FRAMEWORK FOR MATERNAL AND CHILD HEALTH NURSING

(MCN) FOCUSING ON AT-RISK, HIGH RISK, AND SICK CLIENTS

RISK
➢ Is the possibility of something bad is happening.
➢ It involves uncertainty about the effects/implications of an activity with respect to
something that humans value (such as health, well-being, wealth, property or the
environment), often focusing on negative, undesirable consequences.

According to WHO, a RISK FACTOR is defined as an ascertainable characteristic or

circumstance of a person or group of such persons known to be associated with an abnormal
risk of developing or being adversely affected by a morbid process.

HIGH RISK PREGNANCY is defined as one of which is complicated by a factor or factors that
adversely affects the pregnancy outcome maternal or perinatal or both.

Mothers & Newborns (0-28 days) dying everyday

560,000 GLOBAL 4,000,000

4,600 PHILIPPINES 33, 620

MAIN CAUSES OF MATERNAL DEATH

1. HYPERTENSIVE DISORDER OF PREGNANCY
➢ This includes conditions like preeclampsia and eclampsia, characterized by high
blood pressure during pregnancy. These disorders can lead to complications
such as organ damage, seizures (eclampsia), and impaired blood flow to organs,
putting both the mother and the baby at risk.
➢ Severe cases can result in organ failure, stroke, or other life-threatening
complications, contributing to maternal mortality.

2. POSTPARTUM HEMORRHAGE
➢ This refers to excessive bleeding after childbirth, either immediately or within
24 hours. Causes include failure of the uterus to contract, trauma during
delivery, or issues with blood clotting.
➢ Uncontrolled bleeding can lead to severe hemorrhagic shock, causing vital
organ failure. Quick and effective management is crucial to prevent maternal
mortality.

3. PREGNANCY WITH ABORTIVE OUTCOMES

➢ This encompasses situations where pregnancies end in miscarriage, stillbirth, or
other abortive outcomes. Factors such as infections, congenital abnormalities,
or complications during pregnancy contribute to these outcomes.
➢ While the primary focus is on fetal outcomes, complications during abortive
events, such as infection or excessive bleeding, can pose risks to the mother,
contributing to maternal mortality.

MAIN CAUSES OF NEONATAL DEATH

1. PRE-TERM
➢ Preterm birth occurs when a baby is born before 37 weeks of pregnancy are
completed. Preterm infants may have underdeveloped organs and systems,
making them more susceptible to various complications.
➢ Preterm infants are at higher risk of respiratory distress syndrome, infections,
and other complications, which can lead to neonatal death.
 2. INFECTION
➢ Neonates are vulnerable to infections due to their underdeveloped immune
systems. Infections can occur during pregnancy, during delivery, or after birth,
and may affect various organs.
➢ Serious infections, such as sepsis or pneumonia, can rapidly progress in
neonates, leading to systemic complications and increasing the risk of neonatal
mortality.

3. ASPHYXIA
➢ Asphyxia, or lack of oxygen, can happen during birth or shortly after. It may
result from issues like umbilical cord complications, problems with the baby's
airway, or difficulties with the placenta.
➢ Lack of oxygen can lead to brain damage and other organ failures. In severe
cases, asphyxia can be fatal, contributing significantly to neonatal mortality.

>80% of MATERNAL DEATHS are due to 5 DIRECT OBSTETRIC COMPLICATIONS

1. Hemorrhage 28%
2. Unsafe Abortion 19%
3. Eclampsia 17%
4. Obstructed Labor 10%
5. Infection 11%
Others 15%

CURRENT SITUATION OF CHILD HEALTH

➢ UNCOMPLICATED FETAL MOVEMENT RATE (UFMR) - 40/1,000 LBs
➢ INFANT MORTALITY RATE - 30/1,000 LBs
➢ NEONATAL MORTALITY RATE - 17/1,000 LBs

CAUSES OF DEATH IN CHILDREN

1. HIV/AIDS - 3%
2. Diarrhoea - 17%
3. Measles - 4%
4. Malaria - 8%
5. Pneumonia - 19%
6. Injuries - 3%
7. Other - 10%
8. Neonatal - 37%

Neonatal events account for most of the direct causes of under-five mortalities

PREDISPOSING FACTORS
● Poor maternal health
● Inadequate care during pregnancy
● Inappropriate management of complications during pregnancy and delivery
● Poor hygiene during and after delivery
● Lack of poor newborn care

WHAT DO WE WANT TO ACHIEVE?

MILLENNIUM DEVELOPMENT GOALS (MDGs)

GOAL 1: Eradicate extreme poverty and hunger

GOAL 2: Achieve universal primary education
GOAL 3: Promote gender equality
GOAL 4: Reduce child mortality
GOAL 5: Improve maternal health
GOAL 6: Combat hiv and aids malaria and other diseases
GOAL 7: Ensure environmental sustainability
GOAL 8: Develop a global partnership for development

MDG 4: REDUCE CHILD MORTALITY

➢ By 2030, end preventable death of newborns and children under 5 years of age with all
countries aiming to reduce neonatal mortality to at least as low as 12 per 1,000 live
births and under 5 mortality to at least as low as 25 per 1,000 live births.

MDG 5: IMPROVE MATERNAL HEALTH

➢ By 2030, reduce the global maternal mortality ratio to less than 70 per 100,000 live
births.
➢ By 2030, end the epidemics of aids, tuberculosis, malaria and neglected tropical
diseases and combat hepatitis, waterborne diseases and other communicable diseases.
➢ By 2030 reduce by 1/3 premature mortality from non-communicable diseases through
prevention and treatment and promote mental health and well-being

THE DOH STRATEGY FOR MEETING THE MDG GOAL IN

MATERNAL AND NEWBORN DEATH REDUCTION
MATERNAL, NEWBORN, CHILD HEALTH & NUTRITION (MNCHN) STRATEGY

MATERNAL, NEWBORN, CHILD HEALTH & NUTRITION (MNCHN)

➢ It is a program of the DOH based on administrative order 2008 to 2009 or the
implementing health reforms for rapid reduction of maternal and neonatal mortality.

GOAL OF MCHN
● Educate the community
● Modify community behavior on the presentation of occurrences of diseases and
complications to reduce risk factors
● Raise self responsibility for health maintenance
● Conduct an impact assessment of MCHN

UNIFIED STRATEGY TO SAVE MOTHERS, NEWBORNS AND CHILDREN

● Targeting high-risk and low performing areas to fast track attainment of goals
● Empowering mothers to utilize life-saving packages
● Developing incentive mechanisms to influence positive behavior from health providers
and consumers

3 LEVELS OF CARE OF MCHN

1. COMMUNITY LEVEL SERVICE PROVIDERS
➢ Give primary healthcare services EX: RHU, BHS
➢ Role: Community-level service providers play a crucial role in preventive and
promotive healthcare. They often engage in health education, family planning
counseling, antenatal care promotion, and basic maternal and child health
services. Their focus is on health awareness and early detection of potential
health issues.
➢ Services: Services provided at this level are usually preventive in nature,
including maternal health education, immunizations, nutritional counseling,
and identification of high-risk pregnancies for timely referral.
 2. BASIC EMERGENCY OBSTETRIC AND NEWBORN CARE (BeMONC)
➢ Operates 24 hours basis with staff complement of skilled health professionals
such as doctors, nurses, midwives and medical technologists.
➢ Capable network of facilities and providers can be based in hospitals, RHU,
BHS, Lying-in clinics or birthing homes.
➢ Role: BeMONC facilities are equipped to handle basic emergency obstetric and
newborn situations. This includes managing complications during pregnancy,
childbirth, and the immediate postpartum period. The focus is on providing
timely and essential care to prevent maternal and newborn mortality.
➢ Services: Services at this level include basic obstetric care, emergency
cesarean sections, management of complications like postpartum hemorrhage,
and stabilization of newborns. Referral systems are established to transfer
patients to higher levels of care if needed.

