OBSTETRIC NURSING PART 2 (2022 PNLE)

Prof. Kenneth Arzadon

BLEEDING IN PREGNANCY
1st Trimester Bleeding
ABORTION
Termination of pregnancy before the age of viability (20 weeks)
Fetal Cause: (1st trimester)
Rejection of the ovum
Faulty embryonic development
Maternal Causes: (12th- 19th week – 2nd Trimester)
Infection
Drug ingestion Malnutrition Dehydration  posterior Pituitary Gland  Antidiuretic Hormone / Oxyctocin 
Oxytocin causes CONTRACTION  ABORTION
TYPES OF ABORTION
a. Induced – artificially done
- elective , voluntary, therapeutic
-abortifacient
 MIFEPRISTONE – anti progesterone (thinning of endometrium  difficulty/inability to implant
 MISOPROSTOL – prostaglandin  contraction  dilate the cervix
- 3 days
- DEC PROGESTERONE INC PROSTAGLANDIN= 1st Trimester : Abortifacient ; 2nd Trimester:

b. Spontaneous – naturally occurring (Miscarriage) before 20 WEEKS

• Threatened – cervix is CLOSE
• Inevitable – cervix is OPEN (cerclage)
 DYDROGESTERONE (DUPHASTON) – prevents miscarriage (pampakapit)
 Ritodrine Hcl – relax the uterus (inhibit contraction)
 Isoxuprine ( Isoxilan)
 Progesterone Agonist
• Complete – all are expelled
• Incomplete- some are retained
• Missed – all are retained (intra uterine fetal death)
 Mifepristone / Misoprostaglandin (induce abortion)
 Dilatation & Curretage ( Monitor for bleeding ; (+) beeding = retained fragments)
• Recurrent Pregnancy Loss – 3 successive
• Septic – complicated by infection (E.coli)
GENERAL INTERVENTIONS
- Bed rest as prescribed : NO TO STRICT Bed Rest - can cause pooling of blood in uterus
Can ambulate; avoid strenuous activities
- NPO status immediately – for possible emergency surgery
- Maintain adequate hydration (IV fluids)
- Monitor for the FHR
- Monitor for cervical dilation
- Monitor for bleeding
*anything BLEEDING: NO TO INTERNAL EXAMINATION; MANUAL EXAMINATION; VAGINAL EXAM;
VAGINAL SPECULUM – only thing allowed

BEST PREVENTION FOR ABORTION: Adequate prenatal care and education

ECTOPIC PREGNANCY
- Implantation outside the uterus
- MOST common risk factor: Pelvic Inflammatory Disease (inflammation of the reproductive organs)
• Most at risk for PID: multiple sexual partner
- MOST common site: Ampulla (80%)
- MOST dangerous site: Interstitial
- Pain characteristic: unilateral (depending which ovary) lower abdominal discomfort radiating to the
neck and shoulders

Diagnosis: Sonogram

MEDICAL MANAGEMENT:
- Mifepristone
- Misoprostol
- Mitotic Inhibitor : Methotrexate
Surgical Management: Laparoscopic Salphingostomy
 - HCG assessment: every 2 weeks until negative
*HCG is produces by trophoblastic cells of embryo (methotrexate until HCG is negative)
- NOTE: NO TO Pregnancy for 1 year / use contraceptives for 1 year

RUPTURED ECTOPIC PREGNANCY

- Most Common Time: Embryonic Stage (5-8 weeks)
- Pain Characteristic: Sudden knife-like pain
- Manifestations:
- Bleeding  Shock  HypoTachyTachy
- Complication: Disseminated Intravascular Coagulation ; shock
- Cullen sign
MOST IMPORTANT assessment: PULSE RATE (main compensation mechanism for shock)

DISSEMINATED INTRAVASCULAR COAGULATION

Injury fibrinogen (clotting)  Fibrinolysin (coping mechanism)  destroy fibrinogen  paradoxical bleeding
Injury  Platelets will rush to site of injury  unequal distribution of platelet absence of platelet on other
sites  gum bleeding; nosebleed; petechiae

