NCM 109 Lecture Maternal and Child at Risk 3 5

Care of At-Risk / High Risk, and
Sick Mother and Child

Intended Learning Outcomes:
Formulate with the client a plan of care to address needs / problems of at-risk / high risk mother
and child.
DR. JULAIZA PINEDA TANABE

※ Nursing Care of the Pregnant Client
※ Nursing Care of the Client during Labor

and Delivery
※ Nursing Care of the Post-partum Client

Comprehensive Assessment:
The importance of early identification of risk factors through detailed
history-taking and assessment.
Individualized Care Plans:
Developing care plans that address specific risks such as gestational
diabetes or hypertension.
Nutritional Guidance:
Tailoring dietary advice to meet the unique needs of the pregnant
client.
Psychosocial Support:
Addressing the emotional and psychological needs through counseling
or referral to support services.
Interview - comprehensive health history emphasizing the current

pregnancy, previous pregnancies, the family, a psychosocial profile,
a physical assessment, diagnostic testing, and an overall risk
assessment. Two types of data are collected: the patient’s
subjective appraisal of her health status and the nurse’s objective
observations.
Reasons for Seeking Care - chief concerns should be recorded in her

own words to alert other personnel to the priority of needs
identified. Initial visit, a typical desire is for information about the
normal course of pregnancy.
Current Pregnancy - review of symptoms she is experiencing (e.g.
nausea and vomiting) and how she is coping with them helps
establish a database to develop a plan of care. Some early teaching
may be provided at this time.
Childbearing and Female Reproductive System History – menarche;

menstrual history; contraceptive history; history of infertility or
gynecologic conditions; history of any STIs; her sexual history; and a
detailed history of all her pregnancies, including the present one,
and their outcomes; last Papanicolaou (Pap) test and note result;
date of LMP to establish the EDB.
Health History - physical or surgical procedures that can affect the

pregnancy (e.g. diabetes or epilepsy requires special care or
medications being taken such as cortisone, insulin, or
anticonvulsants.)
Nutritional History – dietary assessment can reveal special diet

practices, food allergies, eating behaviors, the practice of pica, and
other factors related to her nutritional status.

Individualized Care Plans:
HYPEREMESIS GRAVIDARUM
- pernicious or persistent vomiting during pregnancy
- Is nausea and vomiting of pregnancy that is prolonged past
week 12 of pregnancy
- Severe that dehydration, ketonuria, and significant weight
loss occur with the first 12 weeks of pregnancy
- Incidence of 1 in 200 to 300 women
- Cause is unknown, but women with the disorder may have
increased thyroid function because of hCG
o Associated with Helicobacter pylori, the same bacteria that
cause peptic ulcers

CAUSES:
- High hCG
- Hyperthyroidism
- Hypofunction of the anterior pituitary gland and adrenal
cortex
- Abnormalities of the corpus luteum
- Helicobacter pylori infection
- Psychologic factors
- High estrogen and progesterone = Ptyalism
- Low gastric motility
- Immune response to fragments of chorionic villi that enter the
maternal bloodstream
- Immune response to the “foreign” fetus
MORNING SICKNESS HYPEREMESIS GRAVIDARUM
Nausea sometimes Nausea accompanied by severe

accompanied by vomiting vomiting
Nausea that subsides at 12 Nausea that does not

weeks or soon after subside
Vomiting that does not cause severe Vomiting that causes

dehydration severe dehydration
Vomiting that allows you to keep some Vomiting that does not allow you
food down to keep any food down

ASSESSMENT
- Excessive nausea, vomiting, weight loss & electrolyte disturbance
during pregnancy
- Elevated Hct concentration because her inability to retain fluid has
resulted in hemoconcentration
- Polyneuritis, because of a deficiency of B vitamins develops
- Urine may test positive for ketones, evidence that a woman’s body is
breaking down stored fat and protein for cell growth
- If left untreated, the condition is associated with intrauterine growth
restriction or preterm birth if the patient becomes dehydrated and can
no longer provide a fetus with essential nutrients for growth

- Determine exactly how much N/V women are having during
pregnancy:
o Ask the woman to describe the events of the day before if she
says it was a typical day.
o How late into the day did the nausea last?
o How many times did she vomit, and how much?
o What was the total amount of food she was able to eat?
- Low Na, K, and Cl
- Polyneuritis
- Weight Loss
- Urine may test positive for ketones
- IUGR

- Determine exactly how much N/V women are having during
pregnancy:
o Ask the woman to describe the events of the day.
o How late into the day did the nausea last?
o How many times did she vomit, and how much?
o What was the total amount of food she was able to eat?
- Low Na, K, and Cl
- Polyneuritis
- Weight Loss
- Urine may test positive for ketones
- IUGR

- Determine the pregnant woman’s:

o Level of support
o Any significant stressors in her life (emotional state)
o Understanding of nutrition and self-care measures
o Amount and character of any emesis
o Nausea and vomiting
o I&O
o FHR
o Jaundice or bleeding
o High hematocrit

THERAPEUTIC MANAGEMENT
If no vomiting after the first 24 hours of oral restriction =
small amounts of clear fluid (gelatin, water, ice, popsicle,
broth soup) may be started.
If on clear fluid, small quantities of dry toast, crackers, or

cereal may be added every 2 or 3 hours, then to a soft
diet, then to a normal diet.
If vomiting returns, enteral or total parenteral nutrition

may be prescribed
Home care follow-up

Need to be hospitalized for about 24 hours to monitor intake,
output and blood chemistries and to restore hydration
All oral food and fluids are usually withheld (NPO)
IVF (3000 ml of Ringer’s lactate with added vitamin B, for
example) = to increase hydration
Antiemetic, such as metoclopramide (Reglan) = to control
vomiting
Carefully measure intake and output, including the amount of
vomitus

PLANNING
The patient will be able to explain hyperemesis gravidarum,
its therapy and its possible effects on
her pregnancy
The patient’s condition will be corrected, and complications
will be avoided
Client remains free of signs and symptoms of dehydration’
no further episodes of vomiting occur.
Client eats at least 2500 calories daily or receives
supplemental nutrition intravenously or enterally

IMPLEMENTATION
1. Nursing Management
Serve small portions of food presented attractively
Hot foods should be hot, and cold foods should be cold
Put emesis basin out of sight
Maintain a relaxed, quiet environment away from food
odors or offensive smells
Oral hygiene
While receiving TPN at home, instruct to check her urine for
glucose and ketones twice daily

IMPLEMENTATION
2. Therapeutic Management
Goal of treatment - Control of vomiting
a. Antiemetics
b. NPO
Correction of dehydration
a. IV fluids (Ringer’s Solution)
b. Measure intake and output, including the amount of vomitus
Restoration of electrolyte imbalance
a. Potassium Chloride is added to the IV infusion (NEVER GIVE IV
push!)

IMPLEMENTATION
Maintenance of adequate nutrition
a. Replacement of Thiamine, Pyridoxine (vitamin B6)
b. Woman may need total parenteral nutrition (TPN) or enteral
feedings
Home care instructions upon discharge:

- Small amounts of clear liquid may be begun
- Small quantities of dry toast, crackers or cereal may be added
every 2 or 3 hours
- Then gradually advance to a soft diet then to a normal diet.

EVALUATION
Expected Outcomes:
The patient is able to define hyperemesis gravidarum and
identify its therapy and its possible
effects on her pregnancy
The patient’s condition is managed and complications are

avoided.



WOMAN WITH DIABETES MELLITUS
● Not a good candidate for oral contraceptives =

progesterone interferes with insulin activity and
raises blood glucose levels
● Estrogen - in oral contraceptives increases lipid
and cholesterol levels and blood coagulation
● IUD devices - not advised for clients with DM due
to difficulty fighting infections
DIABETES MELLITUS
- Endocrine disorders that pancreas cannot regulate

blood glucose level
4 CARDINAL SIGNS OF DIABETES:

1. Polydipsia - why and cause
2. Polyuria
3. Polyphagia
4. Weight loss

GESTATIONAL DIABETES MELLITUS
1. Type 1 - occurs in childhood and represents

failure of the pancreas to produce insulin for
body requirements.
2. TYPE 2 - Failure of adequate insulin production

that occurs with aging.

GESTATIONAL DIABETES MELLITUS
3. Gestational Diabetes
- Women develop insulin resistance as pregnancy
progresses. Phenomenon caused by hormone:
HUMAN PLACENTAL LACTOGEN and high level cortisol,
estrogen, progesterone and catecholamines.
● Infants of women with poorly controlled diabetes tend to
be large (10 Lbs) because the increased insulin the fetus
must produce to counteract the overload of glucose, he or
she receives acts as growth stimulant
DIABETES MELLITUS
Complications:
a. Shoulder Dystocia
b. Cephalopelvic Disproportion
Diabetes during pregnancy:

FETAL
● High incidence of congenital anomaly - Caudal Regression
Syndrome (failure of lower extremities to develop)
● Spontaneous Miscarriage
● Stillbirth infants
DIABETES MELLITUS
Neonates:
● Hypoglycemia - cyanosis, apnea, hypothermia, poor
muscle tone and even seizure might occur
● RDS
● Hypocalcemia - irritability, tremors, and poor feeding
habits
● Hyperbilirubinemia - drowsiness, dark urine, pale
stools and poor feeding habits

GESTATIONAL DIABETES
- Becoming diabetic during pregnancy usually occurs at midpoint

pregnancy when insulin resistance becomes noticeable
RISK FACTORS INCLUDE:

● Obesity
● Age over 25 years
● History of large babies
● History of unexplained fetal or perinatal loss
● History of congenital anomalies in previous pregnancy
● History of PCOS
● Family history of diabetes
● Member of a population with a high risk for diabetes
ASSESSMENT:
● Using a 50g oral glucose challenge test
a. Venous blood sample is taken for 1 hour later
b. If the serum glucose level at 1 hour is more than 140mg/dL
c. The woman is schedules for a 100g 3 hour fasting glucose tolerance
test
d. If two of the 4 blood samples collected for this test are abnormal or
the fasting values is above 95 mg/dL a diagnosis of Diabetes is made
Measurement of glycosylated hemoglobin
- Detect the degree of hyperglycemia present and measure of the
amount of glucose attached to Hgb
THERAPEUTIC MANAGEMENT:
1. Less insulin before pregnancy because the fetus is
using so much glucose for rapid cell growth
2. Later in pregnancy she will need an increased amount
because her metabolic rate and need increases
3. Re-regulation is a necessity because of the changes in
her metabolism
4. Type of insulin is a short-acting insulin (regular)
combined with intermediate type
BLOOD GLUCOSE MONITORING:

a. Uses a fingerstick technique when one of the fingers are punctured
b. Fasting blood glucose level 95-100 mg/dL and a 2-hour postprandial level
below 120 mg/dL are well-adjusted values
c. Hypoglycemia is present, she should ingest some form of sustained
carbohydrate such as a glass of milk and some crackers
INSULIN PUMP THERAPY:

- Maintains her diet and balances her exercise level an effective method to
keep serum glucose constant is to administer insulin by a continuous pump
during pregnancy.

PREGNANCY INDUCED HYPERTENSION
- PIH is a condition in which VASOSPASM occurs during

pregnancy in both large and small arteries.
- A vascular disease of unknown cause which occurs any
time after the 24th wk AOG up to 2 wks post-partum
with triad of sx: HPN, proteinuria & edema (extensive) -
originally termed as “toxemia”

VASOPASM
INTERSTITIAL
VASCULAR EFFECTS KIDNEY EFFECTS
EFFECTS
INVREASED
GLOMERULI DIFFUSION FLUID
INFILTRATION RATE & FROM BLOODSTREAM
VASOCONSTRICTION
INCREASED INTO INTERSTITIAL
GLOMERULI TISSUE
MEMBRANES
INCREASED SERUM
POOR ORGAN
BUN, URIC ACID, & EDEMA
PERFUSION
CREATININE
DECREASED UO &
INCREASED BP
PROITENURIA

RISK FACTORS:
Multiple pregnancies
Primiparas from <20 yrs of age or older than 40 yrs
Women with low socio-economic background
Multigravida
Hydramnios
Hx of heart disease, diabetes with vessel or renal
involvement and essential hypertension
CLASSIFICATION
I. Gestational hypertension
II. Pre-eclampsia:
- Mild
- Severe
III. Eclampsia
Gestational Hypertension
BP: 140/90 mmHg
(-) proteinuria or (-) edema
Mild Pre-eclampsia:
BP of 140/90 mmHg taken on two occasions at least
6 hrs apart
proteinuria (1+ or 2+ on a reagent test strip on a
random sample)
edema
excessive wt gain > 2lb/wk in 2nd trimester
1 Lb/wk 3rd trimester

Severe Pre-eclampsia
160/110 BP or increase on at least two occasions 6 hrs
apart, or her diastolic pressure is 30mmHg above her
pregnancy level
Marked proteinuria, 3+ or 4+ on a random urine
sample, or > 5g in a 24 hr sample
Extreme edema, epigastric pain, nausea & vomiting
Headache, blurring of vision, hyperreflexia – cerebral
edema
Eclampsia:
Most severe classification of PIH
Triad sx + seizure or coma
- Bp rises suddenly
- Temperature rises sharply to 39.4-40c
- Blurring of vision
- Headache
- Hyperactive reflexes- ankle clonus
- Epigastric pain and nausea

Laboratory and Diagnostics:

24 hr urine specimen collection
Random urine dipstick evaluation
BP taking and recording
Weight monitoring