3. COMPREHENSIVE EMERGENCY OBSTETRIC AND NEWBORN CARE (CeMONC)

➢ Capable facilities or network of facilities are end referral facilities capable of
managing complicated deliveries and newborn emergencies. It should be able
to perform the six obstetrics functions as well as provide cesarean delivery
services, blood banking, and transfusion services and other highly specialized
obstetric interventions.
➢ It is also capable of providing newborn emergency interventions, which include,
at the minimum, the following:
A. Newborn resuscitation
B. Treatment of neonatal sepsis/infection
C. Oxygen support for neonates
D. Management of low birth weight or preterm newborn
E. Other specialized newborn services

SKILLED PROFESSIONALS ROLES & RESPONSIBILITIES

PHYSICIAN
● Team leader
● Perform all functions
● Supervisory functions
● Networking and referral
MIDWIFE
● Assistant
● Health education
● Prenatal & Postnatal care
● Networking and referral for community
NURSE
● Assistant team leader
● Administrative function
● Health Education
● Networking & Referral

GENETICS
➢ Introduced by BATESON in 1906
➢ Derived from the Greek Word “GENE” meaning “TO BECOME” or “TO GROW INTO”
➢ Branch of biological sciences which deals with the transmission of characteristics from
parents to offspring
➢ Study of genes and the statistical laws that govern the passage of genes from one
generation to next.

INDICATIONS FOR GENETIC COUNSELING

1. Hereditary disease in patient or family
2. Birth defects
3. Mental retardation
4. Advanced maternal age
5. Early onset of cancer in family
6. Miscarriages
7. Malformations
8. Tendency for develop a neurologic condition

WORLD HEALTH ORGANIZATION (WHO)

➢ Developed a clinical guide entitled “PREGNANCY, CHILDBIRTH, POSTPARTUM, AND
NEWBORN CARE: A GUIDE FOR ESSENTIAL PRACTICE”

PCPNC
➢ It provides evidence-based recommendations to guide healthcare professionals in the
management of women during pregnancy, childbirth, postpartum, and post abortion
periods and newborns during the first week of life including management of endemic
diseases like malaria, hiv/aids, tb, and anemia.
 ➢ Guide for clinical decision making and includes recommendations on the information
to share with women and their families, little guidance is included on how to
effectively communicate and counsel.

OBJECTIVES
1. Understand the woman and community he/she provides services for both the overall
context and which they live as well as their specific need.
2. Counsel and communicate more effectively with women with their partners and
families during pregnancy, childbirth, postnatal, and post abortion periods.
3. Use different skills, methods, and approaches to counseling in a variety of situations
with women, their partners, and families in effective and appropriate ways.
4. Support women, their partners, and families to take actions for better health and
facilitate their process.
5. Contribute to women and the communities increase confidence and satisfaction in the
service he/she provides.

NATIONAL SAFE MOTHERHOOD PROGRAM (OCTOBER 17, 2018)

VISION
● For Filipino women to have full access to health services towards making their
pregnancy and delivery safer.
MISSION
● To provide rational and responsive policy direction to its local government partners in
the delivery of quality maternal and newborn health services with integrity and
accountability using proven and innovative approaches.
OBJECTIVES
● Collaborating with local government units in establishing a sustainable, cost effective
approach of delivering health services that ensure access of disadvantaged women to
acceptable and high quality maternal and newborn health services and enable them to
safely give birth in health facilities near their homes.
● Establishing core knowledge base and support systems that facilitates the delivery of
quality maternal and newborn health services in the country.

NURSING CARE OF THE HIGH-RISK PREGNANT CLIENT

● When a woman enters pregnancy with a chronic condition such as cardiovascular or
kidney disease both she and the fetus can be at risk for complications because either
the pregnancy can complicate the disease or the disease can complicate the pregnancy
affecting the baby or leaving a woman less equipped to function in the future or
undergo a future pregnancy.
● Nursing care for a woman with a pre-existing illness focuses on close observation of
maternal health and fetal well-being, education of a woman and her family about
special danger signs to watch for during pregnancy and actions to minimize
complications whenever possible.

HIGH-RISK PREGNANCY
● It is one in which a concurrent disorder pregnancy-related complication or external
factor jeopardizes the health of the woman, the fetus, or both.
● Some women enter pregnancy with a chronic illness that when superimposed on the
pregnancy makes it high risk.
● Other women enter pregnancy in good health but then develop a complication of
pregnancy that causes it to become high risk.
● In some instances, a combination of particular circumstances, poverty, lack of support
people, poor coping mechanisms, genetic inheritance, or past history of pregnancy
complications can cause a pregnancy to be categorized as high risk.
FACTORS THAT CAUSE A PREGNANCY AS HIGH RISK

PSYCHOLOGICAL
PRE PREGNANCY PREGNANCY LABOR & BIRTH

❖ History of drug ❖ Loss of support ❖ Severely frightened

dependence including person by labor and birth
alcohol ❖ Illness of a family experience
❖ History of intimate member ❖ Inability to
partner abuse ❖ Decreased in self participate because
❖ History of mental esteem of anesthesia
illness ❖ Drug abuse including ❖ Separation of infant
❖ History of poor coping alcohol and cigarette at birth
mechanisms smoking ❖ Lack of preparation
❖ Cognitive challenge ❖ Poor acceptance of for labor
❖ Survivor of childhood pregnancy ❖ Birth of infant who is
sexual abuse disappointing in some
ways such as sex,
appearance, or
congenital anomalies
❖ Illness of newborn

SOCIAL

PRE PREGNANCY PREGNANCY LABOR & BIRTH

❖ Occupation involving ❖ Refusal of or ❖ Lack of support

handling of toxic neglected prenatal person
substances including care ❖ Inadequate home for
radiation and ❖ Exposure to infant care
anesthesia gases environmental ❖ Unplanned cesarean
❖ Environmental teratogens birth
contaminants at ❖ Disruptive family ❖ Lack of access to
home incidents continued healthcare
❖ Isolated ❖ Decrease economic ❖ Lack of access to
❖ Lower economic level support emergency personnel
❖ Poor access to ❖ Conception less than or equipment
transportation for 1 year after last
care pregnancy
❖ Highly attitude
❖ Highly monthly
lifestyle
❖ Poor housing
❖ Lack of support
people

PHYSICAL
PRE PREGNANCY PREGNANCY LABOR & BIRTH

❖ Visual or hearing ❖ Subject to trauma ❖ Hemorrhage

challenges ❖ Fluid or electrolyte ❖ Infection
❖ Pelvic inadequacy or imbalance ❖ Fluid and electrolyte
misshape ❖ Intake of teratogen imbalance
❖ Uterine incompetency such as drugs ❖ Dystocia
position or structure ❖ Multiple gestation ❖ Precipitous birth
❖ Secondary major ❖ A bleeding disruption ❖ Lacerations of cervix
illness (heart disease, ❖ Poor placental or vagina
dm, kidney disease, formation or position ❖ Cephalopelvic
 hypertension, chronic ❖ Gestational dm disproportion
❖ infection such as tb, ❖ Nutritional deficiency ❖ Internal fetal
hemophilic or blood of iron, folic acid or monitoring
disorder, malignancy) protein ❖ Retained placenta
❖ Poor guy gynecologic ❖ Poor weight gain
or obstetric history ❖ Pregnancy induce
❖ History of previous hypertension
poor pregnancy ❖ Infection
outcome ❖ Amniotic fluid
❖ History of child with abnormality
congenital anomalies ❖ Post maturity
❖ Obesity and
underweight
❖ History of inherited
disorder
❖ Pelvic inflammatory
disease
❖ Potential of blood
incompatibility
❖ Younger than age 18
years or older than 35
years
❖ Cigarette smoker
❖ Substance abuse

HOW TO ASSESS?

1. Ask for the history of

★ RHEUMATIC FEVER
➢ is a condition that can happen after a sore throat caused by a bacterial
infection. It can affect the heart, joints, and other parts of the body.
➢ Ask About Previous Episodes: Inquire about any previous episodes of
rheumatic fever.
➢ Symptoms During Past Episodes: Ask about the symptoms experienced during
previous episodes, such as joint pain, fever, and skin rash.
➢ Treatment and Resolution: Discuss the treatments received and whether the
symptoms are resolved completely.

