Ncma219 Ob Lec: BSN 2Nd Year 2Nd Semester Prelim 2022: Bachelor of Science in Nursing 2YB

Bachelor of Science in Nursing 2YB
NCMA219 OB LEC: BSN 2ND YEAR 2ND SEMESTER PRELIM 2022
- 22 pairs of autosomes (homologous autosomes) –

Coverage for Prelim: homologous, they have the same pattern/ shape.
• Genetic Assessment and Counselling - 1 pair of sex chromosomes (No. 23)
• High Risk Pregnancy Terms:
- Diagnostic Exams • Phenotype – outward appearance of a person
- RA 9262 • Genotype – a person’s actual gene composition of person
- Bleeding disorders (1st2nd3rd trimester) • Genome – complete set of genes. Example: 46XX or 46XY
- Gestational conditions (Hyperemesis gravidarum, (46 – no. Of chromosomes: XX – gender, 46XX – it has 46
PIH, Gravido Cardiac, GDM, Isoimmunization, chromosomes and it’s a female)
Anemia) • p-short arm defect – above part
• Problems During Labor and Delivery • q-long arm defect – lower part
- Problems with 4 P’s
- Intrapartal complications Nature of Inheritance
• Postpartum Complications - Each cell, except for the sperm and ovum, contains 46
- Postpartal hemorrhage chromosomes (22 pair of autosomes and 1 pair of sex
- Lacerations chromosomes). Spermatozoa and ova each carry only half of
- Puerperal infection the chromosome number, or 23 chromosomes. For each
- Emotional and Psychological Complications of chromosome in the sperm cell, there is a like chromosome of
Puerperium similar size and shape and function (autosome, or homologous
• Male and Female Clients with General and Specific chromosome) in the ovum.
Problems in Reproduction and Sexuality - A person’s phenotype refers to his or her outward appearance
- Infertility, Alternatives to Childbirth or the expression of genes. A person’s genotype refers to his
- Cystocele/ Rectocele or her actual gene composition.
- Normal genome is abbreviated as 46XX or 46XY (designation
GENETIC ASSESSMENT AND COUNSELLING of the total number of chromosomes plus a graphic description
Discussed by Prof. Carmencita Pacis of the sex chromosomes present).
Genetic disorders
- Inherited or genetic disorders are disorders that can be passed Mendelian Inheritance: Dominant and Recessive patterns
from one generation to the next. - By Gregor Mendel
- Cytogenetics is the study of chromosomes by light microscopy - Dominant gene and non-dominant gene
and the method by which chromosomal aberrations are - Kung may problema ka sa dominant gene then may problem
identified. ka rin sa dominant inheritance, kung may problema ka naman
• Nature of inheritance sa non dominant gene then may problem ka rin sa recessive
• Mendelian inheritance inheritance.
- Dominant pattern - A person who has two like genes for a trait—two healthy
- Recessive patterns genes, for example (one from the mother and one from the
- X-Linked father)—on two like chromosomes is said to be homozygous
• Inheritance of disease for that trait. If the genes differ
- r (a healthy gene from the mother and an unhealthy gene from
Inherited or Genetic Disorders the father, or vice versa), the person is said to be heterozygous
- Disorders that can be passed from one generation to the next. for that trait.
- Namamana - What are you going to inherit? Brown eyes, blue eyes, black
• Genetics hair.
- Study of the way such disorders occur.
- How this genetics or heredity disorders occur?
• Cytogenetics
- The study of chromosomes by light microscopy and the
method by which chromosomal aberrations are identified.
- Used slide to visualize the chromosomes.
• Genes
- Basic unit of heredity
- Made up of DNA
- DNA – they are intertwined with one another to be able to - The father inherited non dominant gene from his parents, and
create chromosomes. his parents has both blue eyes = blue eye. The mother
- DNA – basis of heredity; RNA – synthesizes protein for inherited one non dominant gene which is blue eyes from her
cellular growth, supports DNA growth and heredity. one parent and one dominant gene which is brown eyes from
- Human being composed of 46 chromosomes (23 pairs) one parent.
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CARE OF MOTHER AND CHILD AT RISK OR PROBLEMS – OB LECTURE: BSN2ND YEAR 2ND SEM PRELIM 2022
- If the combination will be dominant brown and non-dominant Inheritance of Disease

blue, brown will dominate. Autosomal dominant inheritance
- Both non dominant and both dominant (same) – homozygous - “Autosomal" means that the gene in question is located on one
- One dominant, one non dominant (different) – heterozygous of the numbered, or nonsex, chromosomes. "Dominant" means
that a single copy of the disease-associated mutation is enough
to cause the disease.”
• One Parent – one of the parents of a child with the
disorder also will have the disorder
• Sex – the sex of the affected individual is unimportant in
terms of inheritance
• History – there is usually a history of the disorder in other
family members
- Homozygous – healthy gene + healthy gene

- Heterozygous – healthy gene + unhealthy gene
- If the father is both dominant gene (BB) and mother is
both non-dominant genes (bb). The father will dominate,
and the combination is heterozygous.
What type of heterozygous? Dominant. So the baby will be
heterozygous dominant.
- Autosomal – the first 22 chromosomes are autosomes almost

the same pattern and shape. And no. 23 chromosome is the sex
chromosome.
- The father has one healthy non-dominant gene and one disease
- If the father has dominant and non-dominant gene, and the
dominant gene, while the mother has both healthy non-
mother has both dominant gene, then the baby will be
dominant gene. Therefore, 50% chances the baby will have
homozygous dominant. (Kasi magkapareho ung nanay at tatay
healthy gene (hh). And 50% chances the baby inherit the
kaya naging homozygous, at both silang dominant, kaya
dominant disease gene (hd & Dh).
naging homozygous dominant)
- If the father has non-dominant and the mother has dominant,
then the baby will be heterozygous dominant. (magkaiba sila –
non domi at domi, kaya tinawag heterozygous.)
- If the father has non dominant and the mother also has non-
dominant, and the baby is homozygous non-
dominant/recessive. (magkapareho silang non-dominant kaya
homozygous dapat.)
- If the mother has both dominant gene and the father has one - The father has dominant disease gene and non-dominant
dominant gene and one non-dominant gene, the child will healthy gene, and the mother also. Then 25% chances the baby
become homozygous dominant 25%. And the heterozygous will get healthy (hh) but the 50% the baby will have disease
dominant is 50%, then homozygous non-dominant is 25%, gene (hd & Dh) and when it’s both dominant disease (DD), the
total of 100%. baby will be incompatible in life. Pwede syang mamatay sa
- Each box has 25%. May dalawa syang heterozygous dominant uterus or during labor and delivery.
kaya 50%. Pero yung homozygous dominant (orange) at
homozygous non-dominant (green) ay iisa lang kaya naging
25%
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Disorders
• Huntington’s Disease
- The father has one dominant healthy gene and one non-
dominant disease gene while the mother has one dominant
healthy gene and one non-dominant healthy gene. Therefore,
25% chances the baby will be healthy (HH), the 50% chances
the baby will be a carrier of the disease but he’s not
experiencing any sign and symptoms (Hd – dh). And 25% of
the baby will be disease state (dd) (hindi sya incompatible in
• Marfan Syndrome life kasi non-dominant yung may disease, mas malakas yung
dominant kaysa non-dominant)
- The father has both dominant healthy gene while the mother
has one dominant healthy gene and one non-dominant disease
gene. Therefore, 50% chances the baby will be healthy (HH)
and the 50% chances the baby will be a carrier of the disease
(dh) – not experiencing any sign and symptoms. So, no baby
will experience a full-blown disease, they can be only a carrier
Autosomal recessive inheritance that can pass on to the next generation. Because most of the
- A genetic condition can occur when the child inherits one genes are healthy and dominant
copy of a mutated (changed) gene from each parent. The
parents of a child with an autosomal recessive condition
usually do not have the condition.
- The father has both dominant healthy gene while the mother
has both non-dominant disease gene, therefore, 100% the baby
will be a carrier of the disease (dh) (not experiencing any sign
and symptoms.
- Both parents of a child with the disorder are clinically free of

the disorder.
- The sex of the affected individual is unimportant in terms of
inheritance.
- The family history for the disorder is negative—that is, no one
can identify anyone else who had it (a horizontal transmission
pattern). - The father has one nondominant disease gene and one
- A known common ancestor between the parents sometimes dominant healthy gene while the mother has both non-
exists. This explains how both male and came to possess a like dominant disease gene, therefore 50% chances the baby will
gene for the disorder. disease state (dd) (nakakaexperience sya ng disease pero hindi
sya incompatible in life/ mamamatay) and 50% chances the
baby will be a carrier (dh) (not experiencing s&s)
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- X-linked dominant inheritance occurs when a gene responsible

for a trait or disorder is located on the X chromosome.
- May problema sa x chromosome. It could be from ovum or
sperm.
• Dominant Gene – All individuals with are affected.
• Affected – All female children of affected men are
affected; all male children affected man are unaffected.
Because the only sex chromosome affected is x. And male
- The father has both nondominant disease while mother has is coming from y chromosome
also nondominant disease. Therefore, 100% the baby will have • Generations – It appears in every generation
a disease (dd) (experiencing disease). • Homozygous/Heterozygous – All children of
homozygous affected women are affected. Fifty percent of
 Dh / hd – will have a disease (nasa dominant yung disease) the children of heterozygous affected women are affected.
 Hd / dh – carrier of the disease (no sign and symptoms kasi nasa - Kasi homozygous, parehas xx. Kaya affected.
non-dominant gene yung disease nya)
 DD – incompatible in life (both silang dominant kaya malala
sya)
 Dd – disease state (experiencing disease)
 HH / hh – healthy
Disorders
• Cystic Fibrosis
- an inherited disorder that causes severe damage to the
lungs, digestive system and other organs in the body.
• Sickle Cell Anemia

- an inherited red blood cell disorder in which there aren't
enough healthy red blood cells to carry oxygen throughout
your body.
- The father has both nondominant normal x and y, while the

mother has dominant disease X and nondominant normal x.
Therefore, 50% chance that the baby girl and boy will have a
disease but the another 50% of the baby girl and boy will be
normal.
 Dominant disease X from the mother + nondominant normal x

from the father = disease state – because the dominant X from
the mother has disease and it will dominate the gene. The baby
girl will have a disease.
 The baby boy of the father will have the disease because the
dominant of the mother has disease.
 Non-dominant x of the mother + nondominant x of the father
= a healthy baby girl
 Non-dominant x of the mother + nondominant y of the father
= a healthy baby boy
X-linked Dominant inheritance
- Some genes for disorders are located on, and therefore - The father has dominant disease X and nondominant normal
transmitted only by, the female sex chromosome (the X y while the mother has both nondominant normal x.
chromosome). If the affected gene is dominant, only one X Therefore, all the baby girls will have a disease and all the
chromosome with the trait need be present for symptoms of boys will not have disease.
the disorder to be manifested. - Father has dominant disease X + the mother has
nondominant normal x = the baby girl will have disease.
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- Father has nondominant normal y + mother has nondominant

normal x = the baby boy will be normal.
 Blue – healthy; red - disease

 Healthy x + healthy y = healthy boy
 Healthy y + healthy x = healthy boy
 Healthy x + healthy x = healthy girl
 Disease x + healthy y = disease boy
 Healthy x + disease y = disease boy
 Disease x + disease x = disease girl
 Disease y + disease y = disease boy - The father has nondominant normal x and y while the
mother has dominant normal X and nondominant disease
• If the mother is affected, then 50% will have a disease and x. Therefore 50% of the children will have disease and
50% will be normal. (may isang affected sa babae at isang 50% of the children will have a disease.
affected din sa lalaki, 50 50) • Father has nondominant normal x + mother has dominant
• If the father is affected, then the baby GIRL will have 100% normal X = healthy girl
disease and baby boy will be normal. (lahat ng babae • Father has nondominant normal y + mother has dominant
magkakasakit because X chromosome is only affected in X- normal X = healthy boy
linked.) • Father has nondominant normal x + mother has nondominant
Disorders: disease x = the girl is carrier
- Characterized by dermatological, Ocular, dental, and • Father has nondominant normal y + mother has nondominant
neurological Abnormalities. disease x = the boy is disease state.
• The X-linked Lissencephaly - (xx) – carrier lang sya kasi yung normal x na galing sa
father, binabalance nya yung disease ng baby girl.
• Double-Cortex Syndrome
Dalawang x kasi meron sya. Yung may disease na x,
• Incontinentia Pigmenti Type 1
nilalaban or binabalance ng healthy x, kaya wala syang
s&s pero carrier sya.
- (xy) – since ito wala syang another healthy x para
ibalance yung problem ng baby boy, kaya naging disease
state sya.
- Interpretation: if both genes of the father is normal and
the mother has one disease gene, then 50% chances the
baby will be normal, 25% chances the baby will be a
carrier, and the 25% chances the baby will be a disease
state. (4 children)
- The father has nondominant disease x and nondominant

normal y while the mother has both dominant X.
Therefore the 100% of baby girl will be a carrier and
X-linked Recessive Inheritance 100% of baby boy is healthy.
- X-linked recessive diseases most often occur in males. Males • Father has nondominant disease x + mother has dominant
have only one X chromosome healthy X = the baby girl will be a carrier
• Males – Only males in the family will have the disorder. • Father has nondominant healthy y + mother has dominant
• History of Death – A history of girls dying at birth for healthy X = healthy baby boy
unknown reason often exists (females who had the affected - (Xx) – the dominant healthy X is overpowering the
genes on both X chromosomes.) nondominant disease that’s why the baby girl is carrier.
• Unaffected – Sons of an unaffected man are unaffected.
• Parents – The parents of the affected children do not have the
disorder.
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Imprinting
- Refers to the differential expression of genetic material
- allows researchers to identify whether chromosomal material
comes from the male or female parent
- ability of a gene to be expressed depends upon the sex of the
parent who passed on the gene
- Examples:
• Angelman Syndrome are expressed only from the
maternal chromosome 15
• Prader-Willi
Chromosomal abnormalities (Cytogenic Disorders)
- Happens when there is abnormality in the number or structure
of chromosomes
- Missing, additional or distorted chromosomes.
Nondisjunction
- If the father x is affected, then all the girls will be a carrier - Division of chromosomes is uneven; failure to separate
while the boys is healthy. (xx – carrier lang si girl kasi - Failure to separate or disjoint
yung another healthy x na galing sa mother nya ay - Abnormalities occur if the division is uneven
binabalance yung problem ni girl.) - if spermatozoon or ovum with 24 or 22 chromosomes fuses
- If the father both x and y is not affected but the mother x with a normal spermatozoon or ovum. The zygote will have
is a carrier. Then the 1 boy will have a disease while the either 47 or 45 chromosomes, not the normal 46
girl is a carrier (xy – the mother x has carrier while the - 45 chromosomes are not compatible with life and could lead to
father y is healthy therefore the boy will have a disease abortion.
BECAUSE yung healthy na y ni tatay ay hindi nya
kayang ibalance yung problem ni baby boy. – kapag both
xx yan at isang x may disease, magiging carrier na sya,
kasi yung healthy x lang
Disorders
• Red-Green Color Blindness – the person cannot distinguish
shades of red and green
• Hemophilia A
Explanation:
- (xx) 1 pair of chromosomes, during pre-embryonic
development that contains chromosomes will divide and
we call that meiosis. Meiosis is a process of cell division
where in cell becomes haploid means it will divide into
half.
- Normal disjunction, 1 pair of chromosomes will split into
one (x) right side (x) left side.
- (x) Right side chromosome will split into another haploid
(l) (l). During fertilization chromosomes coming from the
male will pair here kaya magiging (ll) (ll)
- (x) Left side, failure to disjoin so it will not separate kaya
mag kasama pa din siya (ll) tapos empty ung isa ().
During fertilization chromosomes coming from the male
Patterns of Inheritance: Polygenic Traits will become (ll) → (lll), () → (l). Ung isa sobra ung isa
Multi Factorial (Polygenic) Inheritance kulang we call that chromosomal aberration or
- Many childhood disorders tend to have higher-than usual chromosomal abnormality.
incidence Example:
- occur from multiple gene combinations possibly combined o Patau's syndrome (trisomy 13)
with environmental factors o edwards syndrome (trisomy 18)
- Do not follow the mendelian laws o Trisomy 21: 47XX21+ or 47XY21+
- No set patters in Family History o Klinefelter syndrome: 47XXY
- Example: o Turner syndrome: 45X0
• For example, height is thought to be Polygenically - Klinefelter (47XXY) – it’s a boy and has one extra X.
inherited, but a person's stature also is significantly Boy sya pero may isa syang female trait. (sobra ng
affected by adequacy of diet while growing. Cleft lip with chromosome). Prone to osteoporosis and small scrotum
or without cleft palate is probably an example of a - Turner (45X0) – lacking – it’s a girl but one chromosome
polygenic trait with a threshold effect. Its incidence in the is missing kaya may 0 sa huli. Missing an x chromosome
general population is about 1/1000. on 23rd pair (kulang ng chromosome
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Translocation abnormalities
- A child gains additional chromosome through another route.
- Example:
• Cancer: several forms of cancer are caused by acquired
translocations. This has been described mainly in
leukemia (acute myelogenous leukemia and chronic
myelogenous leukemia). Translocations have also been
described in solid malignancies such as ewing's sarcoma.
Deletion Abnormalities
- Part of a chromosome breaks during cell division resulting to
normal number of chromosomes plus or minus an extra
portion of a chromosome.
- Changes the dna sequence by removing at least one nucleotide
in a gene.
Example:
- Cri-du-chat syndrome – 46xy5q (lalaking may problema Isochromosomes
sa long arm chromosome no.5) - results from chromosome accidentally dividing not by vertical
separation but by horizontal one so a new chromosome with
mismatched long and short arms
- Turner Syndrome
- mutation examples in humans are:

• Angelman Syndrome
• Canavan Disease
• Color Blindness Mosaicism
• Cri-Du-Chat Syndrome - abnormal condition that is present when the nondisjunction
• Cystic Fibrosis disorder occurs after fertilization of the ovum as the structure
• Down Syndrome begins mitotic division.
• Haemophilia - different cells in the body will have different chromosome
• Phenylketonuria counts
- Symptoms of Cri-Du Chat syndrome: - Mosaic Down Syndrome
• A high-pitched cry resembling that of a cat
• Downward slanting eyes
• Extremely low birth weight
• Delayed growth of the child
• Abnormally shaped ears
• Intellectual impairment
• Webbing or fusing of fingers
• Skin tags in front of ear
• Delayed motor development
• Microcephaly
• Small jaw Genetic Counselling
• Wide set eyes 1) Provide concrete, accurate information about the process of
inheritance and inherited disorders
2) Reassure people who are concerned that their child may inherit
a particular disorder or that the disorder will not occur
3) Allow people who are affected by inherited disorders to make
informed choice about future reproduction
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4) Offer support to people who are affected by genetic disorders Risk Factors
5) Offer support to people who are affected by genetic disorders. Demographic Factors
- Timing: before first pregnancy to prevent future problem Age: < 18 and 35 >
- Consideration: confidentiality of information that couple • Optimal Age for Pregnancy: 20-30 years
will share - Ideal age na to para magbuntis (pero mga teh kalma pasa muna
Who should undergo counselling: board exam at maging RN HAHAHA)
- Couple who has a child with congenital disorder or an - The women become at risk at the age of 20-30 because
inborn error of metabolism they become at risk if she primigravida, meaning 1st time
- Couple whose close relatives have a child with a genetic nya mabuntis.
disorder - If the age of the woman who got pregnant is below 18 or
- Any individual who is known balanced translocation above 35, they can lead to hypertension. – young,
carrier primigravida & multipara with advanced maternal age.
- Any individual who has an inborn error of metabolism or • If u got pregnant at the young age, primigravida below 18 will
chromosomal disorder produce new hormones and your blood vessels can act
- A consanguineous (closely related) couple wrongly.
- Any woman older than 35 years and any man older than - Vasoconstriction may arise especially if they are got
55 years pregnant underage (e.g., 18 years old) and that can cause
- Couples of ethnic backgrounds in which specific illnesses hypertension. Lumiliit or nag ta-tighten yung muscle
are known to occur. around the blood vessel and liliit din ung lumen at dahil
Nursing Responsibilities dyan nagkakaroon ng poor circulation.
- Explain what procedures to undergo - The compensatory mechanism of the heart to keep it
- Explain how different genetic screening tests are done and circulating is to increase the pumping action of the heart.
when offered (pag lumakas ung pumping action, ung palo ng blood
- Support the couple during the wait for test results against the wall ng artery lalakas kaya nagkakaroon ng
- Assist couples in values clarification, planning, and decision increase in the blood pressure) and possible na ma-
making based on test results hypertension sya.
Genetic Disorders Assessment - May hypertension na mangyayari kase the heart will be
• History pump more stronger para magkaroon ng sufficient supply
• Physical Assessment ng blood sa mother and the baby.
• Diagnostic Testing • If the woman got pregnant above 35 there is two factors that
• Karyotyping may arise:
• Maternal Serum Screening - Arteriosclerosis – hardening of the walls of arteries bec.
• Chorionic Villi Sampling of aging. (kapag tumitigas yan, nagiging less elastic sya
• Amniocentesis kaya kailangan ng increase pumping action of the heart)
• Percutaneous Umbilical Blood Sampling - Atherosclerosis – fat deposition on the walls of arteries
• Fetal Imaging (wrong diet)
• Fetoscopy - The effect of the hypertension to the baby, there will be
• Preimplantation Diagnoses decrease oxygen and nourishment supply to the baby kaya
ang mangyayari SGA.
HIGH RISK PREGNANCIES & DIAGNOSTIC EXAMS Weight – Pre-pregnant weight
Discussed by Prof. Francis Vasquez • Normal Birth Weight: 2.5 kg – 3 kg ave. - 4kg max.
1) Risk Factors - SGA < 2.5 kg (microsomia)
a) Demographic factors - 4 kg < LGA (macrosomia)
b) Socioeconomic status - Within the average – AGA (Average for Gestational Age)
c) Obstetric history - (3 – 4> the baby is LGA or Large for Gestational Age)
d) Current OB status - LGA, pwedeng maka affect sa normal delivery ng baby
e) Maternal medical history/ status possible that the mother will undergo cesarean section
f) Habits/ habituation - SGA, maapektuhan ang brain and head development that
2) Diagnostic tests in high-risk pregnancy and determination could lead to Neurological Impairment.
of Fetal status o Neurological Impairment = permanent/irreversible
a) Ultrasonography o IQ level = low
b) Non-stress test - Pag nakakita ka ng buntis na below 18 y/o, dapat mag
c) Contraction stress test health teaching tayo sakanila para maprevent ung
d) Oxytocin challenge test hypertension. (Ex: low fat diet, monitoring BP every day,
e) Biophysical profile monitor the weight for edema)
f) Amniocentesis • Pre-pregnant weight: 90 lbs and 150lbs
g) X-ray: Lateral Pelvimetry - Normal Weight Gain: 24-20lbs
h) Serial estriol-determination - Mother weight is < 90 lbs = Anemia (SGA)
i) Chorionic villi sampling - Mother weight 150lbs > = Diabetes – mataas ang glucose
j) Percutaneous umbilical blood sampling (baby size – LGA, possible cesarean section)
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- The most important is pattern of weight gain. Kase every - Unprepared – maybe bcz of finances
trimester may sinusunod na pattern yung mother for her 5) Out of wed lock
weight and yun ang ina-assess natin tuwing check-up. - Possible problem is psychological security or financial
Chinecheck natin kung may sudden weight gain si mother. security.
• Pattern of Weight Gain:
- 1st Trimester – 0.8~1~1.2 lbs/month = (3-4 lbs) Obstetric history
- 2nd Trimester – 0.8~1~1.2 lbs lb/week (12-13 lbs) 1) History of infertility or multiple gestation
- 3rd Trimester – 1 lb/week (12-13 lbs) - History of infertility because possibility of marital
- Ex: If the pre-pregnant weight 115 lbs what is her PWG? problems
o 1st tri = 118 lbs (add mo lang yung 3 months sa 115 lbs) 2) Grand multiparity
- Possible problem uterine atony that can lead to bleeding.
o 4th months = 122 lbs (add 4weeks)
3) Previous abortion or ectopic pregnancy
o 6th months = 130lbs
o if the mother became 138 lbs in her 6th month it - Previous abortion that can lead to RH compatibility or
means there is Sudden Weight Gain. blood compatibility
- Sudden Weight Gain – edema/manas - Ectopic pregnancy may lead to bleeding, if this is repeated
- If the fluid increase between the cells (interstitial) it will the remain fallopian tube can be damage.
4) Previous loses fetal death, still birth, neonatal death or
result to edema.
perinatal death
- Sa paa ka unang titingin para icheck ung edema
- Once na may edema ang mother ang first VS na kukunin 5) Previous operative OB: Cesarian, midforcep delivery
mo sakanya is Blood Pressure. - Recommended interval of CS – 3-5 years
6) Previous uterine abnormality
• Edema based on Grade:
7) Previous abnormal labor
- Grade 0 x 2 = 0 mm
• Preterm – born before 37 weeks
- Grade 1 x 2 = 2 mm
- Grade 2 x 2 = 4 mm • Post term – 42 weeks >
- Grade 3 x 2 = 6 mm • Prolonged labor –24 hrs > because uterine contraction is
- Grade 4 x 2 = 8 (pag pinindot mo yung pa ani mother weak, this called hypotonic uterine contractions.
hindi mo na nakikita yung kuko mo sa point finger) • Precipitate labor – 3 hrs < hypertonic
- To estimate if the baby is growing normally inside the 8) Previous high-risk infant
uterus of the woman: Use Bartolome’s rule, Johnson’s • Low birth weight (LBW)
rule etc. • Macrosomia
- Factors that may affect fundic height: 9) Previous hydatidiform mole
1) Size of the baby
Current OB status
2) Number of fetuses
1) Late or no prenatal care
3) Amount of the amniotic fluid
- Risk factors will not be identified or are identified too late
4) Size of the mother
kaya the women already develop the problem.
- Health teaching to prevent hypertension:
2) Maternal anemia
o Low fat diet
3) Rh sensitization
o Monitoring blood pressure
- Blood incompatibility
o Monitoring the weight, report other s&s
Height: < 5 feet 4) Antepartal bleeding
- Less than 5ft – small pelvis - Abortion
- Small Pelvis could cause CPD or cephalopelvic disproportion 5) Pregnancy-induced hypertension (PIH)
- CPD – the baby is not able to pass through vaginal delivery - SGA
(need mag CS ni mother) 6) Multiple gestation
- Recommended laboratory for CPD is x-ray pelvimetry 7) Premature or post mature labor
- X-ray Pelvimetry – is used to assess the dimension of the 8) Polyhydraminios
maternal pelvis. (ginagawa to para ma sure yung percentage - Excessive amniotic fluid, the uterus will become bigger
kung kaya ang normal delivery ng baby) then the baby have big space to move. So, the cord can
- Performed by 3rd trimester 2 weeks prior EDC coil around the neck.
- Never perform on the 1st trimester. (1st Trimester = 9) Premature rupture of membranes (PROM)
Organogenesis) - If the amniotic sac ruptures prematurely, the mother is
prone to ascending infection. The m.o. can enter the
Socioeconomic Status
vagina, vagina canal, cervical canal, uterine cavity.
1) Inadequate finances
10) Inappropriate fetal size
- Low socioeconomic status (money)
- SGA or LGA
2) Overcrowding, poor standards of housing, poor hygiene.
- Prone to communicable diseases Maternal Medical history/ status
- Nakakahawang sakit 1) Cardiac or pulmonary disease
3) Nutritional deprivation - Ex: permanent cardiac damage, prone to congestive heart
- Balance diet failure. The mother at risk of determination of pregnancy/
4) Unplanned and unprepared pregnancy pwedeng ipaabort – therapeutic abortion
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- Pulmonary disease – ex. COVID, asthma, tuberculosis - To avoid hitting the bladder by the needle, void
2) Metabolic disease before the procedure.
- DM, Thyroid - UTZ aided = to locate and prevent puncturing the
3) Chronic renal disease placenta (upper uterine segment)
- Repeated UTI may lead to abortion - 3 most important purposes of amniocentesis:
4) Chronic hypertension a) To determine chromosomal defect
5) STI/ STD b) Neural tube defects
- There are STD that can affect the baby or can transmuted c) Fetal lung maturity
to the baby. Non-stress test
6) Hemoglobinopathies - Observation of FHR related to fetal movements
7) Malignancy - 30-32nd week
8) Major emotional/ mental disorders - Accelerate – when the baby is awake and moving.
- Depression - Eat your breakfast before the test. (bcz food intake increases
Habits/ habituation glucose in the blood of mother, it goes to the placenta and
1) Sad habit absorbed by the fetal blood. So, the glucose in the fetal blood
2) Smoking will eventually increase after the mother ate. The increase of
- Vasoconstriction, the baby can become SGA glucose will wake up the baby)
3) Alcohol o 8:30am hospital (determine if the mother ate) then rest
- Neurologic impairment = permanent/ irreversible – FAS muna and get VS (FHR 130bpm before the test)
fetal alcohol syndrome o 9:00 am test – left lateral position (if the mother feel the
- No amount of alcohol during pregnancy baby move, ring the bell para ma notify ung nurses/
4) Drug abuse doctor)
- Neurologic impairment o 9:15 am – fetal movement (u need to wait 10mins,
gumagalaw galaw in 10mins, after 10 mins get FHR)
Check yourself: - Normal result = reactive/ positive/ fetal heart rate acceleration.
a) Is the present weight of a pregnancy woman of 144 lbs normal - Reactive: if there’s an increase of at least 15bpm
at 5th month if her pre-pregnant weight is 125 lbs? Contraction stress test
• Ppwt: 125 lbs - To determines reaction of FHR to uterine contraction.
• 1st tri = 128 lbs + 8 = 136 lbs - 34-36 week
• 4th-5th mos = 8 weeks = 8 lbs - Possible of complication is rupture of bag of water.
b) Mrtha is 3 mos pregnant. Her OB score is G5P3T2P2A1L4M1. o 8:30am – rest; then get VS & FHR
Identify the risk factors based on her OB score. o 9:00 am – test; provide mother hospital gown, instruct the
• Grand multigravida mother to roll the nipples at least 10mins
• Preterm - Rolling of nipples will produce mild uterine contraction only.
• Abortion The FHR not affected.
- During actual labor there are strong contraction, decreases
• Multiple gestation
FHR. Can cause fetal heart rate deceleration.
Diagnostic tests - Normal result of CST: negative (no fetal heart rate
Ultrasonography decelerations)
- Uses high frequency sound waves to detect intra-body - Less than 100 bpm – at risk of fetal distress = fetal hypoxia
structures. Oxytocin challenge test
- UTZ vs Amniocentesis - Rolls her nipple causes the posterior pituitary gland to release
o UTZ visualization oxytocin.
- Non-invasive - A drug is given = IV fluid
- To measure the amount of amniotic fluid - Occurrences of premature and rupture of membrane are
- To increase the visualization, increase fluid intake. (if happening oxytocin challenge test compared to contraction
less than 20 weeks) stress test using nipple rolling.
- If 20 weeks above, no need fluid intake except if the Biophysical profile
doctor/ nurse suspects lack of amniotic fluid. • Fetal breathing
- Do not void • Fetal movement
- Semi-fowlers position or dorsal recumbent with • Fetal tone
pillow under one buttock. Para ma-displace ung • Reactivity of FHR – kasama ang nonstress test
uterus sa side, so that the uterus will not totally • Amniotic fluid volume BPP
compress the inferior vena cava. Kase kung compress - Score:
yan the women may feel dizziness or hypotension. o 8-10 = normal, low risk for chronic asphyxia
(supine hypotensive syndrome) o 4-6 = suspected chronic asphyxia
o Amniocentesis – aspiration of amniotic fluid. 15-30 ml o 0-2 = strong suspicion of chronic asphyxia
- Invasive procedure
- Informed consent is required
- Ste of puncture = mid lower abdomen – there’s
tendency that the bladder maybe hit
J.A.K.E 10 of 59
Biophysical - UTZ aided

