NRG 204 HANDOUT

FRAMEWORK - Provision of nursing care of

children from birth through
NRG 204 CARE OF MOTHER, CHILD adolescence
AT RISK OR WITH PROBLEMS
(ACUTE AND CHRONIC) - Provision of nursing care to
families in all settings.
By: Rose Eden U. Tuloy, RN, MN

A. Philosophy of Maternal and Child

Maternal and Child Health Nursing Health Nursing

- Includes care of the pregnant 1. Maternal and child

woman, child, and family. health nursing is:

o Family centered;
assessment should
I. Framework for Maternal & always include the
Child Health Nursing family as well as an
individual.
a. Goals and
Philosophies of Maternal o Community centered;
and Child Health Nursing. the health of families is
both affected by and
influences the health of
communities.

o Evidence based; this is

the means whereby
critical knowledge
increases.

§ A challenging role for

Maternal and Child Health Nursing nurses and a major
Practice Throughout the factor in keeping
Childbearing-Childrearing Continuum families well and
optimally
- Provision of preconception health
functioning.
care
2. A maternal and
- Provision of nursing care of
child health nurse:
women throughout pregnancy, birth,
and postpartum period.
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· Considers the family childbearing and

as a whole and as a childrearing.
partner in care when
planning or · Encourages
implementing or developmental
evaluating the stimulation during both
effectiveness of care. health and illness so
children can reach their
· Serves as an ultimate capacity in
advocate to protect the adult life.
rights of all family
members, including the · Assesses families for
fetus strength as well as
specific need or
· Demonstrates a high challenges.
degree of independent
nursing functions · Encourages family
because teaching and bonding through
counseling are major rooming-in and family
interventions. visiting in maternal and
child healthcare
· Promotes health and settings.
disease prevention
because these protect · Encourages early
the health of the next hospital discharge
generation. options to reunite
families as soon as
· Serves as an possible in order to
important resource for create a seamless,
families during helpful transition
childbearing and process.
childrearing as these
can be extremely · Encourages families
stressful times in a life to reach out to their
cycle. community so the family
can develop a wealth of
· Respects personal, support people they can
cultural, and spiritual call on in a time of
attitudes and beliefs as family crisis.
these so strongly
influence the meaning B. Maternal and Child Health Goals
and impact of and Standards.
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o Nurses use nursing

process, nursing
2020 NATIONAL HEALTH GOALS: theory, and Quality &
Safety education for
The Two Pillars:
Nurses (QSEN)
o To increase quality and competencies to care
years of healthy life. for families during
childbearing and
o To eliminate health childrearing years.
disparities
o Provisions of the four
§ New objective phases of health care:
recommends that all
prelicensure 1. Health
programs in nursing promotion
include core content
2. Health
on:
maintenance
§ Counseling for health
3. Health
promotion and
restoration
disease prevention
4. Health
§ Cultural diversity
rehabilitation
§ Evaluation of health
sciences literature

§ Environmental health

§ Public health
systems

§ Global health

C. Theories Related to Maternal and

Child Nursing
NURSING PROCESS

A framework for Maternal and Child o A Scientific form of problem solving

Health Nursing Care
o Steps:
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1. Assessment o Infant mortality rate: The number of

deaths per 1,000 live births occurring
2. Nursing Diagnosis at birth or in the first 12 months of
life.
3. Planning
o Childhood mortality rate: The number
4. Implementation
of deaths per 1,000 population in
5. Evaluation children aged 1 to 14 years.

Statistics Related to the

Measurement of Maternal and Child
Health

o Birth rate – The number of births per

1,000 population

o Fertility rate – The number of

pregnancies per 1,000 women of
childbearing age.

o Fetal death rate – The number of

fetal deaths (over 500 g) per 1,000
live births.

o Neonatal death rate – The number of

deaths per 1,000 live births occurring
at birth or in the first 28 days of life.

o Perinatal death rate – The number of

deaths during the perinatal time
period (beginning when a fetus
reaches 500 g, about week 20 of
pregnancy, and ending about 4 to 6 Maternal Neonatal and Child health
weeks after birth); it is the sum of the and Nutrition Strategy (MNCHN)
fetal and neonatal rates.
- It applies specific policies and
o Maternal mortality rate: The number actions for local health systems to
of maternal deaths per 100,000 live systematically address health risks
births that occur as a direct result of that lead to maternal and especially
reproductive process neonatal deaths which comprise half
of the reported infant mortalities
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BeMONC – Basic Emergency o Blood transfusion

Obstetrics and Newborn Care

- Life-saving services for

emergency maternal and newborn BeMONC – Basic Emergency
conditions/complications being Obstetrics and Newborn Care
provided by a health facility or
- BeMONC facility shall consist of
professional to include the following
the core district hospital
services:
- For geographically
o Administration of
isolated/disadvantages
parental oxytocic drugs
areas/densely populated areas, the
o Administration of dose designated BeMONC facilities are
of parenteral the following: Rural Health Unit,
anticonvulsants Barangay Health Station, Lying-in
Clinics, and Birthing Homes.
o Administration of
parenteral antibiotics - Accessibility within 1 hour from
residence or referring facility within
o Administrations of the ILHZ (Inter-local Health Zones)
maternal steroids for
preterm labor CeMONC – Comprehensive
Emergency Obstetrics and Newborn
o Performance of Care facility
assisted vaginal
deliveries - lifesaving services for emergency
maternal and newborn
o Removal of retained condition/complications as BEMONC
placental products + provision of surgical delivery and
blood bank services and other
o Manual removal of specialized obstetric interventions.
retained placenta
- It is also able to provide
It also includes neonatal emergency neonatal care, which
interventions which include at include the minimum:
the minimum:
o Newborn resuscitation;
o Newborn resuscitation
o Treatment of neonatal
o Provision of warmth sepsis/infection;
o Referral o Oxygen support; and,
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o Antenatal - Second choice will be followed

administration of carefully by the rural health unit, city
(maternal) steroids for health clinic or peuriculture center.
threatened premature
delivery.