2nd TRIMESTER BLEEDING:

GESTATIONAL TROPHOBLASTIC DISEASE HYATIDIFORM MOLE (H-MOLE)

Predisposing factors: Late Pregnancy (ABOVE 40 YEARS OLD ; matured unhealthy ovum)

OVUM did NOT develop into ZYGOTE = BLIGHTED OVUM

ZYGOTE did NOT develop into EMBRYO = H.MOLE

Assessment:
- Hyperemesis gravidarum
- Absence of fetal heart tone and skeleton
- Rapid INCREASE in uterine size
- Dark brown vaginal discharge
- Management:
• Mifepristone
• Misoprostol
• Methotrextae
Hcg assessment until negative
NO to Pregnancy for 1 year
- If above 40 Y.O : Hysterectomy – to prevent choriocarcinoma

PREMATURE CERVICAL DILATATION / INCOMPETENT CERVIX

Initial Sign: SHOW (pink-tinged discharge)
- More than 20 weeks

Management: CERCLAGE (can be performed as early as 12 weels if w/ history)

 SHIRODKAR – suturing of the cervix
 MCDONALDS - tying of the cervix

Position after: Trendelenburg position (decrease tension at the cervix)

Removal of Sutures: at term
3rd Trimester Bleeding
PLACENTA PREVIA
Definition: abnormal implantation of the placenta

RISK FACTORS: injury in the integrity of endometrium

- Multiparity
- Previous cesarean delivery
- Previous dilation and curettage
- Scarring in the Endometrium
- Endometritis

Fundic Height Assessment: higher than normal

MOST important sign: Painless, Bright red bleeding
Confirmatory Diagnosis: Ultrasound

MOST common cause if fetal loss: Prematurity

MOST common complication: Hemorrhage

GOALS OF MANAGEMENT:
1. Maintain Adequate Circulation
- Strict Bed Rest
Position: Left Side Lying
Vaginal examination: Vaginal Speculum
IV fluids: Lactated Ringer
Monitor Blood loss: save all tissues passed

2. Increase FETAL LUNG MATURITY

- Coritcosteroids: Betamethasone (hasten fetal lung maturity)

ABRUPTIO PLACENTA

Premature separation of abnormally implanted placenta

RISK FACTORS: increased BP

- Pregnancy induced hypertension
- Shabu, cocaine, smoking
- Trauma, stress, emotions

MOST important sign: Painful dark-red bleeding

Management: “same with placenta previa”
Complications: Couvelaire Uterus (purplish uterus accompanied by rigid and board-like abdomen)

High Risk Pregnancy

GESTATIONAL DIABETES MELLITUS

Risk Factors: Age, Obesity, and Genetics

Possible Cause: HUMAN PLACENTAL LACTOGEN – antagonist of Insulin
- Metabolic acidosis

HPL  DEC insulin  glucose NOT converted to energy  LIPOLYSIS (fats->energy)  by product: Ketones 
metabolic ketoacidosis  DEC placental oxygen  fetal hypoxia

DEC Insulin  maternal hyperglycemia  fetal hyperglycemia  glucose  fetal cells  MORE than 4000
grams ( MACROSOMIA / Large for Gestational Age)

Fetal Hyperglycemia Fetal pancreas (16 weeks)  fetal insulin  DELIVERY: INC Insulin; DEC Glucose
(maternal supply cut off)  Newborn Hypoglycemia (common complication upon delivery)

Most common cause of Infection: Candida Albicans = Candidiasis

- White cheesy discharge

Blood Test for Glucose

50- gram oral glucose test
- Done during the initial prenatal visit
- NO preparation needed
- To determine risk for GDM
- AFTER 1 hour : less than 140 mg/dl (if HIGHER: 100 gram OGTT)

100- gram oral glucose tolerance test / 3 HOUR OGTT

- NPO post-midnight
- No smoking and stay seated on the morning of the test
- AFTER Fasting Blood Sugar  give 100g gluscos; check after 1 hr ; 2 hrs ; 3hrs
Normal FBS: <90 mg/dL
After 1 hr: <180 mg/dL
After 2 hrs: <160 mg/dl
After 3 hrs: <140 mg/dl