Normal score = 2 Abnormal = 0 - Cord blood is aspirated and tested.
variable
Greater than equal to 1 Danger signs of pregnancy
Fetal Absence of 30 secs or
episode of 30 secs or • Bleeding – danger sign of preg
breathing long of fetal breathing
more of fetal breathing • Sudden escape of fluid from the vagina (can lead to infection)
movements movement in 30mins
movement in 30mins • Edema
3 or more discreet 2 or less discreet • Sudden weight gain
Gross fetal
movement of the body movements of vbody • Rapidly increasing size of abdomen (polyhydramnios, multiple
movements
or any limb in 30 mins or any limb in 30 mins pregnancy, LGA)
• Foul-smelling vaginal discharge
1 or more episode of
Either slow extension • Fever
extensive and flexion
with return to partial • Headache, blurring of vision
of metal limbs or
flexion or movement • Excessive vomiting
Fetal tone trunk. Opening and
of limb in full
closing of hand is
extension or absent REPUBLIC ACT 9262: ANTI-VIOLENCE AGAINST
considered normal
fatal movement WOMEN AND THEIR CHILDREN
tone.
Discussed by Prof. Melanie Cambel
2 or more episode of - Refers to any act or a series of acts committed by an intimate
Less than 2 episodes partner.
accelerations of 15
of acceleration of fetal - Intimate partner – part of household.
Reactive bpm or more lasting
heart rate or - Against a woman who is his wife, former wife.
FHR for 15 secs or longer in
acceleration of less - Against a woman with whom the person has or had sexual or
20mins; associated
than 15 bpm in 20mins dating relationship
with fetal movement
- Against a woman with whom he has a common child
1 pocket or more of Either no pockets or a - Against her child whether legitimate or illegitimate within or
Qualitative
fluid measuring 1 cm pocket of 1 cm or less without the family abode.
amniotic
or more in two in two perpendicular
volume
perpendicular planes planes. Types of Abuse
Physical violence
Amniocentesis - the act that includes bodily or physical harm.
- Aspiration of amniotic fluid. 15-30 ml - Inaattempt na saktan, nilalagay sa isang situation na nababalot
- Invasive procedure ng takot.
- Informed consent is required Sexual violence
- Ste of puncture = mid lower abdomen – there’s tendency that - The act that is sexual in nature, committed against a woman or
the bladder maybe hit her child.
- To avoid hitting the bladder by the needle, void before the - Rape, sexual harassment, acts of lasciviousness, treating a
procedure. woman or her child as a sex object, making demeaning and
- UTZ aided = to locate and prevent puncturing the placenta sexually suggestive remarks, physically attacking the sexual
(upper uterine segment) parts of the victim’s body, forcing her/him to watch obscene
- 3 most important purposes of amniocentesis: chromosomal publications and indecent shows or forcing the woman or her
defect, Neural tube defects, Fetal lung maturity child to do indecent acts and/or make films thereof, forcing the
X-ray: Lateral Pelvimetry wife and mistress/lover to live in the conjugal home or sleep
- Lateral pelvimetry together in the same room with the abuser.
- X-ray pelvimetry is a radiological investigation that involves - Acts causing or attempting to cause the victim to engage in
the measurement of different anthropometric dimensions of any sexual activity by force, threat of force, physical or other
the pelvis. harm or threat of physical or other harm or coercion.
Serial estriol-determination - Prostituting the woman or child.
- Measure fetoplacental wellbeing. Psychological violence
- Specimens: serum or 24hr urine - Acts or omissions causing or likely to cause mental or
- Normal: 12-50 mg/day at term (there is good fetoplacental emotional suffering of the victim.
circulation, the baby receiving adequate amount of o2 and - Such as but not limited to intimidation, harassment, stalking,
nourishment) damage to property, public ridicule, or humiliation, repeated
Chorionic villi sampling verbal abuse and marital infidelity.
- 10-12th week of pregnancy - It includes causing or allowing the victim to witness the
- Purpose: to determine chromosomal defect. physical, sexual, or psychological abuse of a member of the
- Most common: down syndrome family to which the victim belongs, or to witness pornography
- Once the catheter reaches the chorionic plate, mag aaspirate si in any form or to witness abusive injury to pets or to unlawful
doc. So kapag naaspirate na, gagawin na nila ung sampling. or unwanted deprivation of the right to custody and/or
Percutaneous umbilical blood sampling visitation of common children.
- Kumukuha ng blood coming from umbilical cord
- Performed during the 2nd & 3rd trimesters
J.A.K.E 11 of 59
Economic abuse • Anxious if her appointment is running late

- Acts that make or attempt to make a woman financially • Call and cancel appointments frequently
dependent. • Dress inappropriately for warm weather, wearing long-sleeved,
- Withdrawal of financial support or preventing the victim from tight-necked blouses to cover up bruises
engaging in any legitimate profession, occupation, business or
activity, except in cases wherein the other spouse/partner Assessment
objects on valid, serious and moral grounds as defined in • Presence of bruises or lacerations on breasts, abdomen, or
Article 73 of the Family Code. back she cannot explain during physical examination.
- Deprivation or threat of deprivation of financial resources and • Ask woman with bruises to account for them and determine
the right to the use and enjoyment of the conjugal, community whether explanation correlates with the extent and placement
or property owned in common. of bruises or laceration.
- Destroying household property, • Ultrasound may reveal minimal placental infarcts from blunt
- Controlling the victims’ own money or properties or solely abdominal trauma.
controlling the conjugal money or properties. • Record fetal heart tones and fundal height.
Protection Order Nursing interventions

- An order issued under this act for the purpose of preventing • Support any ability the woman had to make constructive
further acts of violence against a woman or her child and decisions
granting other necessary grief. • Discuss how she can call the police any time and take her to
- The relief granted under a protection order serve the purpose shelter
of safeguarding the victim from further harm, minimizing any • Help to file charges or obtain restraining order to keep the
disruption in the victim’s daily life, and facilitating the abusive person from coming near the woman if necessary
opportunity and ability of the victim to independently regain • Be careful not to blame the victim
control over her life.
• Help find a shelter where the woman will feel safe
Barangay Protection Orders (BPO)
• Do not leave an abused woman without support system after
- Refer to the protection order issued by the Punong Barangay
the birth of her child
ordering the perpetrator to desist from committing acts under
Sec. 5 (a) and (b) of this Act.
BLEEDING DISORDERS IN PREGNANCY
- BPOs shall be effective for 15 days. Discussed by Prof. Francis Vasquez
Temporary Protection Orders (TPO) - Bleeding anytime during pregnancy is a danger sign of
- Refers to the protection order issued by the court on the date pregnancy except of bleeding show. (Because bleeding show
of filing of the application after ex parte determination that is a true labor)
such order should be issued. - First trimester bleeding:
- A court may grant in a TPO any, some or all of the reliefs
• Abortion
mentioned in this Act and shall be effective for 30 days.
• Ectopic pregnancy – common site: fallopian tube, pag
Permanent Protection Order (PPO)
pumutok sya, mag dudugo sya internally, pumupunta sa
- Refers to protection order issued by the court after notice and
abdominal cavity then ung amount ng blood na
hearing. The court shall not deny the issuance of protection
pumupunta sa brain ay magiging low na sya kaya ung
order on the basis of the lapse of time between the act of oxygen supply ng brain ay low din (hypoxia) brain cells
violence and the filing of the application. will die – brain damage. (extrauterine)
- Second trimester bleeding:
Intimate Partner Abuse • Hydatidiform more (H-more)/ GTD
- Abuse by a family member against another adult living in the - Molar pregnancy/ gestational trophoblastic disease
household. (GTD)
- Common injuries suffered by abused women: • Incompetent cervical Os
• Burns • Abortion – the termination of pregnancy before the period
• Lacerations of viability. (Viability – can survive outside the uterus. 20
• Bruises weeks-5 months) Pag lagpas 20weeks/ 5mos, wala ng
• Head injuries abortion.
- Abused women may: - Third trimester bleeding:
• Have unintended and unwanted pregnancy • Placenta previa
• Desire pregnancy because she believes having a child will • Abruptio placenta
change the partner’s behavior - Pag snabe sayo ng pasyente “Nurse, buntis po ako, dinudugo
• Be grateful for the pregnancy ako”. Ang una mong tatanungin ay ilan buwan na syang buntis.
Para alam mo kung anong trimester bleeding si mami.
Behaviors of abused women
Abortion
• May come for care late in pregnancy or not at all - Termination of pregnancy before the fetus reaches the period
• Purchase no maternity clothing of viability
• Decline laboratory tests if they involve additional - Generally, before the 20th week of gestation or anytime whent
transportation or money the fetus weighs < 500 grams.
• Difficulty following recommended pregnancy nutrition
J.A.K.E 12 of 59
• Preterm 20 – 36 weeks • Yutopar – progesterone (prevents)

• Full term 37-42 weeks • Bricanyl/ terbutaline – as bronchodilator and smooth
• Post term more than 42 weeks muscle relaxant (anti asthmatic)
• Abortion less than 20 weeks • MgSO4
• The start of viability is 20th week o Threatened abortion
- 2 main types: - Mahinang pagdudugo, maaring walang contraction or
1) Spontaneous – non-intentional / miscarriage mahinang contraction, hindi pa dilated ung cervix kaya
- The termination of a pre-viable conception thru wala pang lumalabas na products of contraction at intact
natural causes and without the aid of mechanical and pa ang bag of water nya at walang lagnat.
medicinal agents. - There’s a chance to save the pregnancy.
2) Induced – intentional - No IE (because frequent IE may increase uterine
- Therapeutic abortion/ legal abortion – to save the life contraction)
of mother during pregnancy. - Bed rest (because activity can increase contraction)
- Non-therapeutic abortion/ criminal abortion – to get - Tocolytic drug
rid of the unwanted pregnancy. - Possible loss of products of pregnancy.
- The baby has down syndrome, is she qualified to undergo - Sight and symptoms:
abortion if during the test her baby has down syndrome • Vaginal spotting
already. – No, bcz her pregnancy is not at risk. • Mild uterine cramping
• Tenderness over uterus
Different types of Spontaneous abortion • Persistent low back ache with feeling of pelvic
Abdominal Cervical Tissue pressure
Types Bleeding Fever
cramps dilation passage
• Cervix is closed or slightly dilated
Close/ • Stimulates mild labor para kang manganganak.
None to None
Threatened Slight not None
mild
dilated
(+) BOW - Management:
• Complete bed rest (CBR)
Inevitable/ Mild to Mild to None • Restriction of activities
Dilated None
imminent moderate strong (-) BOW
• Pad counts – u also need to inspect the pad. Titingnan
Close or natin kung may tissue.
Absent to Absent to All went
Complete slight None
slight slight out • Avoidance of strenuous exercise, fatigue and
dilated
None or Placenta
excitement
Slight • Tocolytic, sedative drugs – pampakalma (lalo na
Incomplete uterus is Dilated or fetus None
moderate
relax remain kung ang cause ng abortion ay emotional and
psychological stress.
None
None • No IE
None None None o Inevitable/ imminent
Missed If more
Some - Lumakas ang bleeding kase lumakas ang contraction at
(IUFD) than 6wks
Slight Open parts of Present
– slight to
POC nagopen ang cervix, nag rupture na ung bag of water.
mild - We cannot save the pregnancy.
It - Nasa loob pa ung products of concentration. Palabas plng
Habitual / depends - Mapupunta yan sa complete or incomplete.
recurrent on the - Pregnancy cannot survive, signalized by the rupture of the
condition
membranes in the presence of cervical dilation.
Moderate
Septic
to heavy
Strong Dilated Ruptured Present - If the admitting diagnosis is incomplete abortion at lahat
o Threatened abortion – the one that differs to the rest because ng abortion, dapat magiging complete abortion na sa final
the only type of spontaneous abortion wherein there’s still diagnosis.
chance to save the pregnancy. (Tocolytic drug) - Signs and symptoms:
o Inevitable, complete, incomplete, missed, habitual, and • More profuse bleeding
septic abortion – there’s no chance to save the pregnancy. • Cervix is dilated
(Oxytocic drug – to remove all products of conception POC) if • Membranes ruptured
some products remain inside the uterus, the uterus will relax • Painful uterine contraction
and it will bleed. And this can lead to infection. - Management:
o 2 groups of drugs: • Analgesics
1) Oxytocic – promoting contraction • Vaginal discharge should be kepts for inspection
• Syntocinon – given IV incorporation • Oxytoxic drugs to promote uterine contraction
• Pitocin – given IV incorporation • Dilation and curettage – after this, Coomb’s test para
• Oxytocin – IM macheck ung rh incompatibility. Within 3 days, kung
• Methergine – IM negative result, bibigyan ng rhogam.
2) Tocolytic – preventing contraction • Emotional support
• Duvadilan – progesterone (prevents) - Imminent abortion – products of conception are passed
• Dactyl OB – progesterone (prevents) within 2 hours.
J.A.K.E 13 of 59
- Signs and symptoms: Etiology

• Copious vaginal bleeding • Defective products of conception (ovum or germ plasm)
• Passage of blood clots • Insufficient progesterone production – pagmababa ung
• Severe cramp like abdominal pain progesterone during pregnancy, humihilab hilab malakas ung
• Uterine contraction uterus.
- Management: • Acute maternal infections
• Immediate hospitalization • Uterine anomalies – cancer, tumor
• Possible blood transfusion • Trauma – nalaglag sa hagdan, nabangga etc.
• Dilation and curettage • Rh incompatibility – may lead to fetal death
• Oxytoxin at 0.5 ml every half hour x6 doses • Endocrine disorders
o Complete abortion • Abnormal implantation
- All products of conception came out already. • Drugs
o Incomplete abortion • Radiation
- If the POC remain inside, the uterus will relax and bleed. • Environmental hazards
- Pag naiwan ung placenta, the doctor can do dilatation and • Incompetent cervix
curettage.
- Part of the conceptus is expelled, but the membranes or Ectopic Pregnancy
placenta is retained in the uterus - An ectopic pregnancy is one in which implantation occurs
- Signs and symptoms: outside the uterine cavity. (extrauterine) The implantation may
• Fetus usually expelled occur on the surface of the ovary or in the cervix.
• Placenta and membranes are retained - For u to be able to find out the possible cause of bleeding of
• Pain may or may not be present the pregnant woman, u need to ask “u are how many months
- Management: pregnant.”
• Immediate hospitalization PID – Pelvic Inflammatory Disease
• Blood transfusion PRN - Salpingitis – inflammation of fallopian tube. Nagkakaroon ng
• Dilatation and curettage infection sa fallopian tube during the healing process,
• Monitoring of BP and PR for shock nagkakaroon ng scar formation sa lumen kaya nagde-decrease
• Anti-hemorrhagic drug ang lumen and the fertilize egg cannot pass through kasi
• Emotional and psychological counseling sumikip.
- Salphingo – fallopian tube; itis – inflammation
- Sperm cells can pass through, pero pag nafertilize na ung egg,
fertilize egg cannot go inside the uterus.
IUD – Intra uterine Device
- Used for contraception may slow the transport of the zygote
and lead to an increased incidence of tubal or ovarian
implantation.
- She is still positive in Pregnancy test
4 types of ectopic pregnancy
o Missed abortion
- IUFD – intrauterine fetal death/ demise – namatay ung
baby inside the uterus.
- 4-6 weeks can a dead baby stay inside the uterus without
causing a bleeding and contraction.
- How will the mother notice that her baby is dead – no
fetal movement
- Pag more than 6 weeks sya – may cramping
- Management: dilatation and curettage.
o Habitual/ recurrent abortion
- 3 > consecutive – sunod sunod na abortion
- Miscarriage – kusang nalalaglag
- Mahina ang kapit ng baby (tocolytic – pampawala ng
hilab)
- Kailangan ng emotional and psychological counseling
o Septic abortion
- After/ Post incomplete abortion/ missed abortion
J.A.K.E 14 of 59
Tubal Pregnancy - If this manages late, the women can still survive but she’s
- Most common in coma.
- Ampulla – common, widest tube (middle – Isthmus, side of - If it is extrauterine, the doctors will be ready to schedule
tubal ligation) the client to undergo surgery.
- Interstitial – narrowest that connected to the uterus Ovarian Pregnancy
(dangerous). Kaya pwede rin mag rupture ung uterus. Malakas - Lumabas ng fimbriae, at ung pinaka malapit ay ovary.
ang bleeding. Magkakaroon ng abdominal pain.
- Vaginal spotting/ bleeding – interstitial - Pag nagrupture ung ovary, magkakaroon ng internal bleeding.
- Abdominal bleeding/ Internal bleeding – ampulla Abdominal pregnancy
- Easier to manage: ampullary - Most dangerous pregnancy (internal bleeding)
- Implanted in ampulla: the embryo will grow; the ampulla will - The fertilize egg implanted in any on the organs found in the
stretch. The woman will feel unusual pain. That’s why, abdominal cavity.
ultrasound is very important for the 1st trimester pregnancy to Cervical pregnancy
confirm intrauterine pregnancy, para malaman kung nasa - Rare pregnancy
inside or outside ng uterus. - Cervical canal – outside uterine cavity
- To expect the rupture of fallopian tube – bago matapos ang 1st - Hindi ni-raraspa kase ung cervix is easily friable – it bleeds
trimester (10th and 12th week of pregnancy) easily.
3 signs of rupture
1) Kehr’s sign • Paano ung ectopic pregnancy na walang scar formation:
- When the fallopian ruptures, the women experience: sharp - Yung estrogen di masyado tumaas. Mahina ang wave like
abdominal stabbing pain in the sight of tubal pregnancy movement ng fallopian tube. Pwedeng d na sya gumalaw
(para syang sinaksak) at nag i-stay na sa ampulla.
- Right lower quadrant • Kapag sumobrang taas ung estrogen mo, kaya ung movement
- Sharp stabbing pain beginning from the site of the ectopic ng fertilize egg ay magiging mabilis at baka magkaroon ng
pregnancy that radiates in the same side shoulder – implantation sa lower uterine segment – placenta previa.
unilateral pain kasi same side shoulder. • What surgical to be done to remove ectopic pregnancy?
- Example: ectopic pregnancy nya nasa right fallopian tube - Exploratory Laparotomy or ExplorLap or E-Lap – the
– sharp stabbing pain will start in the right lower quadrant doctor will explore the severity of the damage. The doctor
radiating on the same side shoulder – right shoulder. will locate the ectopic pregnancy
2) Cullen’s sign - Followed by Ectomy – removal of the fallopian tube
- Purplish or bluish discoloration of the periumbilical area. o (Right fallopian tube) Salpingectomy
- Several mins of kehr’s sign, around the umbilical area, a o (Left ovary) oophorectomy
semi-circular discoloration and that discoloration is - Cervical pregnancy: the doctor will administer a drug to a
colored bluish/ purplish. It means there is internal pregnant woman. An anti-cancer drug, to kill the fertilize
bleeding. egg in the cervical canal – Methotrexate.
3) Sign and symptoms of shock • Example: When the fallopian tubes ruptures, the woman
- The pregnant women will experience sign and symptoms bleeds, the blood accumulates in the abdominal cavity,
of shock. Hypovolemic shock – low amount of blood bcz amniotic fluid will also accumulate in the abdominal cavity,
the blood is escaping from the fallopian tube to the making the abdomen bigger than usual, para syang 4-5months,
abdominal cavity. when u touch the abdomen of the woman, it is firm because of
- S/S of shock: the accumulation of blood and amniotic fluid.
o BP decreases • Ectopic Pregnancy will be detectable but not preventable
o heart rate will increase because there is blood loss,
the heart will pump faster to be able to circulate the Hydatidiform Mole (H-mole)
blood and to give oxygen to the vital parts organs to - Molar Pregnancy or GTD (Gestational Trophoblastic Disease)
the body. - Trophoblast has the abnormality
o Respiratory Rate increases, to get more oxygen - Tagalog: Kiyawa or Kayawa (the woman feels that she is
o Temperature decreases, the pregnant woman has cold pregnant, but it is not, ang laman ay kiyawa)
clammy skin. - Trophoblast – egg and sperm cell met then it fertilizes →
- she needs to keep warm become zygote → zygote will become a partially divided cell
- When the pregnant woman continues to experience shock, – cleavage → 16 overlapping cells is the marulla → it will
continues to bleed – low supply of oxygen to the brain → become blastocyst, marami na syang cells but the cells move
the woman will experience hypoxia → that will affect the along the side and there will be space inside → outside the
level of consciousness → lethargic → obtunded → blastocyst, finger like projections structures appear is the
stuporous → coma. trophoblast → Inside the trophoblast there is chorionic villi is
- If the woman experiencing internal bleeding, blood loss producing human chorionic gonadotropin (HCG) and this is
and massive blood loss will not be operated soon, the the hormone serving as a basis for pregnancy test. Normal
level of consciousness are decreasing, from conscious to amount: 50,000 – 400,000 units
coma. The women can die bcs when the CNS shutdown - the fingerlike projection of trophoblast is the one to attach on
then the heart fails to pump. the endometrium for the implantation.
J.A.K.E 15 of 59
- Once blastocysts enter the trophoblast, implantation occurred What will the doctor do, if the woman develops H-mole?
in upper uterine segment posterior • Evacuate the H-mole
- Once the implantation occurred on the upper uterine segment, • Dilatation and Curettage
the endometrium is now called decidua of pregnancy. • Suction curettage – kailangan masimot kase if the woman gets
- 3 types of decidua: pregnant again, the next pregnancy will not trigger another H-
1) Basalis – under the site of implantation. mole development.
2) Capsularis – covering the ovum. • After evacuating, it is advised that she must avoid pregnancy
3) Parietalis or vera – lining the rest of the uterine cavity. at least 1 year.
- Placenta is developed with union of decidua basalis plus • If she experiences H-mole again. She will develop
chorionic villi. choriocarcinoma – cancer in uterus (Drug: methotrexate)
- The trophoblast contains chorionic villi and becomes part of • If the uterus is growing faster, it could be:
the placenta. And the blastocyst become the baby. - H-mole
- Polyhydramnios
Predisposing factors of H-mole - LGA
1) Poverty - Multiple pregnancy
2) Low socio-economic status – poor - Nursing Intervention: Do leopold’s maneuver to check if
3) Protein Deficiency there is a baby
- When the level of progesterone increases during the
menstrual cycle the high level of progesterone will cause Incompetent cervix / Premature Cervical Dilatation/
increase vascularity on the endometrium. There will be premature dilatation cervical os
increase blood supply then the supply of nourishment will - Pag sinabing incompetent walang kakayahan
be high. Tataas ung water, glucose, oxygen and amino - The cervix cannot remain close during pregnancy
acid supply – protein. - Kegel’s exercise can help your cervix close during pregnancy.
- Protein is the building block of tissues. (e.g. meat and - The cervix is small, but it places an important role in
fish) other sources na nakukuha lang nila is sa munggo or pregnancy – is to remain close while caring the weight of the
egg kase mura. baby and amniotic fluid.
- When implantation happens, since the trophoblast is not - Cause of incompetent Cervix:
getting good amount of amino acids, the blastocyst will • LGA
die. When blastocyst dies it should be detach but the • Multiple pregnancy
trophoblastic cells continue to proliferate, ang • Poly hydramnios
mangyayare mag poproduce ng vesicle. • The muscle is weak
- Vesicles – fluid filled, size of vesicle will increase and if - In 2nd trimester bleeding if there’s incompetent cervix:
this continues to increase the uterus of the woman will • The cervix begins to dilate
grow bigger. That’s why the woman thinks that she’s
• Possibility spotting
pregnant. (Pregnancy test – positive)
• No contraction
- Chronic villi are high
• Painless vaginal bleeding
- If she develops H-mole, the HCG level becomes 1M – 2M
units. Then she will experience exaggerated nausea and • The BOW is protruding
vomiting. • If there is high pressure on BOW lead to rupture of BOW
- Hyperemesis – severe nausea and vomiting and the mother will experience contraction and it will be
4) Abnormal fertilization painful.
• That can lead to abortion if the AGO if less than 5 months,
4 classical signs of H-mole then if at least 5 months premature labor na sya.
1) Uterus > date
- 5 mos pregnant – located at the level of umbilicus Cerclage
- Pero kapag H mole, nasa taas ng umbilicus. - Main management for incompetent cervix
- No positive signs of pregnancy, no fetal movement, no - Suturing technique
fetal outline, no fetal heart rate etc. - Two types of Cerclages:
- There is probable sign. 1) McDonald’s Suture – temporary suture, normal delivery
2) HCG increase 2) Shirodkar Technique – Permanent, CS section, but not
- 1M – 2M units permanently closed because this suture will allow slight
3) (-) Fetal rate opening of the cervix, to allow escape of menstrual
4) Passage of Vesicle discharge and lochia.
- Bcz the vesicles are expected to rupture. - When will the McDonald’s suture removed?
- Rupture between 16th – 20th week • 37th week
- Brownish foul-smelling vaginal discharge - kahit walang signs of true labor tatanggalin pa din
- Confirms the presence of H-mole kasi full term naman na.
• Ultrasound – to know if she is positively pregnant • The woman experiencing s/s time labor
- 32nd week nag true labor tatanggalin pa rin
- Can the woman get pregnant even in Shirodkar Suture?
• Yes, there’s a slight opening in the cervix, pero lagi ng CS.
J.A.K.E 16 of 59
Abruptio-Placenta - Can cord coil to abruptio placenta?