Planning / Outcomes
Maintenance of blood pressure within normal limits
Improve placental blood flow and fetal oxygenation
Prevent seizures and maternal complications such as
stroke as the patient’s condition stabilized before surgery
Mother and family will understand the need to follow
with treatment regimen
Management – Mild PIH

1. Monitor antiplatelet therapy
2. Promote bed rest
- Left recumbent position
3. Promote good nutrition
- Usual pregnancy diet
4. Provide emotional support

Management severe PIH

If the pregnancy is less than 36 wks AOG – labor can be induced to end
the pregnancy at this point
If the pregnancy is less than 36 wks or amniocentesis reveals immature
lung function – to alleviate the severe sx and allow the fetus come to term
1. Support bed rest
2. Monitor maternal well-being
3. Monitor fetal well-being
4. Support a nutritious diet
5. Administer medications as ordered:
- hydralazine (Apresoline)
- labetalol (Normodyne)
- magnesium sulfate
- nifedipine drip
Bed Rest
women are hospitalized, confined in private rooms
visitors are restricted
noise and light limitation
allow opportunities to express feeling
Monitor Maternal Well Being
take blood pressure frequently
obtain blood studies as ordered
(Cbc, plt cnt, LFT, BUN, crea, fibrin products, blood typing and
crossmatching, Hct)
obtain daily weights
UO monitoring
24hr urine sampling
Fetal Well Being:

doppler auscultation
use of external fetal monitor
NST or BPP
O2 administration to the mother
Medications:
Hypotensive drugs – lowers BP
- Hydralazine (Apresoline)
- Labetalol (Normodyne)
- Magnesium Sulfate (Magsulfate) - Infuse loading dose slowly over 15-30
mins, 10g or deep IM, 5gm/buttocks then IV drip of 1gm per hour
(1gm/100ml dextrose)
Administer a piggyback infusion
Make sure to check the urine output during the administration
WOF: Magnesium sulfate toxicity

Decreased urine output
Depressed respirations
Reduced consciousness
Decreased deep tendon reflexes – patellar reflex (knee jerk)
Long term effect: osteoporosis
Antidote: 10 ml of 10% CALCIUM GLUCONATE (1gm)

Management with Eclampsia

I. Management of the tonic-clonic seizures
Tonic- last for 20 secs, contraction
- Maintain patient airway
- No longer depressors
- O2 supplement
- Side lying position
Clonic- 1 min, contract & relax
- O2 supplement
- Diazepam, or magnesium sulfate
Postictal – semi comatose
- Cannot be aroused except by painful stimuli for 1 to 4 hrs
- Side lying position
- NPO
- Close monitoring and possible labor
- Check vaginal bleeding q15 mins

Nursing Interventions during the Post-partum Period

Occurs no more than 48 hours after birth
Monitor BP and alert that eclampsia can occur as late as 2-to-3-
week post birth
Postpartum check-up to have their blood pressure evaluated to
be certain it has returned to normal
Expected Outcome
Blood pressure within normal limits
Understand maternal complications and prevent seizure episodes
Understand the need and importance to follow treatment
regimen

ABNORMAL UTERINE BLEEDING
o Bleeding problems are caused by an imbalance in the

hormones that control the menstrual cycle
and are referred to as dysfunctional uterine bleeding
o When vaginal bleeding is not related to the menstrual
cycle, it is of increased concern
o This is especially true when it occurs in childhood before
menstruation has begun, during pregnancy, and at
midlife, after a woman has entered menopause.
ABNORMAL VAGINAL BLEEDING
May be more likely associated with the following:

1. In a young pre-pubertal girl: injury, sexual abuse, a blood
clotting problem, early puberty, and severe vaginal irritation.
2. In a woman of reproductive age: hormonal imbalance, tubal
or ectopic pregnancy, molar pregnancy, placenta previa,
uterine fibroids, certain kinds of cysts and tumors (rarely
cancerous), endometriosis, use of
birth control pills, and use of intrauterine device.
3. In post-menopausal women: effects of hormone

replacement therapy, cancer, certain kinds of cysts
and tumors (non-cancerous), atrophic vaginitis
(thinning, drying, and inflammation of the vaginal
walls that may occur when your body has less
estrogen), weakened pelvic floor muscles causing
prolapse
Diagnosis:
Evaluation of Abnormal Uterine Bleeding includes:
1. Endometrial Biopsy
2. Dilatation and Curettage
Treatment
1. Trial of hormonal birth control pills
2. Using oral / injections
3. Intrauterine device delivery
4. Other prescription medication may be prescribed to slow
bleeding down
Treatment
5. Surgical procedures include:
Hysteroscopy
Endometrial ablation
Uterine artery embolization
Hysterectomy
Exploratory laparotomy (EXLAP) through an abdominal
incision
Vaginal approach, laparoscopy

Endometrial Ablation

Uterine Artery Embolization

HYDATIDIFORM MOLE
-an abnormal proliferation and then degeneration of the

trophoblastic villi.
o Become filled with fluid and appear as clear fluid-filled,
grape sized vesicles.
o Embryo fails to develop beyond a primitive start
o Abnormal trophoblast cells must be identified because they
are associated with choriocarcinoma,
a rapidly metastasizing malignancy.

HYDATIDIFORM MOLE
- Tends to occur who have a low protein intake
- In women older than age 35 years
- In women of Asian heritage
- In blood group A women who marry blood group O men
Molar pregnancy can be:
o Complete
-Trophoblastic villi swell and become cystic
-embryo dies early at only 1 to 2 mm in size, with no fetal blood
present in the villi
-chromosomal analysis, was contributed only by the father or an
“empty ovum” was fertilized and
the chromosome material was duplicated
HYDATIDIFORM MOLE
o Partial
- some of the villi form normally
- syncytiotrophoblastic layer of villi, however, is swollen and
misshapen. Macerated embryo, 9 weeks
gestation may be present and fetal blood may be present in the
villi
- 69 chromosomes = a triploid formation in which there are three
chromosomes instead of two for
every pair
- One set of 23 chromosomes did not undergo reduction division
supplied 46

HYDATIDIFORM MOLE
ASSESSMENT
- Confirmation of pregnancy and length of gestation
- Amount of bleeding and description, location and severity of pain
- Assess hCG level
- Assess early development of preeclampsia
Ultrasound Examination:
o A partial mole that includes some fetal tissue and membranes
o Complete mole that is composed only of an enlarged villi but
contains no fetal tissues or
membranes
HYDATIDIFORM MOLE
PLANNING
- The patient will have an eventful recovery following successful
evacuation of the mole.
- The woman will be able to explain GTD and its treatment, follow-
up and long term implications for
pregnancy.
- The patient will be able to discuss the importance of care and will
indicate her willingness to
cooperate with the regimen
- The patient and her partner will verbalize their grief at the loss of
their anticipated child

HYDATIDIFORM MOLE
NURSING MANAGEMENT
Assess the patient’s emotional state and coping ability
Relieve patient’s anxiety and family’s grief about the loss of
pregnancy
Observe bleeding and signs of infection
The patient needs to know the importance of the follow-up visits
She is advised contraception to delay becoming pregnant again
until after the follow-up program
is completed

HYDATIDIFORM MOLE
THERAPEUTIC MANAGEMENT: COLLABORATIVE
Evacuation of the trophoblastic tissue
- Before evacuation, chest radiography, CT scan, or MRI may be
performed
- CBC, coagulation status, and blood type and screen or cross-
matching procedures
- The mole is usually removed by Vacuum Aspiration followed by
curettage
- After tissue removal, IV oxytocin is given, to contract the uterus
- The tissue obtained is sent for laboratory evaluation

HYDATIDIFORM MOLE
Continuous follow-up care
o Chemotherapy – methotrexate
- If after a year of monitoring, the hCG serum titers remain
within the normal limits, the couple may
be assured that subsequent normal pregnancy can be
anticipated, with a low probability of recurring hydatidiform
mole.

ECTOPIC PREGNANCY:
- Implantation occurs outside the uterine cavity; occur on the surface of
the ovary or in the cervix
- common site is in the fallopian tube – distal 3rd
o 80% occur in the ampulla
o 12% occur in the isthmus
o 8% are interstitial or fimbriae
-Second most frequent cause of bleeding in early pregnancy
-Because of increasing rate of PID, leads to tubal scarring
Occurs more frequently in women who smoke, with IUD, or following in
vitro fertilization
Common complication during 1st trimester
Early phase is normal & diagnosed late or when pain is evident
More serious problem is hemorrhage
ECTOPIC PREGNANCY:
TYPES:
1. Tubal – most common type of implantation
2. Cervical – implantation is near or in the cervix
(CS scar / uterine sx)
3. Abdominal – within the abdominal cavity
CAUSATIVE FACTORS:
- Tubal damage – PID
- Previous tubal surgery
- Congenital anomalies of the tube
- Endometriosis
- Previous ectopic pregnancy
- Presence of an IUD
- Exposure to diethylstilbesterol (DES)

ECTOPIC PREGNANCY:
- Amenorrhea
- Nausea & vomiting
- (+) pregnancy test
- (+) sharp, stabbing pain in one of her lower abdominal quadrants at the time
of rupture, followed
by scant vaginal spotting
- If internal bleeding progresses to acute hemorrhage, a woman may
experience:
o Light headedness
o Rapid pulse
o Signs of shock (rapid, thread pulse, rapid respirations and falling blood
pressure)
- Leukocytosis from trauma

ECTOPIC PREGNANCY:
Early Signs
1. Abnormal menstrual period
2. Spotting
3. Positive signs of pregnancy (1st trimester)
4. Dull pain on affected side in some cases
Impending/ Post-tubal Rupture

1. Sudden acute lower abdominal pain
2. Nausea & vomiting
3. Referred pain
4. Neck pain
5. Rectal pressure
6. Signs of shock like elevated PR, RR, and BP during its early
stage and then drops
7. Vaginal bleeding (scanty & dark)

ECTOPIC PREGNANCY:
DIAGNOSTIC EXAMS
- A transvaginal sonogram will demonstrate the ruptured
tube and blood collecting in the
peritoneum
- Det tubal mass and absence of gestational sac within the
uterus
- Either a falling hCG or serum progesterone level suggests
that the pregnancy has ended
- A laparoscopy or culdoscopy can be used to visualize the
fallopian tube
ECTOPIC PREGNANCY:
If a patient waits before seeking help:
- Abdomen is rigid
- Cullen’s sign
- Extensive or dull vaginal or abdominal pain
- Movement of the cervix on pelvic examination may
cause excruciating pain
- Shoulder pain
- A tender mass is usually palpable in Douglas’ cul-de-sac
on vaginal examination.
Complication: cessation of pregnancy – surgery

ECTOPIC PREGNANCY:
Complication:
cessation of pregnancy – surgery
Other complications:
o Hypovolemia
o Shock
o Hormonal problems
o Infertility
o Another / future ectopic pregnancy
ECTOPIC PREGNANCY:
PLANNING
- The patient will be able to explain ectopic pregnancy,
treatment alternatives and implications for future
childbearing
- The patient and her caregivers will be able to detect
possible complications early and manage
them appropriately
- The patient and her partner can begin verbalizing their
loss and recognize that the grieving process usually lasts
several months
ECTOPIC PREGNANCY:
1. Removal of EP with tubal resection
2. Salphingostomy – is a surgical incision into a fallopian tube. This
procedure may be done to repair a damaged tube or to remove an EP
(one that occurs outside of the uterus)
3. Salphingectomy – is the surgical removal of one (unilateral) or both
(bilateral) fallopian tubes. Fallopian tubes allow eggs to travel from
the ovaries to the uterus. A partial salpingectomy is when you have
only part of a fallopian tube removed.
4. Salphingo – oophorectomy – is the surgery to remove the ovaries
and fallopian tubes. Removal of one ovary and fallopian tube is called
a unilateral salpingo-oophorectomy. When both are removed, it’s
called a bilateral salpingo-oophorectomy.
ECTOPIC PREGNANCY:
This procedure is used to treat a variety of
conditions, including ovarian cancer
VS
Vaginal bleeding
Characteristics & location of pain
Abdominal tenderness
LMP
Pregnancy test results

ECTOPIC PREGNANCY:
NURSING MANAGEMENT
Nurses need to be alert to the possibility of ectopic pregnancy if a
woman presents with complaints of abdominal pain and lack of
menses for 1-2 months
If the woman is receiving treatment using methotrexate, the
nurse advises the woman to avoid sun exposure
Stress that some abdominal pain is common
Advise the woman to report heavy vaginal bleeding, dizziness, or
tachycardia
Stress the need to return for follow-up B-hCG testing

ECTOPIC PREGNANCY:
CBC, H&H, typing and cross-matching, and possible hCG level for immediate
pregnancy testing
Intravenous fluid
Blood then can be administered through this same line when matched.
As with miscarriage, women with Rh-negative blood should receive Rh (D)
immune globulin (RhIG) after an ectopic pregnancy for isoimmunization
protection in future childbearing
Encourage verbalization of feelings – grief: emotional support, referrals
The therapy for a ruptured ectopic pregnancy is laparoscopy to ligate the
bleeding vessels and to remove or repair the damaged fallopian tube.