Essential Health Services available in ACITIVITIES:

the Health Care Facilities
Maternal care program: Regular and
- A. Antenatal quality maternal care services
Registration/Prenatal Care
- Prenatal care
- OBJECTIVE: to reach all
- Immunization (tetanus toxoid)
pregnant women, too give sufficient
care to ensure a health pregnancy - Safe delivery care
and the birth of a full term healthy
baby. - Iron, Folate, Vitamin A
supplementation
Normal Patients
- Nursing care after delivery –
- Initial evaluation hemorrhage, laceration, emotional
response, family planning.
- Given healthy instructions and

- Counseling-advice for prompt

prenatal care examination

Mild Complications

- Through evaluation – determine

the frequency of follow-up (rural
health unit, city health clinic or
puericulture center)

Potentiall Serious Complications

- Be referred to the most skilled

source of medical and hospital care
– 1st choice for continuing care or
consultation.
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- Expanded program of
immunization

- NBS and Newborn Hearing

Screening

- Infant and Young Children

Feeding

- Breastfeeding (Executive Order

51 – Milk Code)

- Food fortification

- Deworming

New screening

- It is a public health program

aimed at the early identification of
infants who are affected by certain
genetic/metabolic/infectious
conditions. Early identification and
intervention can lead to significant
reduction of morbidity, mortality and
associated disabilities in affected
infant.

Significance:

- Most babies with metabolic

disorders look “normal” at birth. By
doing NBS, metabolic disorders may
be detected even before clinical
signs and symptoms present. And as
a result of this, treatment can be
given early to prevent consequences
Newborn Care Program of untreated conditions.

- Essential Intrapartum Newborn Timing:

Care – EINC (unang yakap)
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- It is ideally done on the 48th-72nd Roles and Responsibilities of a

hours of life. However, it may also be Maternal and Child Nurse.
done after 24 hours from birth.
Ø Caregivers = nurse provides direct
Genetics and Genetic counselling patient-centered care to women,
infants, children, and their families in
- GC-process of determining the times of childbearing, illness, injury,
risk you have of passing on an recovery, and wellness.
inheritable dose to you baby.
Ø Client Advocates = one who speaks
Involves trained health care on behalf of another. As an advocate
professional the nurse considers the family’s
wishes and preferences when
- Identifies families at risk;
planning and implementing care.
- Investigates the problem present
Ø Researcher = Nurses contribute to
in the family,
their profession’s knowledge base by
- Interprets information about the systematically investigating theoretic
disorder, or practice issues in nursing.

- Analyzes inheritance patterns Ø Teacher = Education is an essential

and risk of recurrence, and role of today’s nurse. Teaching
begins early, before, and during a
- Reviews available options with woman’s prenatal care, and
the family. continues through her recovery from
childbirth and learning to care for her
What is a Gene? newborn and into her care in
women’s health.
· Gene- segment of DNA that is
coded to pass along a certain trait Ø Collaborator = Care if improved by
(i.e determining the color of your an interdisciplinary approach as
eyes). nurses work together with dietitians,
social workers, physicians, and
· Simplest building blocks of
others.
heredity
Trends Impacting Maternal and Child
· Form a unique “blueprint” for
Health Nursing
every physical and biological
characteristic of a person 1. Families contain fewer members

· 46 chromosomes 2. The number of single parents is

increasing.
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3. Ninety percent of women work

outside the home; many are the
primary wage earner.

4. The number of homeless women

and children is increasing.

5. Families are becoming more

mobile.

6. Families are more informed.

7. Child and intimate partner

violence is increasing.

8. Balancing quality and cost

containment in health care is an
increasing initiative.
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GENETICS AND GENETIC 5. Help determine the appropriate

COUNSELING treatment for some types of
cancer.
COMMON TESTS FOR 6. Identify the sex of a person by
DETERMINATION OF GENETIC determining the presence of Y
ABNORMALITIES chromosome. This may be done
when a newborn’s sex is not
A. Before Pregnancy clear.
A. Karyotyping
● A test to identify and KARYOTYPING
evaluate the size, shape, Normal Results
and number of ● Females: 44 autosomes and 2
chromosomes in a sample sex chromosomes (XX), written
of body cells. as 46, XX
● Extre, missing, or ● Males: 44 autosomes and 2 sex
abnormal positions of chromosomes (XY), written as
chromosome pieces can 46, XY
cause problems with a Abnormal Results
person’s growth, ● Down syndrome - (47chrom)
development, and body
functions.

KARYOTYPING: PURPOSES
1. Determine whether the
chromosomes of an adult have
an abnormality that can be
passed on to a child.
2. Determine whether a
chromosome defect is preventing ● Klinefelter syndrome - (XXY)
a woman from becoming
pregnant or causing
miscarriages.
3. Determine whether a
chromosome defect is present in
a fetus; may be done to
determine whether chromosomal
problems may have caused a
fetus to be stillborn.
4. Determine the cause of a baby’s ● Philadelphia chromosome - can
birth defects or disability. cause leukemia
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accurate during the 16th to

18th week
● All pregnant women
should be offered the
MSAFP screening, but it is
especially recommended
for:
1. Woman who have a
family history of
● Trisomy 18 birth defects
2. Women who are 35
years or older
3. Women who used
possible harmful
medications or
drugs during
pregnancy
4. Women who have
diabetes
● Turner syndrome - (X) - High levels:
a. Neural tube defect such as
spina bifida or
anencephaly,
b. Defects with the
esophagus or a failure of
your baby’s abdomen to
close. However, the most
common reason for
elevated AFP levels is
inaccurate dating of the
B. During Pregnancy: pregnancy.
a. MSAFP (Maternal Serum - Low levels and abnormal levels
Alpha-fetoprotein of hCG and estriol:
● The presence of AFP, a ● Baby may have Trisomy
plasma protein normally 21 (Down syndrome),
produced by the fetus, in Trisomy 18 (Edwards
the mother’s blood. Syndrome) or another type
● Performed between the of chromosome
14th and 22nd weeks of abnormality.
pregnancy, but most 2. Chorionic Villus Sampling
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● Generally done when either you analyzed to detect chromosomal

