OVERVIEW OF MATERNAL AND NEWBORN CARE - Every year 4M neonatal deaths

Maternal Mortality Rate RATIO (100,000 per live o Of those who dies in the first month, 2/3 die
birth) in the first week
o 8 neonatal deaths in every minute
o 4M stillbirths
- Philippines is one of 42 countries that account
for 90% of global under-five deaths

Maternal Health: Scope of the problem

- Maternal Mortality is unacceptably high Reason for High Maternal and Neonatal Mortality
o 800 women die from pregnancy or its - Young age at marriage and first pregnancy
complications worldwide = 1 women in - Domestic violence and gender inequality
every 2 minutes - Poor maternal health
o 50% decrease from 1990 statistics of - Poor hygienic during and after delivery
540,000 maternal deaths to 287,000 in - Lack of/ poor newborn care
2010 - The three delays
o Most are preventable and in low-resource
settings The THREE DELAYS
o 99% of maternal deaths occur in developing - Delay in deciding to seek medical care
countries o Failure to recognize danger sign
o Women in developing countries have 15X o Lack of money
risk of dying from pregnancy and related o Unplanned/ unwanted pregnancy
complications o Lack of companion in going to health
facility
o No person to take care of children/ home
o Fear of being ill-treated in health facility

- Delay in identifying and reaching appropriate

facility
o Distance from a woman’s home to health
facility/ provider
o Lack of/ poor condition or roads
o Lack of emergency transportation
o Lack of awareness of existing services
o Lack of community supports
Neonatal Health: Scope of the Problem
El Jireh D. Asauro BSN2E
NCM 109: 1
 Emergency Obstetric and Newborn Care
- Delay in receiving appropriate and adequate (EmONC)
care at health facility - Elements of obstetric and newborn care needed
o Lack of health care providers for the management of normal and complicated
o Shortage of supplies pregnancy, delivery, postpartum periods and
o Lack of equipment the newborn
o Lack of competence of health providers o Early detection and treatment of problem
o Weak referral system pregnancies to prevent progression to an
emergency
How will we make it happen? (Current tools to avert o Management of emergency complications
maternal death and disability)
Basic Emergency Obstetric and Newborn Care
- A skilled health care professional attends every (BEmONC)
childbirth - Parenteral (IV or IM) administration of
- Every woman has access to Emergency emergency drugs
Obstetric and Newborn Care (EmONC) o Oxytocin
- Family planning services to help women space o Anticonvulsants
their pregnancies o Antibiotics
o Dexamethasone
Skilled Health Care Worker - Manual removal of placenta
“The single most important way to reduce maternal - Removal of retained products of conceptions
deaths is to ensure that a skilled attendant is - Assisted vaginal delivery (imminent breech
present at every birth” delivery)
- Essential newborn care
- A skilled attendant is an accredited health - Basic newborn resuscitation
professionals (midwife, nurse or doctor) who
has been educated and trained to proficiency in
the skills needed to manage normal pregnancies,
childbirth and the immediate postnatal period, Comprehensive Emergency Obstetric and
and in the identification, management and Newborn Care (CEmONC)
referral of complications in women and - All BEmONC services
newborns. o PLUS
- Surgery (caesarean section, hysterectomy)
- Blood transfusion
- Advanced newborn resuscitation

Principles of Professional conduct

- In providing professional services, a certain level
of competence is necessary
- Professionals shall undertake only those
services that they can reasonably deliver with
professional competence.