★ HEART LESION
➢ refer to any abnormal changes or damage to the heart, which can affect its
normal function. These changes may include problems with the heart valves or
other structures.
➢ Previous Diagnoses: Ask if the patient has been diagnosed with any heart
lesions or structural heart problems.
➢ Medical Interventions: Inquire about any previous medical interventions, such
as surgeries or procedures related to heart lesions.
➢ Current Symptoms: Ask about current symptoms related to heart lesions, such
as chest pain, palpitations, or fatigue.
 ★ DYSPNEA
➢ means difficulty breathing or shortness of breath. It can happen during physical
activities or even at rest.
➢ Onset and Duration: Inquire about when the dyspnea (shortness of breath)
started and how long the episodes typically last.
➢ Triggers: Ask about factors that trigger dyspnea, such as physical activity or
changes in position.
➢ Associated Symptoms: Discuss any associated symptoms, such as chest pain or
cough.

★ PAROXYSMAL NOCTURNAL DYSPNEA

➢ a term used when a person suddenly wakes up at night feeling short of breath.
It's like having episodes of breathing difficulty during sleep.
➢ Nighttime Episodes: Ask if the patient experiences sudden episodes of
difficulty breathing during the night.
➢ Awakening from Sleep: Inquire about whether the dyspnea wakes the patient
from sleep.
➢ Relief Measures: Discuss any measures taken to relieve paroxysmal nocturnal
dyspnea.

❖ ORTHOPNEA
➢ shortness of breath that occurs while lying flat and is relieved by sitting or
standing.
➢ Number of Pillows: Ask how many pillows the patient typically uses to sleep
comfortably.
➢ Duration of Relief: Inquire about how quickly symptoms improve when the
patient sits up or stands.

❖ HEMOPTYSIS
➢ Coughing up of blood
➢ Frequency and Amount: Ask about the frequency of coughing up blood and the
amount of blood.
➢ Associated Symptoms: Inquire about any associated symptoms, such as chest
pain or respiratory distress.
➢ Triggers or Patterns: Discuss any specific triggers or patterns related to
hemoptysis.

❖ PROPHYLAXIS WITH LONG ACTING PENICILLIN

➢ means taking a specific type of antibiotic regularly to prevent infections,
especially if you have a history of certain health conditions, like rheumatic
fever or heart issues.
➢ Adherence to Prophylaxis: Ask about the patient's adherence to the prescribed
prophylactic regimen.
➢ Last Dose: Inquire about the date and time of the last dose of long-acting
penicillin.
➢ Any Issues or Side Effects: Discuss whether the patient has experienced any
issues or side effects related to the prophylactic medication.

WHAT TO EXPECT DURING EXAMINATION?

● MURMUR
➢ A murmur is an abnormal sound caused by turbulent blood flow through the
heart valves. It can be graded based on intensity and timing.
 TYPES OF MURMURS
1. SYSTOLIC MURMUR - This happens during a heart muscle contraction.
Systolic murmurs are divided into ejection murmurs (due to blood flow
through a narrowed vessel or irregular valve) and regurgitant murmurs
(backward blood flow into one of the chambers of the heart).
2. DIASTOLIC MURMUR - This happens during heart muscle relaxation
between beats. Diastolic murmurs are due to a narrowing (stenosis) of
the mitral or tricuspid valves, or regurgitation of the aortic or
pulmonary valves.
3. CONTINUOUS MURMUR - This happens throughout the cardiac cycle.

● ACCENTUATED HEART SOUND (more noticeable heart sound)

➢ Some heart sounds may be louder or more pronounced than usual. For example,
an accentuated second heart sound (S2) may be heard in conditions like
pulmonary hypertension.

● ARRHYTHMIA
➢ refers to an irregular heart rhythm.

● CENTRAL CYANOSIS
➢ is the bluish discoloration of the lips, tongue, or skin, indicating inadequate
oxygenation.

● DISPLACED APEX BELT

➢ The apex beat is the point where the heart's impulse is most easily felt on the
chest wall. A displaced apex beat may indicate enlargement or displacement of
the heart and can be associated with certain cardiac conditions.

● MANIFESTATION OF LEFT SIDE HEART FAILURE ex: GALLOP RHYTHM, CREPITATIONS

OVER LUNG BASES AND PLEURAL EFFUSION
➢ An abnormal heart rhythm characterized by additional heart sounds (S3 and S4)
may be heard, known as a gallop rhythm.
➢ Crepitations Over Lung Bases: Crackling sounds heard during breathing may
indicate fluid accumulation in the lungs, a common sign of left-sided heart
failure.
➢ Pleural Effusion: Fluid accumulation in the pleural space, causing symptoms
such as shortness of breath and chest pain.

● MANIFESTATION OF RIGHT SIDE HEART FAILURE EX: CONGESTED NECK VEIN,

ENLARGED TENDER, LIVER, ASCITES AND EDEMA LOWER LIMBS
➢ Congested Neck Veins: Visible swelling of the jugular veins in the neck due to
increased pressure in the right side of the heart.
➢ Enlarged, Tender Liver: An enlarged liver may be palpable below the ribcage,
and tenderness may be present due to congestion.
➢ Ascites: Accumulation of fluid in the abdominal cavity, leading to abdominal
swelling.

➢ Edema in Lower Limbs: Swelling of the ankles and lower extremities due to
fluid retention
DIAGNOSTIC TESTS
● CHEST X-RAY may show cardiac enlargement, pulmonary congestion or pleural
effusion
● Electrocardiogram
● Echo Cardiography (2d echo) shows cardiac structure and functions

RHEUMATIC HEART DISEASE (RHD)

➢ It is a condition in which permanent damage to heart valves is caused by rheumatic
fever. The heart valve is damaged by a disease process that generally begins with strep
throat caused by bacteria called streptococcus and may eventually caused by
rheumatic fever.

RHEUMATIC FEVER
➢ It is an inflammatory disease that can affect many cognitive tissues especially in the
heart, joints, skin, or brain. The infection often causes heart damage, particularly
scaring of the heart valves, forcing the heart to work harder to pump blood. The heart
valve damage may start shortly after untreated or undertreated streptococcal
infection such as strep throat or scarlet fever this can result in narrowing or leaking of
the heart valve making it harder for the heart to function normally.
➢ The damage may resolve on its own, or it may be permanent, eventually causing
congestive heart failure which is a condition in which the heart cannot pump out all of
the blood that enters it which leads to an accumulation of blood in the vessels leading
to the heart and fluid in the body tissues.
➢ People with rhd may have a murmur or rub that may be heard during a routine physical
exam. The murmur is caused by the blood leaking around the damaged valve the rub is
caused when the inflamed heart tissues move or rub against each other.

NURSING CARE FOR MOTHER WITH RHD (ANTENATAL)

● Record baseline vital signs especially bp get the bp in sitting or lying position at first
prenatal visit and take it in the same position and arm in the future visits for a most
accurate comparison.
● Instruct to report coughing during pregnancy because simple cough is a first
manifestation of pulmonary edema from heart failure
● Determine edema if it is caused by normal pregnancy (innocent edema) or PIH (serious
edema)
● Assist the client to undergo ECG, CXR, or 2D ECHO
➢ Assure that CXR is safe as long as a woman's abdomen is covered by a lead
apron during the exposure.

REST - Client needs two rest periods a day

1. FULLY RESTING - Not getting up frequently to answer the door or telephone
2. FULL NIGHT’S SLEEP - Not tossing or turning on bed because of excess noise or
heat in the room. Rest should be in the left lateral recumbent position to
prevent supine hypotensive syndrome.