or the father has a diseases that defects or other abnormalities.
runs in the family (genetic PUBS is also known as umbilical
disorder) vein sampling, fetal blood
❖ Can be collected by sampling, and cordocentesis.
putting a thin flexible tube 5. Fetal Imaging
(catheter) through the a. Computed Tomography (CT)
vagina and cervix into the - CAUTION! Women should
placenta. always inform their
❖ Ultrasound is used to physician and CT
guide the catheter or technologist if there is any
needle into the correct possibility that they are
spot for collecting the pregnant.
sample. b. Magnetic Resonance Imaging
3. Amniocentesis (MRI)
● Amniocentesis is a procedure ● Magnetic Resonance
whereby a sample of fluid is Imaging (MRI), or nuclear
removed from the amniotic sac magnetic resonance
for analysis. imaging (NMRI), is
❖ During amniocentesis, primarily a medical
fluid is removed by placing imaging technique most
a long needle through the commonly used in
abdominal wall into the radiology to visualize the
amniotic sac. internal structure and
❖ Sometimes, the woman’s function of the body.
skin is injected first with a c. Ultrasonography
local anesthetic, but this is ● Obstetric sonography
not usually necessary. (ultrasonography) is the
❖ The amniocentesis needle application of medical
is typically guided into the ultrasonography to
sac with the help of obstetrics, in which
ultrasound imaging sonography is used to
performed either prior to or visualize the embryo or
during the procedure. fetus in mother’s uterus
4. Percutaneous Umbilical Blood (womb). The procedure is
Sampling (PUBS) often a standard part of
● A diagnostic procedure in which a prenatal care, as it yields a
doctor extracts a sample of fetal variety of information
blood from the vein in the regarding the health of the
umbilical cord. This blood can be mother and of the fetus, as
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well as regarding the

process of the pregnancy. Genogram
6. Fetoscopy - is a pictorial display of a person’s
● Fetoscopy is an endoscopic family relationships and medical history.
procedure during pregnancy to - It goes beyond a traditional family tree
allow access to the fetus, the by allowing the user to visualize
amniotic cavity, the umbilical hereditary patterns and psychological
cord, and the fetal side of the factors that punctuate relationships.
placenta. A small (3-4 mm) - It can be used to identify repetitive
incision is made in the abdomen, patterns of behavior and to recognize
and an endoscope is inserted hereditary tendencies.
through the abdominal wall and
uterus into the amniotic cavity. 3. Health history
7. Preimplantation Diagnosis - genetic genogram
● Preimplantation Genetic determination
Diagnosis (PGD or PIGD) (also - obtain health record of
known as embryo screening) affected individuals
refers to procedures that are
performed on embryos prior to B. Physical Assessment
implantation. Used to denote - Of any family member with a
procedures that do not look for a disorder
specific disease but to identify - Child’s siblings
embryos at risk. - Couple seeking counseling
C. Diagnostic Testing
UTILIZATION OF THE NURSING
PROCESS IN THE CARE OF CLIENT
SEEKING SERVICES BEFORE &
DURING CONCEPTION IN THE
PREVENTION OF GENETIC
ALTERATION (GENETIC SCREENING
& COUNSELING)
I. Assessment
A. History
1. Detailed family history
- age, ethnic background,
instances of spontaneous
miscarriage, children died
at birth,
2. Extensive prenatal history
- family genogram
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CARE AT-RISK, HIGH-RISK, AND - 8 years or more since last pregnancy

SICK MOTHER (too far apart)
- Pregnancy occurring within last 3
HIGH-RISK PREGNANCY months of last delivery (too close)
- Concurrent disorder, 3. Medical Conditions that exist
pregnancy-related complication before pregnancy
or external factor jeopardizes the - Conditions such as high blood
health of the mother, the fetus, or pressure; breathing, kidney, or heart
both. problems; diabetes; sexually transmitted
diseases (STDs); or chronic infections
IDENTIFYING CLIENTS AT RISK such as human immunodeficiency virus
Assessment of Risk Factor (HIV) can present risks for the mother
● Age (very young and old) and/or her unborn baby.
● Medical condition (pre and post - It's important to consult your doctor
pregnancy) before you decide to become pregnant.
● Number of pregnancy, spacing He may run tests, adjust medications, or
between pregnancies advise you of precautions you need to
● Maternal habits / Lifestyle take to optimize the health of you and
● Obstetric / Gynecologic history your baby.
● Family history 4. Maternal Obstetric and
Gynecologic History (any of
FACTORS THAT CATEGORIZES A the following)
PREGNANCY AT HIGH-RISK - Two or more premature deliveries or
1. Age (very young and old) spontaneous abortions
- Adolescents younger then 15 - One or more neonates born with gross
- Increased incidence of anomalies
Low-birth-weight and preterm - Pelvic Inadequacy or abnormal
neonates. shaping
- Anemia, labor dysfunction, and - Abnormal uterine structure/shape
CPD, nutritional deficiency, - History of Placental Anomalies,
increased risk for PIH Amniotic Fluid Abnormalities, or Poor
- Nulliparas, who are aged 35 and older, Weight Gain
- Multiparas who are aged 40 and older - History of Gestational Diabetes
- Increased risk for placenta Mellitus, PIH, or Infection
previa, miscarriage, - Lack of previous prenatal care or
low-birth-weight babies, genetic preparation for labor and birth
defects. - Poor self-care practices
2. Maternal Parity (with at least
one of the following):
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- Family
environment,
such as history
of battery or
abuse, lack of
support,
inadequate
housing, or
lack of
5. Maternal Lifestyle and Habits adequate
- Inadequate finances
Nutrition =
deficiency of SCREENING PROCEDURE
iron - diet/weight - Early detection is key to providing
(BMI) the best treatment for the mother
- Exposure to and unborn baby.
toxic - experts use the latest tools to
substances diagnose, monitor and treat
such as lead, health problems in pregnant
organic women and their unborn babies.
solvents, certain
gasses (ex. DIAGNOSTIC TEST
Carbon - it is done to establish the
Monoxide), and radiation = fetal presence (or absence) of disease
malformations as a basis for treatment decisions
- Ingestion of over-the-counter and in symptomatic or screen positive
prescription drugs = detrimental to the individuals.
fetus ● Non-invasive diagnostic test:
- Cigarette smoking = intrauterine - Fetal Ultrasound
growth retardation and low-birth-weight - Non-stress Test (NST)
neonates - Contraction stress test
- Involvement with substance abuse via Maternal Blood Screen
injection = posing an increase risk of - The maternal blood screen is a
infection with Hepa-B and HIV simple blood test.
6. Family History - It measures the levels of two
- Some conditions and disorders, such proteins, human chorionic
as family history of multiple births, gonadotropin (hG) and
congenital diseases or deformities, and pregnancy associated plasma
mental disability protein A (PAPP-A).
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- If the protein levels are Electronic Fetal Monitor (EFM)