El Jireh D. Asauro BSN2E

NCM 109: 2
- Keep up with new knowledge and techniques in promotion of early breastfeeding initiation and
their field, continually improve their skills and exclusive breastfeeding and family planning
upgrade their level of competence, and take part - Formulate a birth and emergency plan
in a lifelong continuing education program.
Focused Antenatal Care
Key Messages In Normal, uncomplicated pregnancy, atleast 4
- Most maternal and neonatal deaths occur antenatal visits with a skilled health provider:
during the critical period covering labor, 1st visit: within 3 months
delivery and the immediate postpartum period. 2nd visit: 6 months
- The 4 major direct causes of maternal mortality 3rd visit: 8 months
are: 4th visit: 9 months – return if undelivered
o Hemorrhage within
o Hypertension 2 weeks after the EDC
o Obstructed labor
o Complications from abortion Steps to follow in Antenatal Care
- The 3 delays act as barriers to accessing health 1. QUICK CHECK for emergency signs
care on time. Delay may result to death a. Unconscious/ Convulsing
- The interventions that can save maternal and b. Vaginal bleeding
newborn lives: c. Severe abdominal pain
o A skilled health professional attending d. Looks very ill
every childbirth e. Severe headache with visual
o Access to every mother and newborn to disturbances
EmONC f. Severe difficulty in breathing
o family planning services to help a woman g. Dangerous fever (looks very week)
space her pregnancies h. Severe vomiting
2. Make the women comfortable
“GIVING BIRTH SHOULD BE ABOUT GIVING LIFE, NOT a. Greet her, make sure she is
GIVING UP A LIFE” comfortable and ask how she is feeling
b. At first visit, register the woman and
ANTENATAL CARE issue a Mother and Child Book
(Antenatal record book)
Definition 3. Assess the pregnant woman
- regular and periodic care of a pregnant women - AT FIRST VISIT: do a complete history
and her unborn baby throughout pregnancy (OBSTETRIC RECORD)
- regular visit to a skilled health professional a. Age
b. Past medical history/ Alcohol/ Drugs/
Objectives Substance abuse?
- To identify danger signs of pregnancy and c. Obstetric history: Gravidity/ LMP/ AOG
manage health problem that have an d. Ask about or check record for prior
unfavourable outcome on pregnancy pregnancies:
- To prevent occurring serious complications
- To educate and counsel women for a health i. Preterm birth
pregnancy, childbirth and postnatal recovery,
El Jireh D. Asauro BSN2E
NCM 109: 3
 ii. History of breastfeeding - On the THIRD TRIMESTER: do also,
experiences for non- primipara o Abdominal examination (leopold’s
iii. Stillbirth or death in the first day maneuver)
iv. Heavy bleeding during or after o Check fetal heartbeat
delivery
v. Prior caesarean section, forceps or
abortion
e. Ask about or check record for prior
pregnancies for general danger sings:
i. Severe headache Recognition and Management of Pregnancy
ii. Visual disturbance Complications
iii. Convulsions 1. Check for pallor or anemia
iv. Fever or chills a. Ask about getting tired easily or
f. Vital signs, height, and weight shortness of breath during routine
g. Conjunctival or Palmar Pallor work
h. Abdominal exam – look for any mass, b. Look for conjunctival or palmar pallor
scar c. Count number of breaths in one
i. In the 3rd trimester: leopold’s minute
exam, FHT d. Measure Hb & Hct on 1st visit or
i. Do not perform vaginal exam as a following visit:
routine prenatal care procedure i. The normal hemoglobin cut-off level
(internal examination should only be for a pregnant woman is 11g/dl
done q4h)
4. Get baseline laboratory information of the MANAGEMENT OF ANEMIA
woman on the first or following the first visit. Moderate Anemia
a. CBC or Hb, Hct, Blood types - Hb 7-11 g/dl or Palmar or conjunctival pallor
b. Urinalysis - +/- Dizziness
c. Rapid Plasma Reagin - HR >100/ mins
d. Blood sugar screening a. Give all dose of iron
e. HIV
“If not available, refer to the nearest RHU or Severe Anemia
hospital for the tests” - Hb <7 g/dl
- Tires easily
ON ALL VISITS: - Dizziness
- Check duration of pregnancy (AOG) - HR >100/min
- Ask for occurrence of any danger signs during - RR = 30 breaths/ minute
the pregnancy a. Refer for BT (Blood Transfusion)
- Check record for previous treatment received
during this pregnancy 2. Check for hypertension/ preeclampsia
- Prepare birth and emergency plan a. Measure BP in sitting position
- Ask patient if she has other concerns b. If diastole BP is 90 mmHg or higher
- Educate and counsel on family planning and repeat measurement after 1 hour rest
breastfeeding
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NCM 109: 4
 c. If diastole BP is still 90 mmHg or higher ▪ Upper abdominal pain (RIGHT UPPER
ask the women if she feels: QUADRANT or EPIGASTRIC REGION)
i. Severe headache ▪ Pulmonary edema
ii. Blurring of vision ▪ Hyperreflexia
iii. Epigastric pain
d. Check urine for protein MANAGEMENT OF MILD PREECLAMPSIA
✓ Follow up 2x a week as an outpatient
PREGNANT WOMEN w/ BP: 140/90 mmHg ✓ Monitor BP, proteinuria, fetal condition
Before 20 weeks AOG----------------- ✓ Advise on danger signals of severe
- NO or STABLE proteinuria preeclampsia/ eclampsia
o CHRONIC HYPERTENSION ✓ Encourage additional periods of rest
- NEW or ↑proteinuria r/t increasing BP in HELLP
syndrome (hemolysis, elevated liver enzyme, ✗ salt restriction
low platelet counts ✗ Anti-hypertensive
o PRE-ECLAMPSIA superimposed on chronic ✗ Diuretic
HPN ✗ Sedatives or tranquillizers
After 20 weeks AOG-------------------
- No Proteinuria MANAGEMENT OF SEVERE PREECLAMPSIA
o GESTATIONAL HYPERTENSION - Give anticonvulsant to prevent eclampsia
- Proteinuria - Control blood pressure with anti- hypertensive
o PRE-ECLAMPSIA - Deliver the baby
Diagnosis of Preeclampsia o Give antenatal steroids (Dexamethasone,
- A pregnancy- specific, multisystem disorder, betamethasone for maturation of lung
characterized by the development of surfactant, given IM (deltoid) to mother) if
hypertension and proteinuria after 20 weeks of the baby is preterm
gestation - Best managed by a physician during the entire
o MILD: Systolic BP ’ 140 mmHg or course of the pregnancy
Diastolic BP = 90-109 mmHg, or - 3R’s (REASSESS, RE, REFER)
Both at least 2x 4 hours apart with
proteinuria of 1-2 g/L (++)
o SEVERE: Systolic BP ’ 160mmHg
Diastolic BP ’ 110 mmHg Administration of Magnesium Sulfate (anti-
Both with proteinuria 3 g/L (+++) convulsant)
“Per 1L ang plus (+)” Give Combined IV/ IM dose as Loading Dose
o ECLAMPSIA: (+) convulsion - Insert IV line (normal saline or Ringer’s lactate)
slowly (1liter in 8hours)
o SEVERE ALSO: BP ≥ 140/90 with any of the - Give 4 grams MgSo4 IV slowly over 20 min
following: (woman may feel warm during injection)
▪ Headache (increasing frequency, not - Give 5 grams deep IM in the upper outer
relieved by regular analgesics) quadrant of each buttock (total 10gms) or in
▪ Blurred vision ventrogluteal area
▪ Oliguria (<400mL of urine in 24 hours) - Magnesium sulfate 25% vial = 250mg/ ml
o 4 grams = 16ml
El Jireh D. Asauro BSN2E
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 o 5 grams = 20 ml
- Transfer to a higher-level facility after loading 4. Check for Syphilis
dose - Goal- reduce maternal morbidity, fetal loss and
- Only definitive treatment is termination of neonatal mortality and morbidity due to syphilis
pregnancy or delivery - For all pregnant women, order RPR at first
prenatal visit within the first trimester, again in
Level of Preeclampsia/ Eclampsia Prevention late pregnancy and at delivery
LEVEL STRATEGY DEFINITION - If positive, REFER to the doctor or further MGT
1. Primary Prevention > Avoiding the - For women who do not have test results but with
development high-risk behavior, REFER to the RHU doctor
of the disease
> Avoiding 5. Ask for other illnesses or health problems
pregnancy and - Episodes of fever or chills
conditions o Take body temperature
favorable to o Fever may be a sign of infection
PE o Buring sensation on urination R/O UTI
development o Abnormal vaginal discharge, itching at the
2. Secondary Detection & > Detecting the vulva or if partner has a urinary problem
Screening disease before o Cough ’ 14 days R/O PTB (pneumonia-
clinical Tuberculosis), REFER!!! For sputum exam
symptoms and further diagnosis and treatment
manifest o Tooth decay and gum disease
3. Tertiary Treatment & > Treating the ▪ “One tooth is lost with every
management disease early pregnancy” NOT TRUE!!!
to prevent ▪ Hormones of pregnancy increase the
complications deposition of plaque on teeth. If this is
not removed gums become swollen
3. Check for diabetes mellitus and bleed easily
LOOK FOR ▪ Instruct the pregnant to brush teeth
o Signs of maternal overweight or obesity regularly after each meal to prevent
o Polyhydramnios (>2000mL of amniotic accumulation of plaque on teeth
fluid) ▪ REFER!!! To the dentist for regular
o Signs of large baby or fetal abnormality check-up
o Vaginal infection
PREVENTIVE MEASURES
LABORATORY CHECK
o WHEN
▪ LOW RISK: 24- 28
▪ HIGH RISK: immediately, any AOG
o HOW
▪ 2 hours - 75 grams oral Glucose
challenge test
▪ If result >140 mg/ dL, REFER!!!
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 - Give Mebendazole 500mg single dose once in 6
months after the first trimester (from 4-9
months of pregnancy)
- Give if none was given in the past six (6) months
UPON THE PRESCRIPTION OF THE DOCTOR!!
- DO NOT give mebendazole in the first 1-3
months of pregnancy (might cause congenital
problems in the baby)
o Proven to be safe during pregnancy
o Not absorbed in the bloodstream (remains
only in GIT)
1. Give tetanus toxoid according to the ff. o Paralyzes and kills intestinal parasites
schedule o Global standards in drug safety advise to
avoid giving during the first trimester
2. Give iron and folic acid supplementation to
prevent maternal anemia and fetal neural 5. Antimalarial intermittent preventive
tube defects treatment and promotion of insecticide-
treated nets (in endemic areas)
- Ferrous sulfate 320 mg (60 mg elemental iron) - All pregnant women should sleep under an
- Folic acid 400 mcgram insecticide- treated bednet (ITN)
- Can be given as a tablet with 60 mg elemental - Dip nets every 6 months
iron with 400 mcgrams of folic acide - In areas of stale transmission of falciparum
- Give 1 tablet as soon as pregnancy is confirmed malariae, all pregnant women should be given
- Give at least 180 tablets administered once a intermittent preventive treatment (IPT)
day for the whole duration of pregnancy
3. Iodine supplementation
Preparation is a capsule with 200mg elemental
iodine.
- Give two (2) capsules once a year in any of the Birth and Emergency Plan
following situations: - Confer with the mother and her family regarding
o Iodine deficiency disorder (IDD) is classified the preparation of her Birth and Emergency
as moderate or severe cretinism and Plan
neonatal hypothyroidism are present - A written document prepared during the first
o Area where the patient resides has 90% of prenatal consultation
the households using iodized salt and - Reviewed every visit
median urinary iodine is 100 mcgrams - May change anytime during pregnancy if a
among school children problem is detected
- Give iodine supplementation during the first
trimester, but no later than the second trimester - Important information included
- This has been shown to prevent cretinism and o Woman’s condition during pregnancy
other abnormalities o Preferred birth attendant
o Desired place of birth
4. Deworming o Transportation to health facility
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NCM 109: 7
 o Available resources for her childbirth and o looks very ill
newborn baby and emergency expenses o fever
o Birth companion of her choice o severe breathing difficulty
o Preparations needed should an emergency “DO NOT make a very sick woman wait, attend to
situation arise like blood donors her quickly!!”
2. Greet the woman and make her comfortable
Health Education and Health Promotion o ask for informed consent for any
- Give nutrition education and counselling examination or procedures
- Counsel on self-care during pregnancy o respect privacy
- Advise adherence to prophylactic treatment o communicate with test results
- Counsel against unhealthy lifestyle o reassure her and her family
o Advise the pregnant woman not to smoke, 3. Assess the woman in labor
avoid others who smoke and not allow o take the history of labor and record on the
smoking inside the house and work areas labor record form
o Caution the woman against taking o important question to ask are:
alcoholic drinks ▪ when did contractions begin? How
frequent? How strong?
KEY MESSAGES ▪ Has the bag of water broken? Is the
- ANC is the 1st step towards preventing amniotic fluid clear or stained? How
maternal and newborn death. Encourage early many hours has it been ruptured?
and continued antenatal visits throughout the ▪ Is there any bleeding? And if yes, when
pregnancy and how much?
- Focused ANC means atleast 4 quality visits for ▪ Is the baby moving or not?
health education and management of pregnancy ▪ Are there any other concerns?
complications and timely referral to higher 4. Review for mother and child book for current
facilities when needed pregnancy
- Mother ang her family should prepare a birth o If no record, ask for:
plan for birth preparedness and complication ▪ Last menstrual period (LMP)
readiness together with the health care ▪ When is delivery expected (EDC)
attendant. ▪ Determination whether preterm or
- Counsel the women to deliver in a health facility term
with a skilled health worker as the birth ▪ If in preterm labor, notify assigned
attendant. doctor or nurse for administration of
appropriate medications
Intrapartum care • If not in active labor, properly
Unit 1 ’ steps to follow in intrapartal care REFER TO THE HOSPITAL
• If in active labor, deliver the baby
1. examine the woman for emergency signs and prepare for possible
o unconsciousness, convulsion resuscitation and referral to the
o vomiting hospital
o severe headache with blurring of vision o History of prior pregnancies:
o vaginal bleeding
o severe abdominal pain
El Jireh D. Asauro BSN2E
NCM 109: 8
 If any of the following are present,
▪ o Advise on correct and
REFER to the doctor for referral to the consistent use of condoms to
hospital: prevent new infections
• Prior caesarian section, forceps, 6. Perform an abdominal examination
vacuum delivery o Presence of previous caesarean section scar
• Postpartum hemorrhage ▪ If not yet in late active labor, URGENTLY
• Any prior third-degree tear REFER TO A HOSPITAL
• Other complications ▪ If in late active labor or imminent
5. Review for laboratories, diagnosis exams during delivery: deliver the baby with
previous prenatal check-ups controlled delivery of the head and
o Hemoglobin level prompt active management of third
▪ If the hemoglobin >11g/dL: stage of labor (AMTSL)
Continue routine labor and delivery o Determine fetal lie
care ▪ If longitudinal, assess fetal presentation
▪ If the hemoglobin <7g/dL- 11g/dL and/or: ▪ If transverse lie, notify your doctor and
• Severe palmar or conjunctival URGENTLY REFER TO THE HOSPITAL and
pallor facilitate immediate transfer.
• Any pallor with >30 breaths/min or ▪ Establish IV line with IVF D5LR 1 Liter to
tires easily run at 40 drops per minute
• Breathless at rest +/- dizziness or o Determine fetal number
heart rate >100/min ▪ When there is more than 1 fetus:
• REFER to your doctor for referral to • If the woman is in labor, determine
a hospital the stage of labor
• Establish IV line before transfer o 1st stage of labor, facilitate
• Continue monitoring of vital signs URGENT REFERRAL TO THE
and progress of labor HOSPITAL
• If in late active labor, deliver the o 2nd stage of labor, deliver,
baby then CONDUCT URGENTLY proceed with additional care
TO A HOSPITAL provision
▪ RPR status ▪ If the woman is not in labor: facilitate
• If RPR test is positive (REACTIVE) non-urgent referral/ transfer
o Refer to the doctor or nurse for o When there is more than 1 fetus
administration of Benzyl ▪ Check the presentation of the first fetus
penicillin by the nurse • If cephalic presentation, allow the
o Plan to treat the newborn labor to progress as for a single
o Encourage the woman to bring fetus, and monitor progress of
her sexual partner for labor using partograph
treatment • If breech presentation, apply the
o Advice corrects and consistent same guidelines as for a singleton
use of condoms to prevent breech birth if in imminent delivery
new infections o Listen to fetal heart-beat, count the number
• If RPR is negative (non-reactive) of beats in 1 full minute
▪ If fetal tone is absent
El Jireh D. Asauro BSN2E
NCM 109: 9
 •
Ask several other people to listen, ▪ Warts, keloid tissue or scars that may
using fetal doppler if available, or interfere with delivery
obtain ultrasound if available o Perform gentle vaginal examination (do not
immediately start during contraction)
• If FHT is not detected on available 8. Explain findings to the woman, reassure her
ultrasound: fetus is dead, REFER to 9. Record findings in labor record or in partograph
the doctor or hospital 10. DO NOT DO routine perineal shaving or perform
▪ If still unable to hear FHT (other than OB a vaginal exam if there is bleeding at >7 months
ultrasound) wait for 15 minutes and AOG
then repeat. Place the woman on her
left side and give her oxygen at 4 – 6L Determining stage of labor
per minute
• If FHR is heard and is normal: (120-
160 per 1 full minute) -> proceed
with basic/ routine care provision
• If FHT is abnormal:
Slow (<120 BPM) in the absence of
contractions or persisting after
contractions or a rapid FHT (>160
BPM) in the absence of a rapid
maternal heart rate during labor =
FETAL DISTRESS
o If with FETAL DISTRESS
▪ Place the woman on her left side and
give her oxygen 4 – 6L per minute 11. Decide if the woman can safely deliver
▪ Notify your doctor and facilitate o If facility can manage labor and deliver,
URGENT REFERRAL/ TRANSFER TO THE admit
HOSPITAL o If there is an indication for referral
▪ Continue oxygen per nasal canula on ▪ In early labor and the referral hospital
the way to the hospital can be timely reached, REFER
7. Determine stage of labor URGENTLY
o Explain to the woman that you will perform o If in active labor
vaginal examination and ask for her ▪ Monitor progress of labor and delivery
consent ▪ Prepare for imminent referral if needed
o Respect privacy o If the woman and her family refuses referral
o Observe standard precautions ▪ Explain the possible consequences
o Inspect vulva for: ▪ Continue to take care of her
▪ Bulging perieneum -
▪ Any visible fetal parts 12. Provide relief from pain and discomfort
▪ Vaginal bleeding o Suggest change of position as she wishes
▪ Leaking amniotic fluid; if yes, is it o Encourage mobility and position of choice
meconium stained, foul smelling?