Glycosylated Hemoglobin (Hb1Ac)

Implication: Long term compliance to treatment : 3 MONTHS (lifespan of RBC)
Normal: <6%

MANAGEMENT for DM throughout Pregnancy

1st trimester
Glucose is needed for the fetal brain development
Safest: INSULIN (decrease dose)
Oral diabetic medications: TERATOGENIC

2nd trimester / 3rd trimester : INC HPL= DEC INSULIN

- INCREASE dose of INSULIN

Labor: glucose solution + regular insulin ( to convert glucose to energy for labor)
1st 24 hours after delivery: NO to INSULIN (prevent hypoglycemia)
24 hours after delivery: return to usual dose ( no placenta = no HPL)

PREGNANCY INDUCED HYPERTENSION GESTATIONAL HPN

- Main Problem: VASOCONSTRICTION (DEC nutrient exchange – SMALL FOR GESTATIONAL AGE)
- Complication: SGA/ Intrauterine Growth Retardation
- Predisposing factor: Early / Late (more common in adolescent)

TYPES OF PIH:
- Transient HPN = high blood pressure (140/90)
- Pre-eclampsia = HTN + Proteinuria + EDEMA (abnormal: face and hands)
- Eclampsia = HTN, Proteinuria, edema+ SEIZURE (cerebral edema)
*Complaints: headache ; abdominal pain; visual disturbances = AURA OF SEIZURE

TYPES OF PRE-ECLAMPSIA:
MILD: w/o complication
SEVERE: w/ complication
NORMAL UA: absence / traces of protein

MANAGEMENT OF PIH
Positioning: Left-side lying position
Environment: Less stimulated (admit across the station)

Company: Same diagnosis

PRIORITY: 1Safety and 2Airway

Medical Management: HYDRALAZINE (direct vasodilator)

DIET: High Protein; moderate sodium (1500 mg/day); Dietary Approach to Stop Hypertension (DASH) diet
If LOW SODIUM  activate RAAS ( Renin Angiotensin Aldosterone System)  Increase NA
RAAS Angiotensin  Angiotensin 1  ANgiotensin 2  VASOCONSTRICTION 

DRUG OF CHOICE to prevent convulsions: MAGNESIUM SULFATE = Neurologic and Respiratory Depressant
ASSESSMENT PARAMETERS:
 Respiratory Rate ( should be Above 16 bpm)
 Deep tendon / patellar reflex (must be present)
 Urine output (must be more than 30cc/hr)
Ex: RR= 10 bpm ; UO= 30 cc in 2 hrs = WITHHOLD

Normal level: 1.5 – 2.5 mg/dl

Therapeutic Level: 5 -8 mg/dl
Toxicity level: more than 8 mg/dl

 Antidote: Calcium gluconate

 Long term complication: Osteoporosis (INC Magnesium ; DEC Calcium)
* Seizure = neurologic ; Convulsion= muscle jerking

RH ISOIMMUNIZATION/ SENSITIZATION
Mother: Rh (-)
Father: Rh (+) ; antigen
Baby: Rh (+)
*mixing blood of baby and mom during placental separation

1st Baby  mom produce Antibody because of Positive baby  Baby #1 safe because already delivered
1st baby NOT SAFE for  invasive procedure (ex: amniocentesis)  accidental puncture of baby or cord 
mixing of blood  Baby1 not out yet  mom antibody kills baby1

2nd Baby  mom already has antibody because of Baby #1  mom antibody attacks baby 2  erythroblastosis
fetalis  baby RBC killed  Inc billirubin  Jaundice

MANAGEMENT:
Rhogam / Rh Immunoglobulin
- Weaken existing antibodies
- Prevent formation of new antibodies
- Within 72 hrs
- Every succeeding pregnancy ( earlier the better ; usually 28 weeks)
- Every after invasive procedure
Coombs’s test: test to determine the presence of antibodies