abnormally high or low, there
could be a chromosomal disorder
in the baby.
Alpha-fetoprotein screening (AFR)
- This blood test measures the
level of alpha-fetoprotein in
maternal blood during pregnancy.
Oral Glucose Tolerance Test (OGTT)
- AFP is a protein normally made
- A glucose tolerance test is often
by the fetal liver. It is in the fluid
done in weeks 24 to 28 of
around the fetus (amniotic fluid)
pregnancy.
and crosses the placenta into
- It measures levels of sugar
your blood.
(glucose) in your blood. Abnormal
- Abnormal levels of AFP may be a
glucose levels may be a sign of
sign of:
gestational diabetes.
● Open neural tube defects
- Screening with an oral glucose
(ONTD) such as spina
challenge test ( a fasting plasma
bifida
glucose level) is done; with
● Down syndrome
100grams is loaded to pregnant
● Other chromosome
woman, after 1 hour the blood
problems
sugar level is checked.
Fetal Ultrasound
- Two abnormal levels or a
Obstetrical ultrasound is a useful clinical
fasting glucose level >95mg/dL
test to:
confirms diagnosis of GDM
- establish the presence of a living
embryo/fetus
- estimate the age of the
pregnancy
- diagnose congenital
abnormalities of the fetus
- evaluate the position of the fetus
- evaluate the position of the
placenta as well as maturity ● Invasive diagnostic test:
- determine if there are multiple - Amniocentesis
pregnancies - Chorionic Villus Sampling
- determine the amount of amniotic - Percutaneous Umbilical
fluid around the baby Cordblood sampling
- assess fetal well-being
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WHAT STEPS CAN I TAKE TO - If you're planning to use ART

PROMOTE HEALTHY PREGNANCY? such as (In Vitro Fertilization) to
Schedule a preconception get pregnant, consider how many
appointment. embryos will be implanted.
- health care provider counsel you - Multiple pregnancies carry a
to start taking a daily prenatal higher risk of preterm labor.
vitamin and reach a healthy
weight before you become IVF (In Vitro Fertilization)
pregnant.
- If you have a medical condition,
your treatment might need to be
adjusted to prepare for
pregnancy.
- During IVF, mature eggs are
Seek regular prenatal care. collected (retrieved) from ovaries
- Prenatal visits help you monitor and fertilized by sperm in a lab
your health and your baby's - An egg is fertilized by injecting a
health. Depending on the single sperm into the egg or
circumstances, you might be mixing the egg with sperm in a
referred to a specialist in petri dish
maternal-fetal medicine, genetics, - Then the fertilized egg (embryo)
pediatrics or other areas. or eggs (embryos) are transferred
to a uterus.
Eat a healthy diet.
- During pregnancy, you'll need PRE-GESTATIONAL CONDITIONS (
more folic acid, calcium, iron and AFTER RISKS)
other essential nutrients.
- Special nutrition needs due to a RHEUMATIC HEART DISEASE IN
health condition, such as PREGNANCY (RHD)
diabetes. - chronic heart condition caused by
rheumatic fever
Avoid risky substances. Rheumatic fever is a systemic
- If you smoke, quit. Alcohol and inflammatory disease caused by a
illegal drugs are off-limits, too. group A streptococcus (streptococcal)
- Get your health care provider's infection.
OK before you start to get - develops after infection with
pregnant-- or stop bad habits. GAS, leads to production of
antibodies that affect the
Be cautious when using assisted connective tissues.
reproductive technology (ART). Diagnostic Findings:
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- Lab test: elevated white blood lead to the development of much

cells count, elevated ESR more serious symptoms such as
- Throat culture: presence of GAS pulmonary edema, atrial
(group A streptococcus) fibrillation or clotting.
- echocardiography: valve damage
& pericardial effusion
- Symptoms:
- Pleuritic chest pain SUBSTANCE ABUSE
- dyspnea/tachypnea - is the repeated harmful use of
- cough(non-productive) any substance, including drugs
Treatment: and alcohol. The substances may
- Treating strep throat with be legal, prescription drugs or
antibiotics banned substances as well some
Regular antibiotics (usually that aren't even classified as
monthly injections IM with drugs.
penicillin G benzathine) - Both legal and illegal drugs have
can prevent patients with chemicals that can change how
rheumatic fever from your body and mind work.
contracting further strep - Heavy drinking also can cause
infections and causing liver and other health problems or
progression of valve lead to a more serious alcohol
damage. disorder.
- Bedrest
- Sodium restriction Smoking cigarettes, drinking alcohol
Why at risk for Pregnancy? and using illegal drugs can put a
● During any pregnancy there is an pregnancy at risk.
increase in blood volume of - Research shows that use of
30%-50% resulting in increased tobacco, alcohol, or illicit drugs or
pressure on the heart valves. For misuse of prescription drugs by
women with rheumatic heart pregnant women can have
disease this increased pressure severe health consequences for
presents increased maternal infants.
and/or fetal risks. - This is because many
● Pregnancy can lead to the substances pass easily through
appearance or worsening of the placenta, so substances that
symptoms including shortness of a pregnant woman takes also
breath with simple activity, and reach the fetus.
waking at night out of breath. - Some findings show that babies
● For women with more severe born to women who use cocaine,
rheumatic heart disease, it could alcohol, or tobacco when they are
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pregnant may have brain

structure changes that persist
into early adolescence.
- Drinking alcohol during your
pregnancy puts your baby at risk
of Fetal Alcohol Spectrum
Disorder (FASD). FAD is the
leading known cause of
developmental disabilities in
children.
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GESTATIONAL - HG, HMOLE, GDM