NUTRITION
● Watch out for nutritional intake not to gain so much weight because additional weight
could overburden the heart. Limit salt intake.
● Salt is not severely restricted during pregnancy because sodium is needed for
maintaining fluid balance thus allowing retention of enough blood volume to supply
placenta.
● Take prenatal vitamins especially iron supplements to help prevent anemia.
● Anemia places an extra work to hard because it requires the body to circulate more
blood to supply oxygen to all body cells.
NURSING CARE FOR MOTHER WITH RHD (MEDICATION)
❖ DIGOXIN
➢ To strengthen the heart of the client; to slow fetal heart rate if fetal
tachycardia is present.
➢ Check the heart rate before administering digoxin withhold the meds if below
60 bpm
❖ PENICILLIN ANTIBIOTIC
➢ Client who is taking penicillin to prevent recurrence of rheumatic fever should
continue take the medication during pregnancy. Some physicians begin a
prophylactic penicillin antibiotic as the day of delivery is near approaching as
protection from subacute bacterial endocarditis. This is because postpartum
period always involves mild invasion of bacteria may be streptococci that often
responsible for endocarditis.
➢ Client needs to increase maintenance dose because of expanded volume during
pregnancy (30% to 50% increase of cardiac output during pregnancy). Thus
heart is being stressed further by the increased circulatory load of pregnancy.

AVOIDANCE OF INFECTION
● Avoid visiting or being visited by a people with infection
● Inform health personnel for any signs and symptoms of infection so that antibiotic
could be started
● Monthly screening for urine for bacteriuria
● Infection increases body temperature causing the client to expend more energy and
increased cardiac output, a situation that a heart could too extreme to withstand.

NURSING CARE FOR MOTHER WITH RHD (LABOR & BIRTH)

➢ Monitor fetal heart rate and uterine contractions during labor in all women with heart
disease. Assess a woman's blood pressure, pulse, and respirations frequently. A rapidly
increasing pulse rate 100 bpm is an indication that a heart is pumping ineffectively.

NURSING CARE FOR MOTHER WITH RHD (POSTPARTUM)

➢ Antiembolic stockings and ambulation may needed to increase venous return from the
legs.
➢ In the postpartum period, agents to encourage uterine involution such as oxytocin
(pitocin) must be used with caution because they tend to increase blood pressure and
this necessitates increased heart action.
➢ Kegel exercises are capable for perennial strengthening immediately but the woman
should not begin postpartum exercises to improve abdominal tone until her physician
or nurse midwife approves them.
➢ A stool softener can be prescribed to prevent straining with bowel movement.

EFFECTS OF HEART DISEASE ON PREGNANCY

● Abortion
● Intrauterine Growth Retardation
● Still birth
● Premature Labor
● Intrauterine Fetal Demise (IUFD)

MANAGEMENT
● More frequent antenatal visit
● More rest
● Diet is directed to restrict weight gain and prevent anemia as it increases cardiac
strain
● Infection should be avoided and properly treated
● Hospitalization; if signs of decompensation occur, the earliest evidence is tachycardia
exceeding 100 bmp and crepitations at the lung base
● Rest in a hospital is desirable in the last 2 weeks of pregnancy
MEDICAL TREATMENT (DRUGS)
● DIGOXIN - indicated in atrial fibrillation to slow the ventricular response and in acute
heart failure to increase myocardial contractility.
● DIURETICS - are used in an acute and chronic heart failure with potassium supplement
in prolonged therapy.
● BETA-ADRENERGIC BLOCKERS - as propranolol may be indicated for arrhythmia
associated with ischemic heart disease.
● AMINOPHYLLINE - Relieves bronchospasm
● HEPARIN - Indicated in patients with artificial valves or atrial fibrillation
● MORPHINE 15mg IV - given to treat acute pulmonary edema by decreasing anxiety
venous return.
AND ADMINISTRATION OF OXYGEN

SURGICAL TREATMENT - should be considered in class III and IV patient is seen in early
pregnancy.
CARDIAC SURGERY - it may be an alternative to therapeutic abortion. The principal indication
is recurrent pulmonary edema with mitral stenosis and heart failure not responding to
medical treatment. There is no increased risk to the mother or the fetus in closed cardiac
surgery ex. Mitral valvotomy but there is higher incidence of fetal loss with open surgery.

CLASSIFICATION OF HEART DISEASE

HEART DISEASE is divided into 4 categories based on criteria established by the New York
State Heart Association.

LABOR & DELIVERY

CLASS I
➢ No discomfort (ex. Dyspnea, palpitation, angina pain)
➢ Heart disease can expect to experience a normal pregnancy and birth
CLASS II
➢ Discomfort an ordinary activity
➢ Heart disease can expect to experience a normal pregnancy and birth
➢ SHOULD BE EASY AND NOT A PROLONGED ONE
CLASS III
➢ Discomfort on less than ordinary activity
➢ Can complete a pregnancy by maintaining almost complete bed rest.
CLASS IV
➢ Dyspnea at rest
➢ Heart disease are poor candidates for pregnancy because they are in cardiac failure
even at rest and when they are not pregnant they are usually advised to avoid
pregnancy.

FOR CLASS III & IV - there is “NO TRIAL LABOR” therefore advised “ELECTIVE CESAREAN
SECTION”

ERGOMETRINE - is better avoided as it causes sudden load of the circulation with blood from
the uterus leading to acute heart failure. OXYTOCIN can be used instead.

POSTPARTUM
● Observation for 48 hours is essential as the risk of heart failure is high in this period.
● Although bed rest is essential, early ambulation is desirable to avoid
thromboembolism.
● Breastfeeding is allowed unless there is a heart failure. Estrogen should not be
suppressed and bromocriptine or lisuride can be used.
● Sterilization (permanent ligation) may be advised if decompensation occurred in this
pregnancy.
 DIABETES MELLITUS AND PREGNANCY

DIABETES
➢ Is a condition in which the body does not make enough insulin or the body is unable to
use the insulin that is made.
INSULIN
➢ is the hormone that allows glucose to enter the cells, it builds up in the blood and the
body's cells starve to death. If not managed properly, diabetes can have serious
consequences for you and
your growing baby .

PRE-GESTATIONAL DIABETES
➢ If you already have diabetes and become pregnant, your condition is known as
PRE-GESTATIONAL DIABETES.
➢ The severity of your symptoms and complications often depends on the progression of
your diabetes, especially if you have vascular (blood vessel) complications and poor
blood glucose control.

GESTATIONAL DIABETES
➢ is a condition in which the glucose level is elevated and other diabetic symptoms
appear during pregnancy. Unlike other types of diabetes, gestational diabetes is not
caused by a lack of insulin but by other hormones that block the insulin that is made.
This condition is known as insulin resistance. If you have gestational diabetes, you
may or may not be dependent on insulin.
➢ In most cases, all diabetic symptoms disappear following delivery. However, if you
experience gestational diabetes, you will have an increased risk of developing
diabetes later in life. This is especially true if you were overweight before
pregnancy.

FACTORS AFFECTING GESTATIONAL DIABETES

1. Age over 25 years old
2. A family history of diabetes
3. Previous delivery of a very large infant, a stillborn or a child with certain birth defects.
4. Obesity

DIAGNOSING GESTATIONAL DIABETES

● Glucose Screening Test is usually done between 24 and 28 weeks of pregnancy. To
complete this test, client will be asked to drink a special glucose beverage. Then, they
will measure your blood sugar level one hour later. If the test shows an increased
blood sugar level, a three-hour glucose tolerance test may be done. If the results of
the second test are in the abnormal range, client will be diagnosed with gestational
diabetes.