SPONTANEOUS ABORTION
- Interruption of a pregnancy before a fetus is viable; fetus of more than 20-

24 weeks of gestation; weight less than 500g
- Occurs in 15%-30% of all pregnancies
- Early or Late Miscarriage
CAUSES:
Chromosomal aberration
Implantation abnormalities
Low progesterone from corpus luteum
Maternal & Intra-abdominal infections
Endocrine disorders
Abnormalities of the reproductive system (uterus/cervix)
Teratogenic drugs
Ingestion of alcohol

CLASSIFICATIONS
1. Threatened
- Unexplained bleeding (spotting or light bleeding)
- Mild uterine cramping, or backache
- Feelings of pelvic pressure
- Bleeding may persist for days
- Cervix is closed
- Evaluation for H. mole or ectopic pregnancy is advisable
- FHT assessed or an ultrasound performed to evaluate the viability of the
fetus
- Blood for hCG = start of bleeding and again in 48 hours if the placenta is
still intact
- Avoid of strenuous activity for 24 to 48 hours
- Bed rest
1. Threatened
- Look for reasons such as running up a flight of stairs, forgetting to take an
iron pill, or getting angry with an older child
- Diethylstilbestrol (DES) was prescribed for this purpose & could be
teratogenic.
- Once bleeding stops, she can gradually resume normal activities
- Coitus is usually restricted for 2 weeks after the bleeding episode to
prevent infection and to avoid inducing further bleeding
- 50% of women continue the pregnancy, for the other 50%, unfortunately,
the threatened miscarriage changes to imminent or inevitable miscarriage.

2. Imminent
- Increase in bleeding (moderate to heavy)
- Increase in cramping (mild to severe)
- Dilated internal cervical os
- Membranes may rupture
- “inevitable abortion”
- Tissue fragments can be examined for an abnormality such as
gestational trophoblastic disease (hydatidiform mole)
- Discharged following the D&E, a woman should assess vaginal
bleeding by recording the number of pad she uses
- If more than one pad per hour, it is abnormally heavy bleeding
3. Complete
- All products of conception are expelled spontaneously
without assistance
- Contracted uterus
- Cervical os may be closed after all products of
conception are passed
- Bleeding usually slows within 2 hours and then ceases
within a few days after passage of the
products of conception

4. Incomplete
- Some of the products of conception are retained
- Major manifestations are active uterine bleeding & severe abdominal
cramping
- Slightly dilated internal cervical os
- Danger of maternal hemorrhage because the uterus cannot contract
effectively under this
condition
- Perform D&C or suction curettage to evacuate the remainder of the
pregnancy from the uterus
- Patient knows that the pregnancy is lost and that this procedure is
being done only to protect her from hemorrhage and infection, not to
end the pregnancy.
5. Missed
- Often the embryo actually died 4 to 6 weeks before the
onset of miscarriage symptoms or failure of growth was
noted
- D&E will be done
- Over 14 weeks, labor may be induced by a prostaglandin
suppository or misoprostol (Cytotec) to dilate the cervix,
followed by oxytocin stimulation or administration of
mifepristone techniques used for elective termination of
pregnancy
6. Recurrent
- Abortion occurs consecutively in three or more pregnancies
- Habitual abortion
- Thorough investigation is done to discover the cause of the loss
and help ensure the outcome of a future pregnancy
- Possible causes include:
o Resistance to uterine artery blood flow
o Chorioamnionitis or uterine infection
o Autoimmune disorders such as those involving lupus
anticoagulant and antiphospholipid antibodies
7. Septic
- Self-abort or were aborted illegally using a nonsterile instrument
such as a knitting needle
- Uterus is a warm, moist, dark cavity, infectious organisms, once
introduced, grow rapidly in this environment, such as necrotic
membranes are still present
Symptoms:
o Fever
o Abdominal tenderness
o Vaginal bleeding which maybe slight to heavy is usually malodorous
o Presence of infection

This may occur with:

o Prolonged, unrecognized rupture of the membranes
o Pregnancy with an IUD in utero
o Attempts by unqualified individuals to terminate a pregnancy
- CBC, serum electrolytes, serum creatinine, blood type and
crossmatch
- Cervical, vaginal and urine cultures
- IVF for high-dose, broad spectrum antibiotic therapy is started
- Combination of penicillin (gram (+) coverage), gentamicin (gram (-)
aerobic coverage), and clindamycin (gram (-) anaerobic coverage) is
used
- CVP or pulmonary artery catheter, a D&C or D&E will be

performed
- Tetanus Toxoid given subcutaneously or tetanus
immune globulin given IM for prophylaxis against
tetanus
- Dopamine and digitalis may be necessary to maintain
sufficient cardiac output
- Oxygen and perhaps ventilator support may be
necessary to maintain respiratory function

COMPLICATION
1. Hemorrhage
Complete spontaneous miscarriage = serious or fatal
hemorrhage is rare.
Incomplete miscarriage = develops an accompanying
coagulation defect (usually DIC), major hemorrhage is a
possibility
Monitor vital signs for changes to detect possible
hypovolemic shock. If excessive vaginal bleeding is occurring,
immediately position a patient flat and massage the uterine
fundus to try to aid contraction
COMPLICATION
1. Hemorrhage
Complete spontaneous miscarriage = serious or fatal
hemorrhage is rare.
Incomplete miscarriage = develops an accompanying
coagulation defect (usually DIC), major hemorrhage is a
possibility
Monitor vital signs for changes to detect possible
hypovolemic shock. If excessive vaginal bleeding is occurring,
immediately position a patient flat and massage the uterine
fundus to try to aid contraction
COMPLICATION
1. Hemorrhage
-Need a D&C or suction curettage to empty the uterus of the material that is
preventing it from contracting and achieving hemostasis
-Transfusion to replace blood loss. Direct replacement of fibrinogen or another
clotting factor may be used to increase coagulation ability
- Bleeding is abnormal and color changes in bleeding (gradually changing to a dark
color and then to the color of serous fluid as it does with the postpartum woman)
- Unusual odor or passing of large clots is also abnormal
- Oral methylergonovine maleate (Methergine) to aid uterine contraction
- Repression helps them to handle their anger or grief at the loss of the pregnancy

COMPLICATION
2. Infection
Infection is minimal over a short time, bleeding is self-limiting, and
instrumentation is limited
Need close observation to rule out this second and possibly fatal complication
Danger signs of infection, such as fever, abdominal pain or tenderness, and a
foul vaginal discharge
All temperatures higher than 100.4 F (38.0 C) require careful evaluation of
avoid overlooking the possibility that infection is developing Escherichia coli
Caution
o To wipe her perineal area from front to back after voiding
o Not to use tampons to control vaginal discharge
COMPLICATION
Endometritis (infection of the uterine lining), peritonitis, thrombophlebitis, and
septicemia can develop = safe birth of a child
3. Isoimmunization
Placenta is dislodged, (e.g spontaneous birth or by a D&C at any point in pregnancy,
some blood from the placental villi may enter the maternal circulation.
If the fetus was:
o Rh positive and the patient is Rh negative, enough Rh-positive fetal blood may
enter the maternal circulation to cause isoimmunization – the production of
antibodies against Rh-positive blood
The patient’s next child should have Rh-positive blood, these antibodies would
attempt to destroy the RBC of this infant during the months that infant is in utero

COMPLICATION
After a miscarriage, because the blood type of the conceptus is unknown,
all women with Rh-negative blood should receive Rh (D antigen) immune
globulin (RhIG) to prevent the buildup of antibodies in the event the
conceptus was Rh positive
4. Powerlessness or Anxiety
Assess a woman’s adjustment to a spontaneous miscarriage
Sadness and grief is to be expected & assess partner’s feelings
Spontaneous miscarriage can be particularly heartbreaking for an older
woman, because she realizes that her window of childbearing is limited

ASSESSMENT
VS, UO, amount & appearance of any bleeding, level of
comfort & general physical health
Pelvic cramping & backache
Ultrasound scanning
Hemoglobin & hematocrit
Amount of bleeding & the description, location & severity of
pain
Signs of infection
Blood type & antibody status
FHR if 10-12 weeks AOG or more
Immediate Assessment of Vaginal Bleeding During Pregnancy

Assessment Factor:
- Confirmation of pregnancy
- Pregnancy length
- Duration
- Intensity
- Description
- Frequency
- Associated symptoms
- Action
- Blood type
PLANNING
- The patient will verbalize the understanding of
spontaneous abortion, the treatment measures &
the long-term implications for future pregnancies
- The woman & her partner will verbalize their grief

& recognize their grieving process
NURSING MANAGEMENT/NURSING CARE

- Assess the vital signs, monitor uterine contractions &
FHR
- Measure maternal blood loss by weighing perineal
pads; save any tissue passed
- If at first trimester, cramping or spotting begins,
mother is often evaluated on an outpatient basis
- The nurse provides analgesics as ordered for pain relief
if the patient’s cramps are severe
COLLABORATIVE CARE
- Bed rest, abstinence from coitus & perhaps sedation
- If bleeding persists & abortion is imminent or incomplete =
hospitalization
- IV therapy or BT & D&C or suction evacuation is performed
- Supplementation with folic acid
- Early diagnosis of missed abortion:
o First trimester: suction evacuation or D&C
o Beyond 12 weeks’ gestation: induction of labor; D&E
- The uterine cavity is scraped with a curette to determine whether
any significant amount of tissue remains
EDUCATIVE CARE
- Report all episodes of heavy bleeding, fever, chills, foul
smelling vaginal discharge or abdominal tenderness
- Information about possible causes of the loss; chances
of recurrence; grief process & D&C
- Proper referral
- Psychologic support

PREMATURE RUPTURE OF MEMBRANES
PROM- refers to a patient who is beyond 37 weeks gestation and
has presented (ROM) prior to the onset of labor
PPROM- ROM prior to 37 weeks gestation
Cause of preterm rupture is unknown

Associated with infection of the membranes (chorioamnionitis)
If rupture occurs early in pregnancy, it poses a major threat to the

fetus as, after rupture, the seal of the fetus is lost, and uterine and
fetal infection may occur
2nd compilation = increased pressure on the umbilical cord

from the loss of amniotic fluid, inhibiting the fetal nutrient
supply, or cord prolapse (extension of the cord out of the
uterine cavity into the vagina), a condition that could also
interfere with fetal circulation
Cord prolapse is most apt to occur when the fetal head is still
too small to fit the cervix firmly
Preterm labor may follow rupture of the membranes and end
the pregnancy
Risk factors:
- Infection (cervicitis)
- Previous history of PROM
- Hydramnios
- Multiple pregnancy
- Urinary tract infection (UTI)
- Amniocentesis
- Hx of laser conization or LEEP procedure
- Placenta previa/abruptio placenta
- Trauma
- Incompetent cervix
- Bleeding during pregnancy
- Maternal genital tract anomalies
- Smoking, substance abuse
- Connective tissue disorders
- Lower socioeconomic status
Definition:
Maternal implications:
Infection - Chorioamnionitis and endometritis
Abruptio placenta occurs more frequently in women with PROM
Fetal-newborn implications:
- Risk for respiratory distress syndrome (with PROM)
- Fetal sepsis
- Malpresentation
- Prolapse of the umbilical cord
- Increase perinatal morbidity and mortality
- Fetal anomalies
Assessment:
Determine the duration of rupture of the membranes and gestational
age
observe the mother for s/s of infection:
- WBC count, Temperature (+ fever = check hydration), PR, Character
of amniotic fluid
- Sterile vaginal speculum exam - Fern test
FERN TEST - refers to the visualization of a characteristic “fern-like”

pattern on a slide (pre-cleaned, saline free, slides are required),
viewed under low power on a microscope
- a small amount of cervical mucus is allowed to air dry on a clean,
saline free glass slide

Procedure:
1. when the slide has completely air dried (at least 5 to 7 minutes), place
it on the stage of the light microscope provided for the procedure
2. examine the slide under low power (10x)
3. look for fern-like amniotic fluid, this crystal formation will be present in most microscopic
fields
alpha-fetoprotein (AFP) in the vagina

sonogram (AFI)
cultures for Neisseria gonorrhoeae, streptococcus B, and chlamydia
blood test: WBC & C-reactive protein
urinalysis
note: NO digital exam
assess fetal well being
- fetal heart rate tracing
- biophysical profile
- gestational age

Planning
The patient’s risk for infection will decrease by identifying the sign and
symptoms of infection thru:
- knowing how to read a thermometer and to know what degree of
temperature she should report
- identifying odorous vaginal discharge
- refraining from tub bathing, douching and coitus
- the woman will be able to understand the need for strict compliance to
bed rest
The pregnancy will be maintained without trauma to the mother or fetus
The couple will be able to discuss the implications of PROM and all
treatments and alternative treatments

Management:
focus: patient, her partner and the fetus
monitor; signs of infections
evaluate uterine activity and fetal response to the labor
vaginal exams are not done unless absolutely necessary
rest on the left side, do comfort measures
increase temperature= maintain hydration
take VS & FHR q4h (increase FHR=infection)
WOF temp. >38C (100.4 F) or as directed
Note vaginal discharge
- foul or strong odor
- cloudy or yellow appearance
Note uterine contractions:
- increase frequency or intensity
- change in character
Management:
Q4H
- maternal bp, pulse and temp
- FHR
Regular laboratory evaluations
Fetal lung maturity studies (34 wks gestation)
If leaking of fluid ceases, some patient may be followed at home
- advised to continue bed rest w/o BRP
- monitor temperature and pulse QID
- keep a fetal movement chart
- have weekly NSTs
- she is advised to contact her physician and return to the hospital if she has
fever, uterine tenderness or contractions, increase leakage of fluid, decreased
fetal movement, or foul smelling vaginal discharge
Management:
Single dose of betamethasone for PROM prior to 30-32 wks gestation, if
there is no intraamniotic infection
Repeat courses of corticosteroids should not be routinely used
(+) streptococcus B need intravenous administration of penicillin or
ampicillin
For mature fetus with (-) labor + administration of oxytocin
(+) maternal s/sx of infection
- antibiotic therepy
- fetus is born vaginally or by CS regarding of the gestational age
- upon admission to the nursing the newborn is assessed for sepsis and
placed on antibiotics