HYPEREMESIS GRAVIDARUM

Hyperemesis gravidarum (HG) is an Pathophysiology

extreme form of morning sickness that - Exact cause is unknown, but it is
causes severe nausea and vomiting linked to trophoblastic activity,
during pregnancy. gonadotropin production, and
Definition psychological factors
- Severe and unremitting nausea Various possible causes
and vomiting that persists after - Pancreatitis
the first trimester. - Biliary tract disease
- Usually occurs with the first - decreased secretion of free
pregnancy and commonly affects hydrochloric acid in the stomach
pregnant women with conditions - decreased gastric motility
that produce high levels of - Drug toxicity
Human Chorionic Gonadotropin - Inflammatory obstructive bowel
(hCG), such as gestational disease
trophoblastic disease or multiple - Vitamin deficiency (especially of
gestations. B6)
Possible causes or contributing - Psychological factors
factors include the following: - Trophoblastic disease - abnormal
● Rising levels of hormones, such growth of cells inside the uterus
as human chorionic gonadotropin (trophoblast cells produce hCG)
(HCG), estrogen, and - HCG is released by the placenta.
progesterone early in pregnancy. Assessment findings
● Abnormal tissue growth in the - Unremitting nausea and vomiting
uterus, called a hydatidiform mole (cardinal sign)
- Substantial weight loss
- Thirst
- Oliguria
- Electrolyte imbalance
- "Dehydration
- Metabolic acidosis
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Diagnostic test findings ● Starvation, with ketosis and

- Decreased serum protein, acetonuria
sodium, and potassium levels ● Dehydration, with subsequent
- Increased blood urea nitrogen fluid and electrolyte imbalances
levels (hypokalemia)
- Elevated hemoglobin levels ● Acid-base imbalances (acidosis
- Elevated white blood cell count and alkalosis)
- Ketonuria and slight proteinuria ● Retinal, neurologic, and renal
Management damage
- Restore fluid and electrolyte
balance with IV fluid therapy
- Administer antiemetic to control GESTATIONAL TROPHOBLASTIC
vomiting DISEASE (GTD)
- Maintain adequate nutrition and
rest
- Progress to oral feedings as
tolerated
Nursing Interventions
- Administer IV fluids as ordered.
- Monitor intake and output, vital
signs, Skin turgor, daily weight,
serum electrolyte levels, and
urine ketone levels.
- Suggest decreased liquid intake - Anomaly of the placenta that
at mealtime converts the chorionic villi into a
- Instruct the patient to remain mass of clear vesicles.
upright for 45 mins after eating. - Gestational trophoblastic disease
- Suggest that the patient eat two is a group of rare diseases in
or three dry crackers on which abnormal trophoblast cells
awakening. grow inside the uterus after
- Provide reassurance and a calm, conception.
restful atmosphere. - A tumor develops inside the
- Encourage the patient to discuss uterus from tissue that forms after
her feelings. conception.
- Help the patient develop effective - It is an unsuccessful pregnancy
coping strategies. that occurs after a man's sperm
- Teach the patient measures to has fertilized a woman's egg and
conserve energy. when tissue that would normally
Possible complications: develop into the placenta to
● Substantial weight loss nourish the developing fetus
forms an abnormal growth, or
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mass, containing hundreds of

grape-sized cysts (fluid-filled
sacs).
Definition
- Anomaly of the placenta that
converts the chorionic villi into a
mass of clear vesicles.
- Also called molar pregnancy
Two types of moles
● Complete Moles - there's neither
an embryo nor an amniotic sac
● Partial Mole - there's an embryo
(usually with multiple
abnormalities) and amniotic sac.
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GESTATIONAL CONDITIONS: IC, PIH - It is also associated with

increasing maternal age.

- Implantation in an area of defective

endometrium with no zone
separation between the placenta and
the myometrium.

Assessment

- History of repeated second

trimester spontaneous abortions.

- Cervical dilation in the absences

of contractions or pain.

- Pink-stained vaginal discharge

- Increased pelvic pressure with

possible ruptured membranes and
release of amniotic fluid

What is incompetent cervix? Diagnostic test findings

- also called premature cervical - Ultrasound revealing defect

dilatation
- Nitrazine test result indicates
- refers to a painless premature rupture of membranes has occurred
dilatation of the cervix
Management
- it generally occurs in the 4th to 5th
month of gestation, most commonly - Placement of cerclage in the
around the 20th week of gestation. cervix-help keep the cervix closed
until tem or the patient goes into
Pathophysiology labor.

- This condition is associated with McDonald’s procedure using nylon

congenital structural defects or sutures horizontally and vertically to
previous cervical trauma resulting close off cervix to only a few mm.
from surgery or delivery.
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Management:

- Bed rest after surgery

- Removal of sutures at 37 to 39
weeks’ gestation

- Emotional support

Nursing Interventions

- Assess complaints of vaginal

drainage and investigate history for
previous cervical surgeries

- Prepare woman for cervical

cerclage under regional anesthesia
as indicated; monitor maternal vital
signs and fetal heart rate patterns
closely.

- Instruct woman in signs and

symptoms of labor with the need to
notify health care provider if any
occur.

- Maintain bed rest after surgery

as ordered; if necessary, place
woman in a slight or modified
Shirodkar Procedure using sterile tape Trendelenburg position to alleviate
in a purse=string fashion to close off pressure of the uterus on the sutured
cervix entirely area.
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- Encourage follow-up to evaluate o Incidence increases

progress of pregnancy among women who
have history of
- Advise the woman that the vascular disease
sutures will be removed around the
37th to 39th week of pregnancy. Pathophysiology

Possible complication - Exact cause is unknown

- Spontaneous abortion - Systemic peripheral vasospasm

occurs, affecting every organ system
- Preterm birth
- Geographic, ethnic, racial,
Pregnancy-induced hypertension nutritional, immunologic, and familial
factors may contribute to its
- Also called hypertension of
occurrence
pregnancy or gestational
hypertensive disorder - Age is also a factor, adolescents
younger than age 19 and primiparas
- A potentially life-threatening
older than age 35 are at highest risk.
disorder that usually develops after
the 20th week of pregnancy Assessment Findings
Two categories of PIH: - BP over 140/90 mmHg or an
increase of 30 mmHg systolic and 15
- Preeclampsia
mmHg diastolic over baseline
o Nonconvulsive form of obtained on two occasions at least 4
the disorder to 6 hours apart

o Marked by the onset of - Increase in generalized edema

hypertension after 20 associated with a sudden weight
weeks’ gestation gain of more than 5lbs (2.3 kg) per
week
- Eclampsia
- Usually appears between the 20th
o Convulsive form of the and 24th weeks of gestation and
disorder disappears within 42 days after
delivery
o Occurs between 24
weeks’ gestation and - A final diagnosis usually deferred
the end of the fist until blood pressure returns to
postpartum week normal after delivery; if blood
pressure remains elevated, chronic
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hypertension, either alone or - Bed rest in lateral

superimposed on PIH, may be the position
cause
- Close observance of
Severe preeclampsia BP, FHR, edema,
proteinuria, and signs of
Includes: pending eclampsia
- Increase blood urea - Administration of
nitrogen antihypertensive, such as
methyldopa and
- Creatinine and uric
hydralazine
acid levels
- Administration of
- Frontal headaches
Magnesium sulfate
- Blurred vision
- Nonstress tests every
- Hyperreflexia one to two times per week;
biophysical profile every 3
- Nausea and vomiting weeks