Treatment Options for Gestational Diabetes

THE HEALTH CARE PROVIDER, DOCTOR, NURSE OR MIDWIFE WILL DETERMINE
SPECIFIC TREATMENT PLAN FOR GESTATIONAL DIABETES BASED ON:
● Age, overall health and medical history
● Condition and severity of disease
● Long-term expectations for the course of the disease
● Personal preference
● Tolerance for specific medicines, procedures or therapies
TREATMENT FOR GESTATIONAL DIABETES FOCUSES ON KEEPING BLOOD
GLUCOSE LEVELS IN THE NORMAL RANGE MAY INCLUDE:
● Special diet
● Daily blood glucose monitoring
● Exercise
● Insulin injections or oral medications

Possible fetal complications from gestational

USUALLY MANAGEABLE AND PREVENTABLE
1. FETAL MACROSOMIA
➢ describes a baby that is considerably larger than normal. All of the nutrients
your baby receives come directly from your blood.
➢ If your blood has too much glucose, your baby’s pancreas senses the high
glucose levels and makes more insulin in an attempt to use this glucose.
The extra glucose is then converted to fat. Even when you have gestational
diabetes, your fetus is able to make all the insulin it needs. The
combination of your high blood glucose levels and your baby’s high insulin
levels may result in large deposits of fat that cause your baby to grow
excessively large.
2. BIRTH INJURY
➢ if your baby is large in size, it may be difficult to deliver and become
injured in the process.
3. HYPOGLYCEMIA
➢ This refers to low blood sugar levels that have been consistently high causing
the fetus to have a high insulin in its circulation. After delivery, the baby
continues to have a high insulin level, but it no longer has the high level of
sugar becoming very low. Following delivery, the baby's blood sugar level will
be tested. If the level is too low, it may be necessary to administer glucose
intravenously until the baby's blood sugar stabilizes.
4. RESPIRATORY DISTRESS
➢ Too much insulin or too much glucose in a baby’s system may delay
lung maturation and cause respiratory problems. This is more likely if
it is born before 37 weeks AOG of pregnancy.
 SUBSTANCE ABUSE IN PREGNANCY

WHY ARE PREGNANT WOMEN WARNED NOT TO USE DRUGS?

● What mother takes in, baby takes in too. So possible na matoxic si baby if basta-basta
lang iinom si mother ng gamot without the doctor’s advice or prescription.
● Studies show that using drugs-legal or illegal during pregnancy has a direct impact on
the fetus. If a client smokes, drinks alcohol or ingest caffeine, so does the fetus. The
consequences of using illegal drugs such as cocaine include heart attacks, respiratory
failure, strokes and seizure. Taking drugs during pregnancy also increases the chance
of:
★ BIRTH DEFECTS
★ PREMATURE BABIES
★ UNDERWEIGHT BABIES
★ STILL BIRTH

DRUGS EFFECTS

MARIJUANA ● Cause behavioral problems in early

childhood.
● Affects child memory and
attentiveness.

COCAINE ● May have brain structure changes

that persists into early adolescence.
● Can lead to subtle yet significant
deficits later in children such as
cognitive performance,
information-processing and attention
to tasks.

SAFETY TIPS BEFORE TAKING MEDICATIONS

1. Always read the medication label.
2. Natural dietary supplements such as herbs, amino acids, minerals and mega vitamins
might be considered natural but does not mean they are safe.
3. According to the FDA, aspirin and ibuprofen should not be taken during the last 3
months of your pregnancy unless you are instructed by your doctor to take it.
4. Talk with your doctor about special prenatal vitamins that are safe for mom and baby,
for vitamins may have doses that are too high.

HUMAN IMMUNODEFICIENCY VIRUS (HIV)/ ACQUIRED

IMMUNODEFICIENCY SYNDROME (AIDS)

HUMAN IMMUNODEFICIENCY VIRUS (HIV)

➢ Virus that attacks the body’s immune system.
➢ If untreated leads to Acquired Immunodeficiency Syndrome (AIDS).
➢ Once people get HIV, they have it for life.
➢ It came from CHIMPANZEE in CENTRAL AFRICA

WHAT ARE THE S/S?

● Fever Sore Throat
● Chills Fatigue
● Rash Swollen Lymph Nodes
 ● Night sweats Mouth Ulcers
● Muscle aches

STAGES OF HIV
STAGE 1: ACUTE HIV INFECTION
➢ People have a large amount of HIV in their blood. They are very contagious.
➢ Some people have flu-like symptoms. This is the body’s natural response to infection.
➢ But some people may not feel sick right away or at all.
➢ If you have flu-like symptoms and think you may have been exposed to HIV seek
medical care and ask for a test to diagnose acute infection.
STAGE 2: CHRONIC HIV INFECTION
➢ This stage is also asymptomatic HIV infection or clinical latency.
➢ HIV is still active but reproduces at very low levels.
➢ People may not have any symptoms or get sick during this phase.
➢ Without taking HIV medicines, this period may last a decade or longer, but some may
progress faster.
➢ People may transmit HIV in this phase.
➢ At the end of this phase, the amount of HIV in the blood (called VIRAL LOAD) goes up
and the cd4 cell count goes down. The person may have symptoms as the virus levels
increase in the body and the person moves to stage 3.
STAGE 3: ACQUIRED IMMUNODEFICIENCY SYNDROME (AIDS)
➢ The most severe phase of HIV infection.
➢ People with AIDS have such badly damaged immune systems that they get an
increasing number of severe illnesses, called OPPORTUNITIES INFECTIONS.
➢ People with AIDS can have a high viral load and be very infectious.
➢ Without treatment, people with AIDS typically survive about 3 years.
*A pregnant woman living with HIV can pass on the virus to her baby during pregnancy,
childbirth and through breastfeeding. If you are a woman living with HIV, taking antiretroviral
treatment correctly during pregnancy and breastfeeding can virtually eliminate the risk of
passing on the virus to your baby.

Rh Sensitivity
WHAT IS Rh?
➢ The RHESUS FACTOR, or RH FACTOR, is a certain type of protein found on the outside
of red blood cells. People are either RH-POSITIVE (they have the protein) or
RH-NEGATIVE (they don’t have the protein).

WHAT IS Rh SENSITIZATION DURING PREGNANCY?

➢ RH SENSITIZATION can occur during pregnancy if you are RH-NEGATIVE and pregnant
with a developing baby who has RH-POSITIVE blood. If your blood mixes with the
RH-POSITIVE blood of your baby, you can develop antibodies against your baby’s blood.
➢ Blood test is the only way to know if you have it.
What may happen to baby with Rh disease?
➢ May have anemia, jaundice or more serious problems.

WHO GETS Rh SENSITIZATION DURING PREGNANCY?

➢ Rh sensitization during pregnancy can only happen if a woman has Rh
negative blood and only if her baby has Rh positive blood.
➢ If the mother is Rh negative and the father is Rh positive there is good chance the
baby will have Rh positive blood. Rh sensitization can occur.
➢ If both parents have Rh negative blood, the baby will have negative blood.
➢ Since the mother’s blood and the baby’s blood match, sensitization will not occur, if a
mother has Rh negative blood, the doctor will probably treat her as though the baby’s
blood is Rh positive no matter what the father’s blood type is, just to be on the safe
side.
HOW IS Rh SENSITIZATION DIAGNOSED?
➢ All pregnant women get a blood test at their first prenatal visit during early
pregnancy. This test will show if a client has Rh negative blood and if she is Rh
sensitized.
➢ The blood test may be repeated between 24 and 28 weeks of pregnancy. If the test
still shows that she is not sensitized, probably will not need another antibody test until
delivery. (She might need to have the test again if she has an amniocentesis, if
pregnancy goes beyond 40 weeks, or if she has a problem such as abruptio placenta,
which could cause bleeding in the uterus.)
➢ Your baby will have a blood test at birth. If the newborn has Rh positive blood, the
mother will have an antibody test to see if she were sensitized during late pregnancy
or childbirth.
➢ If you are Rh-sensitized, the doctor will watch the pregnancy carefully.
The mother may have:
a.Regular blood tests, to check the level of antibodies in the blood.
b.Doppler ultrasound, to check blood flow to the baby’s brain. This can show anemia
and how severe it is.
c.Amniocentesis after 15 weeks, to check the baby’s blood type and Rh factor and to
look for problems.

HOW IS Rh SENSITIZATION PREVENTED?

➢ If a mother has Rh negative blood but is not Rh sensitized, the doctor will give one or
more shots of Rh immune globulin (such as WinRho). This prevents Rh sensitization in
nearly all women who use it.
➢ Mother may get a shot of Rh immune globulin: if a mother has a test such as an
amniocentesis, around week 28 of pregnancy, after delivery if the newborn is Rh
positive.