- Common questiona natinatanong kay Mother “how many • Yes, if the cord coil arounds the neck it will become
months pregnant?” (AGO) shorter, especially in double cord coil
- Identify which Trimester: • Trauma (nabangga, nalaglag – it can cause uterine
• Abortion – 1st trimester contraction)
• H-Mole – 2nd trimester • Unwise use of oxytocic (nabigyan sya ng oxytocic drug
• Ectopic pregnancy – 1st trimester masyadong mataas ang dose, the uterus contracted
• Abruptio Placenta – 3rd trimester strongly
• Abruptio – Placenta and Placenta Previa are different. S/s, Possible Cause of Placenta Previa
the causes but management almost the same. • Multiparity – most common factor
• Abruption – Placenta – sudden or early separation of the
placenta from the uterus. The baby is not yet out from the Comparison of Abruptio – Placenta and Placenta Previa
womb of the mother, but the placenta is already separated. Abruptio-Placenta Placenta Previa
Timing of the separation. (premature and abrupt) (kaloob- Firm/ board-like or
looban) Abdomen Soft
Rigid
• Placenta Previa – location of implantation inside the Pain Present Absent
uterus (bukana)
- Normal Delivery: Color of the
Dark Bright Red
• First, the baby goes out Blood
• Second, umbilical cord Type of
• Last placenta goes out last Covert or Overt Overt
Bleeding
• The placenta goes out last so that during delivery it could
still give the baby a O2 Either engaged or not
Engagement Not Engaged
• but in this case the baby is still inside but the placenta is engaged
already separated, and the baby is experiencing fetal o kapag nabasa sa board exam na painless bleeding during
distress or hypoxia the pregnancy it is not a placenta previa, it is a sign of
- Since placenta separated abruptly, what can you say about the incompetence cervix.
uterus? Is the uterus contracting strongly or not contracting o Kase initially in incompetence cervix presents as painless,
strongly? pero pag nag labor sya nauwi sa premature labor
• there is a strong uterine contraction magiging painful na sya.
• In placenta previa the problem is in the location of o In terms of AP nasa kaloob-looban ng matres and
implantation. Sa lower uterine segment sya naka implant. problema
The placenta must implant in the upper uterine segment. o In terms of PP nasa bukana ng matres naman ang
- Since the placenta implanted in the lower uterine segment, can problema
the placenta block the passageway? In AP it will take time to blood to go out?
• Yes, it could be partially block or completely block - Yes, it will take time to go out.
- In Abruptio Placenta, since the placenta separated abruptly, is Types of Bleeding
there a sign of bleeding? 1) Covert – not seen or concealed
• Yes, there will be vaginal bleeding bec. the placenta and 2) Overt – visible bleeding
uterus are partly damaged. - In PP nasa bukana ang placenta kaya overt nakikita agad
• In Placenta Previa since it implanted in the LUS, as the yung bleeding or lumalabas agad ang bleeding
size of the baby is growing and growing and the baby - In AP either covert or overt.
reaches the full-term size, we can no longer prevent the - Why either covert or overt obvious?
baby from compressing the placenta, kaya the mother is • If the center of the placenta separates first, blood can pool
experiencing bleeding under the placenta, and although bleeding is intense, it is
- What type of bleeding will occur in Abruptio Placenta painful hidden from view (concealed bleeding)
or painless bleeding? • It depends on the time of placental separation
• painful kase may contraction - What are the two types of placenta separation?
- How about in Placenta Previa? • Duncan and Shultz
• Not painful kase walang contraction nafe feel naco • Shultz – separated in the center first kaya ang unang
compress lang ng baby yung placenta lalabas is fetal side (nagkaroon ng space sa likod ng
Possible Causes of Abruptio Placenta placenta)
• Pregnancy-Induced Hypertension • Duncan – periphery separated first babaliktad ang
• Short umbilical cord placenta kaya ang unang lalabas is maternal side.
- In Shultz unang humiwalay ang gitna, hindi pa nase separate
- What will happen if the umbilical cord is short? ang periphery, may bleeding or wala?
• Normal Length: 22-24 inches (50-55 centimeters) • Meron, but the blood cannot go out bec. the blood trapped
- If the baby umbilical cord is short, can the baby pull the in the center (concealed bleeding)
placenta? • but in Duncan kapag naunang humiwalay ang periphery
• Yes. may blood agad na lalabas.
J.A.K.E 17 of 59
Summary - No IE (increase bleeding)

• Abruption Placenta - C-section (depends on if it is detected earlier)
- the abdomen is board-like or rigid because of spontaneous - Elective Cesarean Section – not an emergency CS
uterine contraction - No medication needed, just prepare the client for a
- therefore, there is presence painful vaginal bleeding possible CS
- with dark color of blood coming out - Possibility of BT (PNSS 0.9% Sodium Chloride)
- Bleeding can be covert or overt depending on the type of
placental separation either Shultz or Duncan - After CS within 24hrs what woman will undergo?
- engagement of the fetal head either engaged or not • Combs testing – if the result is negative give Rhogam in
engaged during the separation of placenta in the uterus 72 hrs
• Placenta Previa • O2 therapy
- the abdomen is soft • VS monitoring
- therefore, the bleeding is not painful • I and O monitoring
- since the bleeding is just above of the cervix of the Nursing Diagnoses
woman the bleeding is bright red • Acute Pain
- the bleeding is obvious - Painful vaginal bleeding
- and the presenting part is not engaged. - Drug administration: Tocolytic (MgSO4)
- Dovadilan
Placenta Previa • High risk for fluid deficit
- High risk factor is multiparity and the exact cause is still - r/t blood loss
unknown, bakit napupunta sa baba hindi sa taas - monitor the VS
- Four (4) Types - BT
1) Low lying – the placenta did not touch the internal os - provide emotional psychological support
2) Marginal – pag na touch ang gilid ng internal os • Pregnancy-Induced Hypertension
3) Partial – pag natakpan ang kalahati ng internal os - formerly called toxemia pregnancy
4) Total or complete placenta previa – the placenta is - there is a new protein/toxin produced by the mother
touching the internal os Who is the common in PIH?
- To locate the placenta during pregnancy what diagnostic - primigravida young age and multipara with advance
procedure will be done? maternal age
• Ultrasound – can show the placenta where it implanted Risk Factors
• Transvaginal Ultrasound – to determine the extend of • Hypertensive client
obstruction • Obese/DM
- In the two which one is the most problem AP or PP? • Primi or Multi
• Placenta Previa – kase once na lumalaki yung baby and • Low socioeconomic status (w/ protein deficiency)
yung placenta naka implant sa lower quadrant na sisiksik
• Hydramnios
sya ng baby so yung nutrient and oxygen is hindi
Types of PIH
nakakadaloy ng maayos. Nakikita agad ito sa ultrasound
1) Gestational Hypertension
so naagapan din naman (dangerous)
2) Pre-eclampsia
- Which of the two can detected earlier?
3) Eclampsia
• Placenta previa – makikita sa ultrasound kahit second 4) Chronic Hypertensive Client
trimester CODE: PIH
• Management: Monitoring the baby, then if the baby is • P – proteinuria/ albuminuria
viable already the mother will undergo CS it depends on
• I – Idima (tagalog daw spelling sabi Sir V balakayodyan
the type of PP.
HAHAHAHAHAH)
• Abruptio placenta cannot predict it early kase either
• H – hypertension
covert or overt sya. So hindi malaman kung naka separate
Classifications
ba yung placenta or hindi kase walang any sign. It is a
sudden separation.
Management
Abruptio Placenta
- bed rest
- No IE (increase contraction)
- C-section (emergency)
- Tocolytic (MgSO4 – anticonvulsant) to relax the smooth
muscle of the uterus
- Possibility of BT
- O2 therapy
- I and O monitoring
- VS monitoring
Placenta Previa
- bed rest
J.A.K.E 18 of 59
o GHPN, Pre-eclampsia, and Eclampsia blood pressure - The ability of the blood to hold the fluid the water
increases starting 20 wks and above (5 months and above) decreases
o Chronic Hypertension - <20th wk of pregnancy (kase - There will be a fluid shifting to intravascular to interstitial
hypertensive na sya even before ng pregnancy mataas na • Saan una napupunta ang fluid bet. the cells or inside the cells?
BP nya) - Between the cells (Interstitial spaces)
o GHPN s/s is hypertension only - kapag dumami edema na sya
o from Pre-eclampsia to Chronic Hypertension are present • What causes edema?
of edema and proteinuria - proteinuria
Differences in terms of s/s: • What causes proteinuria?
- damage in the glomerulus
• Pre-Eclampsia
- 2 types of PE • What damages the glomerulus?
- Mild Pre-Eclampsia – feet only - Renal hypoxia due to vasoconstriction
- Severe Pre-Eclampsia – feet to facial edema (pwede - The ability of the kidneys who excrete some waste
magkaroon ng lung edema) puffiness of the face. products of the body will also decrease particularly urea,
bilirubin, and nitrogen (BUN)
• Eclampsia
- Laboratory: BUN Crea
- same with SPE but with convulsion (BP is high, O2 in
oxygen is decreases) • What is the normal value of BUN?
- 5 – 20mg/dL
Pathophysiology • Kapag lumampas sya ng 20mg the waste products are not
- if it is the first time of the woman to get pregnant or the excreted?
woman has already advance maternal age there will be - Yes
arteriosclerosis and atherosclerosis, the number one problem - Creatinine Value: 0.6 – 1.1 mg/dL
in PIH is vasoconstriction (Lumiit ang lumen ng blood vessel - same value pa din kahit one kidney lang meron
ni mother) Other Effects:
• Why there is proteinuria and edema?

- because of vasoconstriction
- Hyper reflexia – kunting ingay kunting sound pwede
• What will happen to renal blood supply? magkaroon ng convulsion
- Low - because of cerebral hypoxia it results to severe headache
- Renal hypoxia (bumababa ang O2 sa kidney) - Signs of Impending convulsions
- If there is renal hypoxia it could lead to Glomerular 1) pounding
damage (Increase permeability) 2) Unrelenting (di tinatantanan)
- Permeability substances can easily pass through and that 3) Excruciating
is protein 4) Visual Disturbances (burning of vision)
• Where the protein goes? • What is the earliest sign of impending convulsion?
- in the urine - Epigastric Pain
- Protein attracts water
J.A.K.E 19 of 59
• Uteroplacental Insufficiency – the amount of O2 that given by - sa loob ng isang buwan dapat ang timbang nya ay 4lb.
the placenta is low - 4lb/2.2 = 1.8 kg
- lead to SGA/ IUGR (Intra Uterine Growth Restriction) - 1.8 kg convert to grams
- Fetal Distress - 1.8 kg x 1000 g = 1800 grams/wk divided by 7 days
- Increase Abruptio Placenta - 250 g lang dapat ang itataas ng timbang nya araw araw
• Why there is Abruptio Placenta? • How about the baby what will you monitor?
- because it makes the uterus irritable - fetal HR
Nursing Management - kick count (minimum: 5 ave:10 max: 10)
Medications: - <5 hypoactive
1) Ani-hypertensive drug - 15> hyperactive
- Aprisoline/Hydralazine (with vasodilating effect) • Kapag may fetal distress ang baby kumusta ang kick out nya?
2) Anticonvulsant drug - hyperactive
- particularly MgSO4 - Early sign – tachycardia
• What’s the main action of MgSO4? • What can you say about salt in the diet? (w/ edema and HPN)
- it decreases neuromuscular irritability at the same time - low sodium diet
CNS depressant - cause of edema is loss of protein
• Since MgSO4 is Neuromuscular irritability and CNS • An eclamptic convulsion pt is confined in the hospital, where
depressant, where you can find medulla oblongata? are you going to confine the pt, near the nursing station or
- Under central nervous system away from the nurse’s station?
- babagal ang paghinga ng patient - near the nursing station
- pag na sobrahan ng MgSO4 it will cause slow respiratory - single room kung may ka share man dapat yung hindi
rate (hyporeflexia) maingay na pt din
- Intervention: watch out for toxicity or hypermagnesem - Side rails up to prevent accident with padded rails
- Average dose: 4-6g Maximum: 10grams • Nagco complain ng Epigastric Pain – (malapit na mag
• How do we administer MgSO4? convulsion). Ano ang gagawin mo?
- Intramuscular Injection – z-track technique (the drugs a) put padded tongue depressor
irritate the subcutaneous tissue) b) put a spoon inside the mouth
- the injection site is Upper Outer Quadrant in gluteal site c) turn the pt into left side position
- Hal. ang pinapa carry out ng doctor sayo is 6 g. 1 gram is d) call the doctor
equal to 1cc = 6mL. You can’t give 6mL in one buttock - Ans. C, itagilid na kase malapit na sya mag convulsion
divide it into 2 (3 g in R buttock, 3 g in L buttock) para hindi sya mag aspirate.
- Intravenous • During convulsion are you allowed to restrain the pt?
• Before giving the medication watch out: - no, prone to injury
1) Hyporeflexia (reflex hammer) – deep tendon reflex (knee • After the convulsion the pt is confused. Ano ang gagawin mo
jerk) kung wala may toxicity na. kay pt?
2) Respiratory Rate – less than 12 per min. - orient the pt about what happened
3) Urine output – 30 mL/hr - the pt can undergo cs also
4) Blood Pressure
- but the first 3 are important/priority (Hyporeflexia, SECOND TRIMESTER BLEEDING
Bradypnea, Oliguria) Discussed by Prof. Carmencita Pacis
• Why are we checking urine output? Cause of second trimester miscarriage:
- baka may damage ang kidney kase ang hypertension can • Chromosomal abnormalities – defect on mitosis and meiosis.
damage the kidney • Placental problems – position of placenta is abnormal.
• How the mother receiving MgSO4 excrete the waste products • Thrombophilia – problem in the blood
of magsulfate? • Congenital birth defects
- by urination • Infection
Relate: • Poorly controlled chronic condition
P – protein, primigravida • Cervical insufficiency
I – idima • Abdominal trauma
H- Hypertension, hydralazine • Drug and alcohol use.
• What can you say protein in the diet?
- protein is high in the diet Incompetent Cervix
- promote safety during L&D - Condition characterized by a mechanical defect in the cervix
• How can you ensure or somehow minimize the effect of the causing cervical effacement and dilatation and expulsion of
PIH? the POC.
- monitor vital sign (daily) - Difference of Miscarriage and Abortion
- monitor weight – checking edema and looking SWG • Miscarriage – hindi mo inaasahan, sudden expulsion of
- Hal. 4th month, 1lb/wk, divide it into days para makuha fetus without warning.
ang timbang. • Abortion – spontaneous hindi mo din expected pero
- lb – 2.2 merong tineterminate
J.A.K.E 20 of 59
- Incompetent Cervix – hindi pa umaabot ng 9 months nag da-

dilate na and nag e-efface na yung cervix hindi successful ung
pagdadala ng fetus
- parang pintuan kapag ready na magbubukas sya
- known as cervical insufficiency
- weak tissue
- Walang naramdaman tapos bigla nalang na kunan
- Usually are asymptomatic
Risk Factors
• Congenital Incompetence
- Diethylstilbestrol (Des) Exposure In-Utero
o binibigay ito sa mahina yung kapit ng bata,
pinapainom ito to prevent miscarriage pero yung
baby yung maaapektuhan) 1940-1971
o Kapag babae tawag sakanya is DES daughter mataas
ang chance na magkaroon ng cancer sa reproductive
system a) Shirodkar procedure – permanent suturing of the
o Pero pag sa lalaki DES son sya, and yung effect nya cervix; subsequent deliveries by CS
mataas yung chance na magkaroon ng prostate cancer b) McDonald procedure – temporary, purse string
o madedevelop yung mga side effects kapag lumaki na suturing of the cervix; suture removed at term in
sila preparation for a vaginal delivery.
o the most affective is yung babae
- Women with a Bicornuate Uterus
o Bicornuate uterus – uterine malformation meaning
dahil sa impairment of mullerian duct nagkakaroon
ng division on the uterus
• Acquired Incompetence
- Inflammation
o That could lead to infection
o Inflammation disease one of the factors of Bicornuate
uterus
- Infection
- Subclinical Uterine Activity
o Decrease supply of the oxygen in the uterus
- Cervical Trauma
- Increased uterine volume
o Uterine fibroid mataas ang chance na magkaroon ng
incompetence cervix Nursing Management
Assessment Findings • Provide psychological support to client who may have
• painless contractions resulting in delivery of a dead or non- negative feelings
viable fetus (akala ni mo. na c cr lang sya pero pag cr nya pati • Provide post-cerclage procedure care
yung fetus lumabas)
• Advise limitation of physical activities within 2 weeks after
• pag IE naka open na yung cervical os treatment
• History abortion • Maternal and fetal growth monitoring
• Relaxed cervical os on pelvic examination • Instruct to report promptly signs of labor
Treatment • Assessment for signs of labor, infection, or premature rupture
• Conservative Management of membranes
- bed rest – avoidance of heavy lifting and no coitus • In labor, prepare stitch removal Set in addition to delivery set
• For women with previous losses (post- Mcdonald surgery)
- elective cervical cerclage procedure – late first trimester
or early second trimester Hydatidiform Mole (H-mole)
- cerclage procedure during the 14th to 16th week of - Abnormal proliferation and then degeneration of the
gestation or prior to next pregnancy trophoblastic villi.
- suture or ribbon is placed beneath cervical mucosa to - As the cells degenerate, they become filled with fluid and
close cervix appear as clear fluid-filled, grape-sized vesicles.
- Cause: unknown
- Abnormal fertilization oocyte or egg results to abnormal fetus
- the placenta forms but there is no baby
- cause is abnormal fertilize egg
- gestational trophoblastic disease
J.A.K.E 21 of 59
- Risk Factors: Treatment

• low protein intake • Evacuation by Suction D & C or hysterectomy if no
• women older than 35 years old (yung placenta hindi na spontaneous evacuation
maganda ang placenta) • Hysterectomy if above 45 years old and no future pregnancy is
• Asian women – because of genetic formation or un mga desired or with increased chorionic gonadotropin levels after
kinakain daw nila D&C
• Women with a blood group of A who marry men with - HCG titer monitoring for one year (every 2 weeks HCG
blood group O – para maprevent ito, kailangan mo testing)
kumain ng high in protein. - Medical replacement: blood, fluid, plasma
- Chemotherapy for malignancy: Methotrexate is drug of
choice
- Chest X-ray
• Complications
- Choriocarcinoma - ma
- Hemorrhage
- Uterine perforation – because of D&C. mas nagiging
manipis ung lining ng uterus
- Infection
Nursing Management
• Advise bed rest
Pathophysiology • Monitor VS, blood loss, molar/ tissue passage, I & O
• Fertilization occurs as the sperm enters the ovum. In instances • Maintain fluid and electrolyte balance, plasma, and blood
of a partial mole, two sperms might fertilize a single ovum. volume through replacements as ordered
• Reduction division or meiosis was not able to occur in a partial • Prepare for suction D & C, hysterotomy or hysterectomy as
mole. In a complete mole, the chromosome undergoes indicated
duplication. • Provide psychological support
• The embryo fails to develop completely. There are 69 • Prepare for discharge
chromosomes that develop for the partial mole, and 46 - Emphasize need for follow-up HCG titer determination
chromosomes for the complete mole. for 1 year
• The trophoblastic villi start to proliferate rapidly and become - Reinforce instructions on NO PREGNANCY FOR ONE
fluid-filled grapelike vesicles. (bcz of this excess YEAR; give instructions related to contraception’s
chromosomes, dumami ung trophoblastic villi)
THIRD TRIMESTER BLEEDING:
Assessment Findings
ABRUPTIO PLACENTA, PRETERM LABOR, AND PROM
• Brownish (coffee ground) or reddish, intermittent, or profuse Discussed by Prof. Melanie Cambel
vaginal bleeding by 12 weeks Abruptio Placenta
• Expulsion, spontaneous, of molar cyst usually occurs between - Premature se parathion of the implanted placenta before the
the 16th to 18th weeks of pregnancy birth of the fetus.
• Rapid uterine enlargement inconsistent with the age of - Hindi pa nag uundergo ng 2nd stage of labor or hindi pa nag 1st
gestation stage pero na detach na ung placenta.
• Symptoms of PIH before 20 weeks - Pwede syang complete or incomplete depende sa detachment.
• Excessive nausea and vomiting because of excessive HCG (1 - Placenta is the one supplying the oxygen na nanggagaling kay
to 2 million IU/L/24 hours or 100,000 mlU/ml) – mataas ung nanay papunta kay baby.
HCG kase andami mong trophoblastic villi Predisposing factors
• Positive pregnancy test • Maternal hypertension: PIH, renal disease (kapag hypertensive
• No fetal signs – heart tones, parts, movements ang pasyente, nagkakaroon ng vasoconstriction ng kanilang
• Abdominal pain blood vessels, at pag nagyari yon, nagiging poor circulation)
Diagnosis • Sudden uterine decompression (multiple pregnancy
• Passage of vesicles – 1st sign that aids to diagnosis polyhydramnios – excessive amniotic fluid)
• TRIAD signs: • Advance maternal age – more than 35 yrs. Old. Habang
- Big uterus tumatanda un isang babae, ung kanyang mga diff parts of body
- Vaginal bleeding – may kasamang vesicles are also kind of deteriorating
- HCG greater than 1 million • Multiparity
• Ultrasound • Short umbilical cord
• Flat plate of the abdomen done after 15 weeks • Trauma; fibrin defects – may problema sa blood clotting
• Prognosis Types of Abruptio Placenta
- 80% remission after D & C; may progress to cancer of the • Concealed, Convert, or Central type
chorion: Choriocarcinoma - The most classic type of abruptio placenta wherein the
placenta separates at the center causing blood to
accumulate behind the placenta.
J.A.K.E 22 of 59
- Kung saan nadedetach, un pinaka center kpag nadetach Nursing management

magkakaroon ng space. At dahil may space, mapupuno • Maintain bed rest, LLR – left lateral recumbent position
sya ng dugo. • Careful monitoring: maternal VS, FHT, Labor onsent/
- Signs of shock: tachycardia, pale, decrease BP kasi un progress, I&O, oliguria/ anuria, uterine plain, bleeding
bleeding nya naiipon sa loob. - Oliguria = less than 60 cc per hour
• Marginal, Overt, or External bleeding type - Anuria = less than 30 cc per hour
- Detaches from margins. • Administer IV fluids, plasma, or blood as ordered
Types of seperation • Prepare for diagnostic examinations (ultrasound)
1) Moderate/ High separation • Provide psychological support
- Upper uterine segment. • Prepare for emergency birth
- Internal bleeding • Observe for associated problems after delivery:
- Nadedeprived ung oxygen supplies ng baby. - Poorly contracting uterus
2) Marginal/ Low separation - Disseminated intravascular coagulation
- Ung part ng placenta na malapit sa may opening ng cervix, - Hypofibrinogenemia
doon nag start mag separation of the placenta at may - Premature, neonatal distress
bleeding to.
3) Severe/ Complete separation Preterm Labor
- When the fetus head is already present in the cervical - Labor that occurs after the 20th week and before 37th week of
opening. gestation.
- Nadedeprived ung oxygen supplies ng baby. - Etiology:
• In > 30% cases exact cause of preterm labor is now
known
• Occurs approximately 9-11% of all pregnancies
• Any woman having persistent uterine contractions (4
every 20 mins)
Risk factors
• Maternal factors
Assessment findings - Maternal infection, illness of disease, DM, UTI, STD
• Painful, vaginal bleeding - Premature rupture of membranes (PROM)
• Rigid, board-like, and painful abdomen without the bleeding. - Bleeding
(Type I, kasi naiipon ung dugo sa blood kaya tumitigas.) - Uterine abnormalities, over distention, incompetent cervix
• Enlarged uterus due to concealed bleeding. - Previous preterm labor, spontaneous or induced abortion,
• If the labor: tetanic contractions with the absence of preeclampsia, short interval (less than 1 year) between
alternating contraction and relaxation of the uterus. (kapag pregnancies
nadetach ung placenta from the uterus, automatic na mag - Trauma, poor nutrition, no prenatal care, lack of childbirth
cocontract ung uterus bcz it trying to stop the bleeding) experience
Diagnosis - Extremes of age decreased weight (<100 lbs) and less
• Clinical diagnosis (signs and symptoms) height (< 5 ft) lack of rest. Excessive fatigue
- Smoking
• Ultrasound – detects the retroplacental bleeding.
- Extreme emotional stress
• Clotting studies – reveal DIC, clotting defects
• Fetal factors
- Thromboplastic from retroplacental clot enters maternal
- Multiple pregnancy
circulation and consumers maternal free fibrinogen
- Infections
resulting in:
- Polyhydramnios
o Disseminated intravascular coagulation (DIC): small
- Congenital adrenal hyperplasia
fibrin clots in circulation
- Fetal malformations
o Hypofibrinogenemia: decrease normal fibrinogen
results in absence of normal blood coagulation. (hindi • Placental factors
titigil ung paglabas dugo) - Placental separation
Complications - Placental disorders
• Hemorrhagic shock • Unknown factors
Complications
• Couvelaire uterus – matigas parang bato
• Prematurity
• Disseminated intravascular coagulation (DIC)
• Fetal death
• Cerebrovascular accident (CVA) from DIC
• SGA/ IUGR – due to prematurity or uterine growth retardation
• Hypofibrinogenemia
– may nangyari inside the womb of the mother.
• Renal failure (bcz of poor blood circulation)
• Increase perinatal morbidity and mortality
• Infection
Treatment (Hospitalization)
• Prematurity, fetal distress/ demise (IUFD)
• Bed rest on LLR without bathroom privileges
• Adequate hydration
• Monitoring:
J.A.K.E 23 of 59
- Uterine contractions and irritability (every 1-2 hours) - Kapag nadry na, ilalahgay na sa microscope.
- VS Nagkakaroon ng crystallization of the amniotic fluid kase
- I and O mataas ung sodum.
- Signs of infection - Positive for amniotic fluid ↓
- Cardiac and respiratory status and distress signs
- Cervical consistency, dilatation, and effacement
- Fetal well being
- Early signs of edema
• Promotion of physical and emotional comfort (bawal ang
problema, dapat happy tots lng. Sanaol gusto ko rin ng happy tots lng
sa pagaaral HAHAH jk)
• Administration of tocolytics (magnesium sulfate, terbutaline,
ritodrine) we don’t give tocolytics if… • Sterile speculum
- Advanced pregnancy - Direct visualization of fluid from cervical os is the most
- Ruptured bag of waters reliable diagnosis.
- Maternal distress (bleeding complications, PIH, - Ipapasok ung vaginal speculum
cardiovascular disease) Complications
- Fetal distress • Maternal infection/ chorioamnionitis
- Presence of fetal problems (Rh Isoimmunization) – ung - para malaman natin to, ichecheck natin ung temp. pag
unang pregnancy nya, may Rh incompatibility na may infection 38 and above
nangyari. (diniscuss na ni Sir V to sa lecture nya) - Nag tatachycardia, uterine tenderness, foul smelling
• Administration of corticosteroids vaginal discaharge, tumataas ung WBC counts up util to
- Betamethasone (12mg IM every 24 hours x 2 doses) 15,000
- Dexamethasone (6mg IM every 12 hours x 4 doses) - CRP – C-reactive protein – kung mataas ung
- Assess effects of drugs on labor and fetus inflammation in the body. More than 2.5 mg = may
- Monitor for side effects infection.
Discharge (premature labor stopped) • Cord prolapses
• Maintain bed rest, LLR preferred - Naexpose sa air, kaya pwede mainfection at madadry ung
• Well-balanced diet (high in iron, vitamins, and important cord kaya pwedeng macut off din ung oxygen supply.
minerals) • Premature labor
• Continuation of oral medications Management of PROM
• Frequent prenatal visit every week • Initial assessment
• Activity/ lifestyle evaluated and restricted as necessary - Confirm the diagnosis of PROM
• Illnesses: chronic – monitored; acute treated stats - To determine the gestation of the fetus
• Provide client teaching - To identify the women who need to deliver.
- Symptoms of preterm labor • If pregnancy is >37 weeks and with presence of:
- Prompt reporting physician - Congenital anomalies
- Fetal distress, cord prolapse
Premature Rupture of Membranes (PROM) - Signs of chorioamnionitis
- Spontaneous rupture of fetal membrane any time after the • Then delivery…
period of viability but before the onset of labor. - Induction of labor – if no contraindication. (Giving
- Cause: unknown oxytocin if no contraindication)
- Associated with infection of membranes (Chorioamnionitis) • Balance between risk of infection in expectant management
- Occurs in 5-10% of pregnancies and premature labor
- If rupture occurs early in the pregnancy, it may cause major • Shift the patient where the facility for neonatal care is
threats with regards to the fetus. Pwede mag cause ng infection available
sa loob. • If pregnancy is > 34 and < 37 weeks
- Assessment of findings: - CBC, cervical swab c/s
• Maternal report of passage of fluid per vagina. - Antibiotics
(subjective) - Careful watch on sigh of chorioamnionitis
• Determination of alkaline amniotic fluid and not acidic - Maternal and fetal conditions
urine or vaginal discharge. - If no spontaneous labor in 24-48hrs – induction of labor
Diagnostic test • If pregnancy < 34 weeks
• Nitrazine test - Expectant management – the aim is to prolong the
- Change in color of Nitrazine paper from yellow (acidic pregnancy for fetal maturity
vaginal pH = 4-6) to blue color because of neutral to - Bed rest
slightly alkaline amniotic fluid (pH = 7-7.5) - CBC and cervical swab c/s
• Ferning test - Give corticosteroid and tocolytics
- Amniotic fluid, high in sodium content, will assume a - Antibiotics
ferning pattern when dried on the slide. - Watch for signs of chorioamnionitis, maternal and fetal
condition.
J.A.K.E 24 of 59
GESTATIONAL CONDITIONS - Predisposing Factors:

Discussed by Prof. Carmencita Pacis, Prof. Francis Vasques and • Multiple pregnancy
Prof. Melanie Cambel • Primipara (<20 years or >40 years)
Gestational Conditions • Low socioeconomic backgrounds
• Hyperemesis gravidarum • Multigravida women (>5 pregnancies)
• Pregnancy-induced hypertension • Polyhydramnios
• Gravido Cardiac • Co-existing medical conditions: heart disease, DM with
• Gestational diabetes mellitus renal involvement, and essential hypertension)
• Rh Incompatibility (Isoimmunization)
• Anemia of Pregnancy
Hyperemesis Gravidarum
- pernicious or persistent vomiting
- nausea and vomiting of pregnancy that is prolonged past week
12 of pregnancy
- dehydration, ketonuria, and significant weight loss
- cause is unknown
- Vomiting – from week 9 to week 12
- In hyperemesis gravidarum it exceeded in 12 weeks
Risk Factors:
• High levels of beta HCG (the higher your HCG, the higher of
vomiting)
• High placenta weight (it means related to more HCG, higher
vomiting)
• Psychological and family aspects (due to stress on the increase
Classification
of nausea and vomiting)
Assessment • Gestational hypertension
- an elevated blood pressure (140/90 mm Hg) but has no
• severe nausea and vomiting (more than 4x of vomiting)
proteinuria or edema
• low food intake
- Mild- SBP 140-159 DBP 90-109
• polyneuritis (some)
- Severe- SBP ≥ 160 DBP ≥ 110
• Weight loss
• Management (Mild)
• Lab results: high hematocrit concentration (Normal: Female: - Educate patient about s/s of preeclampsia and when to call
36% - 48% Male: 39% - 54%) decrease sodium, potassium, the HCP
and chloride
- Patient assess daily for signs of preeclampsia and decrease
• urine ketones (+) fetal movement
Nursing Management - B/P evaluated twice at week, one being done by provider
• monitor I and O along with assessing for proteinuria, liver enzymes and
• oral food and fluids are withheld platelets
• Intravenous fluids (3L lactated Ringer Solution with added Vit. • Management (Severe)
B) - Admit to hospital for stabilization
• Antiemetics (Metoclopramide) - Lower B/P to < 160/110: IV Hydralazine or labetalol
• After 24 hrs of no vomiting: (Diet schedule) - Monitor B/P and s/s of preeclampsia
- Small amounts of clear fluids - Administer oral antihypertensive to control B/P
- Small quantities of dry toast, crackers, or cereal every 2 or - Delivery based on fetal status and gestational age
3 hrs Mild Preeclampsia
- Soft diet - has proteinuria (1+ or 2+)
- Normal Diet - elevated blood pressure (140/90 mm Hg), taken on two
• If vomiting returns: occasions at least 6 hours apart
- Enteral or total parenteral nutrition (IV na yung gagamitin, - Edema (upper body)
dadalhin sa ICU) - Management (Mild Preeclampsia):
• Monitor Anti-platelet Therapy
Pregnancy-Induced Hypertension • Low-dose Aspirin (50-150mg) Promote bed rest
- A condition in which vasospasm occurs during pregnancy in
• Advise to rest on lying left side to take the weight of the
both small and large arteries
baby off the major blood vessels.
- Characterized by:
• Promote good nutrition
• Hypertension
• Diet should be high in protein & carbohydrates with
• Edema
moderate sodium restrictions
• Proteinuria
• Drink at least 8 glasses of water a day
- Appears after 20th – 24th week of pregnancy and disappears 6
• Provide emotional support
weeks after delivery
J.A.K.E 25 of 59
Severe Preeclampsia • Postictal stage:

- Elevated BP (>160/110 mm Hg) on at least two occasions 6 o Close observation for signs of separation of placenta
hours apart at bed rest or signs of uterine contractions
- Marked proteinuria, 3+ or 4+ or more than 5 g in a 24-hour o Keep the patient on her side and give nothing to eat
sample, or drink
- Extensive edema (tibia on anterior leg, ulnar surface of the o Limit conversation as the patient may hear even
forearm, and cheek bones) though she does not respond
- Management (Severe Preeclampsia): o Continuously assess FH sounds and uterine
• Needs hospital care, support bed rest contractions
• Rest in left lateral position to promote feto-placental o Continue to check for vaginal bleeding every 15
perfusion minutes
• Room should be dim, quiet, away from areas of activity • If pregnancy is >24 weeks:
• Restrict visitors to allow the patient to rest o Termination of pregnancy by vaginal birth (usually
• Leave BP cuff in place so as not to disturb the patient after 12 to 24 hours after seizure)
o Amniotomy or induction of labor with Oxytocin
Monitor Maternal well-being Postpartum Hypertension
• Monitor vital signs and fetal heart tone continuously - May occur 10-14 days after birth
• Inform on the warning signs - Monitor BP and be alert for eclampsia within 2-3 weeks
• Indwelling catheter to monitor urinary output accurately - Urge to return for a follow-up checkup
• Weigh daily
• Laboratory tests (CBC with PC, liver function test, BUN, HELLP Syndrome
creatinine, hematocrit levels) - A serious complication of severe PIH w/c occurs in about 10%
Monitor fetal well-being of women w/ ↑ BP. It usually develops before delivery but
• Fetal movement counting may also occur postpartum
• Non-Stress test/biophysical profile to assess uteroplacental - Hepatic Dysfunction
perfusion - characterized by:
• Doppler flow studies • Hemolysis - RBC breakdown
• O2 administration to the mother to maintain adequate fetal • Elevated liver enzymes - damage to liver cells causing
oxygenation & prevent bradycardia changes in liver function laboratory test
• Support Nutritious diet • Low platelets - cells found in the blood which act as
• Moderate to high protein, ↓ sodium clotting factor
• Start IV therapy - Increase risk for:
Administer Medications to prevent Eclampsia • Placental abruption
• Hydralazine - given IV when diastolic pressure reaches 110 • Acute renal failure
mm/Hg but should not be lower than 80-90 mm/Hg or • Subcapsular hepatic hematoma
inadequate placental perfusion may occur • Hepatic rupture
• Magnesium Sulfate - drug of choice to prevent Eclampsia • Fetal and maternal death
• Act as CNS depressant - lessens the possibility of seizures by • DIC
blocking the peripheral neuromuscular transmission (Loading Management
dose 4-6 g, given slow over 15-30 minutes and maintenance • Bed rest
dose 1-2 g/hr given thru a piggyback method or deep IM using • Transfusion of Fresh Frozen plasma or platelets to reverse
buttocks) thrombocytopenia (count below 100,000)
• MgSo4 and antihypertensive medications
Classification of PIH • Laboratory testing of liver, urine and blood
Eclampsia • Betamethasone, a corticosteroid may be administered to help
- Seizure or coma accompanied by signs and symptoms of mature the fetal lungs
preeclampsia • Deliver immediately, if HELLP syndrome worsens and
• headache epigastric pain endangers the wellbeing of the mother and fetus
• visual changes
• CNS irritability Cardiovascular Disease and Pregnancy (Gravido Cardia)
- Management of Eclampsia: - 5% maternal deaths during pregnancy
• During seizure: - Cardiovascular diseases that cause difficulty during
o Maintain patent airway pregnancy:
o Administer Oxygen via face mask • Valve damage (Rheumatic fever or Kawasaki disease)
o Turn the patient on her side • Congenital anomalies (Atrial septal defect or uncorrected
o Administer MgSO4 or Diazepam (Valium) coarctation of the Aorta)
o Assess O2 saturation • Coronary artery disease
o Apply external fetal heart monitor and monitor FH • Varicosities for primigravida
sounds and uterine contractions • Peripartum heart disease
o Check for vaginal bleeding - Gavido – Pregnant
J.A.K.E 26 of 59
- Cardia – heart disease • Monitoring of fetal wellbeing: FHR and kick count
- Predisposing factor: Rheumatic heart disease – generic name (Minimum: 5 Ave: 10 Maximum: 15
for a permanent cardiac damage. • UTZ (ultrasound) IUGR -intrauterine growth restriction =
- Mitral valve stenosis – most common heart disease that caused SGA baby
RHD • I and O (intake and output)
- Rheumatic fever – caused by MVS • O2 therapy
- Respiratory tract infection – caused by Rheumatic fever • Screen the visitors (the woman is immunocomprimised –
- Rheumatic Fever – caused by GABHS (Group A Beta- mabilis mahawaan)
Hemolytic Streptococcus) • Freq. hand washing
- GABHS can cause respiratory tract infection that can lead to Medication
rheumatic fever that can lead to MVS and that is the form of
• Digitalis therapy form of Digoxin
RHD that leads to gravido cardia.
• Digoxin – it increases the strength of heart contraction but
- Ex. si nene 9 y/r old frequently sore throat. (Tonsilitis)
decreases the rate of heart contraction. (Pinalalakas pero
• Para hindi mapunta sa MVS, the child has to undergo
pinabagal)
Tonsillectomy – removal of tonsils
• Congested Heart Failure – decrease cardiac output
- Papaano mauuwi sa Cardiac Damage?
• If you give Digitalis Digoxin what is the side effect?
• When the blood goes back to the heart via left atrium and
- bradycardia
left ventricle, the blood does not only bring in the oxygen
• Before giving digitalis drug what are you going to check?
but also bring in the GABHS.
- Hear rate in 1 full minute
• When the m.o. enters the heart, some of the m.o. will
adhere on the walls of the heart – magkakaroon ng carditis. • RULE: Don’t give Digitalis or Digoxin if HR is <60 per min.
Some m.o will adhere on the mitral valve release toxin especially in adult. It could lead hypoxia kapag binigyan mo
and it will irritate and inflamed. (mamamaga) pa.
• lalagnatin at mahihirapang huminga • Other Management:
- Diuretic Drug (edema) – Increase urine excretion to
• Mitral valves prolapse
remove excess fluid)
- Medication: Penicillin to prevent rheumatic fever
- Lasix/Furosemide
• If penicillin given late, penicillin can still eliminate the
- I and O monitoring
m.o. but during the healing process, it will leave a scar
formation in Mitral Valve and cause hardening the mitral
Pregnancy and the Circulatory System
valve.
- Blood volume and cardiac output increases approximately
• Mitral valve prevents the back flow of blood
30%
• Mitral valves stenosis – that is already a form of - Half of increase happens by 8 weeks and maximized by mid
permanent RHD. pregnancy
• When the mitral valve will not fully close the pass- - Normal cardiac changes:
through of blood will continue. • Functional (innocent) or transient murmurs
- During pregnancy, the blood volume will increase. 30-50 %
• Heart palpitations
- Since the mv is not fully close, the blood is pulling back to the
- Pathologic changes occurs due to increase in circulatory
Left upper ventricle to the lungs
volume (peak: 28-32 weeks)
- To accommodate the blood in the left ventricle, the
compensatory mechanism of the left ventricle = distended Classification of Heart Disease
- Since dumami ang blood, there is a need of LV to pump Class I (uncompromised)
strongly, and it will cause left ventricle hypertrophy. - Ordinary physical activity causes no discomfort
- If the LV weakened, the blood goes back to the Left Atrium - No symptoms of cardiac insufficiency and no anginal pain
(magkakaroon ng backflow kase open ung MV) and if the left Class II (slightly compromised)
atrium can no longer accommodate the blood, the blood goes - Ordinary physical activity causes excessive fatigue,
back to the lungs causing pulmonary edema. palpitation, and dyspnea or anginal pain
• Congested Heart Failure – a serious condition where is the - Minimal limitation of physical activities
heart doesn’t pump blood efficiently. Class III (Markedly compromised)
- If the pregnant woman has Congested Heart Failure, left - During less than ordinary activity, woman experiences
ventricle is the location of the abnormality and the woman can excessive fatigue, palpitations, dyspnea, or anginal pain
die because of very irregular heartbeats. - Complete bed rest
- If there is gravido cardia, there is increase workload of the Class IV (Severely compromised)
heart and that required more oxygen. - Severe limitation of physical activity- cardiac failure even
- If the client is a gravido cardia patient, activity intolerance is at rest
the most nursing diagnosis use. (madali syang mapagod) - Advised to avoid pregnancy
Nursing Management
• Look for difficulty therapy
• Complete bed rest
• Monitoring of vital signs
• Weight monitoring
J.A.K.E 27 of 59
Limitations in • If pregnant, hospitalization during the last part of

Damage Method of
Classes S/S Physical pregnancy
in MV Delivered
Activities
May Peripartum Heart Disease
proceed
Very - Peripartal Cardiomyopathy (rare)
I Asymptomatic No limitations with her
Minimal • Cause is unknown
pregnancy,
NSVD • 50% mortality rate
Slight - Signs and symptoms:
Normal
Limitations • Shortness of breath
II Symptomatic Mild Delivery to
(Heavy work • Chest pain
Forcep
only)
• Edema
Markedly
Frocep to • Cardiomegaly
Limitations
III Symptomatic Moderate Therapeutic - Management:
(Heavy and
Abortion • Reduce physical activity
Light works)
Forcep to • Diuretics and Digitalis therapy, Low molecular weight
IV Symptomatic Severe Total/Complete Heparin, immunosuppressive therapy
TA
- The woman is 7 months pregnant and diagnoses gravido cardia • Oral contraceptives are contraindicated
what will be the limitation in physical activities? Assessment of a Woman with Cardiac Disease:
• complete bed rest w/out bathroom privileges • Health Status:
- Pre-pregnancy cardiac status
Left-sided Heart Failure - Level of exercise/ activity performance
- Occurs in mitral stenosis, mitral insufficiency, and aortic - What level she can do before getting short of breath and
coarctation physical symptoms she experiences
- Signs and symptoms: • Presence of coughing (sign of pulmonary edema)
• ↓ systemic BP • Edema
• Productive cough with blood-streaked sputum • Irregular pulse
• Tachypnea • Rapid or difficult respirations
• Dyspnea on exertion, progressing to dyspnea at rest • Chest pain on exertion
• Tachycardia • Assess liver size (Right-sided heart failure)
• Orthopnea • Fetal status:
• Paroxysmal nocturnal dyspnea - Low birth weight
• Pulmonary edema - Preterm labor
- Ultrasound and Non-stress test to determine fetal health Diagnostics
- Mitral stenosis
• ECG – cardiac arrhythmias, hypertrophy
• Difficult for blood to leave the left atrium
• Echocardiography – cardiac status and structural anomalies
• Thrombus formation can occur from noncirculating blood
• Chest X-ray – cardiomegaly, vascular prominence
• Anticoagulant
Nursing Management
- Heparin – early pregnancy and last month of
pregnancy Labor and Birth
- Sodium warfarin (Coumadin) – after week 12 • Monitor FHR and uterine contractions
- Balloon valve angioplasty • Assess BP, PR, and RR
- Coarctation of the Aorta • Side-lying position (hypotensive)
• Dissection of the aorta from high blood pressure from • Semi-fowler’s position (pulmonary edema)
trying to push blood past the constriction Preconceptional Counseling
• Antihypertensives, diuretics and Betablockers • No pregnancy unless most especially in high risk types
• Maternal mortality varies directly with functional
Right-sided Heart Failure classification at pregnancy onset
- Occurs when the output of the right ventricle is less than the
• Optimal Medical/Surgical treatment pre-pregnancy
blood volume received by the right atrium from the vena cava.
• Counselling:
- Congenital anomaly (Pulmonary valve stenosis, ASD, VSD)
- Maternal & Fetal risks
- Signs and symptoms:
- Prognosis
• Hypotension
- Social and cost considerations
• Jugular vein distention - Hospital delivery- Preferable at tertiary care center
• Liver and spleen enlargement
Antenatal care
• Ascites
• Clear counseling of risk and prognosis
• Dyspnea and pain
- Management: • ANC every 2 weeks upto 30 weeks then weekly
• Advised not to get pregnant. • On each visit-note-pulse rate, BP, cough dyspnea, weight,
anemia, auscultate lung bases, reevaluate functional grade
• Ensure treatment compliance
J.A.K.E 28 of 59
• Exclude fetal congenital anomaly by level-III USG and fetal • Morphine (15mg)
ECHO at 20 weeks in maternal congenital heart disease • Watch for signs of CHF & Pulmonary Edema
• Fetal monitoring • Treat PPH
Health Teachings • First Hour After Delivery:
• Rest, Avoid undue excitement/strain - Propped up/sitting position, oxygen
• Diet/ Iron and vitamins - Watch for signs of pulmo-edema
• Hygiene, dental care to prevent any infection - Sedation
• Dietary salt restriction (4-6g/d) - Antibiotics
• Avoid smoking, drugs – betamimetics Advice at time of discharge
• Early diagnosis and treatment of PIH, infections • Continue medical treatment
• Therapeutic/prophylactic cardiac interventions as applicable: • Avoid infection
- Benzathine Penicillin - to prevent recurrence of rheumatic • Reassessment after 6 weeks or earlier if some complication
fever occurs
- Diuretics, Beta Blockers, Digitalis, Anticoagulants • Iron supplementation
- Surgical treatment as applicable - balloon mitral • Cardiological consultation for definitive management of heart
valvotomy disease
Contraceptive advice at time of discharge
Indications for admission • Contraception- Barrier,
Elective admission • Progesterone ‒ good option- DMPA, Norplant
• NYHA 1 – 2 weeks before EDD • IUCD-Less preferre
• NYHA 2 – 28 to 30 weeks • COC – contraindicated
• NYHA-III/IV- Irrespective of AOG as soon as patient comes • Sterilization- vasectomy-best
• To Change from oral anticoagulants to heparin-early • Tubal ligation-Interval, puerperial can be done
pregnancy, 36 weeks in patients on anticoagulant
Emergency admission Gestational Diabetes Mellitus
• Deterioration of functional grade - An endocrine disorder in which the pancreas cannot produce
• Symptoms and signs of complications- Fever/ persistent adequate insulin to regulate body glucose levels.
cough/ basal crepts/ tachyarrhythmias (P/R >100 min)/ JVP - Affects 3% to 5% of all pregnancies and is the most frequently
>2cm /Anemia/ Infections/ PET/Abnormal weight gain/other seen medical condition in pregnancy
medical disorders - Primary problem of any woman with DM is controlling the
Management in first stage of labor balance between insulin and blood glucose levels to prevent
• Confined to bed- position to upright or semi recumbent hypo- or hyperglycemia.
• Intermittent oxygen inhalation 5-6 lpm - Become threats to normal fetal growth. Infants of diabetic
mothers are five times more apt to be born with heart
• Sedation and analgesia- (Epidural, pethidine, tramadol)
anomalies.
• Cautious use of I.V. fluids (not >75ml/hr except in aortic
- Pregnancies complicated by diabetes are at increased risk of
stenosis and VSD)
perinatal morbidity and mortality.
• Stop anticoagulants - Sir V:
• Digitalize if in CHF, P.R.>110/ min, R/R >24/min • GDM – cause by the pregnancy.
• Diuretics in pulmonary congestion • Insulin produces by pancreas. Islets of Langerhans
• Bronchodilators • Insulin – it facilities absorption and metabolism of
• Prevention of infective endocarditis carbohydrates.
• Cardiac monitoring and pulse oximetry • Product of carbohydrates are glucose
- pulmonary artery catheterization- continuous • Diabetes – intolerance to carbohydrates.
hemodynamic monitoring
• Pancreas is not producing an adequate of insulin.
• Evaluation by Anesthetist and Cardiologist
Management in second stage of labor Pathophysiology
• Delivery in upright or semi-fowlers position • If insulin level is insufficient, body cells cannot use the
• Avoid forceful bearing down glucose.
• Adequate pain relief-epidural/pudendal block avoids • The cells register their glucose want; liver quickly converts
spinal/Saddle block stored glycogen to glucose to increase the serum glucose level.
• Cut short second stage of labor- episiotomy, vacuum, forceps • Due to insufficient insulin body cells cannot use the glucose,
‒ but not always (hyperglycemia). Glycosuria occurs when serum glucose level
• Strict Cardiovascular monitoring rises (150 mg/100 ml) to lower the glucose in the body
Management in third stage of labor • Increased amount of glucose in the urine reduces fluid
absorption in the kidney, dehydration begins to occur; the
• 10 U oxytocin IM
blood serum becomes concentrated and ↓ blood volume
• Avoid bolus syntocinon/Ergo metrine
• With reduced blood flow, cells do not receive adequate
• upright – semi fowlers, oxygen inhalation oxygen, and anaerobic metabolic reactions cause large stores
• Furosemide IV 40 mg of lactic acid to pour out of muscles into the bloodstream.
J.A.K.E 29 of 59
• Ketones bodies are acidic. These two acid sources lower the Mataas din ung ketones. Nakahalo ung ketones sa blood kaya
pH of the blood, and a metabolic acidosis develops. mapupunta to sa brain ni mrs at maaapekto ung level of
• Next, the body utilizes protein bodies as it attempts to find an consciousness ni mrs. Bababa ang level ng consciousness.
energy source. Protein breakdown reduces the supply of Diabetic ketoacidosis = diabetic coma
protein to body cells. As cells die, they release potassium and - Ketone can cross placenta, kaya magiging acidosis din ung
sodium, and this is lost from the body in the extensive polyuria. baby. Kung si nanay may poor glycemic control, si baby
• Sir V: during early pregnancy/ 1st trimester plng, expose na sa ketone.
- During the digestive process, RBC caring glucose. And Fetal acidosis:
the body cells need glucose for energy. Needed for 1) Early pregnancy – Chromosomal defect bcz it affects the
metabolism. DNA RNA synthesis. (Trisomy 21 – down syndrome)
- For the blood to push the glucose to the cell, we need 2) Mid pregnancy – the ketones now will be brought by the
insulin to be able to facilitate absorption metabolism of fetal blood to his brain. This can cause neurologic
glucose. impairment.
- During pregnancy, mataas ung HPL. Placenta produces - Deliver the baby, preterm to avoid permanent cognitive
HPL. The production or increase of HPL will start impairment, to prevent neurologic impairment. Hihintayin
between of 24-28th week of pregnancy. (6-7mos) muna ung fetal lung maturity bago ideliver si baby.
- 24-28th week, the pregnant woman should undergo - Poor glycemic control – she cannot control her glucose level
screening for diabetes. by means of diet and exercise.
- During the 24th week of pregnancy, ung tumataas kay
Effect of diabetes to the mother and fetus
baby ay production of surfactant. At the same time
tumataas din ung HPL. Maternal effect
- Since the HPL is increase, it renders the insulin less • Infertility
effective. If the insulin is less effective, the glucose • Abortion
cannot easily absorb by the body cells. The glucose will • PIH (bcz of increase BP)
remain in the blood. • Maternal infections
- Hyperglycemia – excess glucose in the blood - glucosuria is normal during pregnancy bcz of estrogen.
- Glucose attracts water. So, the glucose in the blood High estrogen decreases renal threshold to glucose.
attracts water = Fluid shifting - Moniliasis infection
- Fluid shifting – fluid from the cells will go out, from • Uteroplacental insufficiency
intracellular to intravascular. Dadami na ung fluid sa • Dystocia – painful and difficult delivery = Cephalopelvic
intravascular compartment. And there will be more fluid disproportion (CPD), possibility of CS
being circulated by the blood. • Postpartum uterine atomy – dahil Malaki ang baby
- The blood will bring the excess fluid to kidneys. And the overdistended ang uterus. That can lead to postpartum
amount of fluid will increase = polyuria. – ihi ng ihi si bleeding.
mami. Fetal effect
- When the fluid in the cells goes out, the cell will shrink.
• Chromosomal defect
Kulang na sya sa fluid = cellular dehydration.
- Kapag ung body cells kinulang sa fluid, nauuhaw na si • Neurologic impairment
mrs. Kaya inom ng inom ng tubig. = Polydipsia – • LGA but bcz of uteroplacental insufficiency, the baby can
excessive thirst. develop hypoxia
- Ung glucose hindi pumasok sa cell kaya walang energy, • Hypoxia – this can contribute to neurologic impairment
so ung mother gutom. Kakain sya ng kakain = polyphagia • Fetal distress
– excessive hunger. • Prematurity
- At dahil excess glucose ni mrs = polyhydramnios • Neonatal hypoglycemia – mababa ung glucose level kapag
- Nastimulate ung hunger at kumain si mrs, tataas ung pinanganak na sya.
glucose at hindi papasok kasi meron syang HPL blocking
action of insulin. Kaya kapag kumain nanaman sya, lalo Bakit nagiging LGA si baby?
lng tataas ung hyperglycemia. - Ang HPL pupunta lang sa blood ni nanay. Maternal insulin is
- Then, her body will look for other sources of energy affected. Mataas ung gluvose ni nanay. Hindi makakapaasok
stored in her body. Dahil hindi nya makuha ung glucose, ung blood ni nanay sa placenta pero makakatawid ung glucose
gagamitin nya ung Fats and Protein para magkaroon ng sa placenta. At dahil dyan tataas ung glucose supply sa
energy. Ung protein nasa muscle kaya magiging payat un placenta.
tao. Ung naka istore na protein sa muscle na coconvert - There is increase supply of glucose to the fetal circulation,
sya into amino acid para maging energy. kaya ung fetal pancreas mag iincrease ung fetal insulin.
- Kaya kapag diabetic ka at lagi kang hyperglycemic – d - Walang HPL ang baby, ung insulin ng baby ay functioning
pumapasok ung energy sa cell mo, you are using now the normally kaya ung glucose na binibigay ni nanay ay
protein in the muscle kaya liliit ung muscle at papayat na sya. maaabsorb ni baby kaya lalaki ang baby. = macrosomia LGA
- Fat – stored in the liver, and it will convert to fatty acid as a - After delivery, mawawala/ bababa ung supply ng glucose =
source of energy. Will produce ketones neonatal hypoglycemia. 1st 28 days
- Ketones can cause acidosis – ung ketones pupunta sa blood ni - Normal glucose level at birth = 40-60 mg/dL
nanay, kaya kapag nag tumaas ung level ng glucose ni mrs.
J.A.K.E 30 of 59
Type 1 DM Type 3 DM (Sir V)