*Rh attacks Rh(+) Baby

INDUCTION AND AUGMENTATION OF LABOR

Induction – start
Augmentation – restart
OXYTOCIN
Effective Labor Pattern:
-Contractions occurring every 5 minutes
- Complication: Water Intoxication (oxytocin / ADH = retain water)
*WOF hyperstimulation (uterine rupture)
PROSTAGLANDIN
- Dilates/ soften cervix
- SE: hypertension
Dinoprostone (suppository)
Misoprostol (oral)

PREMATURE and PRETERM RUPTURE OF MEMBRANES

Preterm ROM – occurs before 37 WEEKS
Premature ROM: occurs before ONSET OF LABOR
Manifestation: Sudden gush of fluid
NITRAZINE TEST / PHENAPHTHAZINE
YELLOW – ACIDIC (urine)
BLUE – ALKALINIC (amniotic fluid)
INITIAL NURSING ACTION: 1 rule out cord prolapsed/ cord compression ; 2FHR

THERAPEUTIC MANAGEMENT:
• Before engagement: BED REST to prevent cord prolapse
• Before labor: Administer betamethasone
• During active labor: let the mother walk (dilate)
Complication: POTTER-LIKE SYNDROME
CHORIOAMNIONITIS
Presence of bacteria in the amniotic fluid

Manifestations: “FLUTE”
- Fever
- Leaking foul-smelling amniotic fluid
- Uterine tenderness
- Tachycardia
- Elevated WBC

Nursing Intervention:
- Increase fluid intake
- Tepid sponge bath
- Administer antibiotics as prescribed
SAFE:
1.“-cillins” - ampicillin
2.“-Lycins” - gentamycin
3.cephalosphorines

PROLAPSED UMBILICAL CORD

Predisposing factors: PROM
Shoulder presentation Polyhydramnios
PRIORITY: 1REPOSITION ; 2FHR (compressed cord can cause heart deceleration; rule out cord prolapsed
/compression first)
BEST POSITION:
Knee-chest position Exaggerated Left Sim’s Position

*do not push back the Cord

*push gently the head of baby UPWARD
*cover CORD with sterile gauze, wet, warm (to prevent constriction), NSS
UTERINE ATONY

Assessment: soft, boggy uterus

Interventions
- encourage the woman to void
- encourage the woman to breastfeed
- massage the uterus

HEMATOMA

Assessment
- Sensitive bulging mass in the perineal area with accompanies with severe pain and pressure
- Inability to void
- Bleeding: Hypo Tachy Tachy

Nursing Interventions:
- ICE packs
- Warm sitz bath
- Analgesics as prescribed
- Urinary catheterization
ENDOMETRITIS

Manifestation:
- Fever
- Lochia is foul smelling
- Uterine tenderness
- Tachycardia
- Elevated WBC

Management:
- Encourage fluid intake
- Antibiotics as prescribed
- BEST POSITION: FOWLER’S POSITION – drain the uterus

MASTITIS

Nursing Interventions:
- Cold Compress (severe pain)
- Warm Compress (before breastfeeding)
*better: alternating cold and warm compress
- Increase fluid intake
- Antibiotics
- MORE/ FREQUENT BREASTFEEDING (decongest the breast)
Breastfeed first on the UNAFFECTED  stimulates milk ejection reflex  DECONGESTS AFFECTED

POST PARTUM BLUES / DEPRESSION

Blues: Normal; within 1 week
Depression: Abnormal; more than 1 week
Cause: Hormonal changes (DEC ESTROGEN)
Contributing Factors: Exhaustion and Tension, Abandonment
Manifestations: Hesitance to care for the newborn (unkempt baby)
Interventions: Anticipatory Guidance

BREASTFEEDING

Hepatitis B (+) mother: YES (Hep B is NOT transmitted via Breastmilk; BABY already Vaccinated upon birth)
HIV (+) mother: NO (HIV CAN be transmitted via Breastmilk; baby not HIV positive because of retrovirals)
*Zidovudine @14th week = PREVENT MATERNAL-FETAL TRANSMISSION OF HIV