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NCM 109: 10
 o Encourage the companion to massage the - 1st stage of labor is the period from the onset of
woman’s back, hold the woman’s hand and regular contractions up to fill cervical dilatation
sponge her face between contractions o Uterine contraction of atleast 4 in 20
o Encourage her to use the proper breathing minutes
technique o Progressive change in cervical dilatation
o Encourage warm bath or shower if available and effacement
o Pain medication possess risk, USE W/ o Cervical effacement and loss of canal of the
CAUTION cervix of greater than 75%
o If the woman is distressed or anxious, - Active phase of labor means cervical dilatation
investigate the cause of atleast 4 cm
o If pain is constant (persistent between - First stage latent phase not yet in active labor
contractions) REFER TO THE DOCTOR o Characterized by cervix dilated 0-3cm,
13. Ensure cleanliness contractions are weak, <2 in 10 minutes
o Encourage the woman to take a bath or o Check for emergency signs, FREQUENCY,
shower or wash herself and genitals at the INTENSITY, INTERVAL & DURATION of
onset of labor contractions, FHR, mood and behavior every
o Wash the vulva or perineal area before hour
each examination o Check vital signs and cervical dilatation
o Wash your hands with soap and water every 4 hours
before each examination, use clean gloves o Record findings in labor record
for vaginal examination - First stage of active labor
o Ensure the cleanliness of the labor and o Check temperature (presence of fever),
birthing area blood pressure, pulse rate, cervical
o Clean up spills immediately dilatation q4h
“Cleanliness is important, allow the woman to bathe o Record time of rupture of membranes and
or wash herself during labor” color of the amniotic fluids
- Record findings In WHO partograph
14. Effects of continuous maternal support during o If the partograph passes to the right of the
labor ALERT LINE
o Reduce perception of severe pain thereby ▪ Re-assess the woman and consider
lessening the needs for anesthesia criteria for referral
▪ Duration of labor shorter ▪ Call senior person if available, alert
▪ More spontaneous vaginal birth emergency transport service
▪ Less instrumental vaginal delivery/ ▪ Encourage woman to empty bladder
caesarean section ▪ Ensure adequate hydration but omit
▪ Lest postpartum pain solid foods
▪ Protects the mother’s sense of safety ▪ Encourage upright position and walking
and security and make her less if woman wishes
dissatisfied with birth ▪ Monitor intensively
▪ Reassess in 2 hours and refer if no
UNIT 2 – Management of first stage of labor progress
Definition ▪ if referral takes a long time. refer
immediately
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NCM 109: 11
 ▪ DO NOT wait to cross the ACTION LINE 1st Stage of Labor
o If the partograph passes to the right of the
ACTION LINE, REFER URGENTLY to doctor RECOMMENDED PRACTICES
unless birth is imminent ✓ Admission to labor when in Active phase
o Relief pain and discomfort ✓ companion of choice to provide a continuous
▪ Suggest change in position maternal support
▪ Encourage mobility as comfortable for ✓ Mobility and Up-Right Position
her ✓ Allow foods and drink
▪ Encourage proper breathing technique: ✓ Use of WHO partograph to monitor the progress
breath slowly, make a sighing noise. of labor
Make 2 short breaths followed by long ✓ limit Internal Examination to 5 or less (q4h)
breath out.
▪ Massage her lower back if she finds it NOT RECOMMENDED PRACTICES
helpful ✗ Routine Perineal shaving on admission
o DO NOT do routine enema ✗ Routine Enema
▪ no longer recommended as it is ✗ Routine NPO
uncomfortable ✗ Routine IVF
▪ can damage the bowel ✗ Routine Vaginal Douching
▪ increase the cost of delivery ✗ Routine Amniotomy
▪ does not shorten labor or decrease risk ✗ Routine Oxytocin augmentation
of infection of the newborn/ perineal
wound Definition of the 2nd stage of labor
- DO NOT shave the perineal area - Period of full cervical dilatation to the birth of the
o Routine pubic or perineal shaving is no baby
proven advantage or benefits - Criteria for diagnosis a woman to be in 2nd stage
o Can lead to side effects like irritation, of labor:
redness, multiple superficial scratches, o Fully dilated cervix on internal examination
burning and itching of the vulva o Strong uterine contraction in 2-3 minutes
o If need to remove the hair of the perineum, o Bulging thin perineum with the fetal head
clipping is better alternative to shaving visible during contraction
o BOW will rupture if it has not ruptured
PRECAUTIONS earlier
- DO NOT do IE more frequently than q4h
- DO NOT allow the woman to push unless Preparation of the mother for delivery
delivery is imminent. Pushing at this stage does - Continues close monitoring
not speed up labor. It will just make the cervix o Check uterine contraction, FHR, mood, and
swell and mother tired behavior
- DO NOT give medications to speed up labor. It is o Continue recording in the partograph
dangerous as it may cause trauma to the - Implementing the 3 CLEAN
mother and baby o Clean hands. Wear double gloves
- DO NOT do a fundal pressure as it may cause o Clean delivery surface
uterine rupture or fetal death o Clean cutting and care of the cord

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NCM 109: 12
- Ensure all delivery equipment and supplies. episiotomy. DO NOT PERFORM EPISIOTOMY
Including the newborn resuscitation equipment ROUTINELY
are available and place of delivery is warm (25 – - If breech or other presentation. Manage
28C without air draft) appropriately based on the situation.
- Ensure bladder is empty. - Encourage the mother to bear down when the
Encourage the woman to urinate. baby’s head is coming down
If unable to pass urine, empty bladder using - When the birth opening is stretching, support the
catheter. perineum and anus with a clean pad to prevent
- Stay with the woman and encourage her. lacerations.
Offer her emotional and physical support - DO NOT apply fundal pressure to help deliver
- stay with the woman in labor the baby as this may harm both the mother and
- make her feel comfortable the baby
- encourage her
- give her emotional and physical support ENSURE CONTROLLED DELIVERY OF THE HEAD
- Keep one hands on the head as it advances
Second Stage of Labor during contraction. Keep the head from coming
- assist woman into a comfortable position of her out too quickly
choice as upright as possible - Support the perineum with other hands.
DO NOT let her lie flat (horizontally) on her back - Discard the pad and replace when soiled to
- allow her to push as she wishes with prevent infection
contractions. DO NOT urge her to push. - During deliver of the head, encourage the
o If after 30 minutes of spontaneous expulsive woman to stop pushing and breathe rapidly with
efforts. The perineum does not begin to thin mouth open
out and stretch with contractions. Do a Gently feel if the cord is around the neck (NUCHAL
vaginal examination to confirm full CORDS)
dilatation of cervix. - If it is loosely around the neck, slip it over the
o If cervix is not fully dilated, await 2nd stage. shoulder or head
Place the women on her left side (left-lateral - If it is tight, place a finger under the cord, clamp
position) and discourage pushing but and cut the cord, and unwind it from around the
encourage breathing techniques. neck
- Wait until the head is visible and perineum - Wait for external rotation (within 1-2 mins), head
distending will turn sideways bringing one shoulder just
- DO NOT massage and stretch the perineum below the symphysis pubis and other facing the
- Wash hands and clean water with soap using perineum
the WHO 1-2-3-4-5 method - Apply gentle downward pressure to deliver top
- Follow universal precaution during labor and shoulder then lift the baby up to deliver the
delivery lower shoulder
- If second stage last for 2 hours or more without - Gently deliver the rest of the baby
visible steady descent of the head: REFER!! - Call out the sex and time of the delivery of the
- If with obvious obstruction to progress – warts, baby
scarring/ keloid tissue/ previous third-degree
tear: REFER to doctor to do a generous 2nd stage of labor