- Irritability Nursing Interventions

- Cerebral disturbances - Monitor the patient

regularly for changes in
- Epigastric pain BP, PR, RR, FHR, vision,
level of consciousness,
Diagnostic Test Findings
and deep tendon reflexes
- Proteinuria and for headache.

o In preeclampsia, - Close monitor the

more than 300 results of stress and
mg/24 hours (1+) nonstress tests.

o In eclampsia, 5 g/24 - Keep emergency

hours (5+) or more resuscitative equipment
and an anticonvulsant
Management readily available

- High protein diet, - Maintain patent airway

low-salt diet and have oxygen readily
available
- Adequate fluid intake
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- Prepare for emergency

cesarean delivery, if
indicated

- Maintain seizure
precaution

- If the woman is
receiving MgSO4 IV,
administer the loading
dose over 15-30 minutes
and then maintain the
infusion at a rate of 1 to
2g/hour

- Monitor the extent and

location of edema

- Assess fluid balance

Severe Complications of Eclampsia

- Cerebral Edema

- Stroke

- Abruptio placenta

- Fetal death
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GESTATIONAL CONDITIONS:
ECTOPIC, ABORTION

ECTOPIC PREGNANCY

● Implantation of the fertilized ovum

outside the uterine cavity.
● Most occurs in fallopian tube
(95%), other sites include the
cervix, ovary, or abdominal cavity
● Second most common cause of
vaginal bleeding during
PATHOPHYSIOLOGY:
pregnancy.
● Significant cause of maternal
● Placental factors usually cause
death due to hemorrhage.
spontaneous abortion around the
14th week, when the placenta
takes over the hormone
production necessary to maintain
the pregnancy.
● Premature separation of the
normally implanted placenta
● Abnormal placental implantation
● Abnormal platelet function
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Obstruction:
ASSESSMENT FINDINGS
● Adhesion of the fallopian tube
from a previous infection (chronic ● Normal pregnancy symptoms
salpingitis or PID) other that mild abdominal pain
● Congenital malformations ● Amenorrhea or abdominal
● Scars from tubal surgery menses
● Uterine tumor pressing on the ● Slight vaginal bleeding; unilateral
proximal end of the tube. pelvic pain over the mass - due to
● Zygote cannot travel the length tearing & destruction (rupture) of
of the tube bv
● Lodges and implants at the ● Abnormally low hCG
structured site. ● Sudden, severe abdominal pain
● Ectopic pregnancy radiating to the shoulder
● Tender uterus
Other factors: ● Syncope - brief lapse of
consciousness
● Sexuallay transmitted tubal ● N/V
infections may also be a factor as ● Shock with profuse bleeding -
may the use of IUD - causes due to internal bleeding
irritation of the cellular lining of
the uterus and the fallopian
tubes.
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- Detects free blood in the

DX TEST FINDINGS peritoneum (performed in
ultrasonography detects absence
● Serum pregnancy (hCG) test of gestational sac in the uterus)
- shows an abnormally low level
of hCG, when repeated in 48hrs, Laparoscopy
the level remains lower than than
the levels found in a normal - Reveal pregnancy outside the
intrauterine pregnancy uterus (performed if
Real-time ultrasonography culdocentesis is positive)
- Determination of
intrauterine pregnancy or
ovarian cyst (performed if
serum pregnancy test
results are positive)

Culdocentesis (aspiration of fluid

from the vaginal cul-de-sac)
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● Tube - Salpingectomy
MANAGEMENT

● Unruptured tube
- Methotrexate > attacks &
destroys fast growing
cells.
- Leucovorin> counteracts
the toxic effect of
methotrexate.
- Treated until negative hCG
titer is achieved
- Mifepristone > an
Disadvantage:
abortifacient, causing
sloughing of the tubal
● Rough suture line may lead to
implantation site.
another tubal pregnancy
Advantage : tube is left intact; no
● Tube is removed or saturated
surgical scarring that could cause a
through microsurgical techniques
second ectopic implantation.
- Theoretically, woman is
50% fertile
Ruptured tube - emergency situation
- Not a reliable
contraceptive measure >
- Blood sample: hgb level, typing
translocation of ova from
and cross matching, hcg level
the right ovary can pass
- IVF,BT
through the pelvic cavity to
the left fallopian tube and
● Laparoscopy - to ligate the
become fertilized, and
bleeding vessel; to remove or
vice versa.
repair the damaged fallopian tube
● Ovary - Oophorectomy
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Nursing Intervention

