10/09/2023

Define high-risk pregnancy, including pre-existing factors that contribute to

its development.

Determine assessment methods and care for continuing prenatal visit.

Assess a woman with an illness during pregnancy for changes

OUR LADY OF FATIMA UNIVERSITY
occurring in the illness because of the pregnancy or the pregnancy
COLLEGE OF NURSING
because of the illness.
Valenzuela Campus

PROF. MELANIE CAMBEL, MAN RN

1 2

PREPREGNANCY

Psychological Social Physical

• When a woman and her fetus face a higher-than-normal chance of
History of drug Occupation involving Visual or hearing challenges
experiencing problems/ complications. dependence (includes handling of toxic substances Pelvic inadequacy or misshape
• Pregnancy complicated by a disease or a disorder that may alcohol) Environmental contaminants Uterine incompetence
endanger the life or affect the health of the mother, the fetus or the History of Intimate Partner at home Secondary major illness (HD, DM, KD, HPN, TB,
newborn. Abuse Isolated etc.)
History of mental illness Lower Poor gynecologic or obstetric history, PID
• Nursing care focus: History of poor coping Lower economic level History of child with congenital anomalies
• Prevent disorders from affecting the health of the fetus mechanisms Poor access to Obesity (BMI >30)
• Help to regain health as quickly as possible to continue a healthy pregnancy Cognitively challenged transportation for care Underweight (BMI <18.5)
and prepare psychologically and physically for labor and birth and the Survivor of childhood High altitude History of inherited disorder
arrival of the newborn. sexual abuse Highly mobile lifestyle Small stature
• Help learn more about chronic illness to safeguard health during Poor housing Potential of blood incompatibility
childrearing years. Lack of support people Age (<18 or >35)
Cigarette smoker, substance abuser

3 4
 10/09/2023

PREGNANCY LABOR AND BIRTH

Psychological Social Physical Psychological Social Physical

Loss of support person Refusal of or neglected Subject to trauma Severely frightened by labor Lack of support person Hemorrhage
Illness of a family member prenatal care Fluid or electrolyte imbalance and birth experience Inadequate home for infant Infection
Decrease in self-esteem Exposure to environmental Intake of teratogen Inability to participate care Fluid and electrolyte imbalance
Drug abuse (include teratogens Multiple gestation because of anesthesia Unplanned cesarean birth Dystocia
alcohol and cigarette Disruptive family incident A bleeding disruption Separation of infant at birth Lack of access to continued Precipitous birth
smoking) Decreased economic Poor placental formation or position Lack of preparation for labor health care Lacerations of cervix or vagina
Poor acceptance of support Gestational diabetes Birth of infant who is Lack of access to emergency Cephalopelvic disproportion
pregnancy Conception less than 1 year Nutritional deficiency of iron, folic acid, or disappointing in some way personnel or equipment Internal fetal monitoring
after last pregnancy protein (sex, appearance, or Retained placenta
Poor weight gain congenital anomalies)
PIH, Infection Illness in newborn
Amniotic fluid abnormality
Postmaturity

5 6

Screening Procedures Screening Procedures

• Maternal Serum Alpha-
• Ultrasonography Fetoprotein
• Biparietal Diameter • Triple Screening
• Doppler Umbilical
Velocimetry (Doppler US) • Chorionic villus sampling
• Placental grading • Amniocentesis
• Amniotic Fluid volume • Percutaneous umbilical
Assessment cord blood sampling
• Electrocardiography • Amnioscopy
• Magnetic Resonance • Fetoscopy
Imaging • Biophysical profile

7 8
 10/09/2023

• First trimester: • Third trimester:

• Abortion/ Miscarriage • Placenta previa
• Ectopic pregnancy • Abruptio Placenta
• Preterm labor
• Second trimester:
• Hydatidiform mole
• Incompetent Cervix

9 10

Decreased venous
Decreased
Blood loss return, decreased CO,
intravascular volume
and lowered BP

• Alert health care team of emergency situation

Body compensating
• Place woman flat in bed on her side.
(↑HR, vasoconstriction
Cold, clammy skin, ↓ • Begin IVF as ordered (LR using G16 or G18 needle)
of peripheral vessels, Reduced renal, uterine,
uterine perfusion, BP
↑RR, and feeling of
will continue to fall.
and brain function • Administer O2 (6-10LPM) via face mask
apprehension at body
changes • Monitor uterine contractions and FHR by external monitor
• Omit vaginal examination
• Withhold oral fluid
Lethargy, coma, ↓ renal • Blood typing and crossmatching of 2 units whole blood as ordered
Renal failure Maternal and fetal death
output
• Measure I and O