El Jireh D. Asauro BSN2E

NCM 109: 13
RECOMMENDED PRACTICES - If you are the sole birth attendant, remove the
✓ Upright position during delivery first set of gloves. Check for the cord’s pulsation
✓ Perineal support and controlled delivery of the - Clamp and cut the cord 1-3 minutes after the
head delivery of the baby or when the pulsations have
✓ Use of prophylactic oxytocin for mgt of 3rd stage stopped
labor - Clamp the cord using a sterile plastic clamp or
✓ properly-timed cord clamping tie at 2cm from the umbilical base. Milk it going
✓ controlled cord traction with countertraction outward and clamp again at 5cm from the base.
delivery of placenta Cut the cord clamp close to the plastic clamp.
✓ uterine massage - Observe the stump for arteries and Wharton’s
jelly, and also blood oozing. Do not bandage or
NOT RECOMMENDED PRACTICES bind the stump. Leave it open
✗ coaching mother to push - Place the palm of the other hand on the LOWER
✗ perineal massage in the 2nd stage of labor abdomen to feel for the strong uterine
✗ fundal pressure during the 2nd stage of labor contraction.
- Perform the controlled cord traction (CCT) and
rd th
3 and 4 STAGE OF LABOR counter-traction on the uterus
- Support the placenta with both hands
Definition - Gently move the membrane up and down until
- 3rd stage of labor delivered
o Covers the period from the delivery of the - Massage the uterus
baby to the delivery of the placenta - Examine the placenta and the membranes for
th
- 4 stage of labor completeness
o The hour immediately after the delivery of - Put the placenta into the leak-proof container
the placenta for proper disposal

3rd stage of labor Components of AMTSL

- Call out the sex and time of the birth of the 1. Administration of uterotonic oxytocin within 1
baby. This marks the end of 2nd stage and the minute after the delivery of the baby after
start of 3rd stage of labor excluding the presence of another baby
- Place the baby prone on the mother’s abdomen 2. Controlled cord traction with counter-
- Thoroughly and systematically dry the baby, traction on the uterus
assess the baby’s breathing and perform 3. Uterine massage
resuscitation if needed.
- Discard the wet towel
- Place the baby in skin-to-skin contact with the
mother
- Cover with a fresh dry linen and put a bonnet on
the baby’s head
- Exclude the 2nd baby by palpating the mother’s
abdomen
- Administer 10 IU of oxytocin IM within one
minute of baby’s birth
El Jireh D. Asauro BSN2E
NCM 109: 14
4th stage of labor ✓ Mobility and position of choice during labor
- Monitor both the mother and newborn ✓ Use of partograph to monitor the progress of
(maternal-newborn dyad) immediately after the labor
delivery of placenta, within one hour after ✓ Non-routine practice of perineal shaving, enema,
delivery (immediate post-partum period) NPO, IVF, & episiotomy
o Examine the lower vagina and perineum ✓ AMTSL
o Clean the women and make her
comfortable Harmful/ Unnecessary OB Practices
o Check BP, RP, emergency signs and uterine ✗ Doing early amniotomy to hasten labor
contraction every 15 minutes for 90 ✗ Routine administration of oxytocin to augment
minutes. labor
- Keep the baby warm ✗ Routine administration of analgesia or anesthesia
- Maintain skin-to-skin contact between the ✗ Supine lithotomy position during delivery
mother and baby with linen on baby’s back ✗ Fundal pressure to hasten 2nd stage of labor
- Wait for the baby to have breastfeeding cues ✗ Perineal massage during the 2nd stage of labor
- Initiate breastfeeding within 1-hour when the ✗ Routine manual exploration of uterine cavity
baby is ready ✗ Routine methylergometrine use even without
- Allow baby to have a full breastfeed before bleeding
doing the routine newborn care like eye ✗ Ice pack in the abdomen in an attempt to control
prophylaxis and vaccinations postpartum hemorrhage
- DO NOT interrupt for these reasons
Recommended Maternal Care Practices to ensure
good neonatal practices
3rd and 4th stages of labor ✓ Antenatal steroid given to the mother at risk for
RECOMMENDED PRACTICES PTL
✓ Routinely inspect the birth canal for lacerations ✓ Maintenance of room thermoregulation to 25-28C
✓ Inspect the placenta and membranes for ✓ Performance of the 4 core steps of EINC protocol:
completeness o Immediate and thorough drying at delivery
✓ Early resumption of feeding (<6 hours after o Skin-to-skin contact of mother and baby
delivery) o Properly-timed cord clamping within 1-3
✓ Prophylactic antibiotics for women with a 3rd or minutes of birth or when cord pulsations
4th degree perineal tear stop
✓ early post-partum discharge o Non-separation of mother and baby to
encourage early breastfeeding initiation
NOT RECOMMENDED PRACTICES ✓ Dry cord care
✗ Manual exploration of uterus ✓ Early breastfeeding without use of prelacteals
✗ Routine use of icepacks in hypogastrium
✗ Routine oral methylergometrine HARMFUL/ UNNECESARRY NEWBORN PRACTICES
✗ unnecessary suctioning of the baby’s mouth and
Recommended OB practices nose
✓ Antenatal steroids for mother at risk for preterm ✗ Immediate cord clamping
birth ✗ Foot printing
✓ Allowing a companion of choice ✗ Cord care with antiseptics
El Jireh D. Asauro BSN2E
NCM 109: 15
✗ use of BIGKIS
✗ Early bathing and removal of Vernix
✗ Artificial breastmilk substitutes

El Jireh D. Asauro BSN2E

NCM 109: 16
STEPS TO FOLLOW IN POSTPARTUM CARE BEFORE - Keep the baby in the room with the mother, in
DISCHARGE her bed or within easy reach
- Support exclusive breastfeeding on demand,
Definitions day and night, as often and as long as the baby
- Postpartum period wants
o The period following the delivery of the - Immunize according to the EPI schedule
placenta o BCG and HEPA B vaccines are given after
▪ The first hour immediately after the the full breastfeed
delivery of the placenta was designated - Instruct the mother and her companion to watch
in the previous module as the 4th stage the baby closely and report immediately any
of labor. untoward happening like:
▪ The time after the 4th stage of labor is o Breastfeeding difficulty (poor suck,
designated in this module as the vomiting)
postpartum period. o DOB (cyanosis, or fast breathing)
- Puerperium/ puerperia o Cold feet or hands
o The period six weeks after delivery o Bleeding from the cord or discharge from
umbilical stump
COMPONENTS OF POST-PARTUM CARE VISITS o Fever
- Early detection and management of o Jaundice
complications o Diarrhea or loose watery stool with or
- Complication readiness without blood
- Promoting health and preventing disease - check the baby for 4 and 8 hours and then daily
- Woman-centered education and counselling
EDUCATE AND COUNSEL ON FAMILY PLANNING
CONTINUE CARE AFTER 1 HOUR POSTPARTUM - provide the family method if available. If not
- Keep mother at close watch for at least 2 hours available, refer.
o Check the temperature, blood pressure o Ask what are the couple’s plan regarding
(BP), and pulse every 30 minutes having more children
o Check at 2, 3 and 4 hours, then every 4 o Stress the importance of proper birth
hours for firmness (hardness) of the uterus spacing
and emergency signs o Give relevant information and advice
o Advice the exclusive breastfeeding is the
CHECK FOR BLADDER DISTENSION IF UNABLE TO best contraceptive in the 1st six months
VOID (LAM)
- Advise clean cloth/ napkin to collect vaginal - Help the mother to choose the appropriate
blood method for her and her partner
- Advise the mother to eat high- energy foods that
are easily digestible INFORM, TEACH, AND COUNSEL THE WOMAN ON
- Request the companion: to watch her and call IMPORTANT MCH MESSAGES
you for bleeding or pain, dizziness or for any - Talk to the woman when she is rested and
other problems comfortable
- Also give important information and advice to
CARING FOR THE BABY her companion
El Jireh D. Asauro BSN2E
NCM 109: 17
- Take time to explain, use visual aids, and ▪ How are you feeling?
demonstrate important lessons ▪ Pain, fever, bleeding since delivery?
- Encourage them to participate actively in ▪ Hard to void urine?
discussion and to ask questions ▪ Breastfeeding problems and breast
discomfort?
DISCHARGE THE WOMAN AND HER BABY ▪ Family planning?
- The woman and her baby may be discharged 24 ▪ Other concerns?
hours after delivery ▪ Check records: complications,
- Ensure that the woman is able to breastfeed treatment during delivery
successfully before discharge ▪ HIV status?
- Repeat important health information
- Check understanding of all discharge EXAMINATION
instructions and advice and arrange follow-ups - Look for pallor (conjunctival or palmar)
- Check for BP, temp, PR
SCHEDULE FOLLOW-UP VISITS - Check breast
- Advice mother to bring along the newborn - Feel uterus:
during these visits o Is it hard, round and well-contracted?
o 2-3 days postpartum - Look at vulva and perineum for:
o 7 days postpartum o Tear/s, sweeling, pus,
o 4-6 weeks postpartum - Look at pad for bleeding and lochia:
- Mothers who cannot come to the clinic must be o Does it smell? Is it profuse
visited at home
ASSESS BREASTFEEDING
- Is there any difficulty breastfeeding?
- Observe how mother breastfeeds for at least 4
minutes:
STEPS TO FLOOW IN POSTPARTUM CARE AFTER o Is baby positioned well?
DISCHARGE o Is able to attach to the nipples well?
o Is baby sucking effectively?
ASSESS FOR EMERGENCY SIGNS
o Vaginal bleeding ASSESS NEONATAL HEALTH AND DEVELOPMENT
o Pallor - Danger signs of newborn for immediate referral
o Fever o Fever
o Looks very ill o Jaundice
- DO NOT make a very sick woman wait, attend to o Fast breathing or cyanosis
her immediately o Breastfeeding difficulty- vomiting or poor
- Make the woman comfortable suck
o Diarrhea or loose watery stools with or
INQUIRE THE CIRCUMSTANCES OF HER DELIVERY without blood
- Check her records and her present state of o Foul-smelling umbilical discharge or
health infected cord stump
o Ask and assess: o Poor weight gain or rapid weight loss
▪ When, where delivered?
El Jireh D. Asauro BSN2E
NCM 109: 18
 o Non- response no startle reflex to loud noise
(possible congenital hearing abnormalities)