Nursing Management

● CBR without BRP, after bedpan

use, inspect contents for
intrauterine material
● Note the amount ,color and odor
of vaginal bleeding.
● Save all pads the pt uses for
evaluation
● Assess VS for 24 hrs or more
frequently. Depending on the
extent of bleeding
● Monitor urine output closely.
● Provide good perineal care
● Check the pt’s blood type and
administer RhoGAM as ordered
● Provide emotional support and
counseling during the grieving
process
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● Assess extent of bleeding and task you feel comfortable doing

monitor fundal height every 30 as long as these activities don’t
min for changes increase vaginal bleeding or
● Determine the amount of blood cause fatigue.
loss ● Use a contraceptive when you
● Monitor maternal VS, central and your partner resume
venous pressure, I&O and intercourse.
amount of vaginal bleeding 10-15 ● Avoid the use of a tampon 1 to 2
min wks.
● Begin EFM ● Arrange for ff up visit with your
● Have equipment for emergency physician in 2 to 4 wks.
CS readily available ● Prepare the patient for vaginal
● Reassure the pt fpr her progress examination
through labor and keep her ● Before physically examining a
informed of the fetus condition patient who is expected of having
● Tactfully discuss the possibility of PROM explain all diagnostic test
neonatal death and clarify any
● Encourage the pt and family to misunderstandings.
verbalize their feelings. ● During the examination, stay with
● Help them to develop effective the patient
coping strategies. ● Offer reassurance
● Encourage the pt and her ● Provide sterile gloves and sterile
partner to express their feelings. lubricating jelly
● Help the pt her partner to develop ● Don’t use iodophor antiseptic
effective coping strategies solution discolor nitrazine paper
● Explain all procedures and and makes pH determination
treatments to the pt and provide impossible.
teaching about aftercare and ff up
● Expect vaginal bleeding or
spotting to continue for several
days.
● Immediately report bleeding that
last long than 10 days, is
excessive or appears bright red.
● Watch for signs of infections,
such as fever, (higher than
37.8C) and foul smelling vaginal
discharge
● Gradually increase your daily
activities to include whatever
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● Infertility results in the uterus or

both fallopian tubes or both
ovaries are removed.
● Maternal mortality rate is about
6% dependent on the severity of
the bleeding and the time lapse
between placental separation and
delivery.
● Postpartum pts at risk for
vascular spasm, or hemorrhage
and shock.
● Perinatal mortality dependent on
the degree of placental
separation and fetal level of
maturity
● Most serious neonatal
complications system from
hypoxia prematurity and anemia

Spontaneous Abortion

● Up to 15% of all pregnancies and

about 3-% of first pregnancies
Possible Complications end in spontaneous abortion
● At least 75% of spontaneous
● RUPTURE of the tube causes life abortion occurs during the first
threatening complications, trimester.
including hemorrhage, shock,
and peritonitis Types of Spontaneous Abortion
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1.Complete - uterus passes ALL 6.Septic - infection accompanies

products of conception. abortion. This may occur with
spontaneous abortion, but usually
> Minimal bleeding usually accompanies results from a lapse in sterile technique
complete abortion because the uterus during therapeutic abortion.
contracts and compresses the maternal
blood vessels that fed the placenta. 7. Threatened - bloody vaginal
discharge occurs during the 1st half of
2.Habitual - spontaneous loss of three pregnancy. About 20% of pregnant
or more consecutive pregnancies. women have vaginal spotting or actual
bleeding early in pregnancy.of these,
3.Incomplete - uterus retains part or all about 50% labor.
of the placenta.

> Before 10 wks AIG, the fetus and

placenta are usually expelled together;
> after 10th wk, they’re expelled
separately. Because part of the
placenta may adhere to the uterine
wall, bleeding continues.

Hemorrhage is possible because the

uterus does not contract and seal the
large vessels that fed the placenta.

4.Inevitable - membranes rupture and

the cervix dilates, as labor continues,
the uterus expels the products of
conception

5.Missed abortion - uterus retains the

products of conception for 2 months or
more after the fetus has died.

> Uterine growth ceases; uterine sized

may even seem to decrease.
> Prolonged retention of the dead
products of conception may cause
coagulation defects such as DIC
NRG 204 HANDOUT

GESTATIONAL CONDITIONS: PREVIA,

ABRUPTIO, PROM, ACCRETA

PLACENTA PREVIA

● Is an abnormal low implantation

of the placenta in proximity to the
internal cervical os.
● Is a condition in which the
placenta attaches to the uterine
wall in the lower portion of the
3.Marginal Previa - the edge of the
uterus and covers all or part of
placenta lies at the margin of the
the cervix.
internal cervical os and may be exposed
● One of the common causes of
during dilation.
bleeding during the second half
of pregnancy

Classification:

1.Total Previa - the placenta completely

covers the internal cervical os.

4.Low - lying placenta is implanted in

the lower uterine segment but does not
reach to the internal os of the cervix.

2.Partial Previa - the placenta covers a

part of the internal cervical Os.
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Three types of placenta previa

Low marginal implantation- a small

placental edge can be felt through the
internal os.

Partial placenta previa - The placenta

partially caps the internal os.

Total placenta previa - the internal os

is covered entirely.

PATHOPHYSIOLOGY

● Unknown
● May be linked to uterine fibroid
tumor or uterine scars from
surgey
● Factors that may affect the site of
the placenta’s attachment to the
uterine wall include:
- Defective vascularization
of the deciduous
- multiple gestations
- Previous uterine surgery
● Multiparity
● Advanced maternal age
● The lower uterine segment of the
uterus fails to provide as much
nourishment as the fundus
● Placenta tends to spread out,
seeking the blood supply it
needs, becoming larger and
thinner than normal.
● Placenta willi are torn from the
uterine wall as the lower uterine
segment contracts and dilates in
the 3rd trimester
● As the internal cervical os effaces
and dilates, uterine vessels are
torn
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● Uterine sinuses are exposed at ● Typically, RPOM causes blood

the placental site and bleeding tinged amniotic fluid contraing
occurs vernix caseosa particles to gush
● Contributing factors: multiple or leak from the vagina.
gestations, hydramnios, cocaine ● Maternal fever, fetal tachycardia,
use, decreased blood flow to the and foul smelling vaginal
placenta, and trauma to the discharge indicate infection
abdomen: woman with low serum ● Alkaline pH of fluid collected from
folic acid levels, vascular disease the posterior fornix turns nitrazine
or PIH. paper deep blue
● Blood vessel at the placental bed ● A smear of fluid, placed on a
rupture spontaneously due to slide and allowed to dry, takes on
lack of resilience or to abnormal a fern-like pattern (because of the
changes in uterine vasculature. high sodium and protein content
● An enlarged uterus, which can’t of amniotic fluid); considered a
contract sufficiently to seal off the positive findings that confirm that
torn vessels, and hypertension the substance is amniotic fluid.
complicate the situation
● Consequently, bleeding continues DX TEST FINDINGS
unchecked, possibly shearing off
the placenta partially or ● Pelvic examination under a
completely. double set-up
● As the blood enters the muscle ● Lab studies may reveal
fibers, complete relaxation of the decreased maternal hgb level.
uterus tone and irritability. ● Transvaginal ultrasound scanning
● If bleeding into the muscle fibers is used to determine placental
is profuse, the uterus turn blue or position.
purple and the accumulated ● Pelvic exam under double setup
blood prevents its normal and ultrasonography rule out
contractions after delivery. placenta previa
● Decreased hgb levels and
ASSESSMENT FINDINGS platelet ct
● Periodic assays for fibrin split
● Painless, bright red vaginal products to monitor progression
bleeding after the 20th week of of abruption placenta and defect.
gestation stops spontaneously
● Bleeding increases with each
successive incident
● Soft, non- tender uterus.
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MANAGEMENT ● Anticipate for the need for EFM