- An immune mediated disorder characterized by destruction of - Gestational Diabetes Mellitus (GDM)
the beta cells of the pancreas, which leads to an absolute - Walang diabetes si mrs, pero nun nabuntis sya, naging diabetic
insulin deficiency Gestational diabetes mellitus (GDM) Any sya.
degree of glucose intolerance with onset or first recognition - Predisposing Factors:
during pregnancy • Family history of diabetes
- Sir V: • Diabetogenic effect of hormones during pregnancy – there
• Child onset diabetes – payat are hormones during pregnancy that contribute to the
• Insulin dependent diabetes mellitus (IDDM) development of the diabetes.
• The patient is always dependent on insulin for life. - Estrogen
• Mababa ung insulin - Progesterone
• She will still have DM during pregnancy. - Human Placental Lactogen (HPL) – the main
• After pregnancy, may diabetes pa rin diabetogenic agent. It interferes with the absorption
• Main management: insulin metabolism of carbohydrates. It renders the insulin
less effective.
• Stress
- After pregnancy, pwede mawala or mag istay un diabetes.
- If she has strong diabetes family history, the pregnancy that
develop the diabetes or stimulated/ triggers the development of
diabetes, after giving birth she remains diabetic. Considered
type 2.
- Strong family history – both sides meron silang diabetes, both
mother and father.
- Main management: diet and exercise
Metabolic Alterations of Pregnancy
• During the first trimester, fasting blood glucose decreases
Type 2 DM because of insulin production, and sensitivity slightly
- the most prevalent form of diabetes, accounting for 90- 95% of increases
cases (CDC, 2008) • By the end of the first trimester, insulin sensitivity decreases,
- a disease of insulin resistance and relative insulin deficiency with a responding increase in insulin production; this change
- Can be controlled with lifestyle modification and oral creates the diabetogenic state of pregnancy.
medications Metabolic Alterations of Pregnancy
- Sir V: • Euglycemia is maintained in pregnancy because the pancreatic
• Adult onset – mataba beta cells produce enough insulin to counteract increasing
• Non-insulin dependent diabetes mellitus (NIDDM) insulin resistance
• During childhood, the pancreas producing adequate • In pregnant women, hepatic glucose production is 1.3 times
insulin. higher than it is in nonpregnant women
• Diet related; lifestyle related (hindi na nag eexercise, kain
lng ng kain) Screening and Diagnosis of GDM
• Sobra sobra ung intake ng carbohydrates kaya hindi
nakakacatch up si pancreas in the production of insulin.
• May excess syang glucose
• She will still have DM during pregnancy
• After pregnancy, may diabetes pa rin.
• Main management: diet and exercise
• Women are assessed for GDM at the first prenatal visit. High
risk women are tested as soon as possible; women of average
risk receive the Glucose Challenge Test at 24-28 AOG.
• Women at high risk for GDM:
- Marked obesity
- Personal history of GDM
- Glycosuria
- Strong family history of diabetes
J.A.K.E 31 of 59
Sir V… • 1.0 unit/kg for weeks 36 to term

• Laboratory examination: • Obese patients may require 1.5 to 2.0 units/ kg to
1) Glucose Challenge test (GCT) overcome the combined insulin resistance and obesity.
- Screening only • Monitor blood glucose levels
- Amount of glucose solution: 50 g - Glucometer
- No NPO p midnight – random glucose testing • BP and weight monitoring
- After 1 hour, kukuhanan ng dugo. - To determine hypertension and edema
- Normal result: less than 140 mg/dL • Fetal Surveillance
- Pag mataas ung result, hindi pa sya confirmed, may - Ultrasound – to determine LGA
chance lng na mataas ang glucose nya. - Kick count – ave. 10, min 5, max 15
2) Oral Glucose Tolerance test (OGTT) - Non stress test
- Confirmatory - Contraction stress test
- 100g glucose solution - Alpha-fetoprotein (AFP) – to determine chromosomal
- With NPO p midnight abnormality.
- Increase CHO intake for at least 2-3 days. • The pregnant diabetic client must be able to identify and
(carbohydrates) differentiate signs of hypoglycemia vs hyper glycemia:
- Una kukuhain ka ng blood FBS – Fasting blood sugar, • Hypoglycemia: mag orange juice
then after non bigyan mo na ng 100g glucose solution. - Tremors
Then after 1 hour, kukunin ulit ng blood mo. Then - Lethargy
another 1-hour ulit, kukuha ng dugo. Then another - Cold clammy skin
1hr ulit, kuha ng blood (1hr after glucose - Blurring of vision
administration, 2hrs after glucose administration, 3 - Hunger
hrs after glucose administration) - Disorientation
- Apat na tusok.
• Hyperglycemia: insulin administration
- 1hr – It should be less than 180 mg/dL.
- Fatigue
- 2hrs – it should be less than 155 mg/dL
- Kussmaul's respiration – deep and rapid breathing
- 3hrs – it should be less than 140 mg/dL
- Excessive thirst
- FBS – less than 95 mg/dL
- Dry mouth
- If there are 2 abnormal results out of 4, confirmed
- Acetone/ odor breath
may diabetes.
- Fruity
- Kung may isa lng, uulitin ulit next week
Insulin administration
Management for GDM
Onset Peak Duration
• Diet & Exercise
Regular – 5-8hrs depending
- to maintain good glycemic control na walang insulin na 30-60mins 2-4 hrs
clear on the brand
tinetake.
Intermediate/ 12hrs depending
- Bawal mag exercise na walang laman ang tyan. Pag 1-2hrs 6 hrs
long – cloud on the brand
walang laman ung tyan – hypoglycemic, pwede mahilo.
o Onset – when will the blood glucose begin to decrease
- Nag eexercise to burn the excess carbohydrates.
o Peak – when is the glucose level in the blood of the patient
- Never exercise alone.
lowest
- Pregnant woman: kapag mag eexercise sya araw araw,
o Duration – how long will the patient experience low sugar
bago mag exercise dapat kumain muna ng 2 pieces of
level.
bread and drink one glass of water = sustaining
o Short acting insulin = regular
carbohydrate snack. We will refer the patient to the
o Long acting = intermediate
nutritionist, so she will know that diabetic exchange diet.
o Slow acting = intermediate
(u can have this but you need to limit this)
o Rapid acting = regular
• Insulin
o Regular – fast acting but short acting
- To lower down glucose level
o Intermediate – short acting but long acting
- Pag hindi buntis, type 2 binibigyan ng oral hypoglycemic
o Emergency – regular
agent (OHA) pampababa ng sugar level.
o Maintenance – intermediate/ long
- bawal ito sa buntis kaya ang binibigay natin sakanila ay
o We are allowed to mix the 2 different types of insulin.
insulin. Bawal sa buntis kase teratogenic effect on the
Iaaspirate muna ung regular – to prevent contamination of
baby.
regular insulin with intermediate/ long-acting insulin. To
type 1 – insulin, Diet and exercise
prevent mixing in the vial.
type 2 – diet and exercise, OHA insulin
o Nahaluan ng regular ung intermediate at walang problema
type 3 – diet and exercise, isulin
doon pero kapag nahaluan ng intermediate ung regular, may
- insulin requirements progressively increase throughout
problema na doon.
pregnancy:
o What can the regular affect in the intermediate? – onset,
• 0.7 unit/ kg up to week 12 magiging maaga lng ng 30 mins ung pagbaba ng glucose level
• 0.8 unit/ kg for weeks 13-26 pero ung duration hindi pa rin magbabago, kase mas mahaba
• 0.9 unit/ kg for weeks 26 to 36
J.A.K.E 32 of 59
ung duration ng intermediate kaysa sa regular kaya the same Indications for Delivery in Pregnant Women with Diabetes
pa rin ung duration ng intermediate, hindi magbabago. • Poorly controlled blood glucose
o What can the intermediate affect in the regular? – duration, • Abnormal fetal testing
kase after 8 hours mababa pa rin ung glucose ni mrs because
• Fetal growth restriction
of the effect of intermediate na humalo = prolonged
• Deterioration of vascular complications
hypoglycemia.
o How to admisnister: • Significant macrosomia
- Via subcutaneous injection (upper arm, abdomen, thigh,
buttocks) Rh Incompatibility
- Pregnant woman – self administration, thigh or abdomen. - Occurs when an Rh-negative mother (one negative for a D
- 45 degrees antigen or one with a dd genotype) carries a fetus with an Rh-
- We are going to rotate the site of injection. positive blood type (DD or Dd genotype)
- Kapag sa isang site lng lagi nag iinject, titigas ung subq, - Causes such concern and apprehension during pregnancy (both
lipodystrophy. matenal and fetus)
- Nagkaroon ng lipodystrophy tapos doon ka pa rin nag
inject, hindi na maabsorb ung insulin kaya she will remain
hyperglycemic.
Urine-ketone Testing
- To ensure adequate intake ruling out starvation ketosis,
pregnant women should test urine for ketones daily from the
first void.
- Hyperglycemic levels >200 mg/dl warrant ketone testing.
- Hyperglycemia and ketosis may indicate an infection and
should be evaluated thoroughly.
- Record Keeping:
• Accurate records of blood-glucose levels, urine ketone
testing, dietary intake, timing and dosage of insulin, and
activity level allow for appropriate adjustment of the
diabetes regimen.
• To detect falsification or over- or under-reporting, the
nurse periodically correlates logged values to the meter
memory.
Maternal Surveillance
Pregestational DM
- A comprehensive antepartum assessment includes a history,
physical exam and laboratory evaluation at the first prenatal
visit.
Gestational DM
- Take vital signs.
- Check the woman’s weight.
- Test urine for protein, glucose and ketones.
- Review the self-management log.
- Inspect injection sites for bruising, infection, lipodystrophy
and atrophy
• If diagnosed in the first trimester, providers should
monitor women with GDM similarly to how they monitor - Antigen is a foreign body or substance when introduce to your
women with preexisting diabetes. body, your body is triggered to produce an anti-body towards
• Women diagnosed with GDM at 24 to 28 weeks require to antigen.
weekly visits to evaluate the level of glycemic control. - Example: COVID virus is the foreign body or substance. Pag
• Women who initiate insulin may need more frequent pumasok sa katawan mo ung virus, ung body defense mo ay
visits. ma-nonotify at ma-iidentify ung presence ng virus, Kaya
Fetal Surveillance magpoproduce ung body mo ng anti-body to counteract the
• Ultrasound microorganism producing the disease.
• Maternal serum screening - Agglutinin – an anti-body
• Fetal anatomical survey - Blood type O – can be given to all but cannot receive all.
• Fetal movement count - Blood type AB – can receive all but it cannot give to O.
• Nonstress test (NST) - Rh Factor – is a factor located outside the blood.
• Biophysical profile (BPP) • Example: there are type A blood and another type A blood,
• Contraction stress test (CST) since there are the same blood type, are they 100%
J.A.K.E 33 of 59
compatible? – No, bcz depende pa yan sa Rh factor A-, • Pag nag produce si mami ng anti-body, permanent na sya,
A+ hindi na mawawala.
- 2nd pregnancy – may anti-body (+) na si mami dahil sa 1st
A A pregnancy nya kaya kapag sa 2nd pregnancy nya ung baby ay
(+) ulet. Magkakaroon ng problema. Dahil makakapasok ung
• Blood typing – to identify the blood whether it is type A anti-body sa placental barrier para idestroy ung blood ng baby.
negative or type A positive - Hemolysis – lysis is destruction.
• Crossmatching – compatibility testing - Destroyed fetal RBC will produce bilirubin. Kaya pag tumaas
- Serial number (SN) – pinaka importante sa blood transfusion, ung bilirubin, magkakaroon ng jaundice.
ito ung palatandaan na nacrossmatch ung blood ng pasyente at - can the baby die? – yes
donor. - How can we prevent the production of anti-bodies:
- Baby’s blood ung nasa katawan ni baby while mother’s blood • kailangan ma prevent natin to kase baka sa susunod na
found in the uterus. pregnancy, mamamatay ung baby.
- In the placenta, there is fetal blood only. Because at the back • During the postpartum period, she needs to undergo a test.
of the placenta, maternal side sya. • Coomb’s test – to know if the mother produce antibodies
- Placental barrier – semipermeable membrane (hindi lahat or not.
nakaka pass through) some substances can pass through, but • Normal result: Negative coombs test – the mother did not
some substances cannot. Kaya isa sa mga dahilan kung bakit produce antibodies. Good thing kase sa susunod na baby
fetal blood lng un nasa placenta kase ung blood ng mother ay nya is safe.
malaki, hindi sya makapasok doon sa placental barrier. • Direct coombs test – fetal blood (should be - result)
- Dadaan lng ung blood ng nanay doon through diffusion • Indirect coombs test – maternal blood (should be - result)
nagbibigay sya ng oxygen, glucose, fluid and other • Maternal blood is easier to obtain.
nourishment anti-bodies. • This must be done 48 hrs after delivery
- There’s no direct communication/ mixing between maternal
• If negative result, there is immunoglobulin (rhogam) to be
blood and fetal blood during pregnancy. (Blood of the mother
given to the mother.
and blood of the baby DO NOT MIX because of the placental
• Rhogam – prevents anti-body production by neutralizing
barrier)
the remain fetal blood. This should be given 72 hrs after
- Paano nagkakaroon ng Rh incompatibility:
delivery. Kapag lumagpas ng 3days, mag poproduce na si
• If the mother is Rh (-) and fetus is Rh (+)
mami ng anti-body.
• If the mother is Rh (-) and husband is Rh (+), pwede
• Temporary lang ung rhogam, after several days
ifollow ng fetus ung blood ng rh factor ng husband pero
mawawala din sya.
mas kadalasan ang finofollow ng fetus ay ung rh factor ni
- Paano kapag may anti body (+) na si mommy sa 2nd pregnancy
nanay.
nya at (+) ulit ung baby, is there a chance to save the baby? –
• Example: 1st pregnancy (mother, baby) YES…
• Since may anti-body na ung nanay, pwede sirain ung
blood ni baby or magkaroon ng Hemolysis at mamatay
ung baby pero pwede pa natin sya ma save.
• The fetus will undergo Intrauterine exchange blood
transfusion. (IUEBT)
• Papalitan ung fetal blood
• Blood type O ung ibibigay kase universal donor.
A B
- A – compatible • O negative ang ibibigay kay baby kase may anti body (+)
- B – wala pa syang problem kasi hindi pa nagpoproduce ng si nanay, so kapag binigyan mo ng O positive ung baby,
anti-body ung nanay at hindi pa sila nag mimeet dahil may incompatible pa rin sya kase may anti body (+) si nanay.
placental barrier. • Via umbilical cord, kukunin ung dugo ni baby via
• Incompatibility begins, when the chance is given for the umbilical arteries tapos ibibigay naman kay baby ung
maternal blood and fetal blood meet. Most common bagong dugo via umbilical veins.
example is during labor. • Hindi lahat ng dugo ni baby makukuha, may maiiwan
• Example: abruptio placenta – biglang humiwalay, parin kaya may hemolysis pa rin konti. At ung bilirubin
madadamage ung placenta o possible na mapunit kaya ay medyo mataas kaya may konting jaundice si baby.
pwedeng dumugo ung placenta at uterus. At dahil dyan, • Jaundice at birth – pathologic, may problema pa rin.
mag mimeet na ung blood ng nanay at baby. (management: Bili light, phototherapy)
• CS – nailabas na ung baby pero possible na may fetal • Jaundice at 2nd and 3rd day – physiologic, normal,
blood pa rin sa maternal circulation. Dahil nagdugo or breastmilk jaundice (Management: pinapaarawan
nadamage ung placenta nya, there are remaining fetal
blood in the maternal circulation. Safe na ung baby kasi
nailabas na. if the remaining fetal blood will not be
neutralize then after several hours once the blood of
mother detect the positive fetal blood, the mother blood
will produce anti-bodies (+).
J.A.K.E 34 of 59
Pathogenesis of Rh Iso-immunization • Given at 28 weeks AOG and at first 72 hours after giving birth
Intrauterine Transfusion
• Restore fetal RBC, blood transfusion can be performed on the
fetus in utero.
• Injecting RBC by amniocentesis technique, directly into a
vessel in the fetal cord or depositing them in the fetal abdomen
where they migrate into the fetal circulation.
• Fetus’s own blood type (determined by percutaneous blood
sampling) or group O negative if the fetal blood type is
unknown.
• 75 to 150 ml of washed red cells are used, depending on the
age of the fetus.
• After deposition of the blood in the cord or abdomen, the
woman is urged to rest for approximately 30 minutes while
fetal heart sounds and uterine activity are monitored.
Prevention of Rh Iso-immunization
• Premarital counseling.
• Blood grouping for every woman, before 1st pregnancy.
• Proper management of unsensitized Rh negative pregnancies.
• Blood typing at 1-st visit, If negative → husbandʼs typing.
• Anti-Rh Ab screen (indirect Coombʼs test) of Rh‒ negative
mother.
Assessment/ Diagnostics • At about 28 weeks ‒ negative → 300μg anti D
immunoglobulin.
Indirect Coomb’s Test (maternal)
• In abortion, ectopic pregnancy, abruption of placenta, placenta
- Detect presence of Rh antibodies or other antibodies in
praevia, molar pregnancy, abdominal trauma, chorionic villi
patients serum
sampling, amniocentesis = foetal-maternal hemorrhage →
- To check whether an Rh negative women has developed Anti-
150-300μg anti D
Rh antibodies
• At birth- cord blood for ABO and Rh typing → Baby Rh
- If the results are normal (0) or the titer is minimal (ratio below
1:8 is minimal) – repeat test at 28 weeks AOG. positive → 300μg anti D within 72 hours of delivery
- If anti-D antibody titer is elevated (1:16 or greater) - shows Rh • In case of large fetal-maternal hemorrhage:
sensitization 1) Kleihauer-Betke test estimates the amount of fetal blood
in circulation
Middle Cerebral Artery (MCA) Doppler ultrasound (Fetal)
2) Indirect Coombs test
- A technique that can predict when anemia is present or fetal 3) Additional dose of anti-D, if needed
red cells are being destroyed.
• Errors - Causes of sensitization
- If artery velocity remains high - the fetus is not developing
- Misinterpretation of maternal Rh type
anemia and most likely is an Rh negative fetus.
- Rh+ blood transfusion
- If the reading is low – the fetus is in danger
- Unprotected pregnancy and labour
- Inadequate dose / improper use of IgG on previous
occasions
- Immunization to cross-reacting antigen
Management of Rh Iso-immunized Pregnancy
Antepartum
• Careful planning during antepartum, intrapartum and neonatal
period
• Known repeated maternal anti-D Ab titer
• Intrauterine fetal monitoring with repeated US examinations,
cordocentesis & fetal blood sampling /
• amniocentesis, the measurement of the fetal middle
• cerebral artery peak velocity (Doppler)
Fetus Rh Positive + anemia
Therapeutic Management
• Intrauterine transfusion of Rh-negative blood in selected cases
Rh (D) Immune Globulin (RhIG) • Planned preterm delivery any time after 34 weeks or as soon
• Reduces number of maternal Rh (D) antibodies formed as the lung maturity is documented by inducing the labor or
• Commercial preparation of passive Rh (D) antibodies against cesarean section (for the severely affected fetuses)
Rh factor
• Doesn’t cross the placenta
J.A.K.E 35 of 59
Postpartum • Associated with Low birth weight and Preterm birth – hindi
Management of the infant enough para maprovide ung oxygenation from the maternal to
• Monitoring up to 8 weeks fetal. Kapag less ang oxygen, maapekto din ung growth rate
• Exchange transfusion in the newborn in the umbilical vein ng fetus.
• Phototherapy Management of IDA
• In cases of severely sensitized women, consider medical • Prenatal vitamins containing iron supplement of 60mg
termination of pregnancy and sterilization. elemental iron (prophylactic – 60mg)
• Diet high in iron and vitamins (green leafy vegetables, meat,
Anemias of Pregnancy legumes, fruit)
- A decreased amount of red blood cells or hemoglobin in the • Iron supplement: 120 to 200 mg elemental iron/day
body. (therapeutic)
- Blood volume expands during pregnancy slightly ahead of the - Ferrous sulfate
red cell count, most women have pseudo anemia of early - Ferrous gluconate
pregnancy. (early pregnancy – that is when we needed the - Inform side effects (constipation, gastric irritation, black
most of RBC for the formation of fetus) stool)
- Anemia – a decrease amount of RBC. - Dapat may laman muna ang tyan bago uminom ng
- True anemia is present when a woman’s hemoglobin supplement to prevent gastric irritation
concentration is… - Black stool – normal side effect of taking supplement.
• Less than 11g/dL (hematocrit < 33%) in the first or third • Advice women to take iron supplements with orange juice or a
trimester of pregnancy. vitamin C supplement
• Less than 10.5 g/dL (hematocrit < 32%) in the second • Severe IDA: IM or IV Iron Dextran
trimester.
Parenteral Iron Transfusion
Iron • Iron sucrose for parenteral use
- Absorbed from the duodenum into the bloodstream after it is • Dose calculated – Wt in Kg x iron deficit x 2.2 + 1000 mg for
ingested iron stores
- In the bloodstream, it is bound to transferrin for transport to • Response - by increase in Hb level 1g/week
the liver, spleen, and bone marrow • Increase in Reticulocyte count within 5-10 days
- Incorporated into hemoglobin or stored as ferritin • Clinical symptoms improve
Iron-Deficiency Anemia (IDA)
- Most common anemia of pregnancy complicating as many as Folic-Acid Deficiency Anemia
15% to 25% of all pregnancies - One of the B vitamins (Vit. B9)
- Factors that may contribute to IDA during pregnancy: - Necessary for the normal formation of red blood cells in the
mother as well as being associated with preventing neural tube
• Diet low in iron
defects in the fetus
• Heavy menstrual periods before pregnancy
- The folic acid is necessary for the development of the brain.
• Unwise weight-reducing programs before pregnancy – Especially 1st trimester
namimili ng kakainin - The Recommended Dietary Allowance (RDA) for folate
• Pregnancy < 2 years before present pregnancy during pregnancy is 600 micrograms (μg)/day.
• Low socio-economic levels (poor diet) - Deficiency may develop to Megaloblastic Anemia (enlarged
- Characteristically a microcytic (small RBC), hypochromic RBCs)
(less Hgb than average red cell) anemia. - Kapag nag continue ung deficiency ng folic acid, nagiging
- If there’s inadequate supply of iron, ung iron nagiging megaloblastic anemia – lumalaki
unavailable for binding pagdating sa mga hemoglobin kaya - Pregnant women need to get enough folic acid.
nag rereduce or lumiliit ung hemoglobin count. - The vitamin is important to the growth of the fetus's spinal
- Diagnostics: cord and brain.
• Hemoglobin < 12 mg/dL - At risk:
• Hematocrit < 33% • Women with multiple pregnancies because of the
• Low serum transferrin level ( < 100mg/dL) increased fetal demand
• Transferrin saturation level ( < 5%) • Women with a secondary hemolytic illness in which there
• Serum Iron level ( < 30mcg/dL) is rapid destruction and production of new red blood cells
• Mean corpuscular hemoglobin concentration (MCHC): • Women who are taking hydantoin, an anticonvulsant
<30 agent that interferes with folate absorption
• Increased iron-binding capacity ( > 400mcg/dL) • Women who have been taking oral contraceptives
Effects of IDA • Women who have had a gastric bypass for morbid obesity
• PICA or craving develops (Eating of substances such as ice or – gastric bypass, treatment given on patient’s severe
starch) obesity.
• Extreme fatigue Causes of Folic Acid Anemia
• Poor exercise tolerance – nanghihina; kapag sobrang activity • Inadequate dietary intake
naman, nagkakaroon sila ng shortness of breath. • Excessive alcohol intake
J.A.K.E 36 of 59
• Pregnancy – specially 1st trimester Effects of Sickle Cell Anemia to pregnancy

• Certain medications (Hydantoin, OC) • Prematurity – poor placental perfusion of oxygen
• Diseases of absorption • Miscarriage
• Inherited condition • Perinatal mortality
Diagnostics • Asymptomatic bacteriuria (↑ incidence of pyelonephritis)
• Laboratory CBC: • Fetal effect: Low birth weight and fetal death
- Mean Corpuscular volume (MCV) is elevated
Management: Assessment:
• Advise patient to eat folate rich foods- Green, leafy vegetables, • Laboratory:
liver, fresh fruits, cereals, meats, yeast - Hemoglobin: 6-8 mg/ 100ml
• Folic acid supplementation - Increased Indirect Blirubin level
- Prophylactic before pregnancy 400mcg/day - Urinalysis: presence of bacteria
- Pregnancy: 600 mcg/ day • Fetal status:
• Ultrasound at 16-24 weeks for IUGR
Sickle Cell Anemia • Weekly Non-Stress Test or Ultrasound at 30 weeks
- A recessively inherited hemolytic anemia caused by an onward – measuring the blood flow velocity
abnormal amino acid in the beta chain of hemoglobin. Therapeutic Management
(nagbabago ung shape ng RBC)
• Periodic Exchange transfusions throughout pregnancy
- If the abnormal amino acid replaces the amino acid valine,
• Avoid giving additional levels of:
sickle hemoglobin (HbS) results;
- Iron supplements – to avoid excessive iron buildup
- If it is substituted for the amino acid lysine = non-sickling
- Folic acid supplements – to avoid new cells produced
hemoglobin (HbC) results.
from being megaloblastic
- An individual who is heterozygous (has only one gene in
• If crisis occurs:
which the abnormal substitution has occurred) = sickle cell
- Control pain
disease (HbSS) results
- Administer Oxygen
- Majority of RBCs are irregular or sickle shaped so they cannot
carry as much hemoglobin as can normally shaped RBCs - Increase fluid volume (Hypotonic solution)
- When oxygen tension becomes reduced, as occurs at high • If infection occurs (fever, increased perspiration, ↓PO2),
altitudes, or blodd becomes more viscid than usual hospitalization for observation is necessary to rule out crisis
(dehydration), the cells tend to clump because of the irregular and subsequent hemolysis.
shape. • When fetus is mature, time and method of delivery are
- This clumping can result in vessel blockage with reduced individualized
blood flow to organs. - CS – epidural anesthesia must be used (general anesthesia
- The cells then will hemolyse (mabilis mag break down), poses risk of hypoxia)
reducing the number available and causing a severe anemia. • Postpartal period: (Reduce risk of thromboembolism)
Resulting to increase of bilirubin levels. - Early ambulation
- There will be also reduction in the placental perfusion of - Wearing pressure stockings
oxygen. At maapektuhan din ang baby. • When fetus is mature, time and method of delivery are
individualized
- CS – epidural anesthesia must be used (general anesthesia
poses risk of hypoxia)
- Normal delivery: after 8hrs, we let them walk pero u need
to assist pa rin; CS after 24 hrs
• Postpartal period: (Reduce risk of thromboembolism)
- Early ambulation
- Wearing pressure stockings
Nursing management
• Monitor diet (sufficient amount of folic acid)
• Advise to consume at least 8 glasses of fluids daily
• Advise sitting on a chair with legs elevated or lying on the side
in a modified Sims’ position to encourage venous return from
the lower extremities
• Plan with the woman to limit long periods of standing and
adequate rest periods
• Monitor fetal health
J.A.K.E 37 of 59
PROBLEMS WITH THE 4P’S epinephrine and norepinephrine, oxytocin, estrogen,