11 12
 10/09/2023

• Assess VS every 15 minutes; apply pulse oximeter and automatic BP cuff

as necessary.
• Assist with placement of central venous pressure or pulmonary artery • Abortion
catheter and blood determinations. • Medical term for interruption of a pregnancy before a fetus is
• Measure maternal blood loss by weighing perineal pads; save any tissue viable.
passed. • ELECTIVE ABORTION – planned medical termination of a
• Set aside 5ml of blood drawn intravenously in a clean test tube; observe pregnancy.
in 5 min. for clot formation.
• Assist with ultrasound examination.
• Maintain positive attitude about fetal outcome.
• Miscarriage
• Provide emotional support.
• Interruption of a pregnancy occurs spontaneously.

13 14

Types Bleeding Abdominal Cervical Tissue Fever

cramps dilation passage
Threatened Scant, bright Slight cramping None None No
red
Inevitable/ Imminent Moderate Moderate Open Present No
• Abnormal fetal development (teratogenic factor/ Complete Slows within 2 Moderate Close or Complete No
chromosomal aberration) hrs. to negative partially open placenta with
after few days fetus
• Immunologic factor (rejection of embryo through immune Incomplete Severe (bleeds Severe Open with Fetal or, No
response the most) tissue in cervix incomplete
placental tissue
• Implantation abnormalities
Missed None to scanty None None None No
• Inadequate Progesterone No FHT
• Systemic infection (Rubella, syphilis, poliomyelitis, Recurrent/ Habitual: 3 or
more consecutive
May represent signs of any of the above; usually detected in the threatened phase;
cervical closure may be employed
cytomegalovirus, toxoplasmosis) Septic Mild to severe Severe Close or open Possibly, foul Yes
• Ingestion of teratogenic drug with or
without tissue
discharge

15 16
 10/09/2023

Types Activity Fluid Medications Procedure/ surgery Blood tests

replacement
Threatened Complete Tocolytics (Ritodrine, Isoxsuprine,
Bed rest Terbutaline)

• Hemorrhage Inevitable IVF (LR/ PNSS) Oxytocin (>12) Vacuum aspiration (<12)
Completion Currettage
Bld. Typing/
Cross-matching

• Infection Incomplete IVF (LR/ PNSS) Oxytocin (>12) Vacuum aspiration (<12) Bld. Typing/
Antibiotics (Ampicilin/ metronidazole) Completion Currettage Cross-matching
• Septic Abortion Analgesics

• Isoimmunization Missed Oxytocin (>12)

Prostaglandin
If no spontaneous expulsion
(4 weeks), Dilation &
Evacuation
• Powerlessness or anxiety
Recurrent Tocolytics Counselling
Pregnancy Oxytocin, Prosta-glandin, Misoprostol D & C
Loss/ RhoGam
Habitual
Septic IVF (LR/ PNSS) Oxytocin (>12) Urethral Cathete-rization Bld. Typing/
Antibiotics (Cephalosporins, Currettage Cross-matching
Ampicilin/metronidazole)
Hematinics

17 18

• Implantation occurs outside the

uterine cavity.
Fallopian tube Pelvic
• Types: narrowing or Inflammatory
Puerperal and Surgery of the
postpartal sepsis fallopian tubes
• Tubal (Fallopian tube – interstitial, constriction Disease (PID)
isthmic, infundibulum & fibrial portion)
• Cervical Congenital
• Abdominal Adhesions,
anomalies of the IUD usage
spasms, tumors
• Ovarian fallopian tubes

19 20
 10/09/2023

◦ Amenorrhea or abnormal menstrual period/

spotting
◦ Early signs of pregnancy
◦ Tubal rupture signs Ultrasonography
◦ Sudden, acute low abdominal pain
radiating to the shoulder (Kehr’s sign) or
neck pain Culdocentesis
◦ Nausea and vomiting
◦ Bluish navel (Cullen’s sign) Laparoscopy
◦ Rectal pressure
◦ Positive pregnancy test (50%)
◦ Sharp localized pain when cervix is touched Serial testing of HCG beta-subunit
◦ Signs of shock/ circulatory collapse

21 22

Surgical removal of
Low hemoglobin and hematocrit (Unruptured)
ruptured tube
Methotrexate, Leucovorin
(Salphingectomy)
Low HCG (normal value at its peak: 400,000 IU/ 24 hours)

Elevated WBC Management of profound

shock if ruptured (Blood Antibiotics
replacement)

23 24
 10/09/2023

o Carry out an ongoing assessment for shock

o Implement promptly shock treatment
o Position on modified Trendelenburg
o Infuse D5LR for plasma administration, blood
transfusion or drug administration as ordered Rh
Hemorrhage Infection
o Monitor VS, bleeding, I & O sensitization
o Provide physical and psychological support.