and assist with application as
● Depending on when the first indicated
episode occurred and the amount ● Have oxygen readily available for
of bleeding use should fetal distress occur.
● Limitation of maternal activities ● Rho (D) immunoglobulin
● Monitoring of all relevant VS (RhIG)for bleeding in Rh-negative
● Emotional support patients
● NO / Refrain from performing ● Institute CBR
rectal or vaginal exam ● Betamethasone to enhance fetal
● Vaginal delivery is considered lung maturity
only when the bleeding is minimal ● Emotional support
and the placenta previa is ● During the post partum period,
marginal or when the labor is monitor the patient for
rapid. hemorrhage and shock.
● Immediate c/s delivery performed ● Tactfully discuss the possibility of
as soon as the fetus is sufficiently neonatal death.
mature or in the case of
intervening severe hemorrhage. ABRUPTIO PLACENTA
● Monitoring maternal VS, uterine
contractions and vaginal ● Refers to the abnormal
bleeding. separation after 20 to 24 weeks
● Vaginal delivery depends on the of gestation and prior to birth.
degree and timing of separation ● Also a significant contributor to
in labor. maternal mortality.
● CS indicated moderate to severe ● Common in multigravidas
placental separation. (usually in women age 35 and
● Evaluation of maternal lab values older, and is common cause of
● Fluid and electrolyte replacement bleeding during the 2nd half of
therapy, BT pregnancy
● Emotional support ● Dx is confirmed when there's
heavy maternal bleeding, which
NURSING MANAGEMENT generally necessitates
termination of pregnancy:
● Teach the patient to immediately ● Fetal prognosis depends on the
identify and raport S/S placenta gestational age and amount of
previa blood loss
● If with active bleeding, monitor ● Maternal prognosis is good if
v/s, I&O, and amount of vaginal hemorrhage can be controlled.
bleeding, as well as FHT.
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- Abrupt onset of agonizing

unremitting uterine pain;
boardlike, tender uterus;
moderate vaginal bleeding ;
rapidly progressive
shock;absence of FHT

PREMATURE RUPTURE OF
MEMBRANES

● Refers to membrane rupture 1 or

more hours before the onset of
DEGREE OF PLACENTAL
labor.
SEPARATION IN ABRUPTIO
- Preterm PROM - refers to
PLACENTA
rupture of the membranes
before the onset of labor in
1. Mild separation - begin with small
preterm gestation
areas of separation and internal
● It is a spontaneous break in the
bleeding (concealed hemorrhage)
amniotic sac before onset of
between the placenta and uterine wall
regular contractions.(resulting in
● Gradual onset, mild to moderate
progressive cervical dilation)
bleeding, vague lower abdominal
● The mother is at risk for
tenderness and uterine irritability,
chorioamnionitis if the time
strong and regular fetal heart
between rupture of membranes
tones.
and onset of labor is longer than
2.Moderate separation - may develop
24 hrs.
abruptly or progress from mild to
● Sign include fetal tachycardia
extensive separation with external
maternal fever, foul smelling
hemorrhage.
amniotic fluid, and uterine
● Gradual or abrupt onset,
tenderness.
moderate, dark red vaginal
● Development of chorioamnionitis
bleeding, continuous abdominal
can lead to sepsis and death.
pain, tender uterus that remains
● Risk of development increases
firm between contractions, barely
exponentially after 18 hrs of ROM
audible or irregular and
without delivery.
bradycardic FHT possible signs
or shock.
3. Severe separation - external
hemorrhage occurs, along with shock
and possible fetal cardiac distress.
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FERNING

CAUSES

● Unknown
● Malpresentation and a TREATMENT
contracted pelvis
commonly accompany the ● Depends on fetal age and the risk
rupture of infections
● Predisposing factors ● In a term pregnancy. If
include poor nutrition and spontaneous labor and vaginal
hygiene and lack of delivery don’t result within a
prenatal care, an relatively short time (usually 24
incompetent cervix, hrs after the membranes rupture),
increased intrauterine labor is usually induced with
tension due to hydramnios oxytocin: if induction fails,
or multiple pregnancies, cesarean delivery is performed.
defects in the amniotic
membrane, and uterine,
vaginal, and cervical
infections (most commonly
group B streptococcal,
gonococcal, chlamydial
and anaerobic organisms)
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PLACENTA ACCRETA

● Is an uncommon condition in
which the chorionic villi adhere to
the myometrium.
Types:

1.Placenta Accreta - the placental

chorionic will adhere to the superficial
layer of the uterine myometrium.

2.Placenta Increta - the placenta

chorionic villi will invade deeply into the
uterine myometrium.

3.Placenta Percreta - the placental

chorionic will go through the uterine
myometrium and often adhere to
abdominal structure such as the bladder
or intestine )
NRG 204 HANDOUT

2. Assist with rapid treatment and

intervention. Be prepared for a
dilation and curettage or
hysterectomy.
3. Provide physical and emotional
support.
4. Provide client and family
education.

ETIOLOGY

● Risk factors: placenta previa,

● Maternal age > 35
● Placental location overlying the
previous uterine scar.
● Multiple previous pregnancies,
● Previous uterine surgery,
● Previous D&C.

ASSESSMENT FINDINGS

Associated findings. It is usually

diagnosed in the immediate postpartum
period when the placenta fails to
separate.

Clinical manifestations:

- Placenta fails to separate

- Profuse hemorrhage may result
depending on the portion of
placenta.

NURSING MANAGEMENT

1. Identify placenta accreta in the

patient. Be aware of the patient's
risk status.