HOW IS IT TREATED?
➢ If a mother is Rh sensitizes, she will have regular testing to see how the baby is
doing. She may also need to see a doctor who specializes in high-risk pregnancies (a
peritonologist).
➢ Treatment of the baby is based on how severe the loss of red blood
cells (anemia) is.
➢ If the baby’s anemia is mild, will just have more testing than usual while she is
pregnant. The baby may not need any special treatment after birth.
➢ If anemia is getting worse, it may be safest to deliver the baby early.
After delivery, some babies need a blood transfusion or treatment for
jaundice.
➢ For severe anemia, a baby can have a blood transfusion while still in the uterus.
➢ This can help keep the baby healthy until he or she is mature enough to be
delivered. You may have an early C-section, and the baby may need to have
another blood transfusion right after birth.
Intro Uterine Blood Transfusion

ANEMIA IN PREGNANCY
ANEMIA
➢ a condition that develops when your blood produces a lower-than-normal amount of
healthy red blood cells. If you have anemia, your body does not get enough
oxygen-rich blood. The lack of oxygen can make you feel tired or weak. You may also
have shortness of breath, dizziness, headaches, or an irregular heartbeat.
➢ During pregnancy, the body produces more blood to support the growth of the baby.
It’s normal to have mild anemia when pregnant. But mothers may have more severe
anemia from low iron or vitamin levels or from other reasons. If it is severe and goes
untreated, it can increase the risk of serious complications like preterm delivery.

TYPES OF ANEMIA DURING PREGNANCY

1. IRON-DEFICIENCY ANEMIA
➢ This type of anemia occurs when the body doesn’t have enough iron to produce
adequate amounts of hemoglobin. That’s a protein in red blood cells. It carries
oxygen from the lungs to the rest of the body.
➢ In iron deficiency anemia, the blood cannot carry enough oxygen to
tissues throughout the body.
➢ This is the most common cause of anemia in pregnancy.
2. FOLATE-DEFICIENCY ANEMIA
➢ Folate is the vitamin found naturally in certain foods like green leafy
vegetables, a type of B vitamin, the body needs folate to produce new
cells, including healthy red blood cells.
➢ During pregnancy, women need extra folate. But sometimes they don’t get
enough from their diet. When that happens, the body can’t make enough
normal red blood cells to transport oxygen to tissues throughout the body.
➢ Manmade supplements of folate are called folic acid.
➢ It can directly contribute to certain types of birth defects such as neural tube
abnormalities (spina bufida) and low birth weight.
3. VITAMIN B12 DEFICIENCY
➢ The body needs vitamin B12 to form healthy red blood cells. When a pregnant
woman doesn’t get enough vitamin B12 from their diet, their body can’t
produce enough healthy red blood cells. Women who don’t eat meat, poultry,
dairy products ,and eggs have greater risk of developing vitamin B12
deficiency, which may contribute to birth defects, such as neural tube
abnormalities, and could lead to preterm labor.
RISK FACTORS FOR ANEMIA IN PREGNANCY
1.Are pregnant with multiples (more than one child)
2.Have had two pregnancies close together
3.Vomit a lot because of morning sickness
4.Is the pregnant teenager
5.Don’t eat enough foods that are rich in iron
6.Had anemia before you became pregnant

SYMPTOMS OF ANEMIA DURING PREGNANCY

The most common are:
1. Pale skin, lips and nails
2. Feeling tired or weak
3. Dizziness
4. Shortness of breath
5. Rapid heartbeat
6. Trouble concentrating

RISKS OF ANEMIA IN PREGNANCY

1.Preterm or low birth weight baby
2.A blood transfusion (if you lose a significant amount of blood during delivery)
3.Postpartum depression
4.A baby with anemia
5.A child with developmental delays

UNTREATED FOLATE-DEFICIENCY CAN INCREASE YOUR RISK OF HAVING A:

1.Preterm or low-birth-weight baby
2.Baby with serious birth defect of the spine or brain (neural tube defects)
3.Untreated vitamin B12 deficiency can also raise a baby with neural tube defects.

GESTATIONAL CONDITIONS AFFECTING PREGNANCY OUTCOMES

A. HYPEREMESIS GRAVIDARUM
➢ It is a condition characterized by severe nausea, vomiting, weight loss and electrolyte
disturbance.
➢ Mild cases are treated with dietary changes, rest and antacids.
➢ Most severe cases often require a stay in the hospital so that the mother can receive
fluid through intravenous fluids (IVF).

SIGNS & SYMPTOMS

➢ Severe nausea and vomiting
➢ Food aversions
➢ Weight loss of 5% or more of pre pregnancy weight
➢ Decrease urination
➢ Dehydration
➢ Headache
➢ Confusion
➢ Jaundice
➢ Fainting
➢ Extreme fatigue
➢ Decrease blood pressure
➢ Rapid heart rate
➢ Loss of skin elasticity
➢ Secondary anxiety/depression
TREATMENT
➢ Hydration (IV LINE) as per doctor’s order
➢ Tube feeding (hospital setting)
➢ Medication per IV
➢ Metoclopramide (Antiemetic)
➢ Antihistamine
➢ Antireflux
➢ Others; Bed Rest, Herbs

B. ECTOPIC PREGNANCY
➢ Also known as “TUBAL PREGNANCY”
➢ It is a complication of pregnancy in which the embryo
attaches outside the uterus.

SIGNS
& SYMPTOMS
➢ Abdominal pain and vaginal bleeding.
➢ The pain may be described as sharp, dull or crampy.
➢ Pain may also spread to the shoulder if bleeding into
the abdomen has occurred.
➢ Severe bleeding may result in a fast heart rate, fainting
or hemorrhagic shock.
➢ The fetus is unable to survive.

RISK FACTORS
1. Pelvic inflammatory disease, often due to CHLAMYDIA INFECTION.
2. Tobacco smoking
3. History of infertility
4. Use of assisted reproductive technology
5. Those who have previously had an ectopic pregnancy are at much higher risk of having
another one, most ectopic pregnancies (90%) occur in the fallopian tube which are
known as TUBAL PREGNANCIES.

DIAGNOSIS
● TRANSVAGINAL ULTRASONOGRAPHY
➢ An ultrasound showing a gestation sac with fetal heart in the fallopian tube has
a very high specificity of ectopic pregnancy, transvaginal ultrasonography
sensitivity of at least 90% for ectopic pregnancy.
TREATMENT
● Surgery
● Exploratory laparotomy
● Salpingectomy or Salpingostomy (right or left) removal of the fallopian tube.

C. GESTATIONAL TROPHOBLASTIC
DISEASE (H-MOLE)
HYDATIDIFORM MOLE
➢ Is a growing mass of tissue inside your womb
(uterus) that will not develop into a baby. It is
The result of abnormal conception/abnormally
fertilized egg caused by an IMBALANCE GENE
TIC MATERIAL (CHROMOSOMES) in the pregna

ncy. This leads to the growth of abnormal cells or clusters of water filled sacs inside the
womb. It may cause bleeding in early pregnancy and is usually picked up in an early
pregnancy ultrasound scan. It needs to be moved and most women can expect a full recovery.
TWO TYPES OF MOLAR PREGNANCY
1. COMPLETE MOLAR PREGNANCY
➢ The placenta tissue is abnormal and swollen and appears to form fluid - filled
cysts. There’s also no formation of fetal tissue.
2. PARTIAL MOLAR PREGNANCY
➢ There may be normal placental tissue along with abnormally forming placental
tissue. There may also be formation of a fetus, but the fetus is not able to
survive, and is usually miscarried early in pregnancy.

*** A molar pregnancy may seem like a normal pregnancy at first but most molar pregnancies
cause specific signs and symptoms.

SIGNS & SYMPTOMS

➢ Dark brown to bright red vaginal bleeding during the first trimester
➢ Severe nausea and vomiting
➢ Sometimes vaginal passage of grape like cysts
➢ Pelvic pressure or pain
➢ Symptoms like pregnant
Other signs
➢ Rapid uterine growth
➢ High blood pressure
➢ Preeclampsia
➢ Ovarian cysts
➢ Anemia
➢ Overactive thyroid (hyperthyroidism)
RISK FACTORS
● MATERNAL AGE- more likely in women older than age 35 or younger than age 20.
● Previous molar pregnancy, if you’ve had one molar pregnancy, you’re more likely to
have another. A repeat molar pregnancy happens, on average, in out of every 100
women.