Management:
Inform on the implications of PROM and at treatment methods
The couple needs to know that through help to bear processed
Provide psychological support
Reduce anxiety
Avoid breast stimulation with preterm gestation
Avoid vaginal examinations, vaginal suppositories, and
intercourse
Refrain from tub bathing & douching
Maintain any activity restrictions recommended
Expected Outcome
Client will remain free of signs and symptoms of
infection during the period between membrane rupture
and birth of the baby
Maternal WBC count remains within acceptable
parameters; maternal temperature is less than 38C
(100.4F)

ABRUPTIO PLACENTAE
- premature separation of the placenta

- begins to separate and bleeding results
- separation occurs late in pregnancy / as late as
during the first or second stage of labor
-primary cause is unknown
- rapid decrease in uterine volume, such as occurs
with sudden release of amniotic fluid
ABRUPTIO PLACENTAE
Predisposing factors:
High parity
Advanced maternal age
A short umbilical cord
Chronic hypertensive disease
Pregnancy-induced hypertension
Direct trauma
Vasoconstriction from cocaine or cigarette use
Thromboplastic conditions that lead to thrombosis such as
autoimmune antibodies, protein C, and
factor V Leiden
ABRUPTIO PLACENTAE
Assessment
Sharp, stabbing pain high in the uterine fundus as the initial
separation occurs
Each contraction will be accompanied by pain over and above
the pain of the contraction
Tenderness can be felt on uterine palpation
External bleeding only if the placenta separates first at the
edges and blood escapes freely from the cervix
As bleeding progresses, a patient’s reserve of blood fibrinogen
may be used up in her body’s attempt to accomplish effective clot
formation, and disseminated intravascular coagulation (DIC
syndrome) can occur
ABRUPTIO PLACENTAE
If admitted to the hospital:

1. Assess the time the bleeding began, with pain
accompanied it, amount and kind of bleeding, actions
to detect if trauma could have led to the placental
separation
2. Initial blood work: Hgb level, blood typing and cross-
matching, fibrinogen level and fibrin breakdown
products to detect DIC
3. Assessment of blood clotting ability
ABRUPTIO PLACENTAE
Therapeutic Management
IVF inserted for fluid replacement
Oxygen by mask to limit fetal anoxia
Monitor fetal heart sounds externally and record maternal
vital sign q 5 to 15 mins to establish baselines and observe
progress
Baseline fibrinogen determination
Lateral, not supine, position to prevent pressure on the
vena cava
Do not perform any abdominal, vaginal or pelvic
examination
ABRUPTIO PLACENTAE
Classification of Placental Abruption

PLACENTA PREVIA
- An implantation of the placenta in the

lower uterus
- Cause is unknown but is thought to occur

whenever the placenta is forced to spread
to find an adequate exchange surface
PLACENTA PREVIA
4 DEGREES / CLASSIFICATIONS
1. Low-Lying Placenta – implantation in the lower
rather than in the upper portion of the uterus
2. Marginal Implantation – the placenta edge
approaches that of the cervical os
3. Partial Placenta Previa – implantation that
occludes a portion of the cervical os
4. Total Placenta Previa – implantation that totally
obstructs the cervical os
PLACENTA PREVIA
COMMON IN WOMEN WHO HAD:

Increase parity
Past cesarean births
Past uterine curettage
Multiple gestation
Perhaps a male fetus
PLACENTA PREVIA
BIRTH
If past 36 weeks = birth decision will
generally be made ASAP
If the placenta previa is found to be total =
CS
If the placenta previa is partial, the amount
of the blood loss, the condition of the fetus,
and a woman’s parity will influence the birth
decision
PLACENTA PREVIA
BIRTH (cont.)
Skin incision is still a transverse the uterine
cut must be made high, possibly vertically
above the low
implantation site of the placenta
Fetus reaches 37 weeks of age (2500g), an
amniocentesis analysis for lung maturity shows
a positive result (LS ratio)
PLACENTA PREVIA
BIRTH (cont.)
Bleeding occurs again, labor begins, or the fetus shows
symptoms of distress, the fetus needs to be born
Birth, a woman needs a great deal of support
Talk about being ready for surgery
Had a placenta previa is more prone to postpartum
hemorrhage because the placental site is in the lower uterine
segment, which does not contract as efficiently as the upper
segment and because the uterine blood supply is less in the
lower segment, the placenta tends to grow larger than it would
normally, leaving a larger denuded surface area when it is
removed
PLACENTA PREVIA
ASSESSMENT
Duration of the pregnancy
Time the bleeding began
Woman’s estimation of the amount of blood – ask
her to estimate in terms of cups or tablespoons (q
cup is 240 mL; a tablespoon is 15 mL)
Whether there was accompanying pain
Color of the blood (red blood indicates bleeding is
fresh or is continuing)
PLACENTA PREVIA
ASSESSMENT (cont.)
Routine ultrasounds
The condition is explained to a woman, and she
is cautioned to avoid coitus
Adequate rest
Call her health care provider at any sign of
vaginal bleeding
Bleeding with placenta previa begins and the
cervix begins to dilate
PLACENTA PREVIA
ASSESSMENT (cont.)
Bleeding results from inability to stretch to
accommodate the differing shape of the power uterine
segment or the cervix
Bleeding that occurs is usually abrupt, painless, bright
red, and frightens a woman
Not associated with increased activity in sports
May slow after the initial hemorrhage but continue
we continuous spotting
PLACENTA PREVIA
Immediate Care Measures:
Place the woman immediately on bed rest in a side-lying
position
Estimate the present rate of blood loss
Apt or Kleihauer-Betke test (test strip procedure) can be
used to detect whether the blood is of fetal or maternal
origin
Never attempt a pelvic or rectal examination = may
initiate massive hemorrhage, possibly fatal to both mother
and child
PLACENTA PREVIA
Immediate Care Measures: (cont.)

Hemoglobin, hematocrit, prothrombin time, partial
thromboplastin time, fibrinogen, platelet count,
type and cross-match, and antibody screen will be assessed
to establish baselines
Detect a possible clotting disorder
Ready blood for replacement or necessary
Vaginal birth is always safest for an infant
Vaginal examinations = to determine whether placenta
previa exists
PLACENTA PREVIA

Immediate cesarean birth can be carried out to remove
the child and the bleeding placenta and
contract the uterus
Oxygen equipment available in case the fetal heart
sounds indicate fetal distress, such as
bradycardia or tachycardia, late deceleration, or variable
deceleration
Abdominal examination may reveal that the fetal head is
not engaged because of the interfering placenta
PLACENTA PREVIA
Transvaginal ultrasound to detect this

If no previa is detected, the physician may attempt a careful
speculum examination of the vagina and cervix to rule out
another cause for bleeding, such as ruptured varices or cervical
trauma
Baseline vital signs
Assess BP q 5 to 15 minutes
Intravenous fluid therapy using a large-gauge catheter
monitoring urine output frequently
PLACENTA PREVIA
Attach external monitoring equipment to record fetal

heart sounds and uterine contractions
If bleeding stopped, the FHR are of good quality,
maternal vital signs are good, and the fetus is not yet 36
weeks of age, a woman is usually managed by expectant
watching
Woman remains on be rest for close observation for 48
hours
PLACENTA PREVIA

Laboratory tests, such as hemoglobin or hematocrit
Betamethasone, a steroid that hastens fetal lung maturity,
may be prescribed for the mother of encourage the
maturity of fetal lungs if the fetus is less than 34 weeks
gestation

PLACENTAL ABRUPTION
Premature separation of the placenta
It begins to separate and bleeding results
Separation occurs late in pregnancy/as late as during the
first or second stage of labor
Primary cause is unknown
Rapid decrease in uterine volume, such as occurs with
sudden release of amniotic fluid
Fetal head is low enough in the pelvis that it prevents loss of
the total volume of the amniotic fluid at one time, so normally
a rapid reduction in amniotic fluid does not occur when
membranes rupture
PLACENTAL ABRUPTION
PREDISPOSING FACTORS
High parity
A short umbilical cord
Chronic hypertensive disease
Pregnancy-induced hypertension
Direct trauma
Vasoconstriction from cocaine or cigarette use
Thrombophilitic conditions that lead to thrombosis such as
autoimmune antibodies, protein C, and factor V Leiden

PLACENTAL ABRUPTION
ASSESSMENT
If admitted to the hospital:
1) Assessthetimethebleedingbegan,with pain accompanied it,
amount and kind of bleeding, actions
to detect if trauma could have led to the placental separation
2) Initial blood work: hgb level, typing and cross-matching,
fibrinogen level and fibrin breakdown
products to detect DIC
3) Assessment of blood clotting ability:
Sharp, stabbing pain high in the uterine fundus as the initial
separation occurs

PLACENTAL ABRUPTION
ASSESSMENT (cont.)
Each contraction will be accompanied by pain over and
above the pain of the contraction
Tenderness can be felt in uterine palpation
External bleeding only if the placenta separates first at
the edges and blood escapes freelyfrom the cervix
Blood can pool under the placenta, and although
bleeding is intense, it is hidden from view
PLACENTAL ABRUPTION
ASSESSMENT (cont.)
Signs of shock usually follow quickly because of the
blood loss
Uterus becomes tense and feels rigid to the touch
Couvelaire uterus or utero placental apoplexy, forming a
hard, board-like uterus with no apparent, or minimally
apparent, bleeding present occurs
PLACENTAL ABRUPTION
IVF inserted for fluid replacement
Oxygen by mask to limit fetal anoxia
Monitor for fetal heart sounds externally and record
maternal vital signs every 5 to 15 minutes to establish
baselines and observe progress
Baseline fibrinogen determination
Lateral, not supine, position to prevent pressure on the
vena cava
PLACENTAL ABRUPTION
THERAPEUTIC MANAGEMENT (cont.)

Do not perform any abdominal, vaginal, or pelvic
examination
Unless the separation is minimal(grades 0 to 1), the
pregnancy must be terminated because the fetus cannot
obtain adequate oxygen and nutrients
If vaginal birth does not seem imminent, cesarean birth is
the north method of choice
Fetal prognosis depends on the extent of the placental
separation and the degree of fetal hypoxia
PLACENTAL ABRUPTION
THERAPEUTIC MANAGEMENT (cont.)

Maternal prognosis depends on how
promptly treatment can be instituted
Death leading to shock and circulatory
collapse or renal failure from the circulatory
collapse
Prone to infection after birth than the
average woman
DEFINITION
PROM – refers to a patient who is beyond 37
wks AOG and has presented with rupture of
membranes (ROM) prior to the onset of labor
PPROM – ROM prior to 37 wks AOG
Cause of preterm rupture is unknown
Associated with infection of the membranes
(chorioamnionitis)
If rupture occurs early in pregnancy, it poses a major
threat to the fetus as, after rupture, the seal to the
fetus is lost and uterine and fetal infection may occur
Another risk to the fetus of remaining in a non- fluid
environment is the development of a Potter-like
syndrome or distorted facial features and pulmonary
hypoplasia from pressure
Preterm labor may follow rupture of the membranes
and end the pregnancy
2nd complication = increased pressure on the
umbilical cord from the loss of amniotic fluid,
inhibiting the fetal nutrient supply, or cord prolapse
(extension of the cord out of the uterine cavity into
the vagina), a condition that could also interfere
with fetal circulation
Cord prolapse is most apt to occur when the fetal
head is still too small to fit the cervix firmly
Maternal Implications:
Infection: chorioamnionitis and endometritis
Abruptio placenta occurs more frequently in women
with PROM
Fetal-newborn Implications:
Risk for respiratory distress syndrome (with PROM)
Fetal sepsis
Malpresentation
Prolapse of the umbilical cord
Perinatal morbidity and mortality
Fetal anomalies
RISK FACTORS:
Trauma
Incompetent cervix
Bleeding during pregnancy
Maternal genital tract anomalies
Smoking, substance abuse
Connective tissue disorders
Lower socioeconomic status
Infection (Cervicitis)
Previous history of PROM
Hydramnios
Multiple pregnancy
Urinary tract infection (UTI)
Amniocentesis
HX of laser conization or LEEP procedure
Placenta previa / abruptio placenta
ASSESSMENT
Determine the duration of rupture of the membranes and gestational age
Observe the mother for s/s of infection:
o WBC count
o Temperature(+fever=check hydration)
o PR
o Character of amniotic fluid
Sterile vaginal speculum exam
o Fern test
o Dried AF on a slide demonstrating a positive Fern test
o Nitrazine test
Assess fetal well-being
o Fetal heart rate racing
o Biophysical profile
o Gestational age
Alpha-fetoprotein (AFP) in the vagina
Sonogram (AFI)
Cultures for Neisseria gonorrhoea, streptococcus B, and Chlamydia
Blood test: WBC and C-reactive protein
Urinalysis
Note: NO Digital exam

PLANNING
The woman’s risk for infection will decrease
by identifying the sign and symptoms of
infection thru:
o Knowing how to read a thermometer and to
know to what degree of temperature she
should report
o Identify odorous vaginal discharge
o Refraining from tub bathing, douching, and
coitus
PLANNING (cont.)
The woman will be able to understand the
need for strict compliance in bed rest
The pregnancy will be maintained without
trauma to the mother or fetus
The couple will be able to discuss the
implications of PROM and all treatments and
alternative
treatments
MANAGEMENT
Nursing Care
Focus: woman, her partner and the fetus
Monitor: signs of infection
Evaluate uterine activity and fetal response to the
labor
Vaginal exams are not done unless absolutely
necessary
Note vaginal discharge
o Foul or strong odor
o Cloudy or yellow appearance
MANAGEMENT (cont.)
Note uterine contractions:
o Frequency or intensity
o Change in character
Rest on the left side, do comfort measures
Temperature = maintain hydration
Take VS and FHR q4h ( FHR = infection)
WOF temperature higher than 38°C (100.4° F) or
as directed