Discussed by Prof. Francis Vasquez, Prof. Melanie Cambel progesterone, and prostaglandins
and Prof. Carmencita Pacis - 95% - completed labors with contractions that follow a
A difficult labor arising from any of the 5 components of the predictable, normal course.
labor process:
• Power (uterine contractions) Two possible problems of uterine contraction
• Passenger (fetus)
• Placenta
• Passageway (birth canal)
• Psyche (perception)
Problem with the Power (The Force of Labor)

Two sources of power that will aid the delivering her baby:
1) Uterine contractions
2) Ability of the mother to push
Dysfunctional Labor
- Sluggishness of contractions, or the force of labor, has
occurred
- Can occur at any point in labor
- Classification:
a) Primary – occurring at the onset of labor
b) Secondary – occurring later in labor
- Increases risk of maternal postpartal infection,
hemorrhage, and infant mortality Hypertonic Uterine Dysfunction/ inertia
- Increase in resting tone to more than 15mmHg
Uterine contractions - Contractions occur frequently and are most commonly seen in
- The true labor of uterine contractions is in the myometrium. - the latent phase of labor
- Ang pinakamakapal na myometrium ay Fundus (upper uterine - Contraction occurs because the muscle fibers of the
segment) myometrium do not repolarize or relax after a contraction.
- Fundus is the main origin of the uterine contractions that - Contractions are more painful than usual
pushing the baby down - Strong contraction
- To place your hand on the abdomen of the client, spread your - Even short/faster (precipitate labor) – completed less than 3hrs
fingers on the fundus bcz the source of the contractions will be - Possible of perineal laceration
on the upper uterine segment of the fundus. - happen during the latent phase of labor
1) Power – The ability of the mother to push - maaga palang 1st phase palang pwede na lumabas yung
2) Problems Occur in the Labor include 5P’s hypertonic contraction
- If there is problem on the 5P’s, one of those what will happen - Sige lang ng sige yung contractions
to the labor and delivery? - Predisposing factors:
• more difficult and painful • Primigravida – prone sa PIH so yung placenta
• normal labor and delivery are difficult insufficiency nya is may lead to from uterine contraction
• masakit manganak ng normal lalo nap ag primi (young age)
• kahit walang problem sa 4P’s pero mahina si mother sa • Unwise use of oxytocic – masyadong madami or na
power the labor will become longer, and mother become double ang pagbigay (Ex. syntocinon IV)
exhausted • Trauma
- If in labor masikip ang birth canal, maliit ang pelvis ni mother • Stress
the head can’t pass through, kase mape-press ng todo yung • Drug: Oxytocic
head sa inlet ni mother and it will become more painful - In terms of fetal distress, hypertonic can lead to fetal distress
- What do you call the type of labor wherein more painful and because of too much uterine contraction. Maternal blood
more difficult labor? vessel will constrict, and it will decrease the blood supply of
• dystocia – broad term the baby during delivery.
• there is a problem in passenger like malpresentation hal. - Strong uterine contractions, the descent of the baby is fast. =
nauna yung pwet, breech, transverse, or small pelvis Do not push if there are strong uterine contractions
• it can result to CPD - Teach the mother to pant to prevent pushing and relax
• problem in the placenta (AP & PP) abdominal muscle (pre wag pulling ah, panting lang HAHAHA)
Ineffective Uterine Force - If the baby delivered vaginally, in case of precipitate labor,
- Uterine contractions you are going to deliver the head of the baby between
- Basic force moving the fetus through the birth canal contractions, kase dahil sa strong contractions and doon
- Occur because of interplay of the contractile enzyme malabas ang head ni baby that can result to laceration.
adenosine triphosphate and the influence of major • Kung kalian pahina ng pahina na, pero may crowning
electrolytes such as calcium, sodium, and potassium, courage the mother to push
specific contractile proteins (actin and myosin),
J.A.K.E 38 of 59
• But kapag hindi maiwasan that the head will be delivered • Bricanyl (Tubertaline) – Tocolytic (asthmatic anti-agent,
during contractions instruct the mother to pant to slow bronchodilator)
down the delivery of the baby • Utopar, Ductail OB, Bricanyl and MgSO4 – they relax
- To prevent perineal laceration, use Ritgen’s Maneuver. muscle of the uterus (muscle relaxant)
- During postpartum you need to watch out: - Hypotonic can lead to fetal distress dahil sa haba ng labor
• Bleeding magkakaron ng utero placental insufficiency
• Uterine atony - Uteroplacental insufficiency (UPI) – prone to fetal distress
• Check consistency of the uterus whether too fast or too short both can affect the baby
• The uterus remains contracted and firm - Risk factors:
- If the doctor thinks that the mother will undergo or experience • Administration of analgesia
laceration, the doctor will act immediately and do episiotomy • Bowel or bladder distention
para control yung wound. • Overstretched uterus (multiple gestation, larger-than-usual
- Complications: single fetus, hydramnios)
• Fetal anoxia • Relaxed uterus (grand multiparity)
• Uterine rupture - Complication:
• Abruptio Placenta • Pospartum hemorrhage
- Nursing Management: - Nursing intervention (Postpartum):
• Apply uterine and a fetal external monitor for at least 15 • Palpate uterus and assess lochia every 15 minutes (1st
minutes hour after birth)
• Administer IV fluids and short- acting barbiturates as
prescribed Uncoordinated Contractions
• Provide comfort measures and emotional support - More than one pacemaker may be initiating contractions, or
• Prevent infection receptor points in the myometrium may be acting
• Prepare patient for Cesarean Section if needed independently of the pacemaker
- Uncoordinated contractions occur so closely together that they
Hypotonic Uterine Dysfunction/ inertia do not allow good cotyledon filling
- The number of contractions is unusually low or infrequent (not - Difficult for woman to rest between contractions or to use
more 2 or 3 occurring in a 10- minute period) breathing exercises with contractions
- Resting tone of the uterus remains less than 10mmHg and the - Management:
strength of contractions does not rise above 25mmHg. • Applying a fetal and a uterine external monitor and
- Commonly occurs during the active phase of labor assessing the rate, pattern, resting tone, and fetal response
- Painless to contractions for at least 15 minutes
- Mahina na contraction • Oxytocin administration
- Prolonged labor – it exceedingly more than 24hrs
- occur can be evident during active labor
- meaning ok pa sya pero pag dating nung active humina ang
contraction kaya tumatagal
- Predisposing factors:
• Over distended uterus – masyadong nabatak, numinipis
yung myometrium
o LGA
o Polyhydramnios
o multiple pregnancies
o High parity – ilang beses na nabuntis at nanganak
o Fetal malpresentation (breech, transverse)
- If the uterus is not over distended or normal yung laki ng baby,
pero humihina ung beginning active phase of laborm that is
because of high parity
- You need to prepare Tocolytic drug for hypertonic uterine
contraction. (hindi nya iwawala ang hilab, but it will lessen the
intensity and duration of contractions)
- Medications:
• Duvadilan – Tocolytic
• Mgso4 – Tocolytic
• Syntocinon – Oxytocic
• Pytocin – Oxytocic
• Methergine – Oxytocic
• Utopar – Tocolytic
• Ductail OB – Tocolytic
J.A.K.E 39 of 59
Fetal Distress • Augmentation of Labor

- In term of fetal distress, how are you going to determine fetal - to assist in labor
distress? What are the things that you can check to the baby - Administer oxytocic
while inside the uterus to determine fetal distress? - Already in labor
• FHT – normal 120 – 160 - Humina nga lang ang uterine contractions
- The earliest sign of Fetal distress: - Primary indication: hypotonic uterine contractions
• Fetal tachycardia - Before inducing labor or augmenting labor, the doctor be
• Late sing bradycardia sure that the cervix of woman is ready for labor. How soft
- Wala kang stethoscope, doppler, weigh, para ma determines is non pregnant cervix?
yung FHR ano pa pwedeng ma check sa fetus para ma o Tip of nose
determine ang FD? o Early pregnancy – earlobes
• Fetal movements o Late pregnancy – lips
• Kick counts (5, 10, 15)
• 15 > hyperactive – early sign of FD (restless, magalaw Bishop’s Scoring for Induction and Augmentation of Labor
kulang sa o2) Parameters
• < 5 hypoactive • Cervical dilatation – opening
• Color of amniotic fluid – greenish (meconium stained), • Cervical effacement – thinning of internal os
Nonbreech presentation (cephalic and transverse) • Fetal station – (-, 0, +, along the ischial spine)
- Examples: • Cervical consistency – lambot ng cervix
• Nag IE ka, “Ma’am cephalic, Ma’am greenish ang fluid”, • Cervical position – anterior, posterior or middle
is it automatic FD? = Yes 0 1 2 3
• Nag IE ka, una pwet greenish amniotic fluid automatic CD 0cm 1-2cm 3-4cm 5-6cm
FD? = No – pag breech, meconium staining is common 80% and
in Breech Presentation. Kaya pag breech hindi ka pwede CE 0-30% 40-50% 60-70%
above
mag rely ng FD ng fetus doon, kailangan mo bilangin ang Fetal Station -3 -2 -1 to 0 +1>
FHR and fetal movements. Cervical
• Nag IE ka, shoulder presentation positive of greenish Firm Medium Soft
Consistency
amniotic fluid, is it FD? = Yes, kase non breech Cervical
- If FD cannot be reversed, the baby can die because of the lack Posterior Middle Anterior
Position
of O2. The physician will be performed operative delivery, c- o Kapag nag IE, yung cervix nakababa = posterior, 0; Nasa
section middle = deretso lng 1; Angat na yung cervix = Anterior 2
- If it lacks on O2 supply, that can cause neurological
impairment. This is permanent
Nursing Management for Fetal Distress:
1) Ano ang maternal position who’s experiencing fetal distress?
= Left lateral position to increase systemic circulation
2) We will administer oxygen therapy via face mask (5-8 L/min.)
to the mother to increase the O2 of the baby. o -1 above ischial, 0 station along ischial
3) If there is IV incorporation of Oxytocin (syntocinon), you may o +1 cm below ischial
slow down or stop the oxytocic IV fluid. o The first three parameters, the highest score is 3.
4) Wala si doc. Do a Nursing Management, decision making o For the last two, highest score is 2
skills. o The total overall perfect score = 13 (3+3+3+2+2 = 13)
- Example: Ang IV flow rate 40 gtts/min, may halong o Ex. Cervical dilatation 2cm, effacement 40%, fetal station -1,
syntocinon and positive of FD, slow FHR <100 or 90 cervical consistency medium, cervical position middle. The
beats/min. score is 6, pero hindi pa sya pasado sa bishop scoring.
• First kailangan mo munang bagalan, gawin mong 20 o The minimum score to qualify the labor augmentation is at
gtts/min least a score of 8. Pwede na mag administer ng oxytocin.
• Hatiin mo muna, 20 gtts/min na the FHR is increased 120 o Kapag 6 ang score, the first question of the doctor is cervical
beats/min, so pwede na consistency. Because the softness and firmness can affect
• Pero if the FHR decreased to 80 beats/min, stop the dilatation and effacement.
infusion because the baby cannot tolerate the syntocinon. o Kumatigas mabagal ang pag dilate at ang effacement is
- Accountability – you are answerable to your own actions. mabagal din.
o The slowness of effacement and dilatation can affect the baby
Induction and Augmentation of Labor descent station (kung hindi numinipis and internal os, hindi
nago open ang cervix edi mabagal ang pagbaba ng baby).
• Induction of Labor
o The nurse must be proficient in Internal examination
- To induce, to force – meaning force labor
procedure, so that she can perform bishop scoring.
- Administer oxytocic
o Interventions:
- The woman is not yet in labor
- to increase bishop’s score
- Primary indication: post term pregnancy – 10 months;
- If cervix is still firm or medium, the doctor will effect
baby is overstaying.
ripening of the cervix.
J.A.K.E 40 of 59
o Drugs: • Pain relievers (morphine sulfate)

- Prostaglandin Gel – ipapasok ito sa mother then it will • Provide comfort
draw the fluid in the cervix to become soft • Decrease noise and stimulation
- Cytotec – most common to induced abortion, anti-ulcer • Oxytocin infusion/ amniotomy
drug but can cause strong contractions. • Cesarean Delivery
- 1 tab = 100 mcg/scored tablet – may guhit yung tablet Protracted Active Phase
pwedeng ma divide or mahati
- Active phase lasts longer than 12 hours in a primigravida or 6
- Laminaria tent – the doctor will insert this drug kapag
hours in a multi gravida.
sobrang bagal pa din ang softening ng cervix
- Cervical dilation does not occur at a rate of at least 1.2 cm/
- It will absorb the fluid in the cervix, kaya may swelling na
hour in a nullipara or 1.5 cm/ hour in a multipara.
mangyayari then it will open the cervix
- Tends to be in hypotonic contractions
- The dosage of Cytotec to stimulate induction to stimulate
- Causes:
labor = 25 mcg (1/4 tablet)
• Cephalopelvic Disproportion (CPD)
Summary: (Sir V)
• Fetal malposition
• In induction of labor the score that you will perform is bishop
Prolonged Deceleration Phase
scoring
- When deceleration phase extends beyond 3 hours in a
• Bishop scoring has 5 parameters
nullipara or 1 hour in a multipara
• Cervical dilatation – opening
- Results from abnormal fetal head position
• Cervical effacement – thinning of internal os
- Management: Cesarean birth
• Fetal station – (-, 0, +, along the ischial spine)
Secondary Arrest of Dilatation
• Cervical consistency – lambot ng cervix
- No progress in cervical dilatation for longer than 2 hours
• Cervical position – anterior, posterior or middle
- Management: Cesarean Birth
• For the first 3 the highest score is 3, the last 2 the highest score
is 2, therefore the total score is 13
• You must know how to perform IE
• Most of the time rn/rm ang nagpe perform
• Minimum score req. So that the mother could have augmented
labor is 8 and above
• If below 8 the doctor will ask the cervical consistency
• Medium and firm – prostaglandin
• Pag di kaya Cytotec
• If mabagal pa din laminaria tent
• Performed IE and more than 8 and above administer iv fluid
incorporated w/ syntocinon for strong uterine contractions to
undergo induced labor or augment labor.
Dysfunction at the 2nd Stage of Labor
Dysfunctional Labor and Associated Stages of Labor Prolonged Descent
A. Dysfunction at the 1st Stage of Labor - Occurs if the rate of descent is < 1 cm/ hour in a nullipara or 2
1) Prolonged Latent Phase cm/ hour in a multipara.
2) Protracted Active Phase - When 2nd stage lasts over 3 hours in a multipara
3) Prolonged Deceleration Phase - Contractions become infrequently and of poor quality and
4) Secondary Arrest of Dilatation dilatation stops.
B. Dysfunction at the 2nd Stage of Labor - Management:
1) Prolonged Descent
• Rest and fluid intake
2) Arrest of Descent
• Amniotomy
C. Contraction Rings
D. Precipitate Labor • Oxytocin infusion
Dysfunction at the 1st Stage of Labor • Positioning (semi-fowlers, squatting, kneeling)
Prolonged Latent Phase • More effective pushing technique
- A latent phase that is longer than 20 hours in nullipara or 14 Arrest of Descent
hours in a multipara. - No descent occurred for 1 hour in a multipara or 2 hours in a
- Tends to be in a hypertonic state nullipara
- May occur if: - Occurred when expected descent of the fetus does not begin or
• Cervix not “ripe” at beginning of labor engagement or movement beyond 0 station has not occurred
• Excessive use of analgesic early in labor - Cause: CPD
- Management: - Management:
• Reassess the cervix • Oxytocin (If no CPD)
• If no change, • Cesarean Birth
• Provide adequate fluid for hydration
J.A.K.E 41 of 59
Contraction Rings - Incomplete rupture

- A hard band that forms across the uterus at the junction of the • Localized tenderness and persistent aching pain over the
upper and lower uterine segments and interferes with fetal lower uterine segment
descent - Diagnostic: ultrasound
- Pathologic retraction ring (Bandl’s ring) - Management:
- Causes: • Fluid replacement
• Uncoordinated contractions • IV oxytocin
• Obstetric manipulation • Prepare for possible laparotomy with tubal ligation/ CS
• Administration of oxytocin hysterectomy
- Diagnostic: Ultrasound • Secure Consent
- Management: • Psychological and emotional support
• IV morphine sulfate or Amyl Nitrite Inhalation
• Tocolytics Uterine Inversion
• Cesarean birth - Refers to the uterus turning inside out with either birth of the
• Manual removal of placenta fetus or delivery of the placenta
- Complications: - Causes:
• Uterine rupture • Traction applied to umbilical cord to remove the placenta
• Neurologic damage to fetus • Pressure applied to uterine fundus when uterus is not
• Massive maternal hemorrhage (Placental stage) contracted
Precipitate Labor • Placenta attached at the fundus and the passage of fetus
- Labor that is completed in fewer than 3 hours pulls the fundus down
- Uterine contractions are so strong that birth occurs with obly a - Assessment findings:
few rapidly occurring contractions • Large amount of blood gushes from vagina
- Cause: • Fundus not palpable
• Grand multiparity • Hypotension
• Induction of labor by oxytocin and amniotomy • Dizziness
- Complications: • Pallor
• Premature separation of the placenta • Diaphoresis
• Fetal subdural hemorrhage • Fleshy mass at or outside the introitus
• Lacerations (birth canal) - Management:
- Diagnostic: Labor graph (Partograph) • IV fluids (use Large-gauge needle)
- Management: • Blood transfusion
• Tocolytics • O2 therapy via face mask
• Birth plan for multiparous women and women with • Assess and monitor VS
history of precipitate labor • Be prepared for CPR
• Administer general anesthesia or tocolytics IV
Uterine Rupture
- Occurs when a uterus undergoes more strain than it is capable • Manual replacement of uterus by OB
of sustaining • Administer oxytocin after replacement
- Contributing factors: • Antibiotics
• Vertical scar from previous surgery (CS/ Hysterotomy) • CS in future pregnancies
repair tears
• Prolonged labor Problems with Passenger
Umbilical cord prolapse
• Abnormal presentation
- a loop of the umbilical cord slips down in front of the
• Multiple gestation
presenting fetal part.
• Unwise use of oxytocin
- nauna yung cord nagkakaroon ng compression, nagde decrease
• Obstructed labor yung O2 na maibibigay kay baby that could lead to fetal
• Traumatic maneuvers of forceps or traction hypoxia
• Pathologic retraction rings - Occur:
• Strong uterine contractions without cervical dilatation • Premature rupture of membranes – most common (ung
- Anticipate need for an immediate cesarean birth cord nag fofloat sya sa amnitic fluid kaya pag nawala na ung
- Sudden, severe pain during a strong labor contractions amniotic fluid, bababa ung cord)
- Complete rupture • Fetal presentation other than cephalic (pag cephalic un
• Uterine contractions immediately stop presentation, na peprevent nya na magkaroon ng space for
• Two distinct swelling visible on the abdomen (retracted the umbilical cord to go out)
uterus and the extrauterine fetus) • Placenta previa – yung position or adherence ng placenta
• Hemorrhage is lower kaya mas nauunang lumabas yung umbilical cord
• Signs of shock begin • Intrauterine tumors preventing the presenting part from
• Absent Fetal heart sounds engaging – pag hindi nag engage yung head yung maliit
na part yung papalit.
J.A.K.E 42 of 59
• A small fetus Therapeutic Management

• Cephalopelvic disproportion preventing firm engagement • Manual elevation of the fetal head off the cord
– may condition sa pelvic ni mother hindi kasya yung • Knee-chest or Trendelenburg position – para yung pressure
fetus for NSD, so mas mauuna din lumabas yung nasa taas male-lessen yung pagcompress ng umibilical cord
umbilical cord • Oxygen via facemask (10 L/min) – prevent hypoxia
• Hydramnios – pag masyadong madami yung fluid naka • Tocolytic Agent – lessen the contractions. (MgSO4
float si baby madali syang umikot and may chance na mas administration) kasi everytime na nag cocontract un uterus,
magpresent yung umbilical cord. nacocompress din un umbilical cord.
• Multiple gestation • Amnioinfusion – reduce compression on the cord. Warmed
normal saline. Temporary amniotic fluid para maprevent na
Umbilical Cord Prolapse lumbas ung umbilical cord, kasi kapag nagkaroon ulit ng fluid
inside, mag fofloat ung baby at malelessen ung pagcompress
ng umbilical cord.
• Fetal Blood sampling – to check a positive response to scalp
stimulation usually supplies the information as to whether a
fetus is becoming acidotic
• Cover exposed cord with sterile saline compress/gauze
• NOTE: Do not attempt to push back. Kapag binabalik
nagtutupi so nawawala yung O2 supply para sa fetus
• Forcep delivery (if fully dilated) – assisted delivery para
maprevent yung pag compress ng head
• Occult prolapse – sabay silang lumalabas (kapag nag IE, Problems with Fetal Position, Presentation, or Size
makakapa na nakaikot ung umbilical cord sa ulo) - Fetal Presentation – kung ano yung nakikita na mauunang
• Cord Presentation (Funic) – kung ang cord ay below lumabas
presenting part with or without membrane rupture, mas - Fetal Position – saan nakaharap LOP, ROP, LOA
naunang nag present yung umbilical cord. (kapag nag IE, - Size – yung laki ni baby
makakapa sa gilid ng ulo ung umbilical cord) Occipito-Posterior Position
• Overt cord prolapse – na expose sa air madaling ma dry. - back-to-back
(pinaka delikado) - known as sunny side up
- All types will lead to perinatal asphyxia (decrease oxygen - ideal is occiput anterior position (LOA)
supply to the fetus) - The occiput is directed diagonally and posteriorly, either to the
- Pag na- atrophy, tumitigas ung cord tapos mag nanarrow right or to the left (LOP or ROP) – ito yung common bakit
ung daanan ng oxygen. nagkakaroon ng delay
- To prevent: kukuha ng sterile gauze, wet with warm - Tend to occur in women with android, anthropoid, or
normal saline – ito ung ipangtatapal naten. Pero hindi contracted pelvis
ipupush pabalik sa loob kasi lalo lng mawawalan ng - Does not fit the cervix as snugly as one in an anterior position
daanan ung oxygen. - Heart tone – lateral part of the abdomen of the mother
- Pwede sya manganak normally pero gagamit ng forceps - Increase risk of umbilical cord prolapse
para maprevent ng presenting part na macompress ung - Diagnostic: Vaginal examination/ultrasound
umbilical cord. - Management
Assessment Finding • Pain – medication, back-rub, heat or cold application
• Cord felt as presenting part during IE (rare) • Fetal rotation – side lying opposite the fetal back/hands
• Visible cord at vulva and knees position
• Variable deceleration FHR pattern (irregular FHR) – pwedeng • Keep bladder empty
early or late deceleration hindi sya constant. (combination) • Fluid intake or IV Glucose solution – dextrose, ang sugar
a) Early deceleration – kapag nag contract ito yung mababa ay kailangan para sa power.
yung FHT ng baby • Cesarean Birth
b) Late deceleration – kung kailan pababa na ung contraction, • Frequent reassurance – talk to the mother to minimize her
doon plng bababa ung FHR. fear
• Diagnostic: Ultrasound Breech Presentation
- Fetus in longitudinal with the buttocks or feet closest to the
cervix
- Types
• complete – the bottom is presenting with the feet
• frank – naka letter V yung leg ni baby
• footling – foot is the presentation part
- Causes
• Gestational age < 40weeks
• Fetal abnormalities
J.A.K.E 43 of 59
• Hydramnios – madaling umikot yung baby • Early rupture of the membranes

• Congenital anomalies of uterus – problema sa lalagyan - Assessment findings:
• Mass in the pelvis • FHR heard high in the abdomen
• Pendulous abdomen – yung abdominal muscle ng mother • Leopold’s maneuver and vaginal examination reveals the
is lax mas malapad yung ibaba ng uterus compared to the presentation
upper • Ultrasound confirms breech presentation, information on
• Multiple gestation – mahirapan umikot diameters of pelvis and fetal skull.
- Complications - Management:
• Anoxia • Continuous monitoring of uterine contractions and FHR.
• Traumatic birth injury • Birth technique: vaginal birth or CS
• Fracture of the spine or arm
• Dysfunctional labor Face presentation
• Early rupture of the membranes - Asynclitism (fetal head presenting at a different angle)
Assessment Findings - Head diameter of fetus is often too large for birth to proceed
- FHR heard a high in the abdomen - More prominent head with no engagement
- Leopold’s maneuver and vaginal examination reveals the - Back is difficult to outline during LM
presentation - Confirmed by vaginal examination and ultrasound
- Ultrasound confirms breech presentation, information on - Causes:
diameters of pelvis and fetal skull • Occipito posterior position
- Management • Placenta previa
• Continues monitoring of uterine contractions and FHR • Prematurity
• Birth technique • Hydramnios
• Vaginal birth • Fetal malformation
• CS - Management: vaginal birth (chin is anterior and pelvic
diameters are normal)/ CS)
Fetal Presentation - Complications: Facial edema
Brows Presentation
- Occurs in a multipara or a woman with relaxed abdominal
muscles
- Results in obstructed because the head becomes jammed in the
brim of the pelvis as the occiptomental diameter presents
- Management - CS
- Complications
• Ecchymotic bruise on face – nawawala naman pero need
- Vertex - kapag nag IE yung head ang nakakapa ma observed yung mga patent airway and yung problem
- Sinciput – yung noo kapag maga yung lips is hindi makakapag breastfeed
- Brows
- Face Transverse Lie
- Asynclitism (fetal head presenting at a different angle) - Occurs in women with pendulous abdomens with uterine
- Head diameter if fetus is often too large for birth to proceed fibroid tumors that obstruct the lower uterine segment, with
- More prominent head with no engagement contraction of the pelvic brim, with congenital abnormalities
- Back is difficult to outline during LM of the uterus or with hydramnios
- Confirmed by vaginal examination and ultrasound - Occur in infants with hydrocephalus or another abnormality
- Causes that prevents the head from engaging, prematurity, multiple
• Occipitoposterior position gestations (2nd twins), short umbilical cord
• Placenta Previa - Assessment
• Hydramnios • Horizontal ovoid of the uterus
• Fetal Malformation • Confirmed by LM
- Management – Vaginal birth (chin is anterior and pelvic • Ultrasound
diameter are normal/CS) - Management – CS
- Complications – facial edema (reassure the mother na - Complication – Cord or arms prolapse
mawawala lang din to)
Breech presentation Fetal Size: Oversized Fetus (Macrosomia)
- Complications: - Fetus who weighs more than 4000 to 4500 grams (9-10lbs)
- Born to women who enter pregnancy with diabetes or develop
• Anoxia
GDM
• Traumatic birth injury
- Associated with multiparity
• Fracture of the spine or arm
• Dysfunctional labor
J.A.K.E 44 of 59
- Complications:
• Uterine dysfunction during labor
• Fetal pelvic disproportion – CPD
• Uterine Rupture
- Management – CS
- Complications
• Postpartum hemorrhage – the lacerations is extending to
the anus kaya heavy bleeding
• Cervical nerve palsy
• Diaphragmatic nerve injury
• Fractured clavicle – pwede magkaroon ng injury kase
hinahatak yung balikat
Shoulder Dystocia - Inlet contraction