IDENTIFY ANY ABNORMALITIES ABNORMALITIES IN POSTPARTUM PERIOD

- REFER accordingly - Elevated BP
o Vaginal bleeding - Pallor
o Elevated BP - Vaginal bleeding
o Fever - Foul smelling lochia
o Pallor - Dribbling urine
o Foul smelling lochia - Pus or perineal pain
o Vaginal discharge - Feeling unhappy
o Dribbling urine - Vaginal discharge
o Pus or perineal pain - Breast problem
o Breast problems: o Infection/ breast abscess
▪ Infection/ breast abscess o Sore or cracked nipple
▪ Sore or cracked nipple o Engorgement
▪ Engorgement o Insufficient milk
▪ Insufficient milk - Cough or breathing difficulty
o Cough or breathing difficulty
o Feeling unhappy COMPLETE WORK-UP AND GIVE ANY TREATMENT
OR PROPHYLAXIS DUE
POSTPARTUM BLEEDING - Prevent anemia with iron/ folate
- Women who developed vaginal bleeding supplementation by giving 2 tablets of iron/folate
o >24 hours postpartum have LATE daily for 3 months (or more if mother is pale)
POSTPARTUM HEMORRHAGE - Give one capsule vitamin A (200,00 IU) if none
o <24 hours postpartum have EARLY was given postpartum – to protect the baby
POSTPARTUM HEMORRHAGE from nutritional blindness and infections
- May be due to retained placental fragments - Complete tetanus immunization if not yet done
- Uterus is soft and larger than expected - Do RPR (test for syphilis) if not yet done
- REFER!
- If excessive bleeding: insert IVF, give 10 units ADVISE AND COUNSEL (HEALTH EDUCATION)
oxytocin IM - Postpartum care and hygiene
o Wash hands before and after handling the
ELEVATED BP baby
- Blood pressure >140/90 o Wash the perineum daily
- Look for signs that could indicate severe pre- o Have enough rest and sleep
eclampsia - Avoid sexual intercourse until perineal wound
o Severe headache heals
o Blurring of vision - Advise proper maternal nutrition
o Epigastric pain o Eat a greater amount and variety of healthy
o Sever breathing difficulty foods especially green leafy vegetables and
fruits

El Jireh D. Asauro BSN2E

NCM 109: 19
 o Increase oral fluid intake: water, soup- - All postpartum women should have atleast 2
based diet, fruit juices routine postpartum visits
o Spend more time on nutrition counselling o 1st visits: 1st week postpartum, preferably
with thin women and adolescents within 48- 72 hours
- Encourage breastfeeding o 2nd visit 6 weeks postpartum
o Stress the importance, advantages and
benefits of breastfeeding and the superiority
of breastmilk for infants’ nutrition
o Teach correct positioning and attachment
for breastfeeding
o Support exclusive breastfeeding for the first
6 months of life
o Encourage breastfeeding on demand avoid
supplementary feeds

Monitoring and management after discharge

FAMILY PLANNING METHODS
- Women who do not return for postpartum visits
- Method options for breastfeeding woman
or those who do not bring along their newborns
o Immediate postpartum: LAM, condom, BTL,
during their postnatal visits should be visited at
IUD
home.
o Delay 6 weeks: POP and DMPA
o Delay 6 months: COC & natural FP
- Method options of non-breastfeeding woman
o Immediately postpartum: condoms. IUD,
BTL, POP and injectables
Mothers and newborn (0- 28 days) dying every
o Delay 3 weeks: COC/ CIC, Natural FP
year..
- Stress that a woman who is not exclusively
breastfeeding can become pregnant as soon as
GLOBAL PHILIPPINES
4 weeks after delivery if she has sex
Main causes of maternal deaths
- Reinforce that non-hormonal methods (LAM,
1. Hypertension disorder of pregnancy
barrier contraceptives, IUD and sterilization) are
2. Post-partum hemorrhage
best options for lactating mothers
3. Pregnancy with abortive supplements
- Facilitate free informed choice for all woman

Main cause of fetal deaths

LACTATIONAL AMENORRHEA METHOD (LAM)
1. Pre-term
- 1st line family planning method for postpartum
2. Infection
woman
3. Asphyxia
- 3 conditions should be present:
o Exclusive breastfeeding
Predisposing factors
o Menstruation has not returned
- Poor maternal health
(amenorrhea)
- Inadequate care during pregnancy
o Within 1st 6 months of delivery
- Inappropriate management of complications
during pregnancy and delivery
SCHEDULE RETURN VISITS
El Jireh D. Asauro BSN2E
NCM 109: 20
- Poor hygiene during and after delivery - Placental abnormalities
- Lack of/ poor newborn care - Infection
- Diabetes
Intrapartum and postpartum care - Maternal collagen diseases
- Complications during birth: - Pregnancy-induced hypertension
o Obstructed labor - Asthma
o Fetal malpresentation - Post-term pregnancy
- Postpartum care (within 3 days) provided only - Hemoglobinopathies
to 53% of the mothers - Nutritional status
- Inadequate dietary intake
- Food fads Excessive food intake
- Under- or overweight status Hematocrit value
less than 33%
- Eating disorder

Psychosocial Factors
- Smoking
- Caffeine
- Alcohol
- Drugs
- Inadequate support system
- Situational crisis
- History of violence
- Emotional distress
- Unsafe cultural practices

Sociodemographic Factors
- Poverty status
- Lack of prenatal care
- Age younger than 15 years or older than 35
Biophysical factors years
- Genetic conditions - Parity – all first pregnancies and more than five
- Chromosomal abnormalities pregnancies
- Multiple pregnancy - Marital status – increased risk for unmarried
- Defective genes - Accessibility to health care
- Inherited disorders - Ethnicity – increased risk in nonwhite women
- ABO incompatibility
- Large fetal size Environmental Factors
- Medical and obstetric conditions - Infections
- Preterm labor and birth - Radiation
- Cardiovascular disease - Pesticides
- Chronic hypertension - Illicit drugs
- Incompetent cervix - Industrial pollutants
El Jireh D. Asauro BSN2E
NCM 109: 21
- Somnal-Huinal cigarrile smoke a. Alteration in carbohydrate metabolism
- Personal stress (Gilbert, 2007, Blackburn, 2007) identified before conception
b. Which includes women with type 1 or
High risk pregnancy type 2 disease
- One in which a condition exists that jeopardizes 2. Gestational diabetes
the health of the mother, her fetus or both a. Which develops during pregnancy
- Conditions may result from the pregnancy, or b. Occurs in approximately 8% of all
that was present before the woman became pregnant women
pregnant c. It is associated with either neonatal
- Approximately one in four pregnant (1:4) women complication such as:
is considered to be at high risk or diagnosed with i. Macrosomia
complications ii. Hypoglycemia
iii. Birth trauma
Diabetes d. Maternal complications such as:
- A chronic disease characterized by a relative i. Preeclampsia
lack of insulin or absence of the hormone, which ii. Caesarian birth
is necessary for glucose metabolism
Effects on neonates
SELECTED RISK FACTORS FOR GESTATIONAL - Cord prolapse secondary to polyhydramnios
DIABETES MELLITUS (GDM) and abdominal fetal presentation
- History of a large-for-gestational age infant - Congenital anomaly due to hyperglycemia in the
- History of GDM first trimester
- Previous unexplained fetal demise - Macrosomia due to hyperinsulinemia stimulated
- Advanced maternal age (>35 years) by fetal hyperglycemia
- Family history of type 2 DM or GDM - Birth trauma due to increased size of fetus,
- Obesity (>200 lb) which complicates the birthing process
- Non-Caucasian ethnicity (shoulder dystocia)
- Fasting blood glucose >140 mg/dL. - Preterm birth secondary to hydramnios and an
- Random blood glucose >200 mg/dL aging placenta
- Fetal asphyxia secondary to fetal hyperglycemia
DIAGNOSTIC VALUES FOR THE ORAL GLUCOSE and hyperinsulinemia
TOLERANCE TEST (OGTT) - Intrauterine growth restriction (IUGR) secondary
- Normal values are to maternal vascular impairment and
o Fasting: <95 mg/dL. decreased placental perfusion
o 1 hour: <180 mg/dL - Perinatal death due to poor placenta perfusion
o 2 hours: <155 mg/dL and hypoxia
o 3 hours: <140 mg/dl. - Respiratory distress syndrome (RDS) resulting
- GDM is diagnosed if two or more values meet or from poor surfactant production
exceed the levels listed above - Polycythaemia due to excessive red blood cell
(RBC) production in response to hypoxia
During pregnancy, diabetes typically is categorized - Hyperbilirubinemia due to excessive RBC
into two groups: breakdown from hypoxia and an immature liver
1. Pregestational diabetes unable to break down bilirubin
El Jireh D. Asauro BSN2E
NCM 109: 22
- Neonatal hypoglycemia resulting from ongoing - A diagnosis of gestational diabetes can be made
hyperinsulinemia after the placenta is removed after an abnormal result is obtained on the
glucose tolerance test. Two or more abnormal
EFFECTS on the mother – DIABETES values confirm a diagnosis of gestational
- Polyhydramnios due to fetal diuresis caused by diabetes
hyperglycemia
- Gestational hypertension of unknown etiology Normal values are:
- Ketoacidosis due to uncontrolled hyperglycemia - Fasting blood glucose level less than 105 mg/dL
- Preterm labor secondary to premature - At 1 hour: less than 190 mg/dL
membrane rupture - At 2 hours: less than 165 mg/dL
- At 3 hours: less than 145 mg/dL