DIAGNOSIS
● Ultrasound on the first trimester.

TREATMENT
● have a small operation. This means having a small operation. This is done in the
hospital by a doctor who is a gynecology specialist. You will be given an anesthetic. In
most cases, a small tube is passed into your womb (uterus) through the opening of
your fetus (your cervix) and the abnormal tissue is removed by suction curettage. The
tissue is then sent off to the laboratory for examination.
● Follow up regularly.

D. INCOMPETENT CERVIX
➢ Also called “CERVICAL INSUFFICIENCY”
➢ It is a condition that occurs when weak
Cervical tissue causes or contributes to
Premature birth or the loss of an other
wise healthy pregnancy.

HOW DOES IT HAPPEN?

● Before pregnancy, your cervix - the lower part of the uterus that connects to the
vagina - is normally closed and rigid, as pregnancy progresses and you prepare to give
birth, the cervix gradually softens, decreases in length (effaces) and opens (dilates). If
you have an incompetent cervix, your cervix might begin to open too soon - causing
you to give birth too early.
● An incompetent cervix can be difficult to diagnose and as a result, treat. If your cervix
begins to open early, your health care provider might recommend a preventive
snow-storm pattern seen in an ultrasound, medication during pregnancy, frequent
ultrasound or a procedure that closes the cervix with strong sutures (CERVICAL
CERCLAGE).

DIAGNOSIS
● AN ULTRASOUND EXAM
➢ During this exam, you have a thin, wandlike device, called a transducer, placed
inside the vagina. This is known as a transvaginal ultrasound. The transducer
puts out sound waves that get converted to pictures you can see on a screen.
This type of ultrasound can be used to check the length of your cervix and to
see if any tissues are sticking out of the cervix.
 ● A PELVIC EXAM
➢ During a pelvic exam, your doctor checks the cervix to see if the amniotic sac
can be felt through the opening. The amniotic sac is where the baby is growing.
If the wall of the sac is in the cervical canal or vagina, it's called prolapsed
fetal membranes, and it means that the cervix has started to open. Your doctor
may also check to see if you're having any contractions and track them, if
needed.
● LAB TESTS
➢ If you have prolapsed fetal membranes, you may need other tests to rule out
an infection. In some cases, this may include taking a sample of amniotic fluid.
This is called an amniocentesis. Amniocentesis can be used to check for
infection in the amniotic sac and fluid.

SIGNS & SYMPTOMS

● A sensation of pelvic pressure

● A backache
● Mild abdominal cramps
● A change in vaginal discharge
● Light vaginal bleeding
● Advanced cervical dilation and effacement before week 24 of pregnancy

RISK FACTORS

1. CERVICAL TRAUMA
➢ A previous procedure or surgery on the cervix could lead to an incompetent cervix.
This includes surgery to treat a cervical problem found during a Pap test. A
procedure called a dilation and curettage (D&C) also could be associated with an
incompetent cervix. Rarely, a cervical tear during a previous labor and delivery could
be a risk factor for an incompetent cervix.

2. A CONDITION YOU'RE BORN WITH CALLED A CONGENITAL CONDITION

➢ Certain uterine conditions might cause an incompetent cervix. Genetic problems
affecting a type of protein that makes up your body's connective tissues, called
collagen, might cause an incompetent cervix.

COMPLICATIONS

An incompetent cervix may be risky for your pregnancy.

Particularly during the 2nd trimester. Possible complications include:

1. Premature birth
2. Pregnancy loss

TREATMENT

A. PROGESTERONE SUPPLEMENTATION
➢ If you have a short cervix with no history of a preterm birth, vaginal
progesterone may lower your risk of having your baby too early. This medicine
comes in the form of a gel or a suppository that gets placed in the vagina each
day.
B. REPEATED ULTRASOUNDS
➢ If you have a history of early premature birth, or a history that may increase
your risk of an incompetent cervix, your doctor might closely monitor the
length of your cervix. To do this, you have ultrasounds every two weeks from
week 16 through week 24 of pregnancy. If your cervix begins to open or
becomes shorter than a certain length, you might need a cervical cerclage.
 C. CERVICAL CERCLAGE
➢ During this procedure, the cervix is stitched tightly closed. The stitches are
taken out during the last month of pregnancy or just before delivery. You may
need a cervical cerclage if you are less than 24 weeks pregnant or 14-16 weeks
of pregnancy. This sutures will be removed between 36-38 weeks to prevent
any problems when you go into labor.
➢ Cervical cerclage isn't the right choice for everyone at risk of premature birth.
For instance, the procedure isn't recommended if you're pregnant with twins or
more. Be sure to talk to your doctor about the risks and benefits cervical
cerclage may have for you.
D. PESSARY
➢ A device called a pessary fits inside the vagina and holds the uterus in place. A
pessary may help lessen pressure on the cervix. But more research is needed to
see if a pessary will work well for treating an incompetent cervix.

E. ABORTION/ MISCARRIAGE
Abortion
➢ is the termination of a pregnancy by removal or expulsion of an embryo or fetus.

An abortion that occurs without intervention is known as a miscarriage or "spontaneous

abortion"; these occur in approximately 30% to 40% of all pregnancies

TYPES OF ABORTION/MISCARRIAGE
1. INEVITABLE ABORTION
➢ occurs when vaginal bleeding or rupture of membranes occur before 20 weeks
gestation in the presence of cervical dilatation. Incomplete abortion typically.
2. INCOMPLETE ABORTION
➢ involves vaginal bleeding, cramping (contractions), cervical dilatation, and
incomplete passage of the products of conception. It occurs after 10 weeks
gestation when the fetus is expelled and the placenta is retained in the uterus.
3. COMPLETE ABORTION
➢ experienced bleeding and passed fetal tissue that makes your uterus is empty.
4. THREATENED ABORTION
➢ Your cervix stays closed, but you’re bleeding and experiencing pelvic
cramping. The pregnancy typically continues with no further issues. Your
pregnancy care provider may monitor you more closely for the rest of your
pregnancy.
5. MISSED ABORTION
➢ You’ve lost the pregnancy but are unaware it’s happened. There are no
symptoms of miscarriage, but an ultrasound confirms the fetus has no
heartbeat.
6. SEPTIC ABORTION
➢ refers to any abortion, spontaneous or induced, that is complicated by severe
uterine infection, including endometritis and parametritis.
7. SPONTANEOUS ABORTION
➢ it is the unintentional expulsion of an embryo or fetus before the 24th week of
gestation.
➢ The most common cause of this is chromosomal abnormalities of the embryo
or fetus, vascular disease eg. Lupus, diabetes, and other hormonal problems,
infection and abnormalities of uterus.
8. RECURRENT MISCARRIAGE/HABITUAL ABORTION
➢ patient with 3 consecutive miscarriage prior to 20 weeks from LMP.

CAUSES OF CURRENT ABORTION

Etiology of recurrent pregnancy loss. APS,

antiphospholipid antibody syndrome.

Need to know….
PREMATURE BIRTH pregnancy that ends before 37 weeks of gestation resulting in a
live-born infant.
STILLBORN/ STILLBIRTH/ INTRAUTERINE FETAL
DEMISE (IUFD) when a fetus dies in utero after viability, or during delivery.

SIGNS & SYMPTOMS

•Bleeding that progresses from light to heavy. You may also pass grayish tissue or blood clots.
• Cramps and abdominal pain (usually worse than menstrual cramps).
•Low back ache that may range from mild to severe.
•A decrease in pregnancy symptoms.

CAUSES OF MISCARRIAGE?
1. CHROMOSOMAL ABNORMALITIES cause about 50% of all miscarriages in the first trimester
(up to 13 weeks) of pregnancy.
2. MATERNAL ANATOMIC ANOMALIES such as uterine leiomyomas (fibroid), polyps, adhesion,
or septa, maybe associated with early pregnancy loss (EPL) based on their size and position in
relation to the developing pregnancy. these may not be identified prior to experiencing EPL
but, once diagnosed, can often be surgically or medically addressed before another pregnancy
is attempted.