• Narrowing of the anteroposterior diameter to less than 11
- Occurs at the second stage of labor, when the fetal head is
cm or transverse diameter to 12 cm or less
born but the shoulders are too broad to enter and be born
through the pelvic outlet • Caused by rickets or by inherited small pelvis
- Delikado ito kaya magle lead to lacerations • Engagement does not occur in a primigravida (36-38
- Delikado din sa baby kase naco compress yung cord could weeks) or in a multigravida (until labor begins)
lead to prenatal anoxia • Nag start na ng labor, pero si baby did not engaged kase
- Causes hindi kasya si baby sa pelvic ni nanay. Kailangan i-CS
• Maternal DM • Management:
• Multiparity o Obstretic history
o Pelvic measurements before 24 weeks of pregnancy
• Post-date pregnancies
o CS
- Assessment Findings
• Complications:
• Prolonged 2nd stage of labor
o Malposition
• Arrest of descent
o Cord prolapse
• Turtle sign - Outlet contraction
- Management – McRobert’s maneuver, Suprapubic pressure
• Narrowing of the transverse at the outlet to less than 11
application
cm
- Complications
• Distance between the ischial tuberosities
• Vaginal Lacerations
• Can be measure during prenatal visit
• Cord Compress
Cephalopelvic disproportion (CPD)
Problems of the passage
- Inability of the fetal head to pass through the maternal pelvis
- Refers to the route a fetus must travel from the uterus through
due to discrepancy in size
the cervix and vagina to the external perineum
- Lack of engagement at the beginning of labor, prolonged first
- Fetus must also pass through the bony pelvic ring
stage of labor, and poor fetal descent
- Pelvic measurements:
- Most common cause for arrest of descent during the second
• Anteroposterior diameter of the inlet stage of labor
• Transverse diameter of the outlet - Risk factors:
• Fetal macrosomia
• Narrow pelvis
• Gestational diabetes
• Post-term baby
- Prophylactic measure: CS birth
- Complication: birth injuries (hypoxic-ischemic
encephalopathy and cerebral palsy
- Trial labor:
• Determine whether labor can progress normally
• Continues as long as descent of presenting part and
- Shapes of pelvis
dilation of the cervix continue to occur
• Anthropoid
• Monitor FH sound and uterine contractions continuously
• Gynecoid – mas maganda ito para sa preg woman
• Urge to void every 2 hours
• Android
• Assess FHR carefully after rapture of membranes
• Platypelloid (flat)
• Inadequate progress in labor (6-12 hours) or fetal distress
occurs, schedule for CS.
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External Cephalic Version - Anemia

- Turning a fetus from a breech to a cephalic position before - Gravido cardia
birth Fetal
- May be done as early as 34 to 35 weeks AOG (usual time: 37- - Multiple Pregnancy
38 weeks) - Polyhydramnios
- Procedure: - Multiple pregnancy and Polyhydramnios – and poly
• Continuous recording of FHR and ultrasound
hydramnios give the uterus more weight lead to premature
• Tocolytic agent administration
cervical dilatation and incompetent cervix or PROM.
• Locate breech and vertex of fetus and grasp abdominally
- Fetal Malformations – like hydrocephalus, spina bifida is a
• Gentle pressure applied to rotate fetus in a forward
type of anemia that is caused by lack of folic acid and
direction to a cephalic lie
recommended intake of this during pregnancy is 400
• Rh negative women should receive Rh immunoglobulin
after procedure micrograms.
- Contraindications: - Fetal Distress – lack of oxygen
• Multiple gestation Complications
• Severe oligohydramnios - prematurity
• Contraindications to vaginal birth - fetal death
• Cord coil around fetal neck (nuchal cord) - SGA – maaga syang pinanganak kaya hindi nare reach ni baby
• Unexplained 3rd trimester bleeding yung expected weight
Treatment
Problems with Psyche - Hospitalization – prevent preterm delivery and preterm labor
- a woman w/out a support person can no longer be prevented. (Kapag nag pre-term labor is mrs.
- Rejects or want to labor w/out the infant’s father our goal of care is to stop the preterm labor kase ang organs ni
- Apprehensive about new life role baby is undevelop, we will stop it so that the woman can
- Increased assessment of parent-child bonding (post partal remain pregnant until she reaches full term)
period) CBQ: How can we know if pre-term labor still be prevented or
- Vaginal Birth After Cesarean Birth stopped?
• No experience of labor - BOW should be intact
• Anxious and may be dismayed at length and discomfort of - cervix <3cm dilated
labor - no fetal distress
• Management: Emotional, physical support - mild to moderate uterine contraction. If uterine
• Catecholamines contraction occurs give tocolytic drug
• Oxytocin – kapag tumaas ito magkakaroon ng prolonged How can we prevent pre-term birth?
labor tumataas yung anxiety level
- Reduce uterine contractions
INTRAPARTAL COMPLICATIONS - Avoid increase in the uterine contraction
Discussed by Prof. Francis Vasquez To prevent pre-term birth, we should allow the patient to have:
Preterm Labor - Bed rest – Left lateral position
- 20 wks> to <37 wks - Adequate hydration must be given
- Is the time wherein the baby is delivered after the 20th week of Monitor
pregnancy and before reaching the 37th week of pregnancy. - Uterine contractions and irritability – contraction should be
Risk factors decreased
Maternal - Check the BOW this must remain intact
- Infection – Hal. UTI kapag umiihi si mommy nasa taas ung - Check the cervical dilatation – from 3cm to closed
urethral meatus tapos nasa baba is vaginal opening kaya - Vital signs monitoring
kapag umiihi si mrs. tumutulo sya sa vagina at dahil don - I and O monitoring
papasok ung microorganism pumapasok and nai-infect yung - Temperature to check the sign and symptoms of infection
BOW or the amnion that can cause chorioamnionitis - Cardiac and respiratory status
infection that leads to possible pre-term birth - fetal wellbeing (3 most important: FHR, fetal movement, and
- PROM – premature rupture of membranes maagang nag color of amniotic fluid. Fetal distress is color green because of
rupture ung bag of water, incompetent cervix meconium stain)
- Bleeding – can be cause by incompetence cervix, AP and - Administration of tocolytics: MgSO4, terbatuline, Rtitodrine,
PP Duvadilan
- Trauma – pwedeng nalaglag si mother sa hagdan, nabnagga Contraindications - what are the signs that pre-term labor can
- Smoking – can cause vasoconstriction no longer be stopped. Do not give when:
- Stress – no problem physiologically and medically but have • (-) BOW, cervical dilatation of more than 3cm
psychological stress that causes powerful uterine contraction. • Maternal conditions like – PIH, Cardiac disease, fetal
- PIH – pregnancy induced hypertension distress (check also fetal heart rate). PIH and cardiac
- Diabetes Mellitus disease wait for the doctor but the fetal distress is
J.A.K.E 46 of 59
definitely you cannot give tocolytic. Since preterm labor

siya there is vaginal bleeding.
If the preterm labor of the woman in present pregnancy can
still be stopped, we should give:
• Antenatal Steroid – purpose is to promote fetal lung
maturity. This can be given if the pregnancy reaches 24 2) Sudden acute abdominal – bumuka tapos ang lakas pa nung
weeks or 6months because this is the time that the fetal contraction. Sharp stabbing pain
alveoli will produce surfactant 3) Cessation of uterine contractions and FHT – dahil bumuka
• Dexamethasone – 6mg IM q 12 hrs x 4 doses na ang uterus hindi na masyaodng maririnig ang fetal heart
• Betamethasone (Celestone) – 12 mg IM q 24 hrs x 2 doses tones
- Purpose of Dexamethasone and Betamethasone is to Complications
promote fetal lung maturity (produce surfactant) Two types:
Paano pag di mapigilan and pagla labor? • Impending uterine rupture – malapit na mag rupture.
• edi signs of actual labor ang nangyari is napaaga lang. Surgical procedure is emergency CS section. Signs ay
makikita natin na uterine contraction is progressive, pain matigas ang uterus and have bandl retraction ring.
increases by walking, presence of cervical dilatation, • Uterine rupture – nag rupture na siya. nag li-leak na ung
rupture of BOW. The care we should give is like how we amniotic flood and blood.
care for a labouring patient. - Hemorrhage and shock, Maternal and fetal mortality –
• Preterm labor can be in CS, normal or forcep delivery. kapag nag rupture na ang unang mamatay ay ung baby at
Bakit c-cs ang preterm or forcep yung preterm? kasunod si nanay dahil kaka hemorrhage and shock na si
depedende kung gaano ka preterm ang baby. Hal. 5 mommy at decreased BP due to blood loss. Temperature is
months ang baby so preterm sya at ang organ nya ay also low due to blood loss kaya lumalamig siya but the PR,
undevelop kaya ung skull niya ay malamboot pa at hindi and RR is high. They could both die lalo na pag wala pa sa
pwedeng dumaan sa birth canal mag kakaroon ng hospital.
increased intracranial pressure bali kapag super aga na Treatment
preterm CS. - Laparotomy to deliver the fetus – bago ilabas ung baby
nasira na ung uterus kaya pwede pa itong i-repair. Nabigyan
Uterine Rupture siya ng anesthesia bago i-repair kaya ayaw tumigas nung
- rupture of uterus due to stress of labor with extrusion of matres nya or called uterine atony that causes bleeding. The
uterine contents into abdominal cavity only management for this is hysterectomy.
- bumuka yung matres at pumunta ung laman ng matress sa - Hysterectomy
abdominal cavity in tagalog. - Blood transfusion
Risk factors - Antibiotics
- Previous CS scar (3 to 5 years). Kung si mrs. na CS nung
una anong interval between 2 cs section? 3-5 years. Kung Nursing Care
nabuntis na naman siya after 4 months niyang ma cs pwedeng - Shock position – modified trendelenberg position. Naka taas
bumuka ng uterus/ uterine rupture. ang leg ni mother and naka 20-30-degree angle, para may
- hysterectomy maiwan pa rin na dugo sa lower extremities. In this position
- improper use of oxytocin – na sobrahan sa oxytocin at can help the mother to elevate her BP and also higher O2 in
lumabas ung uterine contraction the brain
- hyperdistended uterus – masyadong lumaki ung matres. - Keep patient warm
Paano kung unang pag bubuntis tapos triplets? Kahit walang - Prompt IV infusion and BT - Ano ng IV infusion ang main
scar pwede siyang mag rupture. line kapag side drip transfusion? Plain NSS .9 sodium chloride
- malpresentation – transverse or breech presentation ni baby - Notify doctor, prepare client for immediate surgery
kaya mababatak. - Provide psychological support
- hypertonic uterine contractions – exp. Powerful uterine
contraction Fetal Distress
- Multiple gestation Risk factors
- traumatic maneuvers of forceps or traction - utero placental insufficiency – kinukulang ng oxygen si baby
Assessment Findings - chord coil
1) BandL retraction Ring – earliest findings. May indention - PIH
and it means tense na ung lower uterine segment matigas na - AP/PP
sya kase hindi pa maklabas ung babay at malakas ung uterine - Prolonged labor
contraction. - Precipitate labor
Signs and Symptoms
- FHR – 160bpm or <120bpm (fetal tachycardia and fetal
bradycardia)
J.A.K.E 47 of 59
- Hyperactive 15> early sign of fetal distress • Pulmonary shock and edema – dahil tuloy tuloy ang AF
- or hypoactive <5KC/hr late sign of fetal distress papunta sa lungs
- Meconeum stained Amniotic fluid in non-breech presentation - Treatment:
(cephalic and transverse). Kase kapag breech hindi siya sign - Oxygenation stat
ng fetal distress you have to check fetal heart rate and - Improve hydration:
movement. • IV Fluid, BT (to inc. oxygen carrying capacity of the
Management blood), monitor I and O
- LLP – left lateral position • Digitalis/Digoxin – it increases contractions of the
- O2 therapy via face mask heart. Bakit pina pa contract yung heart? Para mag
- if with IVF w/ oxytocin drug = ang dapart gawin ay slow circulate yung blood
down or stop. Tingnan kung bumabagal o nag nonormalize • Heparin (is anticoagulant drug) with standby
ang fetal heart rate. Kapag bumaba ang fetal heart rate stop the protamine sulphate – para magtuloy tuloy yung
IV and Notify physician circulation ng blood.
- possible administration of tocolytic if very strong UCs are
present Forceps Delivery
- Prepare for CS - delivery of the baby using obstetrical instruments - forceps
- composed of:
Amniotic fluid Embolism • blade – are inserted to the birth canal and lock it. The
- escape of amniotic fluid into the maternal circulation. Humalo doctor will pull it and rotate the baby.
ang fluid sa maternal blood dahil pumasok ang AF sa blood • Shanks
vessel ng nanay dahil open ang BV ni mrs.
• handle and lock
- Risk factors:
• PROM
• Abruptio Placenta – most common risk factor of AFE.
What could predispose the mother to the to develop
abruptio placenta? PIH tapos may AP at AFE. Ex. Mrs
have PIH type is severe pre-eclampsia BP reading is
160/110 and above. Sa sobrang taas ng BP ang BV ni
nanay ay constricted kaya nag karoon ng vasoconstriction
at ang auto supply sa placenta ay low at magkakaroon ng
placental insufficiency at dahil dito it will trigger
powerful uterine contraction hihiwaly ng biglaan ang Indication for forceps delivery
placeta. Kapag ang placenta ay nagkaroon ng sudden AP Fetal factors
masusugat ang placenta maternal side at prone sa RH - second stage of labor fetal distress – expulsion is the
incompatibility masuusgat din ang lining ng uterus niya. second stage of labor and the station of the baby is
Dahil sa sugat ung blood vessel ni mrs sa portion ng positive so mababa na sya tapos nag fetal distress so need
matres ay naka open at papasok ang amniotic fluid so i-forcep.
mahahalo sya sa blood at pupunta ito sa lungs kaya - Abnormal presentation or arrested descent (e.g breech.
mahihirapan mag circulate ung blood at dahil dito hindi hindi tumuloy tuloy ang pagbaba ni baby)
na makakapagbigay ng oxygen sa blood kaya low ang - Preterm labor
oxygen level sa brain that cause comatose at mamatay si Maternal factors
mrs. - to shorten the 2nd stage of labor
• Ano ang mas prone sa AFE kung ang placenta ay nag AP? - ineffective expulsive effort – si mrs. hindi marunong
Duncan kase humiwaly agad sa periphery makakapsok umire kaya mapapagod si mrs. kaya mag kakaroon siya ng
agad ung AF. maternal exhaustion at cardiac disease. Cardiac disease
• Hypertonic uterine contractions – kapag wala nmn PIH si and gravido cardiac are not allowed to push. Opposite of
nanay tapos nag ka AFE pwede dahil sa amalakas na pushing is panting
impact tulad ng nasagasaan or premature rupture rupture - Exhaustion
of membrane. Criteria/Prerequisites
- Prognosis: Fatal – because time is the essence - We should know kung kailan dapat ipasok ang forcep.
- Assessment Findings: - Fully dilated cervix 10cm, fully effaced to prevent
• Acute dyspnea - Ex. naubo si mrs un pala sudden chest lacerations
pain un sign na pumasok na ung AF sa blood niya - (-) ruptured BOW
- station from 0 to positive
• Cyanosis
- bladder – empty. Kase ang pwedeng matraumatize ng
• Sudden chest pain
forceps is urinary bladder
- w/ anesthesia (epidural)
J.A.K.E 48 of 59
Types - Ensure airway patency

- low/outlet forceps – fetal head is on pelvic floor. Positive - monitor VS q 15 (1st hour), q 30 (2nd hour), q 1 (3rd-6th
3-4 almost crowning until stable)
- Midforceps – fetal head at the level of the ischial spines. 0 - Monitor uterine fundus – firm. Kapag malambot we
station. This is more prone to laceration cannot massage kase may hiwa so dot encourage nipple
Complications stimulation and breast feeding bcs this promotes
- lacerations hemorrhage, UR, and uterine prolapse production of oxytocin.
- bell’s palsy – temporary facial paralysis - Check dressing and perineal pad if there is blood.
- intracranial hemorrhage - inc. intracranial pressure or Kailangan i-check kahit cs kase kapag nag uuterine atony
hemorrhage. hindi naman lalabas ung blood sa skin kundi sa vagina. So
u check sa operative site at sa vagina.
Cesarean Section - Promote bonding – breast feeding
- delivery via abdominal incision - Administer drugs as ordered: Oxytocic, Analgesic,
Indications antibiotic
- Cephalopelvic Disproportion – leading. Small pelvis - Early ambulation – NSD have to ambulate asap if CS
- Previous CS – during the last pregnancy ambulate after 24 hrs. of delivery at hindi pwedeng
- Contracted pelvis – masikip na pelvis tumayo agad dpt mag turning, sipping at sa 3rd day mag
- Fetal distress standing ang walking around the bed. Bago patayuin at
- Dystocia pag lakarin dpt lagyan sya ng girdle or binder it needs
- DM – LGA baby support.
- Placenta Previa and Abruptio Placenta – abnormal - Bladder emptying – to promote involution
presentation bali kapag breech at transverse cs na agad
- Malpresentation Anomalies of the placenta
- Cord Prolapse - Kung nasaan ang UC un ang kay
- Fetal abnormalities like hydrocephalus baby or fetal side
- VBAC – Vaginal birth after cs. - Note that the insertion of the cord
• Is there a chance that mother could undergo VB? is at the center it is centrally and
deeply attach
Yes, vaginal birth after CS
• Pwede ba lahat ng CS mag undergoes ng VB?
No depende sa laki incision sa matres. first
incision classical. low vertical incision
• low transverse cesarean incision – pwede mag
undergo ng VBAC kase ung muscle fiber ng
uterus ay nakahiga. The cuts is along the muscle
fiber. This has better wound healing.
• Classical and low vertical – cuts against the
muscle fibers
Battledore Placenta
- In a battledore placenta, the cord is inserted marginally rather
than centrally. This anomaly is rare and has no known clinical
significance either.
- The cord is at the edge and the insertion is one sided resulting
to retained placental fragments. Kaya kapag may naiwan na
piraso ng placenta the uterus relaxes that leads to postpartum
vaginal bleeding. Management is D & C.
Nursing Care
- BattledorE – edge
1) Pre – operative preparations
- informed consent, NPO post-midnight, shaving
2) Post – operative
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Velamentous Insertion of the Cord manually may lead to extreme hemorrhage because of the deep
- Velamentous insertion of the cord is a situation in which the attachment. Hysterectomy or treatment with methotrexate to
cord, instead of entering the placenta directly, separates into destroy the still-attached tissue may be necessary.
small vessels that reach the placenta by spreading across a fold Two types:
of amnion. This form of cord insertion is most frequently Placenta Increta
found with multiple gestation. Because it may be associated - Invasive implantation kase umabot ang implantation sa
with fetal anomalies, an infant born with this type of placenta myometrium na dapat hanggang endometrium lang. most
should be examined carefully. common
- Cord is superficially attached or naka attach ung cord more on Placenta Percreta
sa blood vessel. Dahil dito the cord will snap or maputol agad. - ang implantation ay lumabas na ng perimetrium. Most
Result to Retained placenta buong placenta ang naiwan. dangerous kase pwede ng dumikit sa urinary bladder or
Management is D & C. large and small intestine.
- VelamentouS – superficially Management
Placenta Succenturiata / Succenturiate - CS at kung buhay pa ung baby it will be followed by
- A placenta succenturiata is a placenta that has one or more hysterectomy
accessory lobes connected to the main placenta by blood - Ano ang problema sa lahat?
vessels. No fetal abnormality is associated with this type. - bleeding
However, it is important that it be recognized, because the
small lobes may be retained in the uterus after birth, leading to
severe maternal hemorrhage. On inspection, the placenta
appears torn at the edge, or torn blood vessels extend beyond
the edge of the placenta. The remaining lobes are removed
from the uterus manually to prevent maternal hemorrhage
from poor uterine contraction.
- have extra lobe or one accessory lobe. Retained placental
fragments. Management is D & C.
- SuccenturiatA – accessory
Bipartite (bilobed)
- Dual placenta
- Can be three parts called tripartite
- Retained placental fragments
Placenta Circumvallata POSTPARTUM COMPLICATIONS
- Ordinarily, the chorion membrane begins at the edge of the Discussed by Prof. Melanie Cambel and Prof. Carmencita Pacis
placenta and spreads to envelop the fetus; no chorion covers • Postpartal Hemorrhage (Uterine atony)
the fetal side of the placenta. In placenta circumvallata, the • Lacerations (cervical, vaginal, perineal, related placental
fetal side of the placenta is covered to some extent with fragments, DIC, subinvolution, perineal hematomas)
chorion. The umbilical cord enters the placenta at the usual • Puerperal infection (endometritis, infection of the perineum,
midpoint, and large vessels spread out from there. They end peritonitis, thrombophlebitis, UTI)
abruptly at the point where the chorion folds back onto the • Emotional and psychological complications of puerperium
surface. (postpartum depression and psychosis)
- Small placenta thick membrane.
Circummarginate Postpartal hemorrhage
- Normal placenta thick membrane - One of the most important causes of maternal mortality
Vasa Previa associated with childbearing,
- In vasa previa, the umbilical vessels of a velamentous cord - Any blood loss from the uterus greater than 500 mL within a
insertion cross the cervical os and therefore deliver before the 24-hour period
fetus. The vessels may tear with cervical dilatation, just as a - Greatest danger of hemorrhage is in the first 24 hours
placenta previa may tear. Before inserting any instrument such Uterine atony
as an internal fetal monitor, be certain to identify structures to - Uterine atony, or relaxation of the uterus, is the most frequent
prevent accidental tearing of a vasa previa as tearing would cause of postpartal hemorrhage
result in sudden fetal blood loss. If sudden, painless bleeding - Factors that predispose to poor uterine tone or any inability to
occurs with the beginning of cervical dilatation, either placenta
maintain a contracted state are:
previa or vasa previa is suspected. It can be confirmed by
ultrasound. If vasa previa is identified, the infant needs to be • Deep anesthesia or analgesia
born by cesarean birth. • Labor initiated or assisted with an oxytocin agent
Placenta Accreta • Maternal age greater than 35 years
- Placenta accreta is an unusually deep attachment of the • High parity
placenta to the uterine myometrium so deeply the placenta will • Previous uterine surgery
not loosen and deliver (Poggi, 2007). Attempts to remove it • Prolonged and difficult labor
J.A.K.E 50 of 59
• Possible chorio amnionitis Secondary maternal illness • Inform and reassure about her and baby’s condition
(e.g., anemia) • Explain the need for anesthetic and the procedures being
• Prior history of postpartum hemorrhage Endometritis carried out.
• Prolonged use of magnesium sulfate or other tocolytic Vaginal lacerations
therapy - Rare
- Management: - Easier to assess than cervical lacerations
• Fundal massage - Hard to repair
• Oxytocin infusion (IVF: LRS) - Some oozing often occurs after a repair
• Other meds if oxytocin failed: - Therapeutic management:
o Carboprost tromethamine (Hemabate) or • Vaginal repair
Methylergonovine maleate administration • Vaginal packing
• Rectal Misoprostol • Indwelling catheter
• Additional measures: • Remove inserted packing after 24 to 48 hours or before
o Offer a bedpan or assist the woman with ambulating discharge.
to the bathroom at least every 4 hours. • Observe for signs of infection or toxic shock syndrome.
o Administer oxygen by face mask at a rate of about 4 Perineal lacerations
L/min (if with respiratory distress)
o Place in supine position
o Obtain VS frequently
Therapeutic management
• Bimanual Massage
- If fundal massage and administration of oxytocin or
methylergonovine are not effective in stopping uterine
bleeding
- The physician or midwife inserts one hand into the - Occur when a woman is placed in a lithotomy position for
woman’s vagina while pushing against the fundus through birth, because this position increases tension on the perineum.
the abdominal wall with the other hand. - Classified by four categories, depending on the extent and
• Blood replacement depth of the tissue involved
- Blood transfusion to replace blood loss. - Therapeutic management:
- Iron therapy • Laceration repair/ Episiorrhaphy
• Hysterectomy or suturing • Diet high in fluid and stool softener
- In the rare instance of extreme uterine atony, sutures or • No enema or rectal suppositories for 3rd and 4th degree
balloon compression may be used to halt bleeding. lacerations/ no to rectal temperature taking
- Last resort. - Complications: 4th degree laceration (long term dyspareunia,
rectal incontinence, or sexual dissatisfaction)
Lacerations Retained Placental Fragments
- Small lacerations or tears of the birth canal are common and - Placenta does not deliver in its entirety; fragments of it
may be considered a normal consequence of childbearing. separates and are left behind
- Large lacerations can cause complications. - The retained fragments keep the uterus from contracting fully
- They occur most often: and bleeding occurs
• With difficult or precipitate births - Incidence: 1 in 3000 births
• In primigravidas - Causes:
• With the birth of a large infant (9 lb) • Placenta succenturiate
• With the use of a lithotomy position and instruments • Placenta accrete
Cervical lacerations - Diagnostic:
- Laceration found on the sides of the cervix, near the branches • Ultrasound
of the uterine artery. • Serum hCG
- If the artery is torn, the blood loss may be so great that blood - Assessment
gushes from the vaginal opening. • (Large fragment) bleeding in the immediate postpartal
- Bleeding is brighter red than the venous blood lost with period
uterine atony. • (Small fragment) bleeding not detected until 6 – 10 post
- Bleeding occurs immediately after delivery of the placenta. partum day
- Management: • Uterus not fully contracted
• Repair of cervical laceration - Therapeutic Management
- Nursing care: • Dilatation and curettage (D & C)
• Maintain an air of calm and if possible, stand beside the • If Placenta accreta:
woman.
J.A.K.E 51 of 59
o Balloon occlusion and embolization of the internal • Lochia Alba

iliac arteries - 10 to 28 days but commonly could see 10 to 14 days,
o Methotrexate creamy or whitish-yellow, slight amount, mucus
• Continuous observation of color of lochial discharge after - Why does subinvolution happens in the patient? it
discharge happens because of some small placenta fragments,
Disseminated intravascular coagulation (DIC) meaning may mga naiiwan pa na ibang part ng placenta sa
- An acquired disorder of blood clotting in which the fibrinogen uterus ng patient
level fails to below effective limits Assessment
- Early symptoms: easy bruising, bleeding May results from…
- Usually associated with: 1) Small retained placental fragment
• Premature separation of the placenta - initially in postpartum nag co contract yung uterus ni
• PIH mother na co control nya yung bleeding ng patient but bec.
• Amniotic fluid embolism na reach nya na yung small particles of the placenta kaya
• Placental retention nahihirapan syang mag contract that is why biglang
• Septic abortion humihinto yung contraction kaya may subinvolution
• Retention of dead fetus 2) A mild endometritis (infection of the endometrium)
- Is an emergency - that could cause subinvolution kase may inflammation
- Therapeutic Management and swelling nahihirapan bumalik yung uterus sa shape
• Heparin (IV) and size painful sya and tender pag nag palpate
• Blood and platelet (fresh frozen plasma) transfusion 3) Accompanying problem such as a uterine myoma that is
• Antithrombin III factor, fibrinogen, or cryoprecipitate interfering with complete contraction (uterine myoma)
- Nursing management Therapeutic Management
• Be sure to fully explain what is happening to the woman - Methylergonovine Maleate, 0.2 mg four times (4x) daily –
and her support system usually is prescribed to improve uterine tone and complete
• Administer heparin therapy and transfusion involution.
• Monitor for blood coagulation studies and circulation. - Oral antibiotic – also will prescribe if the uterus is tender to
Subinvolution palpation, suggesting endometritis
- hindi bumabalik sa normal size Nursing Management
- incomplete return of the uterus to its prepregnant size and - Teach woman about normal process of involution and lochia
shape. discharge, and signs of subinvolution
- at a 4-to-6-week postpartum visit, the uterus is still enlarged - Instruction:
and soft. • these are the symptoms of postpartum
- 1st week may continues contraction of uterus or subinvolution • Lochial discharges – if you still experiencing this
wherein the uterus slowly return to its normal size pero in time brownish blood discharge for 2 weeks, you need to go
na mags stop yung contraction ng uterus hindi na sya back to your doctor to check your uterus again baka po
bumabalik sa normal shape and size nya dito mag vi visit na may mga naiwan pang placental fragments na hindi na
yung client and pag pinalpate the uterus is soft and enlarged. tanggal that is why hindi pa nababawasan yung lochia or
- Lochia discharge usually is still present. discharges na lumalabas
- usually, 4 to 6 wks wala na yung lochia • Gaano ba dapat karami? during the initial usually dapat
- but in subinvolution, there is still a presence of lochia hindi nakakapuno ng isang pad, parang menstruation sya
discharge pero moderate nalang yung menstrual discharges na
Three types of Lochia lumalabas sa patient
• Lochia Rubra • start 3 pads per day, not for 24 hrs
- Seen for the first 3 days (red to bright red, the amount is • for diaper unnecessary na gumamit nito
moderate. The client uses 3 pads for 24hrs.) - Palpation:
- Contains blood clots and other decidual tissues na • when you start palpating for the uterus or the fundus, right
natatanggal sa lining ng uterus after the patient deliver the baby, sa umbilical level magpa
• Lochia Serosa palpate malalaman mo to na parang may matigas na
- Seen for 4 to 10 days, pinkish to brownish, one pad per matigas sa loob or parang may bukol
day • when you palpate that, that is the level of the umbilicus of
- serous liquids, erythrocytes, etc. the patient bandang pusod
- Healing of the uterus • one day after usually starting of involution (lumiit)
- Healing – where the placenta is attached in the lining of • Paano masasabi na normal lumiliit yung uterus?
the uterus it closes kaya may serous fluids bumababa ng at least 1 to 2 finger breadths per day
• by the 10th day hindi na napapalpate kase nasa ilalim na
sya or masyado na syang maliit kaya di na napa palpate
J.A.K.E 52 of 59
- Signs of Subinvolution: Endometritis

