. The cause of preeclampsia is unknown.

 Preeclampsia is a multisystem, vasospatic disease process characterized by hemoconcentration,

1. Clinical manifestations of mild preeclampsia

Renal Function >5.5 mg/dL

Creatinine clearance <150 mL/min

 Among the many causes of preterm labor are:

 Identify shoulder dystocia and assist with management.

1. Maternal conditions associated with SGA babies include:

1. Provide adequate fluid and electrolytes and nutrition.

 Blocks the conversion

 Women on anticoagulopathy therapy should

 Obtain a baseline calcium level.

 Blocks the conversion

 Women on anticoagulopathy therapy should

 Obtain a baseline calcium level.

1. Ascending bacterial infections account for most UTIs.

1. The inverted uterus is unable to restore normal position or contract appropriately.

 Promptly identify and assist with the resolution of uterine inversion.

 The fetal vessels rupture or are compressed, leading to fetal hypoxia.

You might also like