Maternal surveillance
- Urine check for protein and for nitrates and
leukocyte esterase
- Urine check for ketones (may indicate the need
Laboratory and diagnostic testing for evaluation of eating habits)
Screening: - Kidney function evaluation every trimester for
- All pregnant woman at their first prenatal visit creatinine clearance and protein levels
and additional screening of all high-risk - HbA1c every 4 to 6 weeks to monitor glucose
pregnant woman again at 24 to 28 weeks, or trends
earlier if risk factors are present. - Eye examination in the first trimester to evaluate
the retina for vascular changes
Pregnant women who fulfil all of the following
criteria need not to be screened: Fetal surveillance
- Less than 25 years old Ultrasound – to provide information about fetal
- Normal body weight growth, activity, and amniotic fluid volume and to
- No family history (first-degree relative) of validate gestational age
diabetes Alpha-fetoprotein levels – to detect congenital
- No history of poor obstetric outcome anomalies and a fetal echocardiogram may be
- Not from an ethnic/ racial group with a high necessary to rule out cardiac anomalies
prevalence of DM Biophysical profile –
- helps to monitor fetal well-being and
Laboratory and diagnostic testing uteroplacental perfusion.
- If the initial risk assessment is high, rescreening - Nonstress tests performed weekly after 26
should take place between 24 and 28 weeks weeks gestation to evaluate fetal wellbeing
- A 50-g oral glucose load is given, without regard Amniocentesis – to determine the lecithin/
to the timing or content of the last meal. Blood sphyngomyelin (L/S) ratio. Presrnce of phosphatidyl
glucose is measured 1 hour later; a level above glycerol (PG) to evaluate whether the fetal lung is
140mg/dL is abnormal mature enough for birth
- If the result is abnormal, a 3-hour glucose
tolerance test is done. “The ideal outcome of every pregnancy is a healthy
newborn and mother”
El Jireh D. Asauro BSN2E
NCM 109: 23
El Jireh D. Asauro BSN2E
NCM 109: 24
 - Administer the correct dose of insulin at the
correct time every day
- Eat breakfast within 30 minutes after injecting
regular insulin to prevent a reaction.
- Plan meal at a fixed time and snacks to prevent
extremes in glucose levels
- Avoid simple sugars (cake, candy, cookies),
which raise blood glucose levels.
- Know the signs and symptoms of hypoglycemia
and treatment needed.
- Sweating, tremors, cold, clammy skin, headache
- Feeling hungry, blurred vision, disorientation,
irritability Treatment:
- Drink 8 ounces of milk and eat two crackers of
glucose tablets
- Carry "glucose boosters" (such as Life Savers) to
prevent hypoglycemia.
- Know the signs and symptoms of hyperglycemia
and treatment needed:
- Dry mouth, frequent urination, excessive thirst,
rapid breathing
- Feeling tired, flushed, hot skin, headache,
drowsiness Treatment:
- Notify health care provider, since hospitalization
may be needed.
- Wear a diabetic identification bracelet at all
times.
- Wash your hands frequently to prevent
infections.
Teaching for the Pregnant Woman with Diabetes
- Report any signs and symptoms of illness,
- Keep appointments for frequent prenatal visits
infection, and dehydration to your health care
and tests for fetal well-being
provider
- Perform blood glucose self-monitoring usually
before each meal and at bedtime
Cardiac Disorders
- Perform daily "fetal kick counts."
- Approximately 3% of pregnant women have
- Drink 8 to 10 8-ounce glasses of water each day
cardiac disease
to prevent bladder infections and maintain
- Responsible for 10% to 25% of maternal deaths
hydration
- Prevalence is increasing as a result of lifestyle
- Wear proper, well-fitted footwear when walking
patterns, including
to prevent injury.
o Cigarrete smoking
- Consider breastfeeding your infant to lower your
o Diabetes
blood glucose levels.
o Stress

El Jireh D. Asauro BSN2E

NCM 109: 25
Cardiac disorders Medical management
- Rheumatic heart disease 1. Confirm first the diagnosis
o Represent the majority of cardiac conditions 2. Hospitalization may be necessary 1-4 weeks
during pregnancy before delivery
- Classic symptoms of heart disease mimic 3. Prophylactic antibiotic treatment to prevent
common symptoms of late pregnancy subacute bacterial endocarditis
o Palpitations, shortness of breath with 4. Vaginal delivery (method of choice using
exertion, and occasional chest pain regional anesthesia and forceps/ vacuum
- Offspring are at risk of complications assisted)
o Premature birth, low birth weight for
gestational age, respiratory distress Medical management
syndrome, intraventricular hemorrhage and - Intrapartal period
death o Client is frequently delivered with use of
forceps/ vacuum extraction to shorten
CLASSIFICATION (AHA) “pushing” stage of labor
Class 1 – Uncompromised, no limitation of activity; - Do not put on lithotomy position during delivery
no symptoms of cardiac insufficiency to avoid increasing venous return
Class 2 – Slightly compromised, slight limitation of - Semi-sitting position is one of the preferred
activity; asymptomatic at rest; ordinary activities positions to facilitate easy respirations
cause fatigue, palpitations, dyspnea, or angina - Woman who is at risk for endocarditis needs
Class 3 – Markedly compromised, limitation of antibiotic prophylaxis
activities; comfortable at rest; less than ordinary - Antibiotic begins when labor begin
activities cause discomfort - Administration continues through the first
Class 4 – Severely compromised, unable to perform postpartum day
any physical activity without discomfort; may have - Post partum period – because the 30% - 50%
symptoms even at rest increase in blood volume during pregnancy will
be absorbed into the mother’s circulation in
Signs and symptoms matter of 5-10 minutes and the weak heart must
The woman may complain of make a rapid adjustment to this change
- Dyspnea - Client will remain a regime of rest, exercise and
- Orthopnea nutrition to prevent anemia and cardiac
- Nocturnal cough decompensation
- Dizziness
- Fainting NURSING CARE
- Chest pain - Monitor for and report for jugular vein
Physical examination may reveal distention, clubbing, and slow capillary refill time
- Cyanosis - Monitor and reach mother to recognize signs
- Clubbing of the fingers and symptoms of cardiac decompensation
- Neck vein distention - Advice mother to protect herself from infection
- Tachycardia - Avoid prolong sitting and standing
- Heart murmurs - Advise the woman to get adequate rest and to
- Edema avoid strenuous physical activity

El Jireh D. Asauro BSN2E

NCM 109: 26
- Instruct the woman to do a fetal kick count in the 6. Increase your exercise fluids, and high-fiber
second and third trimester foods to reduce constipation
7. Plan frequent rest period during the day
Iron-deficiency anemia
- Affects one in four pregnancies and is usually RH sensitization
related to an inadequate dietary intake of iron - Rh Disease
- For most pregnant women, supplements of o A disease that occurs when the mother’s
30mg of ferrous iron per day recommended. blood is not compatible with the fetal blood
(<28 weeks) (72 hours postpartum)
Factors that may contribute to the development of o Ex.
iron deficiency anemia ▪ When the Rh-Negative mother had a
- Poor nutrition Rh-positive baby
- Hemolysis o If the baby’s blood is exposed to the
- Pica mother’s blood, the mother’s body become
- Multiple gestation sensitized and develops antibodies the Rh-
- Limited interval between pregnancies positive blood
- Blood loss o Kernicterus – brain damage to fetus
- Dietary intake, quantity and timing of ingestion
of substance that may interfere with iron
absorption, such as: tea, coffee, chocolates, and
high-fiber foods
- Ask the woman if she has fatigue, weakness,
malaise, anorexia, or increased susceptibility to
infection such as frequent cold
- Inspect the skin and mucous membranes noting
any pallor.
- Obtain vital signs and report any tachycardia
- Prepare the woman for laboratory testing

Teaching for the woman with iron deficiency anemia

1. Take your prenatal vitamin daily; if you miss
a dose, take it as soon as you remember.
2. For best absorption, take iron supplement
Rh Disease
between meals.
Signs and symptoms:
3. Avoid taking iron supplement with coffee,
1. Anemia
tea, chocolate, and high-fiber foods
2. Jaundice
4. Eat foods rich in iron, such as: meats, green
Complications:
leafy vegetables, legumes, dried fruits, whole
1. Fetal death
grains, peanut butter, bean dip, whole-
2. Stillbirth
wheat fortified breads, and cereals
3. Brain damage
5. For best iron absorption from foods,
4. Heart failure
consume the food along with a food high in
5. Death soon after birth
vitamin C
El Jireh D. Asauro BSN2E
NCM 109: 27
 1. Avoid noxious stimuli – such as strong flavor,
Rh Disease/ Treatment perfume, or strong odors such as frying.
- Rh immunoglobulin injection prevents 2. Avoid wearing tight waistbands to minimize
sensitization in Rh-negative mother. (RhoGAM) pressure on abdomen
- Blood transfusion to the fetus if anemia 3. Eat small, frequent meals throughout the
day – six small meals
The Blood Types (A, B, O, AB) 4. Separate fluids from solids by consuming
- Although it is not as common (especially in a fluids in between meals
first pregnancy), a similar incompatibility may 5. Avoid lying down or reclining for at least an
happen between the blood types (A, B, O, AB) of hour after eating
the mother and the baby in the following 6. Use high- protein supplement drinks
situations: 7. Avoid foods high in fats
8. Increase your intake of carbonated
Mother’s O A B beverages
blood type 9. Increase your exposure to fresh air to
Baby’s A or B B A improves symptoms
blood type 10. Eat when you are hungry, regardless of
normal meal time
Hyperemesis gravidarum 11. Drink herbal teas containing peppermint or
- Is exaggerated nausea and vomiting during ginger
pregnancy 12. Avoid fatigue and learn how to manage
- Can be experience with or without food intake stress in life
any time of the day 13. Schedule daily rest period to avoid becoming
- “Morning Sickness” usually disappear after 12 overtired
weeks as the woman’s accustomed to changes 14. Eat foods that settle the stomach, such as
within it dry crackers, toast, or soda
- Anti emetic – metoclopramide
- 16 weeks - Intractable vomiting during pregnancy that
- NPO 30 minutes after vomiting results in dehydration and electrolyte imbalance
- Signs of dehydration – skin turgor, acetone smell - More often in primiparous, young and women
with increased body weight
Interventions - Etiology: unknown, but stress and lifestyle
1. Anti-emetic (Promethazine) believe to play an important role
2. High Carbohydrates o Increase HcG
3. Decrease stress Characteristics Morning Hyperemesis
4. IV hydration Sickness Gravidarum
5. Electrolyte replacement Onset 4 – 8 weeks Early pregnancy
6. Provide calm and quite atmosphere
Resolution 14 – 16 weeks Persists
7. Emesis basin should be kept handy but out
throughout
of sight to prevent unpleasant reminder.
pregnancy
Weight Maintained or Loss
Teaching to minimize nausea and vomiting increased