1) Check the bleeding - Infection of the endometrium, the lining of the uterus.
2) Palpate the uterus - Bacteria gain access to the uterus through the vagina and enter
3) When you palpate the uterus, it is soft the uterus either at the time of birth or during the postpartum
Prevention of Subinvolution period.
• Promote breastfeeding – BF can help to release normal - This may occur with any birth, but the infection is usually
oxytocin and can help the uterus to contract associated with chorioamnionitis and cesarean birth.
• Early ambulation - Chorioamnionitis – nagkakaroon ng bacterial infection doon sa
• Binder – for CS chorion at amnion (ito un mga membrane that surrounds the
fetus).
• Cold application
- Assessment:
Complications
• Fever (3rd or 4th day PP) >38 deg.
• Infection • Chills
• Anemia • Loss of Appetite
Perineal Hematomas • General weight
- Collection of blood in the subcutaneous layer of tissue of the • Not well contracted uterus and painful to touch -
perineum. • Strong afterpains
- Overlaying skin is intact with no visible sign of trauma • Dark brown lochia and has a foul odor
- Caused by injury to blood vessels in the perineum during birth, - Treatment
nagkakaroon ng pulling of blood inside. (wala kang makikita • Administration of an appropriate antibiotic (e.g.
na bleeding, makikita mo lng na purplish) clindamycin – cleocin)
- Occur after rapid, spontaneous birth and in women with • Oxytocic agent – Methylergonovine maleate (prevent
perineal varicosities (meron silang malalaking ugat) postpartum hemorrhage, improve the muscle tone)
- Site: episiotomy or laceration repair. • Fluids
- Seen on vulvar or vaginal hematoma. • Analgesics
- Hindi agad gumagaling pero as long as nag poproper treatment, • Fowler’s position/ambulation
bumabalik or maaabsorb over the next 3-4 days. Pero kung - Diagnostic:
malaki (more than 8cm or lumalaki lalo), nag uundergo na ng • Vaginal swab culture – doon sa opening uterus (to
surgery. determine the microorganism causing the infection)
- Most women, their hematoma is absorb over the next 6 weeks. • Ultrasound if cause is placental fragments
- Assessment - Nursing Management
• Severe pain or feeling of pressure in the perineal area. • Encourage early ambulation
• Purplish discoloration of area. • Regularly change perineal pads (use gloves)
• Size: 2-8 cm in diameter • Good handwashing techniques before and after handling
• Tender and firm to palpate (dapat gumamit ng clean pads
gloves) • Observe lochia discharge for color amount and odor
• Estimate the size of hematoma (by cm) and degree of pain • Discharge planning about signs of infections
scale. - Complications
- Therapeutic management • Tubal scarring – pagdidikit dikit ng fallopian tube, kapag
• Administer mild analgesic (Ex: methanoic acid) nagkaroon ng infection, nababarahan or naboblock para
• Ice pack application (dapat naka wrap sa towel para hindi makalabas ung egg cells
maprevent ung thermal injury) • Interference in future infertility
• Incision and ligation of blood vessel (for large hematoma Perineal Infections
and increasing in size) - Infection of the perineum
• Packing with gauze pad for drainage - If a woman has a suture line on her perineum from an
- Nursing management episiotomy or laceration repair
• Record when packing was placed and when to remove. - usually remain localized.
• Suture line care - Symptoms
- Keep dry and clean (perineal care regularly, kasi may • Pain
lochia pa ang mader kaya pwede mapunta sa sugat) • Heat
- Sitz bath once or twice a day. (or peri light) • Feeling of pressure
• May or may not have fever
Puerperal Infection • Inflammation of suture line
- Infection of the reproductive tract is another leading cause of
• One to two stitches are sloughed away
maternal mortality. When caring for a woman who has any of
• With purulent drainage
these circumstances, be aware that the risk for postpartum
infection is greatly increased.
J.A.K.E 53 of 59
- Diagnostic - Assess skin for mottling or inflammation – mottled cold

• Culture of suture drainage – kapag may lumalabas na to touch due to edema. Inflammation hot to touch
konting fluid sa suture line, yon ung kukunin nating - Exercise (walking)
sample para maipadala doon sa lab to determine what m.o. Femoral Thrombophlebitis
- Therapeutic Management - femoral, saphenous, or popliteal veins are involved.
• Removal of sutures for drainage – para lumabas ung mga - an accompanying arterial spasm often occurs, diminishing
pus tas kapag Nawala na ung swelling, saka ulit tatahiin. arterial circulation to a leg and phlegmasia alba dolens (“white
• Packing (Iodofrom gauze) – ito un mga nilalagay sa loob inflammation”).
ng 24hrs para maabsorb ung pus at naggagamot din sya at - Assessment
the same time. • Elevated tempt
• Systematic or topical antibiotic • Chills
• Analgesics • Pain
• Sitz bath, moist warm compresses, or Hubbard tank • Redness of affected leg 10 days after birth
treatments (kung sa bahay lng sya magpapagaling) (warm • Swelling below the lesion
water – increase circulation or improve the healing) • Homan’s sign (+) – dorsiflex of the foot then
- Nursing Management magkakaroon ng pain sa ilalim
• Teach the woman about proper hygiene - Diagnostics
- Remind woman to cleanse the area and change pads • Doppler ultrasound – noninvasive test.
frequently • Contrast venography – x-ray examination
- Wipe front to back after a bowel movement - Treatment
- Proper hand washing techniques • bed rest with the affected leg elevated
• Encourage ambulation • Anticoagulants (Coumarin derivative or heparin)
• Administer anagesics • Application of moist heat
Thrombophlebitis • Monitor blood coagulation levels daily before
- Inflammation of the lining of a blood vessel with the administration of anticoagulant (aPPT or PT) - Partial
formation of blood clots Thromboplastin Time – minomonitor ung response ng
- Extension of an endometrial infection pasyente natin to the anticoagulant therapy. prothrombin
- Causes: time – kung gaano kabilis mag coagulate
• A woman’s fibrinogen level is still elevated from • Never massage the skin over the clot (pwede kumalat or
pregnancy, leading to increased blood clotting. tumakbo ung clot)
• Dilatation of lower extremity veins is still present as a • Provide activities to exercise other parts of the body and
result of pressure of the fetal head during pregnancy and stimulate mind
birth. • Analgesics for pain
• The relative inactivity of the period or a prolonged time • Antibiotics – pag superficial type lng kasi may swelling
spent in delivery or birthing room stirrups leads to pooling, • Assess for possible signs of bleeding (bleeding gums,
stasis, and clotting of blood in the lower extremities. ecchymotic spot on skin, from episiotomy, suture line)
• Obesity from increased weight before pregnany and • Aspirin (Salicylic Acid) – preventive measure
pregnancy weight gain can lead to relative inactivity and Urinary Tract Infection
lack of exercise. - bacteria may be introduced into the bladder at the time of
• The woman smokes cigarettes. catheterization during childbirth and post-partum period
- Classification - 3-day pinapalitan na yung catheterization (72 hrs)
• Superficial vein disease (SVD) – namamaga - Cause: E coli
• Deep vein thrombosis (DVT) – nasa loob - Symptoms
- Risk factors • Burning on urination
- Obese • Hematuria
- have varicose veins • Feeling of frequency or always must void
- Previous thrombophlebitis • Sharp pain on voiding
- >35 yrs of age w/ increased parity • Low-grade fever
- high incidence of thrombophlebitis in family • Lower abdominal pain
- Prevention - Diagnostic: Urinalysis
- Good aseptic technique during birth - two numerous to count
- Ambulation and limiting time a woman remain in - Therapeutic Management:
obstetric stirrups. (nakataas ung paa nya sa stirrups, • Antibiotics (amoxicillin or ampicillin)
kailangan natin to i-limit kasi the longer na nakataas ung • Increase fluid intake
legs, mas tumataas ung risk for thrombo.) • Analgesics
- Support stockings for the 1st 2 weeks after birth (if with
varicosities)
J.A.K.E 54 of 59
Mastitis Postpartal Psychosis

- Infection of the breast - A woman with postpartum psychosis usually appears
- May occur as early as the seventh postpartal day or not until exceptionally sad
the baby is weeks or months old - Psychosis exists when a person has lost contact with reality.
- The organism causing the infection usually enters through - A psychosis is a severe mental illness that requires referral to a
cracked and fissured nipples. professional psychiatric counselor and antipsychotic
- Prevention: medication.
• Proper position and latching - Symptoms: Hallucinations, Delusion, Confusion, Paranoia,
• Releasing suction on nipple before removing the baby Insomnia, Suicidal thoughts, Severe mood swings
• Handwashing between handling perineal pads and
touching breasts Postpartal Postpartal Postpartal
• Keep nipples air dry Blues Depression Psychosis
• Vitamin E ointment to soften nipples daily Within first year
1-12 months
after birth
• Begin breastfeeding with unaffected breast 1-10 days after birth
Onset Delusions or
- Assessment after birth Anxiety,
Symptoms hallucinations of
• Usually unilateral but may be bilateral Sadness, tears feeling of
harming infant or
• Painful loss, sadness
self
• Swollen 10% of all
1% - 2% of all
• Reddened births
70% of all births
• Fever History of
births Possible
• Scant breast milk previous
Incidence Probable activation of
- Therapeutic Management depression,
Etiology hormonal previous mental
• Antibiotics (Dicloxacillin or Cephalosporin) hormonal
(possible) changes, illness, hormonal
response,
• Continue Breastfeeding except if abcess is present stress of life changes, family
lack of
• Cold or ice compresses for pain and a good supportive bra changes history of bipolar
social
• Warm, wet compresses to reduce inflammation and edema disorder
support
Psychotherapy,
Emotional and psychological complications of puerperium Support, drug therapy
Postpartal Despression empathy Counselling, Refer to
Therapy
- Feelings of sadness continue beyond the immediate postpartal Offer drug therapy psychiatric care,
Nursing
period and may be present for longer than 1 year. compassion Refer to safeguarding
role
- Sensations of overwhelming sadness can interfere with and counselling mother from
breastfeeding, childcare, and returning to work. understanding injury to self or
- May also have extreme fatigue, an inability to stop crying, to newborn
increased anxiety about self and infant’s health, insecurity,
psychosomatic symptoms, and either depressive or manic GENERAL & SPECIFIC PROBLEMS IN REPRODUCTIVE
mood fluctuations. AND SEXUALITY
- Risk Factors Discussed by Prof. Melanie Cambel
• History of depression, Troubled childhood Cystocele/ Rectocele
• low self-esteem - Cystocele – Herniation or relaxation of the anterior vaginal
• stress in effective support people wall, allowing the building or prolapse of the bladder.
- It may also affect the reproduction of the patient kasi
• different expectations bet. partners or disappointment in
humaharang sya sa vagina.
the child
- Humihina ung anterior vaginal wall, kaya ung bladder na may
- Management
laman, tutulakin nya ung anterior wall at sisikip ung vaginal
• assess the problem as soon as symptoms develop
canal.
• Counseling
- Mahirapan magbuntis.
• Antidepressant therapy
- Rectocele – relaxation of the posterior vaginal wall, with
- Pharmacological: anti-depressant drugs prolapse of the rectum into the vagina. (nawawala ung muscle
- Psychological: CBT, Interpersonal therapy tone ng urinary bladder, nag rerelax sya at humaharang sa
- Health teachings: vaginal wall)
• Plan a balanced program of nutrition, exercise, and sleep. - ung rectum itutulak nya ung posterior vaginal wall kaya pwede
• Share feelings with support person rin sumikip ang vaginal wall at mahihirapan din magbuntis
• Take some time every day to do something for herself so
she have a break from baby care
• Tell her not to try to be perfect
• Do not let herself be isolated by baby care.
J.A.K.E 55 of 59
Assessment Findings
Cystocele
- cystitis
- Retention, Incontinence
- Retention – hindi lumalabas yung ihi ng patient
- Incontinence – nagkakaroon ng leakage urine
- Dribbling with sneezing, coughing, or any activity that
increases intra-abdominal pressure – lumalabas ng kusa yung
urine
Rectocele
- Sensation of pressure – sa bandang gluteal area to perineum
area
Cystocele Grading - Constipation
- Hemorrhoids
- visual examination para makita yung problem
Therapeutic Management
• Pelvic floor exercises (Kegel exercise) – for Grade 1 client, to
strengthen the pelvic floor
• Biofeedback – ginagawa ito together with Kegel exercise, pt
yung gumagawa, kinoconnect ito sa patient. It is a monitoring
device para malaman kung tama ung ineecercise ng pasyente.
It involves physical therapy.
• Grade 1
• Biofeedback and Kegel’s Exercise can decrease the symptoms
- Bladder droops only a short way into the vagina.
but cannot change the size of the prolapse
- Medyo hihilig ng unti pero meron pa ding way, mild
• Vaginal pessary – supported device, a plastic or rubber.
treatment and exercise. No specific medication.
Iniinsert into vagina para masupport yung bladder. This is not
• Grade 2
cure, sinussupport lng para ma relieve ung symptoms.
- Bladder sinks far enough to reach the opening of the
(temporary)
vagina.
• Colporrhapy (anterior or posterior vaginal repair) – surgery
- Medyo malapit sa vaginal opening, masyado nya nang
• Vaginal hysterectomy – especially for the severe type, last
naba block but not enough para ma close, magkakaroon
resort for the patient. Tatanggalin yung uterus, lalo na kapag
na ng problem sa patient
kasama yung uterine prolapse
• Grade 3
- Cystocele occurs when the bladder bulges out through the Nursing Management
opening of the vagina. - Prevention of the laceration of the vagina and perineum by
- Lumalabas na nakikita na yung prolapse ng bladder, promoting gradual extension and expulsion during delivery.
masakit ito and uncomfortable and may urine leakage, - Teach postpartal perineal exercise to improve the tone of the
especially if the patient is laughing, sneezing, and perineal and vaginal muscles (Kegel’s exercise)
coughing. - Kegel’s Exercise – empty the bladder first before u do exercise,
Risk Factors: it’s like you are stopping to urinate for 5 to 10 seconds and
• Pelvic tearing during labors – sumisikip yung vaginal canal then do it for 10 minutes
nagkakaroon ng pressure towards the perineal area, pwede - Advise proper spacing of the pregnancies to give adequate
magkaroon ng lacerations time for reproductive organs to fully recover (2 year)
• Congenital weakness of the vaginal wall – merong mga babae - Promote perineal healing
na weak yung connective tissue. Congenital – anterior vaginal o Kegel’s exercise can improve muscle tone around the
wall ang weak reproductive organs
• Multiparity – high risk kase humihina nay ng vaginal wall, o Instruct on gradual increase of roughage in the diet;
nao-overuse yung area regular bowel movement is necessary.
• Advanced age resulting to vaginal muscle weakness – 35 y/rs - Increase fluid intake, high fiber diet
old >
Alternative to Childbirth
• Poor bearing down in labor – hindi marunong umere
- mga di na magkakaanak
• Vaginal lacerations causing weakness
Surrogate Mothers
- A surrogate mother is a woman who agreed to carry a
pregnancy to term for a sub fertile couple.
- Ibang mother yung nagdadala ng baby
- a woman na di kaya magbuntis for this baby
J.A.K.E 56 of 59
- Pwedeng sa surrogate mother na egg cell yung gagamitin and 3) Coping – to cope up with the infertility problem, they can
be impregnated by the man’s sperm, no intercourse na go adoption.
mangyayari 4) Ego integrity/ psychological
- Sometimes nagkakaroon ng legal issues arises kase 5) Sexual problems/ martial problems
nagkakaroon ng emotional attachment yung surrogate mother 6) Physiological
sa baby 7) Financial
- They need to undergo therapist
Adoption
- Urge couples to consider foreign-born or physically or
cognitively challenged children or children of other races to
make their family feel complete.
- Methods of Adoption:
o Agency Adoption – traditional adoption may mga
kinokontak na agency or bahay ampunan for waiting list.
o Sa Pilipinas ang pinaka mahaba ang proseso for Adoption
o International Adoption – often provide a baby in less time
than a traditional agency adoption but may create Two types of infertility
unanswered questions about prenatal health care or the 1) Primary infertility
birth parent’s background. Countries that are willing to - No previous pregnancy
permit abandoned or orphaned children to be adopted 2) Secondary infertility
internationally are often poor or war torn, meaning the - With previous pregnancy pero ung mga sumunod wala na.
child’s health or development may have suffered. Mga
war babies. Kapag nagbago yung condition hindi nila Female infertility
makukuha yung bata bago makapag travel ulit yung • Ovulation disorders:
couple para makuha yung bata kapag na notice na sila - Aging – no.1 cause, this can result to anovulation
para kuhanin yung bata. There are political reforms na - Diminished ovarian reserve – konti na ung egg cells
nagi interfere - Endocrine disorder – such as diabetes
o Private Adoption – families who have exhausted other - Polycystic ovary syndrome – may problem sa ovary
options or who cannot wait for the traditional agency - Premature ovarian failure
adoption process, private adoption is another alternative. • Tubal factors:
- the adopting parents usually agree to pay a certain - Obstruction – in the fallopian tube
amount of money to a birth mother, part of which o History of pelvic inflammatory disease (PID)
presumably goes toward the birth mother’s prenatal and o Tubal surgery
medical expenses. o Previous ectopic and salpingectomy
- Strict anonymity is maintained between the two parties; in • Uterine/ cervical factors:
other instances, the adopting couple and birth mother come to - Congenital uterine anomaly
know each other well. Some pregnant women prefer to place - Fibroids
their child for adoption directly with a couple this way rather - Poor cervical mucus quantity/ quality – masyadong
than through an agency, so they can approve of the couple and malapot
maintain contact with the child afterward o Smoking
- Hindi basta basta nagbibigay ng money kase parang binibili o Infection
yung baby ang gagawin yung money na binibigay is for the - Your chance of pregnancy each month declines with age:
expenses of the true mother talaga. • A healthy 30-year-old woman has about 20$ chance of
- Pwedeng di kilala yung nagpa pa adopt ng baby or pwedeng getting pregnant each month.
kilala yung mother and thru lawyers • A healthy 40-year-old woman has about a 5% chance of
Child-Free Living getting pregnant each month.
- an alternative lifestyle available to both fertile and sub fertile - Nakakaapek din ung sobrang taba, your ovaries may compress.
couples.
- couples who have been through the rigors and frustrations of
subfertility testing and unsuccessful treatment regimens, child-
free living may emerge as the option they finally wish to
pursue.
Infertility discussed by Prof. Francis Vasquez

- The failure to conceive following 12 months of unprotected
and regular sexual intercourse.
- Both husband and wife should undergo test.
- Infertility issues:
1) Acceptance
2) Blaming game
J.A.K.E 57 of 59
- Genetic disorders
- Exposure of scrotum to high temperatures
- Psychologic disorders – stress, u will not able to erect –
impotence (erectile disfunction)
• Substance abuse
- Changes in sperm (smoking, heroin, marijuana, amyl
nitrate, butyl nitrate, ethyl chloride, methaqualone)
- Decrease in sperm (Hypopituitarism, debilitating or
chronic disease, trauma, gonadotropic inadequacy,
decrease in libido, heroin, methadone, selective serotonin
reuptake inhibitors and biturates.)
- Impotence (Alcohol, antihypertensive medication)
• Obstructive lesions of the epidymis and vas deferens
• Nutritional deficiencies
Male Infertility
Normal values for human semen
1) Volume = 2.0 ml or more (3-5ml)
2) pH = 7.2 or more (alkaline)
3) Sperm count = at least 20 M/ ml
4) Motility = 50% or more motile
5) Morphology = 15% or more normal forms (actual: 30%)
6) WBC’s < 1M/ mL
7) Viability = 50% or more live
Cause of male infertility o Paano sila itetest:

• Structural or hormonal disorders - Male: sperm count, physical exam, history taking,
- Undescended testes – ung testes wala sa scrotal sac, nasa substance abuse
abdominal cavity. Kaya sya nasa scrotal sac, to maintain - Female: histerosalpingografie – i-Xray ung buong
the temperature lower than the body temp. reproductive organ.
- Varicocele – tumigas ung blood vessels supplying blood
to ur testes. Types of Assisted pregnancy
- Hypospadias – nasa ibabaw ung butas, prone to UTI 1) GIFT – Gamete Intra Fallopian Tube Transfer
- Low testosterone level - Sperm and eggs are placed in a fallopian tube to allow
- Testicular damage cause by mumps fertilization in the natural site.
• Other factors - Harvest the sperm, harvest the egg cell tas kinombine at
- Endocrine disorders pinasok sa fallopian tube.
- Sexually transmitted infections
- Exposure to workplace hazards such as radiation or toxic
substances
J.A.K.E 58 of 59
o GIFT, ZIFT and AI – dapat may tubal patency, walang

bara sa fallopian tube para makalad or makadaan ung
fertilized egg
4) In Vitro fertilization process
- A woman’s egg cells are combined with a man’s sperm
cells outside the uterus. The fertilized egg is then
implanted in the woman’s uterus and if successful, begins
the pregnancy cycle.
- Pag may trophoblast tissue, ipapasok intrauterine tapos
iaattach na sa uterine wall.
2) ZIFT – Zygote Intra Fallopian Tube Transfer

- Eggs and sperm are first fertilized in the lab. Then the
zygote (fertilized egg) is transferred to a fallopian tube.
5) Mitochondrial donation
- Kukuha ng egg cell sa donor na babae, ang gagamitin lng
ay mitochondria nun donor tapos tatanggalin ung nucleus
ng donor at ipapalit ng nucleus ni nanay.
3) Artificial insemination
• AI by source
a) Therapeutic husband insemination (THI) – kay
husband pa rin
b) Therapeutic donor insemination (TDI) – another
person. (sperm bank)
• AI by placement
a) Via cervical canal
b) Via uterus
- Ex: super acidic ng vaginal canal ni mrs kaya
namamatay lahat ng sperm ni mr. So ang
gagawin, i-THI si husband tapos ilalagay sa
uterus or cervical canal.
- Surrogate mother – It's a woman who gets
artificially inseminated with the father's sperm.
She will not see and know the information of the
couple. And she will now also see her baby.
Surprise! 59 pages HAHAHA. May gagamit at magpiprint pa kaya

neto? HAHA hindi rin namin napansin na ganto pala karami ung
prelims naten HAHHAHA so ayon good luck nlng saten! Sa
sobrang dami naming tinype baka marami rin kaming typo/
corrections, kayaa paayos nlng kung may nakita kayo hehe Review
well and Good luck! – Aki
J.A.K.E 59 of 59

Ncma219 Ob Lec: BSN 2Nd Year 2Nd Semester Prelim 2022: Bachelor of Science in Nursing 2YB

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Ncma219 Ob Lec: BSN 2Nd Year 2Nd Semester Prelim 2022: Bachelor of Science in Nursing 2YB

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Bachelor of Science in Nursing 2YB

NCMA219 OB LEC: BSN 2ND YEAR 2ND SEMESTER PRELIM 2022

- 22 pairs of autosomes (homologous autosomes) –

- If the combination will be dominant brown and non-dominant Inheritance of Disease

- Homozygous – healthy gene + healthy gene

- Autosomal – the first 22 chromosomes are autosomes almost

- Both parents of a child with the disorder are clinically free of

- X-linked dominant inheritance occurs when a gene responsible

• Sickle Cell Anemia

- The father has both nondominant normal x and y, while the

 Dominant disease X from the mother + nondominant normal x

- Father has nondominant normal y + mother has nondominant

 Blue – healthy; red - disease

- The father has nondominant disease x and nondominant

- mutation examples in humans are:

Biophysical - UTZ aided

Economic abuse • Anxious if her appointment is running late

Protection Order Nursing interventions

• Preterm 20 – 36 weeks • Yutopar – progesterone (prevents)

- Signs and symptoms: Etiology

Abruptio-Placenta - Can cord coil to abruptio placenta?

Summary - No IE (increase bleeding)

• Why there is proteinuria and edema?

- Incompetent Cervix – hindi pa umaabot ng 9 months nag da-

- Risk Factors: Treatment

- Kung saan nadedetach, un pinaka center kpag nadetach Nursing management

GESTATIONAL CONDITIONS - Predisposing Factors:

Severe Preeclampsia • Postictal stage:

Limitations in • If pregnant, hospitalization during the last part of

Type 1 DM Type 3 DM (Sir V)

Sir V… • 1.0 unit/kg for weeks 36 to term

• Pregnancy – specially 1st trimester Effects of Sickle Cell Anemia to pregnancy

PROBLEMS WITH THE 4P’S epinephrine and norepinephrine, oxytocin, estrogen,

Problem with the Power (The Force of Labor)

Fetal Distress • Augmentation of Labor

o Drugs: • Pain relievers (morphine sulfate)

Contraction Rings - Incomplete rupture

• A small fetus Therapeutic Management

• Hydramnios – madaling umikot yung baby • Early rupture of the membranes

Shoulder Dystocia - Inlet contraction

External Cephalic Version - Anemia

definitely you cannot give tocolytic. Since preterm labor

Types - Ensure airway patency

o Balloon occlusion and embolization of the internal • Lochia Alba

- Signs of Subinvolution: Endometritis

- Diagnostic - Assess skin for mottling or inflammation – mottled cold

Mastitis Postpartal Psychosis

Infertility discussed by Prof. Francis Vasquez

Cause of male infertility o Paano sila itetest:

o GIFT, ZIFT and AI – dapat may tubal patency, walang

2) ZIFT – Zygote Intra Fallopian Tube Transfer

Surprise! 59 pages HAHAHA. May gagamit at magpiprint pa kaya

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