25 26

• Abnormal proliferation and then

degeneration of the trophoblastic Low protein intake.
villi.
• As the cells degenerate, they Women older than 35 years old.
become filled with fluid and appear
as clear fluid-filled, grape-sized
vesicles Asian women.
• Gestational Trophoblastic Disease
• Cause: unknown Women with a blood group of A who marry men with blood group
O.

27 28
 10/09/2023

• Fertilization occurs as the sperm enters

the ovum. In instances of a partial mole,
two sperms might fertilize a single ovum.
• Brownish or reddish, intermittent or profuse
• Reduction division or meiosis was not vaginal bleeding by 12 weeks
able to occur in a partial mole. In a • Expulsion, spontaneous, of molar cyst usually
complete mole, the chromosome occurs between the 16th to 18th weeks of
undergoes duplication. pregnancy
• The embryo fails to develop completely. • Rapid uterine enlargement inconsistent with
the age of gestation
There are 69 chromosomes that develop
for the partial mole, and 46 • Symptoms of PIH before 20 weeks
chromosomes for the complete mole. • Excessive nausea and vomiting because of
excessive HCG (1 to 2 million IU/L/24 hours)
• The trophoblastic villi start to proliferate
rapidly and become fluid-filled grape-like • Positive pregnancy test
vesicles. • No fetal signs – heart tones, parts, movements
• Abdominal pain

29 30

• Passage of vesicles – 1st sign that aids to

diagnosis
• TRIAD signs:
• Evacuation by Suction D & C or hysterectomy
• Big uterus
if no spontaneous evacuation
• Vaginal bleeding • Hysterectomy if above 45 years old and no
• HCG greater than 1 million future pregnancy is desired or with
• Ultrasound increased chorionic gonadotropin levels
• Flat plate of the abdomen done after 15 after D & C
weeks • HCG titer monitoring for one year (no
pregnancy for 1 year)
• Medical replacement: blood, fluid, plasma
◦ 80% remission after D & C; may • Chemotherapy for malignancy:
progress to cancer of the chorion: Methotrexate is drug of choice
Choriocarcinoma • Chest X-ray

31 32
 10/09/2023

• Advise bed rest

• Monitor VS, blood loss, molar/ tissue passage, I & O
• Maintain fluid and electrolyte balance, plasma, and blood volume
through replacements as ordered
• Prepare for suction D & C, hysterotomy or hysterectomy as
indicated
• Provide psychological support • Choriocarcinoma
• Prepare for discharge • Hemorrhage
• Emphasize need for follow-up HCG titer determination for 1 year • Uterine perforation
• Reinforce instructions on NO PREGNANCY FOR ONE YEAR; give
instructions related to contraceptions • Infection

33 34

• Painless contractions resulting in

• A condition characterized by a delivery of a dead or non-viable
mechanical defect in the fetus
cervixcausing cervical effacement
and dilation and expulsion of the • History of abortions
POC
• Associated with: • Relaxed cervical os on pelvic
• Increased Maternal age examination
• Congenital structural defects
• Trauma to cervix

35 36
 10/09/2023

• Provide psychological support to client who may have negative

CONSERVATIVE MANAGEMENT: feelings
• Bed rest; avoidance of heavy • Provide post-cerclage procedure care
lifting; no coitus
• Advise limitation of physical activities within 2 weeks after treatment
FOR WOMEN WITH PREVIOUS • Maternal and fetal growth monitoring
LOSSES: elective cervical • Instruct to report promptly signs of labor
cerclage (late first trimester or • Assessment for signs of labor, infection or premature rupture of
early second trimester) membranes
• Shirodkar procedure • In labor, prepare STITCH REMOVAL SET in addition to delivery set
• McDonald procedure (post-McDonald surgery)

37 38

• Maternal hypertension: PIH, renal disease

• Sudden uterine decompression (multiple pregnancy,
polyhydramnios)
• Advance maternal age
• Multiparity
• Short umbilical cord
Premature separation of the implanted placenta before the birth of
• Trauma; fibrin defects
the fetus

39 40
 10/09/2023

Type I: Concealed, Covert or Type II: Marginal, Overt or

Central type External bleeding type

1. Marginal/low separation
2. Moderate/high separation
3. Severe/complete
separation

41 42

• Hemorrhagic shock
• Painful, vaginal bleeding
• Couvelaire uterus
• Rigid, board-like, and painful
abdomen • Disseminated intravascular coagulation
(DIC)
• Enlarged uterus due to concealed
bleeding • Cerebrovascular accident (CVA) from DIC
• If in labor: tetanic contractions with • Hypofibrinogenemia
the absence of alternating • Renal failure
contraction and relaxation of the • Infection
uterus
• Prematurity, fetal distress/ demise (IUFD)