El Jireh D. Asauro BSN2E

NCM 109: 28
 Ketosis Absent present 4. Incomplete – is one in which part of the
products of conception has been passed, but
Electrolytes Normal Abnormal
part is retained in the uterus
Skin Turgor Normal Abnormal 5. Complete – Expulsion of all products of
conception
6. Missed – The fetus died in the uterus but is
retained
7. Illegal – is the termination of pregnancy
outside appropriate medical advise
Bleeding disorder
8. Induced – is one that is artificially induced
- Definition of term
whether for therapeutic or other reasons
o Abortion
▪ Any interruption/ termination of
pregnancy before the fetus is viable
o Abortus
▪ A fetus that is aborted before it is 500
grams in weight

Spontaneous abortion
- Expulsion of products of conception before the
age of viability (20 weeks and above & fetal
weight 500gms and above)

Definition of terms:
- Early abortion
o The termination of pregnancy before 16
weeks
- Late abortion
o Abortion occurs between 16 – 20 weeks

Types of Abortion
- Spontaneous/ Therapeutic abortion
1. Threatened – If vaginal bleeding or spotting
occur in early pregnancy.
2. Inevitable/ imminent – bleeding copious and
pains are severe, membranes may or may
not ruptured, and the cervical canal is
dilatating
3. Habitual/ Recurrent pregnancy loss – occur
in successive pregnancies, usually three or
more spontaneous abortion

El Jireh D. Asauro BSN2E

NCM 109: 29
Types of Signs/ Management - Passage of and emotional
abortion symptoms tissue support
Threatened - Light - Bedrest to Habitual - No FHT - Treat the
vaginal stop bleeding - No cause (most
bleeding or - no coitus for 2 increase in common is
spotting weeks after fundal incompetent
- Mild the bleeding height cervix)
uterine stopped - Signs of - Ultrasound
cramps - gradual pregnancy confirms fetal
- Cervix resumption to disappear demise
closed/ normal - Slight - Watch for
slightly activities bleeding signs of
dilated - No uterine complications
Inevitable/ - moderate - hospitalization cramping - Induction of
imminent to profuse is necessary - Close labor
bleeding - dilatation and cervix -
- moderate curettage - No
uterine - Sympathetic passage of
cramping understanding tissue
- open and emotional
cervical os support
- rupture of
membrane
- no
passage of
tissue
Complete - Slight - No treatment
bleeding is necessary
- Mild as bleeding is
uterine self-limiting
cramping - Provide Predisposing factors
- Passage of sympathetic 1. Faulty germ plasma
tissue understanding - Imperfect ova or sperm cells; abnormal
and emotional development
support 2. Decrease in production of progesterone
Incomplete - Heavy - Dilatation and - Insufficient progesterone leads to increase
vaginal curettage uterine sensitivity and contractions which
bleeding - Keep uterine causes expulsion of the embryo
- Severe firm 3. Incompetent cervix
uterine - Administer - Mechanical defect in the cervix causes dilatation
cramping oxytocin and effacement in early pregnancy
- Open - Sympathetic 4. Acute infections cause fetal death
cervical os understanding
El Jireh D. Asauro BSN2E
NCM 109: 30
- Transmission of bacterial toxins from the mother - Continue to be satisfied with the decision for
to fetus induced abortion, the procedure, and her
- Passage of microorganism from mother to fetus experience with the health-care team
- High temperature which may stimulate uterine - Absence of hemorrhage, v/s within normal
contractions limits, hct and hb levels are in acceptable range,
decrease amount of vaginal bleeding
Assessment - Absence of infection, no evidence of fever, no
- Immediate assessment of vagina during foul discharge, or abnormal urinary
pregnancy - Achieve relief of pain, uses controlled breathing
o Confirmation of pregnancy and relaxation techniques
o Duration/ intensity
o Description HYDATIDIFORM MOLE (Gestational trophoblastic
o Frequency neoplasms)
o Associated symptoms - Cystic degeneration of the chorionic membrane
o Action that results in a mass of clear vesicles (3-6
- Physical examination months to coitus again) 3 months HcG
- Laboratory test monitoring (1year)
o CBC - Vesicles occur like a grape structure
o Blood type - Signs and symptoms
o Uterus is larger than normal for expected
gestational age
o Brownish vaginal bleeding/ spotting
o Anemia due to blood loss
Nursing Diagnosis o Abdominal cramping
- Decisional conflict r/t values system o Excessive nausea na vomiting
- Fear r/t abortion procedure - Diagnostic test
- Anticipatory grieving r/t distress at loss o Auscultation – for FHT will prove negative
o Feeling of guilt o Ultrasound – reveals absence of fetus
o Loss of pregnancy o CBC – to evaluate signs of anemia
- Risk for infection r/t effects of the procedure - Medical and surgical management
o Lack of understanding of preoperative and o Dilatation and curettage
postoperative self-care o X- ray
- Acute pain r/t effects of the procedure o HcG
o Postoperative-event
- Risk for fluid volume deficit r/t bleeding during - Nursing care
pregnancy o Accurate observation for vaginal bleeding
o Observation for hypertension
Expected Outcome o Preoperative teaching
- Verbalize understanding of the information - Postoperative care
necessary to give informed consent o VS monitoring
- Undergo a successful procedure and uneventful o Bleeding monitoring
recovery o Promotion of early ambulation
o Prevention of post op infection
El Jireh D. Asauro BSN2E
NCM 109: 31
- NURSING ALERT! - Spontaneous abortion
o Pregnancy should be avoided to prevent o Most common cause of spontaneous
increase HcG, if HcG level remain within abortion during 2nd trimester
normal limits within 1 year prognosis is good - Signs and symptoms
pregnancy maybe attempted o Prescence of show and uterine contraction
o Emphasize the importance of follow up o Rupture BOW
checkup to monitor for chorionic carcinoma o Painless cervical dilatation
- Gestational Trophoblastic Tumors. conditions - MANAGEMENT
characterized by persistent trophoblastic o Shirodkar suture
proliferation after H mole evacuation. ▪ Permanent suture which is left in place
o Choriocarcinoma: A disorder that is most for subsequent pregnancies, fetus is
severe malignant complication of H Mole delivery via caesarian section
that involve the transformation of chorionic ▪ Suture pass through the wall of the
villi into cancer cells that invade and erode cervix
blood vessels and uterine muscles. ▪ Less common and technically more
o Invasive Mole: characterized by excessive difficult
formation of trophoblastic villi that o McDonald suture
penetrates the myometrium. ▪ Temporary suture removed at 37 to 39
o Placental site trophoblastic tumor: weeks gestation
Trophoblastic tumor composed of ▪ Fetus delivered vaginally
cytotrophoblast cells arising from the site of ▪ Most commonly used
the placenta ▪ Tightly tie the ends of the suture to close
- Management of all trophoblastic tumors is the cervix
Hysterectomy o Abdominal cerclage
Types Signs/ management ▪ Least common type
symptoms ▪ Is permanent and involves stitching at
Threatened - Light - Bedrest to the very top of the cervix, inside the
vaginal stop abdomen
bleeding of bleeding - Complications of cerclage
spotting - No coitus o Early complication
- Mild for 2 weeks ▪ Infections (chorioamnionitis,
uterine after vulvovaginitis)
cramps bleeding ▪ Bleeding
- Cervix stopped ▪ Anaesthetic complication
closed/ - Gradual ▪ Accidental rupture of BOW
slightly resumption ▪ Premature labor
dilated to normal ▪ Maternal death
activity ▪ Deep cervical laceration
▪ Puerperal pyrexia
Premature cervical dilatation/ incompetent cervix ▪ UTI
- Is a mechanical defect in the cervix that cause it Placenta previa
to dilate prematurely during pregnancy and - Classic symptoms
cause late habitual abortion and preterm labor
El Jireh D. Asauro BSN2E
NCM 109: 32
 o Painless, bright red vaginal bleeding during - Aorta dilation from Marfan syndrome and is also
2nd or 3rd trimester corrected
o First episode of bleeding occurs (on - Puerperium heart disease
average) at 27 to 32 weeks gestation - BV and Cardiac output approximately 30 to
- 3 reasons for early interruption of pregnancy 50 percent during pregnancy - half of this occur
1. Uncontrolled hemorrhage by 8 weeks.. maximize during mid pregnancy
2. Fetal hypoxia due to excess detachment of - blood flow to the valve = Functional
placental tissues (innocent) or heart murmur may be heard
3. Fetal hypoxia due to hypovolemia in the - 28 to 32 most danger time after blood vol peak
mother - cardio circulatory = can no longer perfuse
- Nursing management adequately
o Bed rest, side lying position o Class 1 - uncompromised, normal vaginal
o Oxygen delivery and birth
o Vital signs o Class 2- slightly compromise, normal
o Perineal pad count vaginal delivery and birth
o Apt or kleihauer- betke test o Class 3 - markedly compromised,
Abruptio placenta maintaining special conditions and bed rest
- Occurs when a normally impaired placenta o Class 4 - compromised, are usually advised
separates prematurely from the uterine wall to avoid pregnancy
- After the 20th week of gestation
- Occurs in 3rd trimester Infants of those with severe heart disease
- If woman in prolonged bed rest Instruct - LOW BIRTH WEIGHT or SGA caused by ACIDOSIS
appropriate skin care measures Encourage to due to poor uteroplacental exchange or not
eat a balanced diet with adequate fluid intake to enough nutrient = preterm labor
ensure adequate nutrition and hydration and - If inadequate placental circulation fetus may not
prevent complications associated with urinary respond well to contraction
and bowel elimination
- prepare the family for possible caesarean Chronic hypertensive vascular disease
delivery and care for the immature infant - Enter with increase BP (140/ 90)
- At risks for
-------------------------------REVIEWER------------ o Poor heart
------------------ o Poor kidney
o Poor placental perfusion
High risk pregnancy - Management
- is a concurrent disorder, it is a factors that o administrating labetalol & nifedipine=
jeopardizes the health of pregnant person and peripheral dilatation
the unborn child or both
Anemia
Cardiovascular disorders in pregnancy - Mostly have pseudoanemia in early pregnancy
- Valve damage caused by rheumatic fever or - True anemia
Kawasaki disease and congenital anomalies o Hb: <11gm/dL Hct: <33% in first and third
such as atrial septal defect or uncorrected trimester
coarctation of the aorta.
El Jireh D. Asauro BSN2E
NCM 109: 33
 o Hb: <10.5gm/dL Hct: <32% in first and second - If blood glucose reach 150mg/ 100mL it can
trimester cause glycosuria
- As dehydration occur = concentrated blood
Iron deficiency anemia glucosen and decrease blood volume = lactic
- Most common anemia in pregnancy acid to pour out = acidic ketones accumulation
- Low serum iron level under 30 microgram/ dL in bloodstream
and increase iron-binding capacity over 400 - Then use protein for energy = release potassium
microgram/ dL and sodium and lost because of polyuria =
- Extreme fatigue, poor exercise tolerance immediate severe metabolic acidosis.
- Associated with restless leg syndrome
- Prenatal vitamins of 27 mg of iron prophylactic Diabetes in pregnancy
therapy - Both type is probable as autoimmune disorder
- Eat high in iron and vitamins (green leafy because of marker antibodies
vegetable) - The resistance to insulin may beneficial to avoid
- Elemental iron of 65mg/ day ferrous sulphate hyperglycemia but increase heir insulin dosage
throughout pregnancy then 3 months after starting at 24 weeks to prevent hyperglycemia
delivery - Tends to be-large for gestational age
- best absorbed in in acidic environment (vitamin - Glycosuria and polyuria
C supp.) - Polyhydramnios
- Macrosomic
Folic acid deficiency anemia - Uncontrolled diabetes in the first trimester are
- Necessary for normal formation of RBC and more prone to hypoglycemia, RDS,
prevention for neural tube and abdominal wall hypocalcemia and hyperbilirubinemia
defects - Dizziness if hypo, confusion if hyper
- Hydantoin interfere with folate absorption - Classification
- Take several weeks to develop may not be o Usually at midpoint of pregnancy when the
apparent until 2nd trimester May cause early insulin resistance become most noticeable.
miscarriage or PSOP o Type 1 - autoimmune destruction of beta
- MUST TAKE 400microgram/ day cells in the pancreas.
o Type 2 - arise usually from deficiency
Diabetes mellitus o Gestational - arise from pregnancy and
- Is an endocrine disorder in which pancreas fade after pregnancy increase risk for
cannot produce adequate insulin to regulate reoccurrence
body glucose level o Impaired glucose homeostasis - between
- Those with DM tends to have higher weight = normal and diabetes in which no longer
Increase risk for thromboembolic disease using or secreting insulin
- If more than DM is more than 20 years they are - Assessment
not candida to use estrogen- containing birth o A pregnant should be
control so progestin only is used ▪ Fasting = greater than or equal to
- Disorder to regulate serum level of glucose 126mg/ dL
- Infants w/ unregulated diabetes are 5x apt to ▪ Non fasting = greater than or equal to
have LGA or w/ congenital anomalies 200mg/ dL
- Normal glucose level is 80 to 120 mg/ dL
El Jireh D. Asauro BSN2E
NCM 109: 34
 o All pregnant patient should receive 50-g - Incompetent cervix
glucose tolerance test between 24 to 48 o Pinkish, painless cervical dilatation
weeks of gestation Third trimester (28 to 40)
▪ Result 130 mg/ dL then need to do 3 - Abruptio placenta
hours o Dark red, painful, sharp abdominal pain
▪ followed by uterine tenderness hard board
- The patient will drink 100-g glucose solution, like dilatation
then obtain blood, if 2 of the 4 is are abnormal or - Premature rupture of membrane
fasting value is above 95mg/ dL them it is o Fluid leaking from cervical os, tested by
diabetes paper dipstick (litmus test)
o Fasting: 95mg/ dL
o 1 hour: 180mg/ dL Gestational diseases
o 2 hours: 155mg/ dL Abortion is the interruption pregnancy before it
o 3 hours: 140mg/dL reaches viability
Threatened miscarriages
- scant and bright red, slight cramping, no
Bleeding disorder in pregnancy cervical dilatation
first trimester (1 to 13 week) - if pregnancy not confirmed in uterus, it may be
- Spontaneous Abortion ectopic pregnancy
o Threatened - Key intervention
▪ Bright red, no cervical dilatation o avoidance of strenuous activity 24 to 48
o Imminent hours
▪ Cervical dilatation o Coitus restriction for 2 weeks
o Missed
▪ Painless bleeding Imminent abortion
o Complete - Threatened abortion becomes imminent if
▪ Complete expulsion of uterine content uterine contraction and cervical dilatation began
o Incomplete - If no FTH and reveals an empty gestational sac
▪ Incomplete expulsion of uterine content or nonviable fetus - C&D will be performed
o Illegal - They should assess their vaginal bleeding by
o Habitual recording the number of pads (1 pad per hour is
- Ectopic pregnancy abnormally severe bleeding)
o Lower abdominal quadrant pain, minimal
vaginal bleeding, possible signs for Complete miscarriage
hypovolemia or hemorrhage - entire product of conceptions is expelled without
- Hydatidiform Mole any assistance
o Brownish vaginal bleeding/ spotting - The bleeding usually slows after 2 hours then
resembling prune juice or as profuse fresh cease within days
flow following clear fluid filled vesicles - No therapy / report for vaginal bleeding
Second trimester (14 to 27)
- Placenta previa Incomplete abortion
o Bright-red bleeding, painless bleeding at - part of conceptus is expelled, but membranes or
begging of cervical dilatation placenta remains.
El Jireh D. Asauro BSN2E
NCM 109: 35
- Danger for hemorrhage because uterus cannot Ectopic pregnancy
contract effectively - Implantation occurs outside the uterine cavity
- D&C - Most common site is fallopian tube - ampulla
- prevent from hemorrhage and infection (distal third)
- Risk factors
Missed abortion o Past surgery
- A.k.a — Early pregnancy failure o Malformation
- Fetus died but not expelled o Fibrous bands
- Prenatal checkup o Tumor
o When fundal height has no increase in size - Second most frequent cause of bleeding in early
o Previously heard fetal heart sound but can pregnancy
no longer be heard - Can reoccur
- Ultrasound - Assessment
o No heart rate o No menstrual flow occurs
- Expectant management o Nausea and vomiting
o Can be offered in the first trimester o Positive HcG
o Wait up to 8 weeks for the pregnancy to - Diagnosed by ultrasound
occur - Sharp, stabbing pain in lower abdominal
o Heavy bleeding as pregnancy passes quadrant followed by scant vaginal spotting
- Medication management - Laparoscopy or culdoscopy
o Misoprostol - Cullen signs if patient wait abdomen become
o Mifeprestone rigid and peritoneal irritation
- Surgical management - Pain in the shoulder irritation in the phrenic
o D&C nerve
o 2nd trimester increases risk so induced - Administration of methotrexate
labor
Gestational trophoblastic disease
Recurrent pregnancy loss - Abnormal proliferation and degeneration of
- Habitual abortion trophoblastic villi
- Have 3 or more spontaneous miscarriages at the - Clear fluid filled, grape-size vesicles
same gestational age Septic abortion - Rapidly metastasizing malignancy
- Complication from infections o Chromosome analysis
o Fever - Complete mole all trophoblastic villi will swell
o Cramping and become cystic - 46
o Abdominal pain - Partial mole some villi form normally - 69
o Feel tender to palpation o Rarely lead to choriocarcinoma
- D&C o HcG titer is lower
o Dopamine and digitalis - Assessment
o Oxygen ventilators o Gestational age for diagnosis is around 10
to 12 weeks
Complications o 1m to 2m IU of hCG
- Hemorrhage and infection o Identified by ultrasound