Collaborative Care
Conservative management of <37
weeks
Hospitalization, on bed rest
Electronic fetal monitoring
Monitor Fetal Well-being:
o Regular non-stress tests (NSTs)
o Biophysical profiles

Collaborative Care (cont.)
If leaking of fluid ceases, some women may be
followed at home
o Advised to continue bed rest w/o BRP
o Monitor temperature and pulse QID
o Keep a fetal movement chart
o Have weekly NSTs
o Advised to contact physician and return to the hospital
of there’s fever, uterine tenderness or
contractions, increased leakage of fluid, decreased fetal
movement, or foul smelling vaginal discharge
Single dose of for PROM prior to 30-32 weeks
gestation, of there is no intra-amniotic infection
Repeat courses of corticosteroids should not
be routinely used
(+) Streptococcus B need intravenous
administration of penicillin or ampicillin
For mature fetus with (-) labor =
administration of oxytocin
(+) Maternal s/sx of infection:
o Antibiotic therapy
o Fetus is born vaginally or by CS regardless of the
gestational age
o Prophylactic antibiotics for the first 48hrs
o Upon admission to the nursery, the newborn is assessed
for sepsis and placed on antibiotics
Q4H:
o Maternal BP, pulse and temperature
o FHR
Regular laboratory evaluations
Fetal lung maturity studies (34 weeks AOG)
Educative Care:
Avoid breast stimulation with preterm
gestation
Avoid vaginal examinations, vaginal
suppositories, and intercourse
Refrain from tub bathing and douching
Maintain any activity restrictions
recommend
Educative Care: (cont.)
Inform on the implications of PROM and
all treatment methods
The couple needs to know that although
the membranes are ruptured, amniotic
fluid continues to
be produced
Provide psychological support
Reduce anxiety
EXPECTED OUTCOME
Client will remain free of signs and
symptoms of infection during the period
between membrane
rupture and birth of the baby
Maternal WBC count remains within
acceptable parameters, maternal
temperature is less than 38°C (100°F)
ANEMIA in Pregnancy
SICKLE CELL ANEMIA:

- Recessively inherited hemolytic anemia
caused by an abnormal amino acid in the
beta chain of
hemoglobin
- Majority of red blood cells are irregular
and sickle-shaped typed
SICKLE CELL ANEMIA
ASSESSMENT:
- A woman with sickle cell disease may have
normally a hemoglobin level of 6 to 8 mg/ 100 mL:
hemoglobin level can fall from 5-6 mg/100mL
- Fetal health is monitored during pregnancy by an
ultrasound exam at 16-24 weeks and by weekly
NST or UTZ exam about 30weeks
SICKLE CELL ANEMIA
PLANNING
- The pt will be able to describe her
condition and identify its possible impact
on her pregnancy
- The pt will give birth to a healthy infant
SICKLE CELL ANEMIA
IMPLEMENTATION:
● Therapeutic:
○ Periodic exchange transfusion
○ Administer IV fluid: hypotonic (0.45
saline) solution

SICKLE CELL ANEMIA
● Nursing Management
○ Health teaching on the risk of sickle cell disease:
○ If the other one has disease and the other is free from
disease or traits child will inherit the disease zero
○ If the woman has disease and her partner has the trait
50% chance the child may inherit
○ Both parents have the disease all of their children will
inherit the disease
SICKLE CELL ANEMIA
● Collaborative Management
○ Should not be given iron supplements
during pregnancy
○ Hospitalization observation if the
woman develops infection
○ Electrophoresis of RBC obtained during
fetal life by percutaneous umbilical blood
sampling
QUIZ

Nursing Care of the Male and Female Clients
with General and Specific Problems in
Reproduction and Sexuality

Fertility Assessment
Subfertility - is said to exist when a

pregnancy has not occurred after at least 1
year of engaging in
unprotected coitus
Sterility - inability to conceive because of a

known condition, such as absence of the
uterus
Fertility Assessment
A woman younger than 35 years old is usually

suggested to have an evaluation after 1 year of
subfertility
Older than 35 years old, she should be seen
after 6 months. Referral is recommended sooner
because assisted reproductive strategies such as
IVF, as well as common alternatives to natural
childbearing such as adoption, are also limited by
age
Initial history taking for the subfertile couple:
Male
General health
Typical 24-hour food intake including alternative
therapies such as herbs and whether he ingests alcohol,
uses recreational drugs, smokes, or uses tobacco
Congenital health problems, such as hypospadias,
cryptorchidism, past illness such as mumps (alters
hormonal balances), orchitis (inflammation of the
testicles), urinary tract infection, or sexually transmitted
diseases that could affect fertility

Male
If he ever had radiation to his testes because of
childhood cancers, x-rays, or an industrial
accident
If he had an operation such as surgical repair of
a hernia or torsion of the testes, which could have
compromised blood supply to his testes
Any current illness, particularly an endocrine
one or a low-grade infection
Male
If his job or lifestyle involve sitting all day
Sexual practices, such as frequency of coitus,
masturbation, coital positions used, or if ever he
experiences failure to achieve ejaculation
Past contraceptive measures, if any, he has
used or if he has children from a previous
relationship
Female
General health
Nutrition, including an adequate source of folic
acid and avoidance of trans fat
Current or past reproductive tract problems,
such as infections
Past history of a childhood cancer treated with
radiation that might have reduced ovarian
function or any exposure to occupational hazards,
such as x-rays or toxic substances
Female
Abdominal or pelvic operations that could have

compromised blood flow to the pelvic organs
Overall health, emphasizing endocrine
problems such as galactorrhea (breast nipple
secretions) or symptoms of thyroid dysfunction
(always tired or hyperactive)
Past pregnancies, miscarriages, or abortions
Female
If she can detect ovulation through such

symptoms as breast tenderness, midcycle
“wetness”, or one-sided lower abdominal pain
(mittelschmerz)
o Breast examinations are best done after the
menstruation
Use of douches or intravaginal medications or
sprays that could interfere with vaginal pH
Female
Menstrual history, including age of menarche,

length, regularity, flow, and any difficulties the
woman experiences such as dysmenorrhea or
premature dysphoric disorder
o PDD- severe depression, irritability, and tension
before menstruation
o >40 years old breast examination and pap
smear is recommended
Physical Assessment
Men
o Important aspects of this include whether
secondary sexual characteristic, such as pubic
hair, are present as well as no genital
abnormalities, such as absence of the vas
deferens or the presence of
an undescended testes (cryptorchidism), or
varicocele (enlargement of the testicular vein) are
present
Physical Assessment
Men
o A hydrocele (a collection of fluid in the tunica

vaginalis of the scrotum) is rarely associated with
subfertility but should be documented if present

Physical Assessment
Women
o Includes breast and thyroid examination, is
necessary to rule out illness
o Secondary sex characteristics, which indicate
maturity and suggest good pituitary function
o A complete pelvic examination, including pap
test is needed to rule out anatomic disorders and
infections
Factors that cause male subfertility
The factors that most commonly lead to male
subfertility include:
o Disturbance in spermatogenesis (production of
sperm cells)
o Inadequate production of FSH and LH in the
pituitary which stimulates the production of
sperm cells
o Obstruction in the seminiferous tubules, ducts,
or vessels which prevent the movement of the
spermatozoa
o Qualitative or quantitative challenges in the

seminal fluid, which prevents sperm motility
(movement of the sperm)
o Development of autoimmunity, which immobilizes
sperm
o Problems in ejaculation or deposition, which
prevents spermatozoa from being placed close
enough to a woman’s cervix to allow ready
penetration and fertilization and changes in
lifestyle, such as avoiding
o Chronic or excessive exposure to x-rays or

radioactive substances, general ill health, poor diet,
and stress, all of which may interfere with sperm
production
Limited sperm count:

Oligospermia - low sperm count
Azoospermia - absence of sperm cells
Sperm count - number of sperm in a single
ejaculation or in a milliliter of semen
The minimum sperm count considered normal is: 33-46

million sperm/mL of seminal fluid, or 50 million /ejaculation
o 50% of the sperms should be motile
o 30% that are normal in shape and form
Spermatozoa must be produced and maintained at a
temperature slightly lower than body temperature to be
fully motile
Any condition that significantly increases body
temperature, such as chronic infection from tuberculosis or
recurrent sinusitis, has potential to raise scrotal heat enough
to lower sperm count
o Working at desk job or driving at a great deal everyday

may also be a cause of increasing scrotal heat
Cryptorchidism (undescended testes)- may occur if
surgical repair was not completed until puberty or if
spermatic cord became twisted after the surgery
Varicocele - or varicosity (enlargement) of the internal
spermatic vein, can also increase
temperature and congestion within the testes, which may
slow and disrupt spermatogenesis
Low sperm count
o Problems with sexual function, low sex drive/ difficulty in
maintaining erection (erectile dysfunction)
o Pain, swelling, or lump in the testicular area
o Decrease in facial or body hair or other signs of chromosome
or hormone abnormality
Foods that may contribute to problems in erection
o Greasy or fried foods, especially trans fat
o Chocolates
o Dairy products, like ice creams and cheeses- due to lactic
acid and cow’s milk present that lowers testosterone levels
o Refined carbohydrates, such as pastas, cereals, bread, and
cookies
Other conditions that inhibits sperm production:
o Past trauma to the testes
o Surgery on or near the testicles that has resulted in
impaired testicular circulation
o Endocrine imbalances, particularly of the thyroid,
pancreas, or pituitary gland
o Drug use or excessive alcohol use
o Environmental factors, such as exposure to x-rays or
radioactive substances
Semen analysis - on average, ejaculation of 1.4-1.7 mL of
semen should contain a minimum of 33-46 million
spermatozoa/mL or 2.5-5.0 mL with
20 million spermatozoa/ mL
o Steps in semen analysis:
o Patient is instructed to be sexually abstinent for 2-4 days
prior to analysis
o Patient ejaculates by masturbation into a clean, dry
specimen jar or a special condom (one
without spermicide)
o Number of sperm in the specimen are counted and then
examined under a microscope within
one hour after ejaculation
o Repeated after 2-3 months because spermatogenesis is
an ongoing process and 30-90 days are needed for new
sperms to reach maturity
Sperm penetration assay and antisperm antibody testing
o With the use of an assisted reproduction technique such
as IVF, poorly mobile sperm or those with poor
penetration can be injected into a woman’s ovum under
laboratory conditions
Therapy for increasing sperm count
o A man may be advised to abstain from coitus for 7-10
days at a time to increase count
o Ligation of a varicocele (if present) recreational
marijuana, wearing looser clothes, avoiding long periods of
sitting, and avoiding prolonged hot baths
Obstruction or impaired sperm motility
Benign hypertrophy of the prostate gland (BPH) - occurs in most men
beginning at about the age of 50. Pressure from the enlarged gland on
the vas deferens can interfere with sperm transport
Infection of the prostate, through which the sperm and seminal fluid
must pass, or infection of the seminal vesicles (spread from urinary tract
infection) can change the composition of the seminal fluid enough to
reduces sperm motility
Hypospadias (urethral opening on the ventral surface of the penis),
epispadias (urethral opening on the dorsal surface), or peyronie disease
(a bent penis) can cause sperm to be deposited too far from the sexual
partner’s cervix to allow optimal cervical penetration.
Extreme obesity in a male may also interfere with effective
penetration and deposition
Ejaculation Problems:
Erectile Dysfunction - inability to achieve an erection

(formerly called impotence), which may occur from
psychological problems; diseases such as a CVA
(cerebrovascular accident), DM, or Parkinson disease;
use of certain antihypertensive agents; as well as the
discontinuation of finasteride, a drug used for male
pattern baldness
Infections may also interfere with ejaculation
Therapy for ejaculation concerns
o Psychological or sexual counseling as well as the
use of a phosphodiesterase inhibitor, such as
sildenafil (viagra) or tadalafil (Cialis)
o Viagra- effect is 30-60 minutes until 2 hrs
Retrograde ejaculation - semen enters the
bladder during ejaculation instead of emerging to
the tip of the penis
o Due to diabetes
o Medications given: alpha- blockers, such as
minipress – can cause priapism (>4hrs)
Factors that cause Female subfertility
Limited production of FSH and LH, which interfere with
ova growth
Anovulation (faulty or inadequate expulsion of ova)
Problems of ova transport through the fallopian tubes to
the uterus
Uterine factors, such as tumors or poor endometrial
development
Cervical and vaginal factors, which immobilize
spermatozoa
Poor nutrition, increased body weight, and lack of
exercise which may compound these problems
Anovulation
Absence of ovulation or release of ova from the ovaries
The most common cause of subfertility in women, may
occur from a genetic abnormality such as turner syndrome
(hypogonadism), in which there is limited ovarian tissue
available to produce ova
More often, it results from a hormonal imbalance cause
by a condition such as hypothyroidism
abnormalities such as Turner’s syndrome-

hypogonadism
Ovarian tumors or polycystic ovarian ovary
syndrome may also cause anovulation
o Due to the feedback stimulation on the pituitary
o Signs and symptoms: change in the bowel system,
weight loss, enlargement of the abdomen
o May also be because of genetic