43 44
 10/09/2023

• Maintain bed rest, LLR

• Careful monitoring: Maternal VS, FHT, Labor onset/ progress, I & O, • Labor that occurs after the 20th
oliguria/ anuria, uterine pain, bleeding week and before 37th week of
gestation
• Administer IV fluids, plasma, or blood as ordered
• In >30% cases exact cause of
• Prepare for diagnostic examinations preterm labor is not known
• Provide psychological support • Occurs approximately 9-11% of all
• Prepare for emergency birth pregnancies
• Observe for associated problems after delivery: • Any woman having persistent
• Poorly contracting uterus uterine contractions (4 every 20
• Disseminated Intravascular Coagulation minutes)
• Hypofibrinogenemia
• Prematurity, neonatal distress

45 46

• Dehydration
• Urinary tract infection • Prematurity
• Periodontal disease • Fetal death
• Chorioamnionitis • Small-for-gestational
age (SGA)/ IUGR
• Increase perinatal
• Strenuous job/ extreme fatigue morbidity and
• Small stature mortality

47 48
 10/09/2023

(Hospitalization) (Hospitalization)
• Bed rest on LLR • Promotion of physical and emotional
• Adequate hydration comfort
• Monitoring: • Administration of Tocolytics
• Uterine contractions and irritability (every 1-2 (magnesium sulfate, Terbutaline,
hours) Ritodrine)
• VS • Contraindications:
• I&O • Advanced pregnancy
• Signs of infection • Ruptured bag of waters
• Cardiac and respiratory status and distress • Maternal distress (bleeding
signs complications, PIH, cardiovascular
• Cervical consistency, dilatation, and disease)
effacement
• Fetal well being
• Fetal distress
• Early signs of edema • Presence of fetal problems (Rh
isoimmunization)

49 50

(Hospitalization)
(premature labor stopped)
• Administration of corticosteroids • Maintain bed rest, LLR preferred
• Betamethasone (12mg IM every 24 • Well-balanced diet (high in iron, vitamins, and
hours x 2 doses) important minerals)
• Dexamethasone (6mg IM every 12 • Continuation of oral medications
hours x 4 doses) • Frequent prenatal visit every week
• Activity/ Lifestyle evaluated and restricted as
• Assess effects of drugs on labor necessary
and fetus • Illnesses: Chronic – monitored; Acute – treated
stat
• Monitor for side effects
• Provide client teaching
• Symptoms of preterm labor
• Prompt reporting to physician

51 52
 10/09/2023

• Spontaneous rupture of fetal • Maternal report of passage of fluid

membrane any time after the period per vagina
of viability but before the onset of • Determination of alkaline amniotic
labor
fluid and not acidic urine or vaginal
• Cause: UNKNOWN discharge
• Associated with infection of the
membranes (Chorioamnionitis)
• Occurs in 5-10% of pregnancies

53 54

• Nitrazine test
• Change in color of Nitrazine paper from
yellow (acidic vaginal pH = 4-6) to blue
color because of neutral to slightly
alkaline amniotic fluid (pH = 7-7.5)
• Ferning test
• Amniotic fluid, high in sodium content,
will assume a ferning pattern when dried
on the slide
• Maternal infection/ chorioamniotnitis
• Sterile speculum examination
• Direct visualization of fluid from cervical • Cord prolapse
os is the most reliable diagnosis
• Premature labor

55 56
 10/09/2023

• If Pregnancy is >37 weeks and with presence of:

• Congenital anomalies
• Initial Assessment - objectives of the initial assessment are: • Fetal distress , cord prolapse
- Confirm the diagnosis of PROM • Signs of chorioamnionitis

- To determine the gestation of the fetus

Then deliver....
- To identify the women who need to
deliver • Induction of labor- if no contraindication

57 58

• If pregnancy <34 weeks

• Balance between risk of infection in expectant management &

Expectant Management- The aim is to prolong
Premature labor
the pregnancy for fetal maturity
• Shift the patient where the facility for neonatal care is available
.
- Bed rest
• If pregnancy is >34 and <37 weeks - CBC & Cervical swab c/s
- CBC, cervical swab c/s - give corticosteroid & tocolytics
- Antibiotics - Antibiotics
- Careful watch on signs of chorioamnionitis - Watch for signs of chorioamnionitis,
Maternal & fetal conditions Maternal & fetal condition.
- If no spontaneous labor in 24-48hrs-induction
of labor

59 60
 10/09/2023

61