El Jireh D. Asauro BSN2E

NCM 109: 36
 If not them at 16 weeks it will be identified as
o - Sonogram
bleeding - Approximately week 30
▪ Dark-brown blood - Abrupt, painless, bright red, and sudden
- Management - Management
o D&C o Bed rest, sidelying, adequate oxygen supple
o HcG will be analyzed every few days for the o Test strip
first 2 weeks, then weekly until level are o Assess blood pressure q5 to 15 or
negative again, then every 4 weeks for the 3 contentious
months - If more than 1 cm from cervical os = vaginally
o After 3 months, then free of risk from - If less than 1 cm from os = caesarian
malignancy
o If malignancy occur, use methotrexate Premature separation of the placenta (abruptio
Cervical insufficiency placenta)
- Premature cervical dilatation and painless - Begins to separate and start bleeding
bleeding - Revealed (80%) - covert, incomplete
- Dilatation usually occurs painlessly detachment, less complications - externally
- Light red or pink stained vaginal discharge - Concealed (20%) - overt, complete, severe
- Commonly occurs at 20 weeks of pregnancy complications - internal bleeding
- Cervical cerclage at approximately 12 to 14 - Assessments
o Healthy fetus o Sharp, stabbing pain high in the uterine
o Intact BOW fundus as the initial separation occurs
o Confirmed by ultrasound o Each contract will be accompained by pain
- Mcdonalds o Couvelaire uterus or uteroplacental
o Temporary apoplexy causing a hard, board- like uterus
o Can be delivered vaginally - Management
o Usually removed at 36 to 37 o IV insertion
- Shirodkar and transabdominal o Fluid replacement
o Permanent o Oxygen
- Emergent cerclage o Monitoring VS
o If intact BOW o Left lateral position
o HYSTERECTOMY
- Maintain on bed rest Trendelenburg position

Placenta previa
- Abnormally implanted in then lower part of the
uterus
- Most common cause of painless bleeding in the
third trimester
- Types
o Low lying placenta
o Marginal
o Partial
o Complete
El Jireh D. Asauro BSN2E
NCM 109: 37