Chronic or excessive exposure to x-rays or
radioactive substances, general ill health, poor diet,
and stress may all contribute to poor ovarian
function
Nutrition, body weight, and exercise are all
important for adequate ova production, because
they influence blood glucose / insulin balance
Polycystic Ovary Syndrome
Associated with metabolic syndrome which is
diagnosed in patients with:
o Waist circumference of 35 inches or more in
women
o Fasting blood glucose over 100 mg/dl
o Serum triglycerides over 150 mg/dl
o BP over 135/85 mmHg
o High-density lipoprotein cholesterol over 50 mg/dl
o Development of hirsutism (unwanted body hair)
Therapy for Anovulation
Administration of GnRH (gonadotrophin releasing
hormones)
o This will stimulate the pituitary to secrete FSH and
LH
Clomiphene citrate (clomid) or letrozole (femara)
o Used to stimulate ovulation
o Patients taking clomid may have a 50% chance of
bearing twins
o Due to overstimulation of the ovaries
Therapy for Anovulation
Administration of GnRH (gonadotrophin releasing
hormones)
o This will stimulate the pituitary to secrete FSH and LH
Clomiphene citrate (clomid) or letrozole (femara)
o Used to stimulate ovulation
o Patients taking clomid may have a 50% chance of bearing
twins
o Due to overstimulation of the ovaries
Combinations of FSH and LH in conjunction with
administration of hCG
o Stimulation of ovarian follicular growth
Tubal Transport Problems
Pelvic Inflammatory Disease (PID) is the
infection of the pelvic organs: uterus, fallopian
tubes, ovaries, and their supporting structures
Infection is usually STD such as chlamydia or
gonorrhea
Most apt to occur at the end of a menstrual
period because menstrual blood provides such an
excellent growth medium for bacteria
PID
o There is also loss of the normal cervical
mucus barrier, which increases the risk of
initial invasion
When left unrecognized and treated, enters
the chronic phase
o Causes scarring that can lead to the stricture
of the fallopian tubes and resulting to fertility
problems
Higher risk of PID among women who have
multiple sexual partners
Sonohysterosalpingogram
A sonographic examination of the fallopian tubes and

uterus using an ultrasound contrast agent introduced into
the uterus through a narrow catheter inserted into the
uterine cervix
if tubes are patent, they will fill with the contrast
medium and be detailed on the ultrasound screen
o contraindicated if there is infection of the vagina, cervix,
or uterus
o infectious organisms might be forced through the tubes
into the pelvic cavity
Hysterosalpingogram
Iodine - based radiopaque contrast

medium is used and the fallopian tubes
are revealed in the x-ray
Scheduled immediately following the
menstrual flow when pregnancy could not
be present
Lack of Tubal Patency Therapy
Canalization of the fallopian tubes

and plastic surgical repair
(microsurgery) are other possible
treatments

Uterine Concerns:
Tumors such as fibromas (leiomyomas) or fibroids, may be rare

because of subfertility
Blocks the entrance of the fallopian tubes into the uterus of limits
the space available on the uterine wall for effective implantation
Congenitally deformed uterine cavity may also limit implantation
sites
Endometriosis and poor secretion of estrogen or progesterone are
more common uterine reasons
for subfertility as these result to inadequate endometrial formation
(overproduction and underproduction)
Endometriosis refers to the implantation of the uterine
endometrium, or nodules, that have spread from the interior of the
uterus to locations outside the uterus
Hysteroscopy
Visual inspection of the uterus through the
insertion of a hysteroscope (a thin hollow
tube) through the vagina, cervix, and into the
uterus
Evaluates uterine adhesions, malformations,
or other abnormalities such as fibroid tumors
or polyps
that were discovered on sonogram imaging
Uterine Endometrial Biopsy
May be used to reveal an endometrial problem,
such as luteal phase defect
It is done 2-3 days before an expected menstrual
flow (day 25 or 25 of a typical 28-day menstrual
cycle)
After a paracervical block and a screen for
chlamydia, a think probe and biopsy forceps are
introduced through the cervix
Possible complications include pain, excessive
bleeding, infection, and uterine perforation
Laparoscopy
Introduction of a thin, hollow, lighted tube (fiber optic telescope
or laparoscope) through a small incision in the abdomen, just
under the umbilicus, to examine the position and state of the
fallopian tubes and ovaries
The woman is positioned in a steep Trendelenburg (which brings
the reproductive organs down out of the pelvis)
Carbon dioxide is usually introduced into the abdomen to move
the abdominal wall outward and to offer better visualization
o May feel bloating of the abdomen from the infusion of the
carbon dioxide
o If some CO2 escapes under the diaphragm, they may feel
extremely sharp shoulder pain from the pressure of the gas on the
cervical nerves
Vaginal and Cervical Concerns
Cervical mucus may be too thick to allow spermatozoa to penetrate the
cervix
Infection or inflammation of the cervix (erosion) can also cause cervical
mucus to thicken so much
o Spermatozoa cannot easily survive in it
Stenoic cervical os or obstruction of the os by a polyp may further
compromise sperm penetration
Those who have undergone dilatation and curettage several times or
cervical conization (cervical surgery) should be evaluated in light of the
possibility that a scar tissue or tightening of the cervical os has occurred
Infection of the vagina can cause the pH of the vaginal secretion to become
acidotic, limiting or destroying the motility of the spermatozoa
Women appear to have sperm-immobilizing or sperm-agglutinating
antibodies in their blood plasma
o Act to destroy sperm cells in the vagina or cervix
Unexplained Subfertility
No known cause for subfertility can be

discovered
Problem of one partner alone is not
significant, but when combined with a
small problem in the other partner,
together, these become sufficient to
create subfertility
Alternative Insemination
Alternative or IUI is the instillation of sperm from a
masturbatory sample into the female reproductive tract by
means of a cannula to aid conception at the time of ovulation
The sperm can either be instilled into the cervix (intracervical
insemination) or directly into the uterus (intrauterine
insemination)
Male partner’s sperm (alternative insemination by male
partner) or donor sperm (alternative insemination by donor)
Donor insemination can be used if the man has a known
genetic disorder he does not want to be
transmitted to children or if female does not a have a male
partner
Invitro Fertilization
May be done due to obstructed or damaged fallopian tubes

Also used when the man has oligospermia or a very low
sperm count
Absence of cervical mucus prevents sperm from entering
the cervix or antisperm antibodies cause
immobilization of the sperm
Steps of in vitro fertilization:
o Ovulation
o Capture of the ova (done intra-abdominally)
o Fertilization of the ova and growth in culture medium
o Insertion of the fertilized ova into the uterus
Gamete Intrafallopian and Zygote Intrafallopian Transfer
GIFT- ova are obtained from the ovaries exactly as in IVF.
Instead of waiting for fertilization to occur
in the laboratory, both ova and sperm are instilled within the
matter of hours using a laparoscopic
technique, into the open end of the patent fallopian tube
Requires at least one patent fallopian tube
Preferred procedure by some couples because conception
occurs in the fallopian tubes
ZIFT- similar to IVF, egg is fertilized in the laboratory but like
GIFT the fertilized egg is transferred through laparoscopic
technique into the end of a waiting fallopian tube
Surrogate Embryo Transfer
Oocyte is donated by a friend, relative, or as
anonymous donor
Menstrual cycles of the donor and the recipient
are synchronized by administration of
gonadotrophic hormones
Donor’s ovum is removed by a transvaginal
ultrasound - guided procedure
Oocyte is then fertilized in the laboratory by the
recipient woman’s partner’s sperm
o Placed in the recipient’s uterus by embryonic
transfer
QUIZ

Nursing Care of at Risk / High Risk /
Sick Clients
Newborn
Infant and Young Infant
Toddler
Preschool
School Age
Adolescent
Nursing Care of High-Risk Newborn
Dysmature - a newborn whose birth weight is

inappropriately low for the gestational age
Parents need thorough explanation of their baby’s
health because this problem may require
rehospitalization or additional follow-up at home
Being able to predict, allows for advanced preparation
so that specialized, skilled healthcare personnel can be
present at the child’s birth to perform necessary
interventions, such as resuscitating a newborn who has
difficulty establishing respirations
Assessment
Assessed at birth for obvious congenital
anomalies and gestational age
o Number of weeks the newborn remained in
the utero
Cardiac, apnea, oxygen saturation, and blood
pressure monitoring
o Needed for continuous assessment of high-
risk newborn
o Carefully evaluate comments from fellow
nurses
Nursing Diagnosis
Aware of the usual parameters of newborns
Outcome Identification and Planning

Be certain when establishing expected outcomes that they
are consistent with a newborn’s potential
Plans of care are individualized considering a newborn’s
development level as well as physiologic strengths,
weaknesses, and needs
Families of high-risk newborns will need support
o May need referral to a home health care or other agency

Implementation
Best carried out by a consistent caregiver and should

focus on conserving the baby’s energy and providing a
thermoneutral environment to prevent exhaustion and
hypothermia
Painful procedures should be kept to a minimum to
help to help the infant achieve a sense of comfort and
balance
Assisting the parents to participate in care
o Such as bathing or feeding - can set the stage for
effective bonding
Outcome Evaluation
Need long-term follow up
Special schooling or counseling can be made
Newborn priorities in the first days of life
Initiation and maintenance of respirations
Establishment of extrauterine circulation
Maintenance of fluid and electrolyte balance
Control of body temperature
Intake of adequate nourishment
Establishment of waste elimination
Prevention of infection
Establishment of an infant-parent/caregiver relationship
Institution of developmental care or care that balanced
physiologic needs and stimulation for best developments
Initiating and Maintaining Respirations
Prognosis of a high-risk newborn depends primarily on how
the first moments of life are managed
because most deaths occurring during the first 48 hours after
birth result from the newborn’s inability to establish or maintain
inadequate respirations
o Infants who experience this may experience residual
neurologic morbidities as a result of cerebral hypoxia
Establish respirations must be started immediately after birth,
because by 2 minutes the development of severe acidosis is
already well under way
Resuscitation is important for both infants who fail to take a
first breath and for those who have
difficulty maintaining adequate respirations on their own
Resuscitation
Establish an airway
Expand the lungs
Initiate and maintain effective ventilation
If respiratory depression becomes severe that a
newborn’s heart begins to fail (heart rate less than
60 bpm) despite positive airway pressure
ventilation, resuscitation should then also include
chest compressions
Airway
Well, term born, usually warming, drying, and stimulating the

baby by rubbing the back is enough to initiate respirations
Rubber bulb syringe - piece of equipment used in the past to
suction infant’s noses and mouths
Meconium stained at birth but is breathing does not need
suctioning to clear the airway
Infants who still makes no effort at spontaneous respirations
after these initial steps may require insertion of an endotracheal
tube
Oxygen may be administered to achieve a preductal oxygen
saturation close to the interquartile range measured in healthy
term infants after vaginal delivery
Lung Expansions
Once airway has been established, newborn’s

lungs need to be expanded
If an infant needs air or oxygen by bad and
mask to aid lung expansion be certain the mask
covers both the mouth and the nose
It is important not to let the oxygen levels in a
newborn fluctuate greatly because fluctuation can
cause bleeding from immature cranial vessels
Drug Therapy
Even if an infant’s respiratory depression

appears to be related to the administration of a
narcotic such as morphine of meperidine
(Demerol) to the mother during the labor,
naloxone (narcan), a drug to reverse the action
of narcotics, should not be routinely
administered because it has a little effect and
may cause seizures in newborn
Ventilation Maintenance
Use of pulse oximetry is crucial to be certain, O2 sat
remains adequate
Place infants with difficulty maintaining respirations in a
radiant warmer to prevent cooling and acidosis
Positioning an infant on the back with the head of the
mattress elevated, approximately 15 degrees can also help
because it allows the abdominal contents to fall away from
the diaphragm, thus increasing breathing space
If secretions accumulating in the respiratory tract appears
to be creating ineffective breaths, an infant may need
additional suctioning
Establishing Extrauterine Circulation
If an infant has no audible heartbeat,

or if the cardiac rate is below 60
beats/min, chest
compressions should be started
Continue to monitor pulse oximetry to
evaluate respiratory function and cardiac
efficiency
Maintaining Fluid and Electrolyte Balance
Hypoglycemia often results from the effort of the

newborn expended to begin breathing
o Treated initially with intravenous 10% dextrose in
water to restore their blood glucose level
Dehydration may also result from increased
insensible water loss caused by rapid respirations
Monitor UO and specific gravity
o Output less than 2 ml/kg/hr or specific gravity greater
than 1.015 to 1.020 suggests inadequate fluid intake
Regulating Temperature
All high-risk infants have difficulty in maintaining
temperature
o Due to stress form an illness or immaturity, the infant’s body
is often exposed for long periods during procedures such as
resuscitation
Using a radiant warmer or prewarmed incubator, or suggest
skin-to-skin contact with one of the parents
Radiant heat sources - open beds that have an attached
overhead source of radiant heat and
provide both warmth and visibility for observations
Incubators - similar to radiant heat warmers, allows
observation, the need for clothing may be eliminated
Establishing Adequate Nutritional Intake
Severe asphyxia at birth usually receives intravenous
fluids so they do not become exhausted from sucking or
until necrotizing enterocolitis has been ruled out, which
can result when there is a temporary reduction of
oxygen to the bowel
Preterm infants should be fed milk, if possible,
because of the immune protection this offers
A mother can manually press breast milk or use a
breast pump to initiate and continue her milk supply
until the time the infant is mature enough or otherwise
ready to breast feed
Establishing Waste Elimination
May void later then term newborns, because as a
result of all the procedures for resuscitation
o Blood pressure may not be adequate enough to supply
the kidneys
Carefully document any voiding that occur during
resuscitation because this is proof that
hypotension is increasing and the kidneys are being
perfused
Immature infants also may pass stool later than the
term infant because meconium has not yet reached the
end of the intestines at birth
Preventing Infections
Infection, like chilling, has the detrimental effect of increasing metabolic