3. TRAUMA significant trauma can cause EPL. The developing embryo is relatively protected
within the uterus in early pregnancy, but trauma that results in direct impact to the uterus
can result in EPL. This can be due to violent trauma (gunshot wounds, penetrating injuries) or
iatrogenic trauma, as with chorionic villus sampling and amniocentesis.

GENERAL MATERNAL FACTORS

➢ Infection
➢ Environmental factors
➢ Psychological factors
- Depression
- Mental health issues
- Emotional stress
- Systemic disorders

DIAGNOSIS
➢ Ultrasound – to determine what type of abortion

Treatment/ Management
DILATATION AND CURETTAGE
➢ A procedure to remove tissue from inside the uterus. Doctors perform dilation and
curettage to diagnose and treat certain uterus conditions – such as heavy bleeding- or
to clear uterine lining after a miscarriage or abortion.
SYMPTOMATIC TREATMENT
1.BLOOD TRANSFUSION- IF WITH DECREASE HEMOGLOBIN
2.ANTIBIOTICS- IF SEPTIC
3.FLUIDS

F. PLACENTA PREVIA
Normally the placenta attaches toward the top of the uterus,
Away from the cervix. The baby passes from the uterus into
The cervix and through the birth canal during a vaginal
Delivery.
PLACENTA PREVIA
➢ It happens when the placenta partly or completely
covers the cervix, which is the opening of the uterus.

WHAT HAPPENS WITH PLACENTA PREVIA?

As the cervix opens during labor, it can cause blood vessels that
connect the placenta to the uterus to tear, this can lead to
bleeding and put both the mother and her baby at risk. Nearly all
women who have this condition will have to be a C-section to
keep this from happening.

TYPES OF PLACENTA PREVIA

MARGINAL PLACENTA PREVIA

The placenta is positioned at the edge of your cervix. It's

touching your cervix, but not covering it. This type of
placenta previa is more likely to resolve on its own before
your baby's due date.

PARTIAL PLACENTA PREVIA

The cervix is partly blocked

COMPLETE/ TOTAL PLACENTA

PREVIA
means the entire cervix is
obstructed.

RISK FACTORS
● Smoke cigarettes or use of cocaine
● Women 35 years or older
● Have been pregnant before
● Have had a c-section before
● Have had other types of surgery on her uterus
● Are pregnant with more than one baby
SYMPTOMS OF PLACENTA PREVIA
● The most common sigh is bright red bleeding from the vagina during the second half of
pregnancy, it can range from light to heavy, and it’s often painless.
● Some women have contractions with bleeding.

HOW IS PLACENTA PREVIA TREATED?

1. More ultrasounds to track where the placenta is. Avoid pelvic exams.
2. Bed rest or hospital stay. Limit traveling.
3. Early delivery of the baby. This will be based on how much bleeding you have, how far
along your baby is, and how healthy the baby is.
4. Avoid intercourse
5. Cesarean section delivery
6. Blood transfusion for severe blood loss

G. ABRUPTIO PLACENTA
➢ The placenta has detached from the wall of the uterus,
either partly or totally. This can cause bleeding in the
mother and may interfere with the baby's supply of
oxygen and nutrients.

SIGNS & SYMPTOMS

● Present with bleeding, uterine contractions, and fetal distress

RISK FACTORS
● Maternal hypertension - most common cause of abruptio placenta.
● Maternal trauma - eg. motor vehicle, assault falls
● Cigarette smoking
● Alcohol consumption
● Cocaine use
● Short umbilical cord
● Sudden decompression of the uterus ex. Premature rupture of membranes.
● Retroplacental bleeding from needle puncture. EX: POST AMNIOCENTESIS
● Idiopathic, EX: probable abnormalities of uterine blood vessels and desidua
● Previous placental abruption
● Prolonged rupture of membranes (24 hours or longer)

COMPLICATIONS
HEMORRHAGE/ COAGULOPATHY
➢ Dissemination intravascular coagulation (DIC) may occur as a sequels of placental
abruption/ Patients with a placental abruption ar at higher risk of developing a
coagulopathic state than those with placenta previa. The coagulopathy must be
corrected to ensure adequate hemostasis in the case of a cesarean delivery.
PREMATURITY
➢ Delivery is required in cases of severe abruption or when significant fetal or maternal
distress occurs, even in the setting of profound prematurity. In some cases, immediate
delivery is the only option, even before the administration of corticosteroid therapy in
these premature infants. All other problems and complications associated with a
premature infant are also possible.

H. PREMATURE RUPTURE OF MEMBRANE

RUPTURE OF MEMBRANE
➢ Rupture of membrane is a normal part of giving birth it's the
medical term for saving the water broke. This means that the
amniotic cell that surrounds the baby has broken, allowing the
amniotic fluid to flow out. While it's normal for the sack to
break during labor, if it happens too early it can cause serious
complications this is called premature rupture of membranes or
PROM although the cause of PROM isn’t always clear, sometimes
an infection of the amniotic membranes is the cause.

TREATMENT
● Women are often hospitalized and given antibiotics, steroids (lung maturation of fetus)
and drugs to stop labor (TOCOLYTICS).
● When from occurs at 34 weeks or more some doctors recommend inducing labor at
the, risks of prematurity are less than the infection risk.

I. PREGNANCY INDUCED HYPERTENSION

➢ Old term is Toxemia of pregnancy is a severe condition that sometimes occurs in the
latter weeks of pregnancy. The term toxemia is actually a misnomer from the days
when it was thought that the condition was caused by toxic (poisonous) substances in
the blood. The illness is more accurately called preeclampsia before the convulsive
stage and eclampsia afterward.

Signs & symptoms

ØHigh blood pressure
ØSwelling of the hands, feet, and face
ØExcessive amount of protein in the urine
ØIf worsen: the mother may experience convulsions (eclampsia) and coma and the baby
maybe stillborn/ IUFD

CAUSE
The cause of preeclampsia and eclampsia are not clearly understood but often
1. Primigravida
2. Teenage pregnancy
3. Women from lower socioeconomic groups
4. Dietary deficiency
5. Deficiency of blood flow in the uterus

3 STAGES OF PIH
MILD PREECLAMPSIA
S/S
§Edema (puffiness under the skin due to fluid accumulation in the body tissues, often noted
around the ankles)
§Mild elevation of blood pressure systolic BP ≥140 mmHg diastolic BP = 90-109 mmHg
§Presence of small amount of protein in the urine (proteinuria)
at least 2x 4 hours apart with proteinuria of 1-2g/L (++)
SEVERE PRECLAMPSIA
S/S
§Extreme edema
§Extreme elevation of blood pressure systolic BP ≥160 mmHg diastolic BP ≥ 110 mmHg
§Presence of large amounts of protein in the urine
at least 2x 4 hours apart with proteinuria of 3g/L (+++)
§Headache
§Dizziness
§Double vision
§Nausea and vomiting
§Severe pain in the right upper portion of the abdomen

ECLAMPSIA
§+ Convulsions and coma
§Bp ≥140/90 with
§Headache (increasing frequency, not relieved by regular analgesics)
§Blurred vision
§Oliguria (‹400ml of urine in 24 hours)
§Upper abdominal pain (epigastric or RUQ pain)
§Pulmonary edema
§Hyperreflexia

TREATMENT
● Preeclampsia and eclampsia cannot be completely cured until the pregnancy is over
● Control of high blood pressure
● Intravenous administration of drugs to prevent convulsion, and stimulates the
production of urine.
● Some cases, delivery of the baby is needed to ensure the survival of the
Mother.
● Magnesium sulfate administration
● If uncontrolled blood pressure occurred or convulsions are present, emergency
C-section is performed

PREVENTION
§There is no known preventive measure for PIH
§Though the restriction of salt in the diet may help reduce swelling
§Prevent the onset of high blood pressure or the appearance of protein
in the urine.
§During prenatal visits, the doctor routinely checks the woman’s
weight blood pressure and urine.
§If toxemia is detected early, complications may be reduced.