oxygen demands
o As well as stressing an immature immune system, thus lowering defense
mechanism protection
The most prevalent perinatal infections are those contracted from the
vaginal canal during birth such as herpes simplex 2 and hepatitis B
Early onset sepsis is most commonly cause by group B-streptococcus,
Escherichia coli, klebsiella (a gram-negative rod that causes pneumonia),
and listeria monocytogenes (a gram-positive bacteria associated with
nausea, vomiting, and possibly meningitis)
Hospital-acquired infections are commonly spread to all newborns from
healthcare personnel
o Good hand washing techniques and standard precautions to reduce the
risk of infection transmission
Establishing Parent-Infant Bonding
Parents of a high-risk newborn are kept informed of what is

happening during resuscitation at birth
They should be able to visit the special nursing unit where the
infant is admitted and as soon as possible and as often as they choose
Should an infant not survive an initial illness, these interactions can
also help make the death more real and can help parents work
through their feelings to accept this event
Urge parents to spend as much time with their infant in the
intensive care nursery as possible
Reassure the parents
o May be able to develop confidence to plan for other children or
simply continue their lives after such a devastating event
Anticipating Developmental Needs
High-risk newborns need special care to ensure

that the amount of pain they experience during
procedures is limited to the least amount of pain
possible
They quickly move to playing with age -
appropriate toys and interacting with parents
Discussing usual growth and development of
infants can help prepare them and look forward to
the next developmental step
Altered Gestational Age of Birth Weight
Term infants - those born after the beginning of the 38th week and
before the 42nd week of pregnancy
Preterm infants - infants born before term (before the beginning of
the 38th week)
Post term infants - born after the end of the 41st week of
pregnancy
Normally, birth weight increases for each additional gestational
week. Infants who fall between the 10th and 90th percentiles of
weight for their gestational age, whether they are preterm, term, or
post term, are considered appropriate for gestational age (AGA)
o Small for gestational age(SGA)- those who fall below the 10th
percentile of their weight
o Large for gestational age(LGA)- those who fall above the 90th
percentile of their weight
Other terms include:
o Low-birth-weight(LBW)- weighing less than
2,500g at birth
o Very-low-birth-weight(VLBW)-weighing less
than 1,500g at birth
o Extremely-low-birth-weight(ELBW)- weighing
less than 1,000g at birth
Preterm infant
Preterm - born between 34 to 37 wks
Early preterm - born between 24 to 34 wks
Preterm Full-term Preterm Full-term
Resting position Very little, if any, flexion in the upper Exhibits flexion in all for extremities
extremities and only partial flexion of the
lower extremities
Wrist flexion (angle of the hypothenar 90- degree angle Possible to flex the hand unto the arm
eminence and the ventral aspect of the
forearm)
Recoil of extremities Response is minimal or absent Extremities return briskly to full flexion
Scarf sign Reach near or across midline Will not reach the midline
Heel to ear Very little resistance Marked resistance, impossible to draw the
baby’s foot to the ear
Sole (plantar) creases Few or no creases Has creases involving the heel
Breast tissue <34 weeks areola and nipple are 39-40 weeks 5-6 mm of breast tissue
barely visible
<36 weeks, no breast tissue
Ears <34 weeks, very flat, relatively shapeless ear Incurving of the 2/3 of the pinna, 39 weeks
34-36 weeks, slight incurving of the superior incurving continues to
part of the ear the lobe
Male genitalia Testes are very high in the inguinal canal with Lower in the scrotum with many rugae
few rugae on the scrotum
Female genitalia Very prominent clitoris,PINEDA
DR. JULAIZA labia majora
TANABEis very Labia minora and clitoris are covered by the
small and widely separated labia majora
Small for Gestational-Age Infant
Also called microsomia
Birth weight below the 10th percentile on
an intrauterine growth curve for that age
Intrauterine growth restriction (IUGR) -
SGA infants are small for their age because
they have experienced IUGR or failed to
grow at the expected rate in the utero
Appearance
Poor skin turgor
Large head than the rest of the body
Skull sutures are widely separated
Hair is dull and lusterless
Abdomen is sunken
Umbilical cord often appears dry and
may be stained yellow
Nursing Diagnosis
Ineffective breathing pattern related to underdeveloped
body systems at birth
Outcome evaluation: newborn maintains respirations at a
rate of 30-60 breaths / min after resuscitation or at birth
Closely observe both respiratory rate and the character in
the first few hours of life as
underdeveloped chest muscles not only making the first
breath difficult, maintaining adequate
respiratory rate as well
Risk for impaired parenting
Parents express interest in infant and ask questions about
what the child’s care needs will be at home; parents hold
family warmly
Large for Gestational-Age Infant
Also termed as macrosomia
Birth weight above the 90th percentile
Etiology
Women with diabetes mellitus
Multiparous women
Beckwith-Wiedemann Syndrome
o General body overgrowth
Congenital anomalies
o Omphalocele

Assessment
Nonstress test - to test the placentas ability to
sustain a large fetus during labor
Lung maturity may be assessed by amniocentesis
Baby may appear to be large to descend to the
pelvic rim
o Cesarean may be done because shoulder dystocia
(wide fetal shoulders cannot pass; or needs
significant manipulation to pass through the outlet
of the pelvis) would have the vaginal birth
Nursing Diagnosis
Ineffective breathing pattern related

to possible birth trauma in the LGA
newborns
Outcome evaluation - newborn
initiated independent breathing at birth
Risk for imbalanced nutrition
Post term Infant
Born after the 41st week of pregnancy
Characteristics are dry, cracked, almost
leather-like skin from lack of fluid, and an
absence of vernix
Amount of amniotic fluid may be less at
birth, and it may be meconium stained
Fingernails will have grown well beyond
the end of the fingertips
Respiratory Distress in Newborns
Formerly termed as hyaline membrane

disease
Other causes of RDS include newborns
with meconium aspiration syndrome,
sepsis, slow transition to extrauterine
life, and pneumonia
Formed from an exudate of
an infant’s blood that
begins to line terminal
bronchioles, alveolar ducts
and alveoli
membrane prevents
exchange of O2 and CO2 at
the alveolar-capillary
membrane, interfering
with effective oxygenation

Respiratory Distress in Newborns
RDS is a low level or absence of surfactant,

the phospholipid that normally lines the
alveoli and
reduces surface tension to keep the alveoli
from collapsing on expiration
o Surfactant does not form until the 34th
week of pregnancy
RDS may occur in infants with diabetic
parents
Pathophysiology
if alveoli will collapse with

high pressure is required
each expiration, as happens poor oxygen exchange results
to fill the lungs with air
with surfactant deficiency, to tissue hypoxia which
for the first time and
forceful inspirations requiring causes the release of lactic
overcome the pressure of
optimum pressure are still acid
lung fluid
required to inflate them
lactic acid combined with acidosis causes

with surfactant production
increasing CO2 level resulting vasoconstriction and
almost lost, ability to stop
from the formation of the decreased pulmonary
alveoli from collapsing with
hyaline membrane on the perfusion, due to constriction,
each expiration becomes
alveolar surface leads to which further limits
more difficult
severe acidosis surfactant production

Assessment
Clinical sings of grunting, central cyanosis in room air,

tachypnea, nasal flaring, and retractions
Chest x-ray will reveal diffuse pattern of radiopaque areas that
look like ground glass (haziness) in the lungs
Blood gas studies will reveal respiratory acidosis
A beta-hemolytic, group b streptococcal infection may mimic
RDS because it is so severe that
stops surfactant production
o Cultures of blood, cerebrospinal fluid, and skin may be
obtained, therefore, to rule out this condition
o Antibiotic (penicillin or ampicillin) and an aminoglycoside
(gentamycin or kanamycin) may be
started while culture reports are pending
Therapeutic Management: Surfactant Replacement
Administration of surfactant at birth
Administered into an endotracheal tube by a syringe or
catheter (lung gavage)
Dexamethasone or betamethasone are drugs that are
administered that would act as surfactant
o Betamethasone is given to the mother within the 12-24 hours
Oxygen Administration
Often necessary to maintain correct PO2 and pH levels
following surfactant administration
Ventilation
Inspiration is shorter that expiration
I/E ratio of 1:2
Additional Therapy: nitric oxide
A potent vasodilator
Causes pulmonary vasodilation without
decreasing systemic vascular tone
Combines with hemoglobin in the intravascular
space to for methemoglobin
o This causes systemic vasodilation
Nitric oxide enters the alveoli on ventilation and
redirects pulmonary blood by dilating the
pulmonary arterioles

Extracorporeal Membrane Oxygenation (ECMO)
Oxygenating blood to manage severe hypoxemia in
newborns with meconium aspiration, RDS, pneumonia,
and diaphragmatic hernia
Supportive Care
Infants with RDS should be kept warm
Provide hydration and nutrition with intravenous
fluids and glucose or gavage feedings
o Because the respiratory effort makes an infant too
exhausted to suck
Prevention
Dating a pregnancy by sonogram and by documenting

level of lecithin in the surfactant
o Ratio of lecithin-sphingomyelin is obtained through
amniocentesis
o Ratio should be 2:1
Using tocolytics such as Mg SO4 and terbutaline to
prevent preterm labor or birth for a few days
o Before administering Mg SO4 check RR, urine output,
and deep tendon reflexes
o Mg SO4 softens the cervix which halts preterm labor
o Terbutaline has a side effect of increased HR
o Isoxilan or isosuxprine - another tocolytic drug that halts
the progression of preterm labor
Two injections of glucocorticoids, such as
betamethasone may possibly prevent RDS
o Administration is most effective between 24 and 34
weeks of pregnancy
o Steroid does not take effect before 24-48 hrs, some
labors, and births will progress too rapidly for this
preventive measure to be effective
Biophysical examination is done to check fetal heart one
and movement, volume of amniotic fluid, breathing, and
fetal heart reactivity
Nursing Care Planning
Nx Diagnosis - Impaired gas exchange r/t
immaturity of newborn’s lungs and lack of
surfactant
Outcome criteria - vital signs within acceptable
parameters
o Temperature - maintained at 97.7ºF (36.5ºC)
o Absence of cyanosis
o Diminished retractions
o ABG values within acceptable parameters
o No sound of grunting with respirations
Interventions
o Maintain a neutral thermal environment, so infant’s
temperature remains stable
o Consult with developmental care coordination for
regarding specific developmental care measures for infant
o Maintain ET tube, mechanical ventilation, and
supplemental warm humidified O2
o Anticipate the need for continuous positive airway
pressure (CPAP) or positive end-expiratory pressure (PEEP)
o Administer surfactant via ET tube as per protocol. Refrain
from suctioning for 1 hour if possible
To prevent from suctioning the surfactant
o Administer nutrition via enteral feeding breast milk
supplemented with high-calorie formula
o Anticipate the need for total parenteral nutrition if weight gain is
not sufficient
o Report hypoglycemia (blood glucose level <45mg/dL)
o Teach parents the cause of preterm birth often cannot be
identified
o Invite parents to see, touch, and spend as much as time as
possible with newborn. Guide them in activities such as skin-to-skin
contact and basic caregiving
o Suggest parents to bring a mobile or toy to keep near the
newborn
o Refer parents to helpful websites for preterm information and
suggest they can join local parents of preemies organization
Meconium Aspiration
Meconium is present in the bowel as early as 10
weeks
If hypoxia occurs, the vagus reflex is stimulated,
resulting to the relaxation of the rectal sphincter
releasing meconium into the amniotic fluid
Infant may aspirate meconium either in utero or with
the first breath at birth
May cause autism due to the decrease of oxygen
going to the brain
May be evidenced by difficulty of crying and barrel
chest

Pathophysiology

Assessment
Difficulty establishing respirations at birth
o Those who were not breech have had a hypoxic episode
in utero to cause the meconium in the amniotic fluid
Apgar score is apt to be low
Almost immediately tachypnea, retractions, and
cyanosis begins
Infant may continue to have retractions because of the
inflammation of the bronchi tends to trap air in the alveoli
o Limiting entrance of oxygen

Therapeutic Treatment
Amnioinfusion can be used to dilute the amount of meconium in the amount of
amniotic fluid
Antibiotic therapy may be prescribed to forestall the development of
pneumonia as a secondary
problem
Surfactant may be administered
If lung noncompliance continues, this may necessitate high inspiratory pressure
Do not administer low pressure oxygen until infant is suctioned and intubated
Hemolytic disease of the newborn (Hyperbilirubinemia)
Hemolytic is Latin for “destruction” (lysis) of red blood cells
Causes the yellowish color or jaundice
o Abnormal in the first 24 hours of life
o Due to early hemolysis of the RBCs
May be caused by two factors: RH incompatibility and ABO incompatibility

RH Incompatibility
If the mother’s blood type is Rh negative and the fetal blood
type is Rh positive, this introduction of
fetal blood causes sensitization to occur and the woman to
begin to form antibodies against the
specific antigen (most commonly the D antigen)
In a second pregnancy, there will be a high level of antibody
already circulating in the pt’s bloodstream
o This will then act to destroy the fetal RBCs beginning early in
the next pregnancy if the new fetus is not a match to the
mother
o Leading to severely compromised by the end of the pregnancy

ABO Incompatibility
Maternal blood type is O and the fetal
blood type is either A or B blood type
Hemolysis of the blood begins with birth,
when blood and antibodies are exchanged
during the mixing of maternal and fetal
blood as the placenta is loosened;
destruction may continue for as long as 2
weeks

Assessment
Rh incompatibility may be predicted by finding a rising anti-Rh
titer or a rising level of antibodies
(indirect Coomb’s test) in a woman during pregnancy
Can be confirmed by detecting antibodies on the fetal erythrocytes
in cord blood (positive direct Coomb’s test) by percutaneous
umbilical blood sampling
Liver and spleen may be enlarged from the attempts to destroy
damaged blood cells
If number of RBCs has significantly decreased, blood in the
vascular circulation may become hypotonic to interstitial fluid,
causing fluid to shift from the lower to higher isotonic pressure by
osmosis resulting to severe edema

Severe anemia can result in heart failure as the heart has to beat
at a faster rate than normal to
push the diluted blood forward
Hydrops fetalis - Greek term that refers to a pathologic
accumulation of at least to or more cavities with a collection of fluid
in the fetus
Normally, cord blood has a total serum bilirubin (TsB) level of 0-
3/100 ml
An increasing bilirubin level becomes dangerous if the level rises
above 20 mg/dl in a term infant and perhaps as low as 12 mg/dl in a
preterm infant because brain damage from bilirubin-induced
neurologic dysfunction
o Kernicterus
o Hearing loss

Initiation of Early Feeding

Bilirubin is removed from the body by
being excreted through the feces
The sooner the bowel elimination begins,
the sooner bilirubin removal begins
Early feeding (either breast milk or
formula) stimulates bowel peristalsis

Phototherapy
Fetal liver processes little bilirubin in the utero because the

mother’s circulation does this for the fetus
With birth, exposure to light is believed to trigger the liver to
assume this function
Phototherapy appears to speed the conversion of
unconjugated (fat-soluble) into conjugated
(water-soluble) bilirubin
Phototherapy exposures the infant to continuous specialized
light such as quartz halogen, cool
white daylight, or special blue fluorescent light
Lights are placed for only 12-30 minutes

Exchange Transfusion
Use of intensive phototherapy in

conjunction with hydration and close
monitoring of serum bilirubin levels has
greatly reduced the need for exchange
transfusion

Retinopathy of Prematurity
An acquired ocular disease that leads to partial or total

blindness in children
It is cause by the vasoconstriction of immature retinal blood
vessels
Eyes of newborns should be examined if they have received
oxygen, especially the LBW before discharge from a hospital
nursery and again at 4-6 weeks of age to detect any occurrence
of the syndrome
o Too much oxygen administration may lead to ROP
Securing the oxygen saturation levels and by conscientious
management of oxygen may prevent
the illness from occurring
The Newborn at Risk because of
Maternal Infection
Newborns are susceptible to infections during

pregnancy and at birth
o Due to immature production of antibodies
A number of infections in newborns, such as
toxoplasmosis, rubella, syphilis, and
cytomegalovirus infections, spread to the fetus
across the placenta in utero

Beta-Hemolytic, Group B Streptococcal Infection
A serious infection in newborns that are caused by a
gram-positive b hemolytic, group b
streptococcal (GBS) organism
o Natural habitant of the female genital tract
May be spread from baby to baby if good hand washing
technique is not used it caring for the
newborns
If a woman is found to be positive for GBS during late
pregnancy, ampicillin is administered via IV during
pregnancy and again during labor helps to reduce the
possibility of newborn exposure

Assessment
With the early-onset form, signs of pneumonia such
as tachypnea, apnea, extreme paleness, hypotension, or
hypotonia (decrease in muscle tone) become apparent
within the first day of life
Late-onset type occurs 2-4 weeks of age. Instead of
pneumonia being the infection focus, meningitis tends
to occur
o Typical signs include lethargy, fever, loss of appetite,
and bulging fontanelles from increased intracranial
pressure

Antibiotics such as penicillin, cefazolin,
clindamycin, or vancomycin are all effective
against the GBS organism
If the newborn survives the infection but is
left neurologically challenged
Immunization of all women of childbearing
age against Streptococcal B organisms could
decrease the incidence of newborns infected at
birth
Ophthalmia Neonatorum
Eye infection that occurs at birth or during the first
month of life
Most common causative agent are Neisseria
gonorrhoeae and chlamydia trachomatis
o Contracted from vaginal secretions
An N. gonorrhea infection is an extremely serious
infection
o If left untreated, the infection progresses to corneal
ulceration and destruction, resulting in opacity of the
cornea and severe vision impairment
May be treated with erythromycin

Assessment
Prophylactic instillation of erythromycin ointment
into the eyes of newborns prevent both gonococcal
and chlamydial conjunctivitis
If gonococci are identified, intravenous ceftriaxone
(Rocephin) and penicillin are effective drugs
If chlamydia is identified, an ophthalmic solution of
erythromycin is commonly used

Hemorrhagic Disease of the Newborn
Is lack of clotting ability resulting from deficiency of vitamin
K at birth
o Due sterile intestines at birth
o Bacteria required for clotting takes 24 hours to grow
This disorder is prevented by administering vitamin K to a
newborn within the first hour following birth
Normal prothrombin time is 11-13.5 seconds
Sign and symptom: petechiae
Guaiac test is done
o Stool is checked for the presence of blood, if (+) blood,
colonoscopy is done

Hepatitis B Virus Infection:
Can be transmitted to the newborn through contact with infected
vaginal blood at birth when the mother is positive for the virus
o Positive for surface antigen of the hepatitis b virus [HBsAg(+)]
Is a destructive illness with greater than 90% of infected infants
becoming chronic carriers of the virus as well as the risk of developing liver
cancer later in life
If the mother is identified as HBsAg(+), her infant should be bathed as
soon as possible after birth
o To remove HBV-infected blood and secretions
Gentle suctioning is necessary to avoid trauma of the mucous
membrane, which could allow HBV invasion
To further prevent infection, infant is given serum hepatitis B immune
globulin (HBIG) in addition to HBV vaccine

Generalized Herpesvirus Infection
A herpes simplex virus type 2 (HSV-2) infection,

which is most prevalent among women with
multiple sexual partners
o Can be contracted by a fetus across the placenta
The virus is contracted from the vaginal
secretions of a mother who has active herpetic
vulvovaginitis at the time of birth

Assessment
Signs: stomatitis (mouth ulcerations) and few
vesicles on the skin appear
Herpes vesicles always cluster, are pinpoint in size,
and are surrounded by a reddened base
Vesicles appear after infants become extremely ill
o They develop dyspnea, jaundice, purpura,
convulsions, and hypotension
o May have permanent central nervous system
sequelae

Antiviral drug such as acyclovir (Zovirax), a drug that inhibits viral
DNA synthesis, is effective in combatting this overwhelming infection
Women with active herpetic vulvar lesions are advised to have
cesarean birth rather than vaginal birth to minimize the newborn’s
exposure
Healthcare personnel who have herpes simplex infection should
not care for newborns until the
lesions are crusted
Limiting contact does not mean excessive in light of severity of
HSV-2 disease
Urge a woman who is separated from her newborn at birth to view
her infant from the nursery window and participate in planning care
to aid bonding

The Newborn at Risk because of Maternal Illness
An infant of a woman who has diabetes mellitus

Baby also has greater chance of having a
congenital anomaly such as cardiac anomaly because
hyperglycemia is teratogenic to a rapidly growing
fetus
Babies tend to be lethargic or limp in the first day
of life as a result of hyperglycemia

Complications
Macrosomic infant has a greater chance of birth injury, especially
shoulder and neck injury
o Clavicles are palpated to rule out broken bones
Infants tend to be hyperglycemic immediately after birth because
the mother was at least slightly
hyperglycemic during pregnancy and excess glucose transfused
across the placenta
During pregnancy, fetal pancreas responded to this high glucose
level with islet cell hypertrophy,
resulting in matching high insulin levels
o After birth, as an infant’s glucose level begins to fall because the
mother’s circulation is no longer supplying glucose, overproduction
of insulin will cause the development of severe hypoglycemia

Hyperbilirubinemia may also occur in these infants
because, if immature, they cannot effectively clear
bilirubin from their system
Hypocalcemia also frequently develops because
parathyroid hormone levels are lower in these infants
due to hypomagnesemia from excessive renal losses of
magnesium
Usually infant are LGA, an infant born to a woman
with extensive blood vessel involvement may be SGA
because of poor placental perfusion

In a newborn, hypoglycemia is serum glucose <45mg/dl
Initiation of early feeding
If they are unable to suck, continuous infusion of D5050 glucose can be
prescribed
o It is important that infant not be given only a bolus of glucose; otherwise,
rebound hypoglycemia can occur
Monitor blood glucose from blood sample taken from the heel
Infants of women with diabetes have a smaller than usual left colon
o Another effect of intrauterine hyperglycemia, which can limit the amount
of oral feedings they can take in the first days of life
o Signs of inadequate colon: vomiting and abdominal distention after the
first few feedings

Infant of a Drug-Dependent Mother
Infant tend to SGA
If the woman took a drug close to birth, her infant may show withdrawal
symptoms (neonatal abstinence period) shortly after birth:
o Irritability
o Disturbed sleep pattern
o Constant movement, possibly leading to abrasions on the elbows, kneed, or
nose
o Tremors
o Frequent sneezing
o Shrill, high-pitched cry
o Possible hyperreflexia and clonus (neuromuscular irritability)
o Convulsions
o Tachypnea, possibly so severe that it leads to hyperventilation and alkalosis
o Vomiting and diarrhea, leading to large fluid losses and secondary dehydration

An Infant with Fetal Alcohol Exposure
Alcohol crosses the placenta in the same concentration as
is present in the maternal bloodstream so may result in
fetal alcohol exposure
o Also termed as fetal alcohol spectrum disorder
Characteristics that mark the syndrome include:
o Prenatal and postnatal growth restriction
o Central nervous system involvement such as cognitive
challenge, microcephaly, and cerebral palsy
o Distinctive facial feature of short palpebral fissure, thin
upper lip, and low nasal bridge

During neonatal period, an infant may appear
tremulous, fidgety, and irritable
o May demonstrate weak sucking reflex
Sleep disturbances are common, with the baby
tending to be either always awake or always asleep
depending on the mother’s alcohol level close to birth
Most serious long-term effect is cognitive challenge
Behavior problems such as hyperactivity may occur in
school-age children
Growth deficiencies may remain throughout life
QUIZ

Thank You!

NCM 109 Lecture Maternal and Child at Risk 3 5

Uploaded by

Copyright:

Available Formats

NCM 109 Lecture Maternal and Child at Risk 3 5

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

NCM 109 Lecture Maternal and Child at Risk 3 5

Uploaded by

Copyright:

Available Formats

Care of At-Risk / High Risk, and

Sick Mother and Child

DR. JULAIZA PINEDA TANABE

※ Nursing Care of the Client during Labor

※ Nursing Care of the Post-partum Client

Interview - comprehensive health history emphasizing the current

Reasons for Seeking Care - chief concerns should be recorded in her

Childbearing and Female Reproductive System History – menarche;

Health History - physical or surgical procedures that can affect the

Nutritional History – dietary assessment can reveal special diet

DR. JULAIZA PINEDA TANABE

DR. JULAIZA PINEDA TANABE

Nausea sometimes Nausea accompanied by severe

Nausea that subsides at 12 Nausea that does not

Vomiting that does not cause severe Vomiting that causes

DR. JULAIZA PINEDA TANABE

DR. JULAIZA PINEDA TANABE

DR. JULAIZA PINEDA TANABE

DR. JULAIZA PINEDA TANABE

- Determine the pregnant woman’s:

DR. JULAIZA PINEDA TANABE

If on clear fluid, small quantities of dry toast, crackers, or

If vomiting returns, enteral or total parenteral nutrition

Home care follow-up

DR. JULAIZA PINEDA TANABE

DR. JULAIZA PINEDA TANABE

DR. JULAIZA PINEDA TANABE

DR. JULAIZA PINEDA TANABE

Home care instructions upon discharge:

DR. JULAIZA PINEDA TANABE

The patient’s condition is managed and complications are

DR. JULAIZA PINEDA TANABE

DR. JULAIZA PINEDA TANABE

DR. JULAIZA PINEDA TANABE

● Not a good candidate for oral contraceptives =

- Endocrine disorders that pancreas cannot regulate

4 CARDINAL SIGNS OF DIABETES:

DR. JULAIZA PINEDA TANABE

1. Type 1 - occurs in childhood and represents

2. TYPE 2 - Failure of adequate insulin production

DR. JULAIZA PINEDA TANABE

Diabetes during pregnancy:

DR. JULAIZA PINEDA TANABE

- Becoming diabetic during pregnancy usually occurs at midpoint

RISK FACTORS INCLUDE:

BLOOD GLUCOSE MONITORING:

INSULIN PUMP THERAPY:

DR. JULAIZA PINEDA TANABE

- PIH is a condition in which VASOSPASM occurs during

DR. JULAIZA PINEDA TANABE

DR. JULAIZA PINEDA TANABE

DR. JULAIZA PINEDA TANABE

DR. JULAIZA PINEDA TANABE

Laboratory and Diagnostics:

DR. JULAIZA PINEDA TANABE

Management – Mild PIH

DR. JULAIZA PINEDA TANABE

Management severe PIH

Fetal Well Being: