Abnormal Obstetrics f2o6u
This document was ed by and they confirmed that they have the permission to share it. If you are author or own the copyright of this book, please report to us by using this report form. Report 3b7i
Overview 3e4r5l
& View Abnormal Obstetrics as PDF for free.
More details w3441
- Words: 11,708
- Pages: 296
Õ Õ
Õ Õ ! Second Trimester !" "# $ %& Third Trimester '/$ $
$ %
Õ ( Õ Õ Õ $ ! ) !
! "'" !
$ $ Õ Õ Õ $ $$'
Õ #$!
$ # Teenage pregnancy of 16 yrs. and below is considered a high risk pregnancy from both physical and psychosocial standpoint ˜
Physical
Éecause of the physical task of adolescence Æ Æ
˜
Õapid growth during adolescence Õapid growth of the fetus
Psychosocial Æ Æ Æ Æ Æ Æ Æ Æ Æ
ack of motivation Denial Ignorance Õebellion against authority Failure to complete education Dependence on others for Failure to establish a stable family life High rate of marital failure High incidence of repeated out of wedlock pregnancy
‘dvanced age of 35 yrs and above is a high risk of pregnancy because of increased incidence of : Æ Æ Æ Æ Æ Æ
Placenta previa Chromosomal abnormalities ‘bruptio / ‘blatio placenta Hypertension Toxemia Low birth weight babies
! ! is the period of highest risk "*)" "') ! the risk of death for the mother is at its lowest #) ! marked increase especially when the pregnant mother is over 40 years of age.
ª
ª •
•
•
ªª ª •
!
ª
ª • ! !
" ª ª # $ ª
{ % & ''
ª¯ #
#
&
&&
¯ ‘ ‘ ‘ ‘‘‘
# ( ! (
" ( ! !
$
{
( {
( "
( " ( &
!"#$%& •
ª (
) ¯ * *
%anagement: Éed rest Save all pads No coitus up to 2 weeks after bleeding has stopped
INEVITABLE OR IMMINENT ABORTION is a loss of pregnancy that cannot be prevented. Clinical Manifestations: Moderate to profuse Bleeding Moderate to severe uterine cramping Cervix dilated Membranes rupture
%anagement: Hospitalization D&C Oxytocin after D & C Emotional
TYPES OF INEVITABLE ABORTION: Complete ² all products of conception are expelled. Sxs of complete abortion: Moderate bleeding Mild uterine cramping age of tissue 1)
Management: Sympathetic understanding & emotional 2) Incomplete ² not all products of conception are expelled from the uterus. Signs and Sxs: Profuse vaginal bleeding Severe uterine cramping Open cervix age of tissue Other products are retained
Treatment and MX: D and C Oxytocin after D & C Emotional
%issed ‘bortion Õetention of all products of conception after the death of the fetus in the uterus S/Sx: No FHT Signs of pregnancy disappear %anagement: D&C
Septic ‘bortion ‘bortion complicated by infection S/Sx: Foul smelling vaginal dischrage terine cramping Fever %anagement: Treat abortion ‘ntibiotics
î
Induced Abortion ² is an intentional loss of pregnancy through direct stimulation either by chemical or mechanical means. Types of induced abortion: 1) Therapeutic abortion ² to preserve the life of the mother 2) Elective abortion B.
Õeasons for Induced ‘bortion: Therapeutic to end a pregnancy that is life threatening to the mother To end a pregnancy of a fetus found to have severe congenital abnormalities that may be incompatible with life To end an unwanted pregnancy that is a result of rape or incest To end a pregnancy because of woman·s choice not to have a child yet
Prevention of abortion: Prepregnancy correction of maternal disorders Immunization against infectious diseases Proper early antenatal care Treatment of pregnancy complications Correction of cervical incompetency
Complications: Hemorrhage Sepsis Rh sensitization
#
###
&
" ': $ ' $ ") %' ! %'' $'! '$$%' ') ")' & $ #)%' '"%+ , -
"&.
( $$" '$ " # ) $' #$$/"!$)'$"
#' $''. %) 0#$0 )$/ 1' " #) " " $"! ' "% /)2")2 ) $ $3" )%& $ & +/$-
#)) . 4 '$$5 6 $')"$ #) '$'"')#$") $ %! 4 "" "$0 " 2#)0. 4 $$ 7 "'$ 4 )) "" 4 $$ 4 ! $" 4 $"$ !0
Culdocentesis aspiration of bloody fluid from Cul de sac of Douglas ltrasound reveals presence of the gestational sac outside of the uterine cavity
" . #!''". $! 6 % $# ' $ ) 8$ " )" $#) # $$ '!# $ %) !2)' /$$ &'"#)9%" ' $$!2 $! 6 $'" $ " %) !9)' %"'#$' $ % ' 6 % $#)' !$09'#)# $$ '
#''". 4 % $#)''"' ' )# #' " 9$# $ " )' $ !2 ' $ . 4 $! 4 $! 6 % $#) %"'
Prevent and treat hemorrhage which is the main danger of ectopic pregnancy. Élood transfusion Place patient flat in bed with legs elevated %onitor Vital signs, I & O, & amount of blood loss
Prevent infection as the woman who lost so much blood is susceptible to infection
Contraception must be started upon discharge from hospital. Ovulation begins as early as 19 days or 3 weeks after resection of ectopic pregnancy.
ªª
ª ª ª ' (( ' $)*) )!%"*)+")$,+ -".$%-#"/!+)#$0 #$1$%./$0/ )2)01+)" 2$0+ +,-. /- .0,123/42 53678207
"# . ''0/ :;! $"$/ "<=!2% / ' / 0 %'$ )" /
&
(
î # "% 90 "%
¯ : : •"
&
: "
•"%
:
:
•"%
"&. Õ " '3 ) $ #)#' 0" >(.?@@7@@' &% ' "%"' $% " /)% $") '""
# $0$
!9)& # $ !# #8?)/0
BB"##2 4$94$ 4 #8@/0C $ 4 #8@/0'8/0 'C$
DX: ltrasound will identify the characteristic vesicles.
" . " 9 %)$2+ #) / ) ?@!$"7)!! ")) ))) #"%$ Õ Õ #:! + )$" % 84D/0 #% $# 4$2-
)E !%!< #D2)$' )# # ) )) !+)& -#. 4 "#< '% /0"'$ ! 4 $% "<4"$%!
The woman is advised not to get pregnant for 1 year, contraceptive method should NOT be the pills. Pills contain estrogen which promote regrowth of the chorionic villi. Hysterectomy is the method of tx for women above 40 yrs old because of the higher incidence of malignancies & to clients who have completed childbearing & require sterilization.
Prognosis: % $# "' # % ' #)$ ,# % $# $ !"%$ " ' "
„estational Trophoblastic Tumors persistent trophoblastic proliferation after Hmole. ** Choriocarcinoma most severe malignant complication that involve the transformation of chorion into cancer cells that invade & erode blood vessels & uterine muscles.
,-,.2;2-8 9< ,33 8091+9=3,78/5 86;907 /7
¯ '
3 4%,*(
5
ª & #
#
¯ ( 7+908 520>/? @ *
Signs and Sxs: $)% $$" #' " Õ''#) #/ &'$#)' # $% $"$ Õ$ &"% $$%&
¯ (
"
)ª ª6 ( 82;190,0A
'
= ª7 ( 120;,-2-8 #
‘fter suturing the cervix: Place woman on bed rest for 24 hours Observe for bleeding, uterine contractions, and rupture of ÉOW If ÉOW ruptures the sutures are removed If uterine contractions occur, the woman is given ritodrine to stop the contractions Postop care: Õestrict activities for the next 2 weeks including coitus
Cervix not dilated Intact membranes No vaginal bleeding & uterine cramping
# & ' (
(
(
(
Predisposing factors: '$ ! "% " $ 6 %<=! '$$ ! ,' 0 #%'%' "% '$ !#''
' 9
Signs and Sxs: $7)"% $$" "')<" "#7" ,$ '"% $$ %
¯ ! !
' B/8+968 @7 .= 58 ! ª' ¯ 8+2 /7 1021,02C <90 >,./-,3 2?,; ,-C <90 527,02,- =/08+ /- 5,72 8+2 2?,;/-,8/9- 1025/1/8,827 109<672 =322C/-.
! #
! ! "
# $$' '! %#
)) % )1'
Complications of placenta previa: ) # '!
& =25,672 9< 6820/-2 59-80,58/9-7 ! D
¯
E
!
# & &
(
(
¯ (
" $ {
) ¯
! ! ! #
"
‘ ‘‘ ‘‘
ª
&
ª8
!
9 ª !
!
!
ª9 ! !
!
ª: • ! ! !
5&
! ' ! !
(
"ª & ;; ª î
! ª ( !
& (
( (
Disorder of blood clotting ô Fibrinogen levels fall below effective limits ( Hypofibrinogenemia) Symptoms ô Éruising or bleeding ô massive hemorrhage initiates coagulation process causing massive numbers of clots in peripheral vessels (may result in tissue damage from multiple thrombi), which in turn stimulate fibrinolytic activity, resulting in decreased platelet and fibrinogen levels ô signs and symptoms of local generalized bleeding (increased vaginal blood flow, oozing IV site, ecchymosis, hematuria, etc) ˜ monitor PT, PTT, and Hct, protect from injury; no I% injections
Õesult from an imbalance between clot formation systems and clot breakdown systems that results in hemorrhage. This problem begins with the excessive triggering of coagulation mechanisms, most commonly encountered in abruptio placenta, PIH, amniotic fluid embolism. This overstimulation of the coagulation system leads to rapid formation of massive numbers of clots. In turn, the fibrinolytic system is overactivated & clots are broken down. ‘s a result, clotting factors are used up & generalized hemorrhage occurs leading to shock & death. Tx: Õeplacement of clotting factors _ Cryoprecipitate or fresh frozen plasma or platelet transfusion
ª < ª ' '
! &&& # && && &
•
!
¯ , (
!
= ª (
) ¯ 5=! (
! ! ! E
ª ª¯
¯
¯
E '
! ! (
(
¯
¯ #
E
E
ª #
&& ¯
¯ , = 5 C 2
< ,
=
5
Or spurious pregnancy occurs in women nearing menopause & in women who have intense desire to become pregnant. These women develop the belief that they are pregnant when in fact they are not. The women often experiences all the subjective symptoms of pregnancy: fatigue, amenorrhea, tingling sensations & fullness of the breast, nausea & vomiting. Some of these women repost feeling fetal movements which are actually movement of air in the intestines or muscular contractions of the abdominal wall.
%anagement: Explain pregnancy test result, clarify misconceptions & false beliefs Provide referrals when necessary, psychologic counselling Provide emotional & understanding
Excessive nausea & vomiting that persists beyond 12 weeks gestation & which leads to complications like dehydration, weight loss, starvation & fluid & electrolyte imbalance. Etiology: nknown SSx: 1.Excessive nausea & vomiting not relieved by ordinary remedies persisting beyond 12 weeks 2. Signs of dehydration: thirst, dry skin, increased pulse rate, weight loss, concentrated & scanty urine.
)%)-*%#& ¯ &
&&& F F # (
ªª
¯ ¯ #
!
&
¿ ¿ ¯
‘ ‘ ‘ ‘ ‘
¿ ¿ ¯
‘ ‘ ‘‘ ‘
¿ ¯ ‘ ‘‘ ‘‘ ‘‘ ‘ ‘ ‘ ‘
‘ ‘
‘ ‘‘ ‘‘ ! ‘ "#$%&'(()*+,&-.+./,$0"('-$'-.-0(' ,$*( 1 '(2.$3-"#$%&'(()*+,&-.+
‘¯ ‘ !‘‘ ‘ ‘
‘4¯ ‘ ‘ 5/6 *(+6./7)+3-($%,+0('/+*6(+0" 5)".(%)+3-(-$%,+0('/+*6(+0"63(0$ ¯ )('(8'+*"(,$''"+7( )+'6.+)%+.*3'(9.0"&3*,$/+':(6(,+ '(/+ "(&+0.)$''(-&%+.*3'( $8-0(0'.)"(,$''"+7(+--$)9.0"+8'3&0.$
&*+)(/0+
‘ ‘ 63(0$6+,7(0$0"((/6$0"(*.3, ‘‘
‘
‘‘ ‘ ‘ ‘‘‘
‘ ‘
‘/) ‘
‘ ‘ ‘ ‘
‘ ‘
Warning Signs: Õapid weight gain, 45 lbs in a single week Sudden swelling Swelling of face & hands Swelling of ankles or feet that does not go away after 12 hours rest ‘ rise in ÉP Protein in the urine Severe headaches Élurry vision Seeing spots in the eyes Severe pain over the stomach, under the ribs Decrease in the amount of urine
¯
¿
¿
!;<=:-0$*.)(*(2+0.$/ 1; $%,,; 7 .+-0$*.)(*(2+0.$/$% ,,; 7
'$0(./3'.+
>0$> ,7;! "$3'3'./( )$**()0.$/
>0$>!./)*(+/)+0)" 7;! "$3'3'./( 3'./($'7;! 3'./($' )$**()0.$/
6(,+
.7.0+*(6(,+>> (&(/6(/0(6(,+
.00./7(6(,+>>! (/('+*.?(6(6(,+
(.7"0+./
*8;9((@
$'('+&.69(.7"07+./
'./+':30&30
$0*(--0"+/,*;! "$3'-
(--0"+/,*;! "$3'-=$*.73'.+ "$3'-= $*.73'.+
(+6+)"(
))+-.$/+*"(+6+)"(
(2('("(+6+)"(
(%*(#(-
$',+*0$>>
:&(''(%*(#.+ >>!
.-3+*.-03'8+/)(-
‘8-(/0
"$0$&"$8.+ 8*3''./7 -&$0-8(%$'(0"((:(-
&.7+-0'.) +./ *.2(' ./2$*2(,(/0
‘8-(/0
.7"03&&('A3+6'+/0 &+./+3'+0$ )$/23*-.$/
‘¯ >
‘ ‘ 4 > ‘‘ 4 ‘ > ‘ ‘ >! ‘‘‘‘‘‘
¿ ¯ ‘
‘ ‘ ‘ ! B ‘‘ ‘‘ ‘ ‘ ‘ ‘ ‘ ‘
1 ‘ B ‘ ‘ ¯ ‘
‘‘ ‘ ‘ ‘‘ ¿ ‘ ‘
‘ ‘‘‘ &/ $-+7( ,7; +6,./.-0('-*$9*:0$+2$.6 -366(/%+**./
+./0+./6.+-0$*.)&'(--3'(+0<,,; 70$ (/-3'(+6(A3+0(&*+)(/0+*%.**./7
7! ‘ +*-$+,3-)*('(*+#+/0 $+6./76$-(.-! 17+./0(/+/)(6$-(.- 7;" /%3-(*$+6./76$-(-*$9*:$2(' ,./ ‘*9+:-+6,./.-0('+-+&.77:8+)@./%3-.$/ ('3,7*(2(*-"$3*6'(,+./8(*$9,A;
¿ + 8 ¿ ¿ ¯ 4 >‘ ‘‘ ‘‘;
Diazepam ( Valium) Halt seizures 510 mg/IV ‘dminister slowly Dose may be repeated every 510 mins ( up to 30 mg/hr) Observe for respiratory depression or hypotension in mother & respiratory depression & hypotonia in infant at birth.
66 7!4 ‘ ‘ ‘
‘‘ ‘ ¿ ¿¿
‘ 7; ,*$%+C-$* "+2(&'(&+'(6+08(6-.6(9"(/+6,./.-0('./7 7! 66 7! ‘ ‘‘‘‘ ‘4‘
¿ ¯ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘
¯ ‘ ‘ ‘4 ‘‘‘ ¯ + !;< 8 ‘ ) ‘ ‘‘ 6 ‘‘
‘‘ ‘ ‘ ‘
‘‘
‘ ‘ ‘‘ ! ‘ ‘ ‘ ‘‘‘ 1 ‘‘ ‘¯ + ‘ ‘‘‘ 8 ‘ ‘ ) ‘‘
6‘‘ ‘‘‘¯ ‘ !;<,, 7 ‘ ‘ + ‘‘
‘‘
¿ ¯ ‘ ‘ ‘‘ ‘ 4 ‘
‘ ‘‘ ‘ ‘ ‘‘ ‘ ‘
‘ D‘ ‘ ‘ ‘‘4‘‘
‘‘ ‘ ‘‘ ‘ ‘ ‘ ! ‘
‘‘ ‘ ‘ ‘ ‘ ‘ ‘
¿ ‘‘ ‘ ¯ ‘ ‘
‘‘ ‘‘ ‘ ‘ ‘ ‘¯‘‘
‘‘‘ ‘ D ‘ ‘ ‘‘ ‘ ‘ ‘ ‘ ! ‘ ‘‘ ‘‘
‘ ‘ ‘ 1‘ ‘ ‘‘¯ ‘‘ ‘ ‘ ‘ ‘ ‘‘ ‘ ‘ ‘ ‘ E ‘ ‘ ‘‘‘ ‘
66 ‘‘ ‘ ‘ ‘ 66 ‘‘ 66 ‘ ‘ ‘ ‘‘
¿ ¯ ‘ 4!
‘ 7! ‘ ‘!
‘ ‘‘‘ ‘ ‘ ‘ ‘ ‘
‘‘ ‘ ‘ B ‘
Serious complication of pregnancy induced hypertension & the client develops multiple organ damage. sually develops before delivery but may occur postpartum as well. HELLP syndrome consists of the following problems: Hemolysis red blood cells break down Elevated liver enzymes damage to liver cells cause changes in liver function lab tests Low platelets cells found in the blood that are needed to help clot the blood to control bleeding
HELLP syndrome can cause other problems ‘nemia breakdown of ÕÉC·s may cause anemia DIC may lead to severe bleeding Placenta abruptio may also occur
SSx of HELLP syndrome: syndrome Õight sided upper abdominal pain around the stomach ( epigastric area) Nausea & vomiting Headache Increased ÉP Protein in the urine edema
How is HELLP diagnosed? ÉP measurement ÕÉC count ( hemolysis) Éilirubin level substance produced by the breakdown of ÕÉC Liver function tests ( ‘LT & ‘ST) Platelet count ( thrombocytopenia ) rine tests for protein
Treatment: Éedrest Élood transfusion %gSO4 ( as anti convulsant) ‘ntihypertensive medications Lab testing of liver, urine & blood ( for changes that may signal worsening of HELLP syndrome Corticosteroids to help in the maturity of fetal lungs Delivery ( if HELLP syndrome worsens & endangers the well being of the mother or fetus)
+2- 8B/-! 80/1328! G6,C061328 90 2>2- G6/-861328 <286727 C2>2391 /- 8+2 682067 ,8 8+2 7,;2 8/;2 ¥ 7795/,82C B/8+ ;902 0/747 8+,- , 7/-.3289102.-,-5A ¥
¯ ¥ ' 90 ¥
¾ 2>2391 <09; 9-2 9>6; 9-2 7120; 5233 8+,8 6-C20.9 0,1/C 5233 C/>/7/9- ,<820 <208/3/H,8/9- 8+,8 0276382C /- 8B9 90 ;902 /-C/>/C6,37 /-52 8+2A 59;2 <09; 9-3A 9-2 7120; ,-C 9-2 9>6;! 8+272 /-C/>/C6,37 1977277 8+2 7,;2 .2-28/5 80,/87 ,-C ,02 ,3B,A7 9< 8+2 7,;2 72?
¥
< 8B/--/-. 9556002C B/8+/- $ +9607 ,<820 <208/3/H,8/9-! 8+202 B/33 =2¯ ¾ ,;-/9-7 C/,;-/9-/5 ¾ 5+90/9-7 C/5+90/9-/5 ¾ 2;=0A97
¥
< 8B/--/-. 9556002C =28B22- 8+2 8+ {8+ C,A ,<820 <208/3/H,8/9-! 8+202 B/33 =2 ¯ ¾ ,;-/9-7 ¾ 5+90/9- ;9-95+90/9-/5 ¾ 2;=0A97
¥
< 8B/--/-. 9556002C ,<820 { C,A7! 8+202 B/33 =2 ¯ ¾ ,;-/9- ;9-9,;-/9-/5 ¾ 5+90/9¾ 2;=0A97
¥
< 8B/--/-. 9556002C ,<820 8+2 2;=0A9-/5 C/75 /7 <90;2C! I B/33 C2>2391 9-J9/-2C 8B/-7 ,02 53,77/
-820/90 ( +90,591,.67 97820/90 ( 1A91,.67 21+,3/5 ( 50,-/91,.67 ,6C,3 ( 75+/91,.67
¥
' 90
¾ 2>2391 <09; 90 ;902 9>, ,-C 7120; 52337 8+,8 B202 <208/3/H2C ,8 8+2 7,;2 8/;2 +2A +,>2 8+2 7,;2 .2-28/5 80,/87! ;,A 90 ;,A -98 =2 9< 8+2 7,;2 72? ,-C ,3B,A7 +,>2 5+90/9-7 ,;-/9-7
902 <2;,327 8+,- ;,327 =25,672 <2;,32 HA.982 +,7 , +/.+20 82-C2-5A 89 C/>/C2 /-89 8B/-7 2;,32 HA.9827 +,>2 +/.+20 0,82 9< 760>/>,3 8+,;,32 HA.9827
¥
02C/7197/-. <,58907 9< /HA.98/5 B/--/-. ¾ ,52 ( +/.+278 /- =3,54 B9;2¾ 202C/8A ( ;902 59;;9- /- B9;2- B/8+ <,;/3/,3 ¾ ¾ ¾ ¾
+/7890A 9< 8B/--/-. .2 1,0/8A ( /-502,72C /-5/C2-52 /- +/.+ 1,0/8A ,C>,-52C ;,820-,3 ,.2 /.+20 /-5/C2-52 /- B9;2- 8,4/-. <208/3/8A C06.7 8+,8 109;982 9>63,8/9- 0232,72 9< 72>20,3 9>, ,8 8+2 7,;2 8/;2 /.+20 /-5/C2-52 B/8+/- 8+2 27 =25,672 9< 8+2 76CC2- .02,820 ,;96-8 9< 1/86/8,0A .9-,C98091/- 0232,72C ,8 8+/7 8/;2 - >/809 <208/3/H,8/9- ( 78/;63,8/9- 9< <90;,8/9- 9< -6;20967 <933/5327! +,0>278/-. 8+2; /- 8+2 9>,0A <208/3/H/-. 8+2; /- >/809 33 HA.9827 8+,8 B202 <208/3/H2C ,02 02860-2C 89 8+2 682067 89 .09B C2>2391
¥
9;13/5,8/9-7 9< 638/132 286727¯ ¾ ¾ ¾ ¾ ¾ ¾ ¾ ¾ ¾ ¾ ¾ ¾
=908/9 2,8+ 9< 9-2 <2867 20/-,8,3 ;908,3/8A 02820; 3,=90 ( ,7 8+2 -6;=20 9< <286727 /-502,727! 8+2 C60,8/9- 9< 102.-,-5A C2502,727 9B =/08+ B2/.+8 9-.2-/8,3 ;,3<90;,8/9-7 AC0,;-/97 ,820-,3 +A12082-7/93,52-8, 102>/, =0618/9 13,52-8, -80,6820/-2 .09B8+ 028,0C,8/990C 2-8,-.32;2-8! 1093,172 59;10277/9,820-,3 ,-2;/,
¥
) ? ¾ 82067 3,0.2 <90 .278,8/9-,3 ,.2 ¾ 675638,8/9- 9< 8B9 90 ;902 <28,3 +2,08 89-2 ¾ ? 9< 8B/-7 /- 8+2 <,;/3A ¾ ,31,8/9- 9< 8+022 90 ;902 3,0.2 <28,3 1,087 ¾ 380,796-C 02>2,37 8B9 90 ;902 .278,8/9-,3 7,5
3/-/5 /7/8¯ ¥ /078 0/;27820 ( 2>20A ;9-8+ ¥ 259-C 0/;27820 ( 2>20A B2247 ¥ +/0C 0/;27820 ( 2>20A B224 ¥ 680/8/9- ( ,CC/8/9-,3 && 45,3 89 8+2 -90;,3 102.-,-5A 02G6/02;2-8 ¥ " 7;,33 ;2,37 0,8+20 8+,- 3,0.2 ;2,37 89 C2502,72 C/759;<908 9< , 3,0.2 682067 59;10277/-. , <633 789;,5+ ¥
,=90 ,-C 23/>20A¯ ¥ +2 590C /7 568 0/.+8 ,<820 C23/>20A 9< 8+2 ,3 9< C23/>20A 9< 8+2 202C >,./-,33A =25,672 9< ,=-90;,3 197/8/9-! /7 C9-2
27,02,- C23/>20A ( C23/>20A 9< 5+9/52 /< 8+2 8B/-7 90 9-2 9< 8+2; 5,--98 =2 C23/>202C -90;,33A 90 /< 59;13/5,8/9-7 ,0/72 8+,8 -25277/8,82 /;;2C/,82 C23/>20A ¥ 978 1,086; 120/9C ( B,85+ 968 <90 2;900+,.2 C62 89 9>20C/782-8/9- 9< 8+2 682067 ¥
Is labor that occurs between 20 weeks to 37 weeks gestation characterized by regular uterine contraction that lasts more than 30 seconds & result in cervical dilatation & effacement. It is the greatest cause of neonatal mortality & morbidity. morbidity
'. PÕO% most often associated with infection Infection of amniotic fluid Õetained I D Fetal death History of premature labor & abortion Overdistention of the uterus caused by multiple pregnancy, hydramnios ‘bnormal placentation terine abnormalities Incompetent cervix Serious maternal conditions
SSx: Dx is made when there is regular uterine contractions occuring 5 minutes apart accompanied by: Progressive cervical changes Cervical dilatation of more than 2 cm Cervical effacement of 0% or more Duration of at least 30 secs 10 mins apart
%enstrual like cramping Watery or bloody vaginal discharge Low back pain
¯ 02>2-8/9- ( 02.63,0 102-,8,3 5+254 61 < <2867 /7 3277 8+,- # B2247! ,-C 78/33 102;,8602 89 =2 C23/>202C! 3,=90 ;678 =2 ,002782C¯ 2C0278 9- 89 109;982 =399C <39B 89 8+2 13,52-8, AC0,8/9- ( <36/C7 9593A8/57 ( ;2C/5,8/9-7 89 7891 6820/-2 59-80,58/9-7 023,?27 7;998+ ;675327 /89C0/-2 53 20=68,3/-2 ( 5+254 16372 0,82 =25,672 /8 5,5,672 8,5+A5,0C/, 0978,.3,-C/- /-+/=/8907 -C9;28+,5/-
06.7 89 +,782- <28,3 36-. ;,860/8A¯ # 8+20,1A /< 3,=90 5,- =2 C23,A2C <90 { +9607 ( ,C;/-/780,8/9- 9< ,552320,82 <28,3 36-. ;,860/8A 102>2-87 0271/0,890A C/780277 +A,3/-2 ;2;=0,-2 C/72,72 ;978 59;;9- 109=32; 9< 8+2 102;,8602 -29-,82 #
%
%
¿
¿ ¿
!‘ 5‘ ‘ ‘
‘ ‘ ¿
5 ‘ ‘ ‘ ‘ ‘ ‘ ‘
‘ ‘
¿
5‘‘ ‘ ‘‘ ‘ 4 ‘=
‘ ‘ ‘ ‘ !¿
5 ‘= ‘ 4 ‘=‘ ‘
‘‘
¯ ‘ ‘ ‘ ¿ ‘ 4 ! ‘ ‘
E <‘
¯ 66 ‘ ‘‘
‘‘ ‘ ¿ ¿
‘ ‘ ‘ ‘
4¯ ‘ ‘‘‘¯ ‘‘ 6E
‘ B ‘ 6 ‘ ‘ ‘ 4 ‘ 6 ‘ ‘
‘ ‘ ‘‘ ‘ ‘‘ ‘‘ ‘ ‘ ! 6‘ ‘ 6‘‘ ‘
‘ ‘¯ 6 ‘‘ ‘ ‘ ‘
6‘ ‘ ‘ ‘‘ ‘ ‘
‘¯
‘ ‘‘ ‘ ‘‘ ‘‘ ‘‘ ‘ ‘ ‘‘ ‘ ‘
‘ ‘
¿ ‘ ‘‘ ‘ ‘ ‘ ‘ ‘‘ F ‘‘ ‘ ‘‘ ‘ ‘‘‘ ‘ ‘ ‘!‘ ‘‘ ‘ ‘ ‘ ‘ B ‘
! ‘‘ ‘
‘‘ ‘ ‘‘ ‘‘‘ ‘‘ ‘
‘ 6 ‘
‘‘ ‘ ‘
‘ ‘ ‘ ‘
‘ ‘
‘ ‘‘
‘ ‘‘‘ ‘ ‘ !‘ ‘‘‘ ‘
‘ 6‘ 6 ‘‘ ‘ ‘‘ ‘
1 ‘ ‘ ‘ ‘‘ ‘
‘ ‘ ‘
Hemoglobin level of less than 11g/dl in the first and third trimester and less than 10.5g/dl in the second trimester.
%ost common type of anemia during pregnancy. %ost women enter pregnancy without enough iron reserve so that deficiency develops particularly on the 2nd and 3rd trimester when iron requirements increases.
Predisposing Factors: Poor diet and poor nutrition Heavy menses Pregnancies at close intervals, successive pregnancies nwise reducing programs
**Nurse ‘lert** ´ The newborn of the severely anemic mother IS NOT ‘FFECTED by iron deficiency anemia. This is because the amount of iron transported to the fetus of an anemic mother is almost the same as the amount transported to the fetus of a mother without anemiaµ
Signs and Symptoms Easy fatigability Sensitivity to cold Proneness to infection Dizziness Laboratory findings will reveal low hgb
Decreased resistance to infection ‘ssociated with prematurity & low birth weight infants Predispose to heavy bleeding during labor & puerperium %ay increase digestive discomfort of pregnancy
1. Oral iron supplementation 200 mg of elemental iron daily in the form of: Ferrous Sulfate the most absorbable form of iron Ferrous Fumarate Ferrous „luconate ˜ Inform the mother about the possible side effects. Tarry
stool, constipation, „I discomfort
˜ Never take with milk but with citrus juice ˜ If given in liquid form, use straw to prevent
staining the teeth. Tell patient to rinse mouth. ˜ If iron is to be given parenterally, give I% by Z tract technique to prevent tissue staining. Do not massage after injection.
Oral iron should be continued until 3 months after anemia has been corrected. Increase intake of iron rich foods: lean meat, liver, dark green leafy vegetables. „ood food sources of iron include the following: %eats beef, pork, lamb, liver,& other organ meats Poultry chicken, duck, turkey, liver ( especially dark meat) Fish shellfish, including clams, mussels, oysters, sardines and anchovies
Leafy greens of the cabbage family such as broccoli Legumes such as lima beans & green peas; dry beans & peas Yeastleavened whole wheat bread & rolls Iron enriched, white bread, pasta, rice & cereals
Folic acid is necessary for the normal formation and nutrition of red blood cells. Deficiency in folic acid leads to the formation of large and immature blood cells that have shorter life span than normal red blood cells. Women who have folic acid deficiency during pregnancy are more at risk of giving birth to babies with neural tube defects.
Effects on Pregnancy: ‘ÉOÕTION, ‘bruptio placenta, Neural defect in fetus
Predisposing Factors: 1. Long term use of oral contraceptives 2. Poor nutrition 3. %ultiple pregnancies 4. Successive pregnancies
Signs and Symptoms 1. Nausea 2. Vomiting 3. ‘norexia lack of appetite
Folic acid supplementation of 1 mg/day accompanied oral iron. ÕD‘ for all women 0.4mg/day Vit supplements containing 400 micrograms of folic acid are now recommended for all women of chilbearing age and during pregnancy. These supplements are needed because natural food sources of folate are poorly absorbed and much of the vitamin is destroyed in cooking. Food sources of folate include the ff: Leafy dark green vegetables, dried beans & peas, nuts, citrus fruits & juices & most berries, fortified breakfast cereals, enriched grain products
"#$%&'() (*"+*" , ¿ ‘ ‘ ‘‘ ‘‘ ‘ ‘
6
‘
C F >
‘ > ‘ ‘
‘‘ ‘
‘ > ‘ ‘ ‘ ‘ ‘ ‘ ‘‘ ‘
‘‘ ‘
‘‘ ‘ ‘‘ ‘+*-$ ‘ ‘ ‘ ‘ ‘ ‘‘ ‘ ‘‘ ‘‘‘ ‘‘‘ ‘‘ ‘ ‘4 ‘ ‘‘ ‘ ‘ ‘‘
B
‘ > ‘ ‘‘ ‘ ‘‘‘‘ ‘ F ‘ ‘ ‘ ‘‘ G ¿ H
¯ ¿ ¿- ‘ ‘‘ ¿ ¿-
‘ ‘
‘dministration of Õh ( anti D) globulin (Õhogam) at 2 weeks gestation and within the first 72 hours after delivery to a woman who: Have delivered Õh positive fetus Have had untypeable pregnancies such as ectopic pregnancies, stillbirth & abortion Have received ‘ÉO compatible Õh positive blood Have had invasive diagnostic procedure such as amniocentesis, P ÉS ( cordocentesis)
‘ÉO INCO%P‘TIÉILITY Occurs when maternal blood type is O and fetus is: ˜ Type ‘ most common ˜ Type É most serious ˜ Type ‘É rare
4$% ‘¯ ‘ ! ‘ 4 ‘ D‘
‘ F ‘ ‘ 4 ‘‘ ‘ ‘‘
+
./ 01¿ ‘ ‘ ¿ ‘ 4 4 4 ‘
! ‘ ‘ ‘ ‘ 4 ‘ ‘ ‘ 1‘ ‘= ‘‘ ‘ ‘ ‘ ‘ ‘
‘ E‘‘ 1
¿ ¯ ‘‘ ¯ D F‘ ‘ ‘‘ ‘ B ‘ F ‘ ‘ ‘ F ‘
‘‘ ‘ ‘ ‘‘ ‘ ‘ ‘ ‘ ‘ ‘‘ ‘ ‘"D "$‘‘ ‘ ‘ ‘ ‘‘ ‘‘ ‘ ¯‘¯
¯ ‘"$‘‘" ‘‘E‘ ‘ ‘ ‘"> 66
‘ ‘‘B ‘4 ‘‘
‘ ‘ $0.%::$3'"(+*0")+'(&'$2.6('.%:$3'8+8:"+- +/:$%0"(%$**$9./7-;-+%0(''(03'/./7"$,(¯ (2(' D+3/6.)( $$'+&&(0.0($'&$$'9(.7"07+./ #)(--.2()':./70"+06$(-/$0-0$&9"(/ 0"(8+8:.-"(*6
Signs in the newborn: Paleness Jaundice that begins within 24 hours after delivery ( pathologic jaundice) nexplained bruising or blood spots under the skin Tissue swelling ( edema) Seizures Lack of normal movement Poor reflex response
(-0+0.$/+*.+8(0(-(**.03.-+"('(6.0+':(/6$)'./(6.-$'6('63(0$ ./+6(A3+0( $'*+)@$%./-3*./ &'$63)0.$/0"+0 '(-3*0-./.,&+.'(67*3)$-(+8-$'&0.$/ ,(0+8$*.-, +**9$,(/+&&(+'0$6(2(*$&+/./-3*./ '(-.-0+/)(+-&'(7/+/):&'$7'(--(-./-3*./6$(- /$0-((,/$',+**:(%%()0.2(63'./7&'(7/+/):+ &"(/$,(/$/0"+0.-&'$8+8*:)+3-(68:0"( &'(-(/)($%0"("$',$/( 3,+/ *+)(/0+* +)0$7(/
#¯ :&('7*:)(,.+ &+/)'(+-6$(-/$0&'$63)( (/$37"./-3*./ 0"3-7*3)$-(.-3/+8*(0$(/0(' 0"()(**-+))3,3*+0(-./0"(8*$$6-0'(+, '(-3*0./7./":&('7*:)(,.+
%&)$*23(+ 9"(/8*$$67*3)$-(*(2(*-7$(- 8(:$/60"('(/+*0"'(-"$*6%$'-37+' 7*3)$-(-&.**-$/ 0"(3'./( $%&23(+ / 7*3)$-(+00'+)0-9+0('-$0"+09"(/.0.- (#)'(0(6./0"(@.6/(: .08'./7-+*$/79.0".0*+'7( +,$3/0-$%9+0(''(-3*0./7./0"(9$,+/(#)'(0./7 *+'7(+,$3/0-$%3'./( +)$/6.0.$/)+**(6 !$%&4(5*(+ 0"((#)'(0.$/$%*+'7(+,$3/0-$%%*3.6 %'$,0"(8$6:*(+6-0$6(":6'+0.$/#)(--.2(0".'-0$' &$*:6.&-.+.-+/.,&$'0+/0-:,&0$,$%6(":6'+0.$/
"(6'%$** -./)(7*3)$-()+//$08(30.*.?(6+- +-$3')($%(/('7: 0"(8$6:3-(-.0-&'$0(./%+0- -0$'(-./0"(,3-)*(-+6.&$-(0.--3('(-3*0./7./ 9(.7"0*$-- 1"'$+)(4$*(* 8'(+@6$9/$%&'$0(./-%+0- '(-3*00$(#)(--.2(%$',+0.$/$%@(0$/(8$6.(-0"+0 0"(8$6:)+//$0(#)'(0('.7"0+9+:)+3-./70"(,0$ +))3,3*+0(
77")'*$7 (+8"'"*¯ $'6"3¯ /)'(+-(60(/6(/):0$&'( ()*+,&-.+ ()*+,&-.+ )+/6.6.+-./)'(+-(6'.-@%$'&$-0&+'03,"(,$''"+7(6;0 $2('6.-0(/0.$/$%0"(30('3- +0('/+*,$'0+*.0: ! '(0(',6(*.2(':
/%+/0¯ +)'$-$,.+ :6'+,/.$ '(,+03'.0: !/0'+30('./(7'$90"'(0+'6+0.$/ :&$7*:)(,.+*$9('(6-('3,7*3)$-(*(2(*- 1 '(6.-&$-.0.$/0$6.+8(0(-,(**.03-*+0('./*.%(+- 0"(6.-(+-(.-"('(6.0+':
$,&*.)+0.$/-¯ +)'$-$,.+ /%+/0-$%9$,(/9.0"&$$'*: )$/0'$**(66.+8(0(-0(/60$8(*+'7(,$'(0"+/ *8-8()+3-(7*3)$-()+/)'$--0"(&*+)(/0+* 8+''.(' .0+)0-+)0-+-+7'$90" -0.,3*+/0 "( ./)'(+-(67*3)$-(+66--38)30+/($3-%+0 6(&$-.0-‘**0"(/30'.(/0-0"+00"(%(03-'()(.2(- )$,(-6.'()0*:%'$,0"(,$0"('F-8*$$6 .'0"/I3': ,+:$))3'63(0$0"(8+8:F-*+'7( -.?(+/66.%%.)3*0:8(./78$'/,+:)+3-( 9".)",+:/()(--.0+0(8(./78$'/8:
3. refers to low blood sugar in the baby immediately after delivery delivery. This problem occurs if the mother·s blood sugar levels have been consistently high, causing the fetus to have a high level of insulin in its circulation. ‘fter delivery, the baby continues to have a high insulin level, but no longer has the high level of sugar from its mother, resulting in the newborn·s blood sugar level becoming very low. The baby·s blood sugar level is checked after birth, and if the level is too low, it may be necessary to give the baby glucose intravenously
4. Õespiratory distress (difficulty breathing) too much insulin or too much glucose in a baby·s system may delay lung maturation and cause respiratory difficulties in babies. This is more likely if they are born before 37 weeks of pregnancy.
Prenatal %anagement: 1. Diagnosis; Suspect D% in a woman a. b. c. d. e.
With family history of D% With history of unexplained repeated abortions and stillbirth With glycosuria Who are obese Who have history of giving birth to large infants, over 10 lbs. and infants with congenital anomaly
2. Screening tests a.
niversal screening screening 50 gram oral glucose tolerance test ( O„TT) between 24 242 weeks gestation irregardless of the time of the day and meals taken for all pregnant women. If the plasma value is more than 140 mg/dl after one hour, 100 gram three hour oral glucose tolerance test is performed to confirm if the woman is having hypergycemia.
Criteria of 100 gram Oral „lucose Tolerance Test (Instruct not to eat after midnight) /;2 9< 278
2-967 2>23
3,7;, 2>23
,78/-.
%&;.)C3
&;.)C3
#+960
";.)C3
%&;.)C3
#+960
;.)C3
";.)C3
#+960
;.)C3
;.)C3
b.
c.
Élood tests for sugar by Testape and Clinistix. Éenedict·s test and Clinitest are inaccurate when testing sugar during pregnancy because these test measure all kinds of sugar including lactose which is normally present in the urine of pregnant women, thereby, giving false positive result. rine test for acetone by acetest.
3.
Diet a.
b.
c.
Caloric intake should be enough to meet needs of pregnancy, fetus and mother (1,00 to 2,400 cal/day) but not too much to promote excessive weigh gain. 20% of caloric intake should come from protein foods, 50% from carbohydrates, 30% from fats. Weight gain should be about 24 lbs. Too much weight gain can lead to large infants and cephalopevic disproportion. disproportion Teach and instruct to: ˜ ˜ ˜ ˜
Õeduce saturated fat Õeduce cholesterol Increase dietary fiber ‘void fasting and feasting
d.
e.
Have the woman become familiar with food exchange list and caloric values of foods she usually eats to enable her to plan her diet properly and estimate her caloric intake accurately. The goal is to maintain a fasting blood sugar level of 0 mg/dl and postprandial blood sugar level of 110mg/dl
Exercise
4.
‡
‡ ‡ ‡
‘ liberal cardiovascularconditioning exercise and diet therapy is the management for „estational Diabetes %ellitus Exercise lowers blood glucose levels and decreases the need for insulin. insulin The exercise regimen should be individualized, performed regularly and under supervision. ‘dvise woman to eat complex carbohydrates before exercising to prevent hypoglycemia.
Õemember that hypoglycemia could occur in persons undergoing insulin therapy during peak action hour of insulin: Short acting or regular insulin after 23 hours of injection Intermediate or Lente insulin after 6 hours of injection Longacting or ultralente after 16 1 hours of injection The sign of hypoglycemia are: dizziness, diaphoresis, weakness, blurring of vision „ive a hypoglycemic person a glass of orange juice.
Insulin therapy
5.
‡ ‡
‡
‡ ‡
Insulin requirements increase during pregnancy Oral hypoglycemics such as Tolbutamide and Diamicron are contraindicated during pregnancy because they are teratogenic for they can cross the placenta and may cause fetal and new born hypoglycemia. Combined fast acting and intermediate insulin made up of human derivative/humulin. Humulin is the insulin of choice during pregnancy because it is the least allergenic 2/3 in the morning, 1/3 at dinner istered subcutaneously ½ hour before meals. Insulin requirement is decreased on the first trimester due to nausea & vomiting and highest during the third trimester.
6.
Home blood glucose monitoring a. b. c.
Dextrometer 4x a day, upon rising in the morning, before breakfast, lunch, dinner Normal fasting 0 mg/dl, postprandial 110mg/dl
7. Observe for urinary and vaginal tract infections particularly candidiasis . Fetal wellbeing assessment teroplacental Function Tests NST and CST b. ‘mniocentesis to determine fetal lung maturity
a.
Delivery: 1.
2. 3.
Delivery is effected when the fetus is mature enough after 3 weeks gestation, but not too large so as to cause cephalopelvic disproportion. Thus, early hospitalization and labor induction is performed to deliver the baby before it becomes too large to the birth canal If cervix is not yet ripe, baby is macrosomic and fetal distress occurs, CS is performed Õegular insulin is given on the day of delivery not long acting insulin because insulin requirement drop immediately after delivery. delivery The woman may not require insulin during the first 24 hours postpartum and her insulin requirements usually fluctuates during the next few days.
Postpartum: 1. 2.
3.
Õecurrence of diabetes may occur in subsequent pregnancies. Women who develop gestational diabetes have higher tendency to develop overt diabetes later in life. Newborn Care: ô ô
ô ô ô
Keep warm because of poor temperature control mechanisms Observe respiration (stomach aspiration necessary at time of birth, since hydramnios inflates stomach which pushes up and interferes with diaphragm and lung expansion) Observe for signs of hypoglycemia (shrill cry, weakness) give glucose water Observe for signs of hypocalcemia (tetany, tremors) give calcium gluconate Observe for congenital anomalies: esophageal atresia, neural tube defect
4. Contraception: a.
a.
I D and combined oral contraceptives are contraindicated *Progesterone interferes with insulin activity therefore increases blood glucose levels. *Estrogen increases lipid & cholesterol levels & risk for increased blood coagulation Norplant (subcutaneous progestin implant system) or Depo provera may be good choices & safely used by diabetic women
¿¿ ¿ ‘ ‘ ‘‘ ‘!
¿ ¯ ‘‘ ‘ ; + ¿ ¿ ¿ ‘ B‘ ‘ ‘ 4 ‘ ‘
‘
‘¯ ‘ 4 !‘‘‘
4¯ ‘‘ ‘ ‘‘ ‘‘ 4 ‘‘ ! ‘ ‘
8 ¿ ¿ ¿
‘ ‘‘ B ‘ ‘4 ‘‘‘
‘ 4¯ ‘ ‘‘
‘
‘ ‘
‘‘‘‘ ‘‘ ‘ ‘4 ‘‘
82 Õ Õ*
Õ Õ . 4$ $ F<)#)# ))## Õ . :2 0#''' 82$ #%&7% " ' <2 ')) . :2)!&
: <<( ¯
¯
¯
&
: ª ª ª ª
2 Õisks associated with ruptured membranes : 1. Intrauterine infection 2. Cord Prolapse
:: >>
" ª ªª
( ;; ! & !
! #& !
$&#$ &
¯
‘ ‘ ‘ ‘ ‘ ¯ + ‘ ‘¿ 8 4 ‘ ‘ ¿
) ‘ ‘ ‘‘‘
6‘‘4 ( ‘ ‘‘
66 4 ‘ ‘ 66¿ ¿ 4 ‘ ‘
:: >>
!
!
Tearing of the muscles of the uterus. This occurs when the uterus can no longer withstand the strain placed upon it. It is a serious complication of labor that can lead to maternal & fetal death.
Õupture of scar from previous cs %ultiple gestation Injudicious use of oxytocin Forceps & vacuum extraction Overdistention of the uterus External trauma sharp or blunt „estational trophoblastic neoplasia
Impending uterine rupture is often manifested by a pathologic retraction ring or Éandl·s ring During the peak of a contraction, the woman suddenly complain of a sharp tearing pain after which, relief will be felt as the uterus will no longer contract.
Complete rupture when the uterus ruptures, the woman experiences a S DDEN EXCÕ CI‘TIN„ P‘IN at the peak of a contraction, cessation of fetal heart tones, then contractions stop. Internal hemorrhage follows & vaginal bleeding may or may not be present. Two swellings will be visible in the abdomen, the uterus & the extrauterine fetus. Õupture results in separation of the placenta from the uterus cutting blood supply to the fetus resulting in hypoxia & fetal death.
ÉT & IVF to correct shock ‘dminister mask O2 ´Eµ laparotomy to deliver the baby Postop care: Explain need to avoid driving for 36 weeks Explain need to avoid jogging, sexual intercourse, dancing & lifting heavy objects for 6 weeks
Or Pathologic retraction ring seen as a horizontal indentation running across the abdomen
%orphine SO4 to relax the uterus CS section for immediate delivery of the fetus & prevent uterine rupture if %orphine SO4 is ineffective If Éandl·s ring develop during the placental stage, woman is placed under anesthesia & the placenta is removed manually.
terus is completely turned inside out Causes: Pulling of the umbilical cord ‘pplying pressure on uncontracted uterus Placenta accreta Sudden increase in intraabdominal pressure such as when coughing, sneezing or straining
Fundus is no longer palpable Sudden gush of blood from the vagina terus appear in the vulva
1.
Prevention: 1. 2.
Never apply pressure on an uncontracted uterus Never pull the cord to hasten placental delivery
2. Lower uterine segment is inserted first manually & fundus last. 3. ÉT & IVF to combat shock 4. Do not attempt to remove the placenta if it still attached to the uterus as this will only enlarge the bleeding area 5. „ive oxytocin only after the uterus is properly replaced 6. If the placenta is still attached to the uterus, remove it when the uterus is replaced & contracted
1. Postpartum Hemorrhage is the leading cause of maternal mortality. Élood loss of more than 500 ml is considered hemorrhage. The most dangerous time at which hemorrhage is likely to occur is during the first hour postpartum
terine atony Lacerations & episiotomy Placenta previa complication Inversion of the uterus Õupture of the uterus DIC Overdistention of the uterus twins, hydramnios Prolonged & rapid labor
Early postpartum hemorrhage occurs during the first 24 hrs after delivery Causes: ˜.
terine atony ˜ Laceration of the birth canal ˜ Inversion of the uterus
Late postpartum hemorrhage occurs from 24 hrs after birth until 4 weeks postpartum
%ost common cause of E‘ÕLY postpartum hemorrhage. When the uterus fails to contract, open blood vessels in the placental site continue to bleed resulting in hemorrhage.
Overdistention of the uterus hydramnios, multiple pregnancy Complication of labor precipitate, prolonged labor High parity & advanced maternal age Presence of fibroid tumors Overmassage of the uterus Õetained placental fragments
First action taken when uterus is relaxed & boggy is to %‘SS‘„E IT „ENTLY. Keep bladder empty since a full bladder interferes with effective uterine contractions %onitor vital signs & amount of blood loss during the early postpartal period ‘dminister oxytocin if uterus is not contracted ÉT & IVF to replace blood loss If retained placental fragments is the cause, curettage is performed If bleeding cannot be controlled by the above measures, HYSTEÕECTO%Y is performed as the last resort.
When bright red blood continue to gush from the vagina & the uterus is firmly contracted, lacerations of the birth canal are usually the cause of bleeding. Lacerations can occur anywhere in the cervix, vagina, & perineum.
ª ( !
ªª ( ªª ( (
Operative delivery forceps delivery Precipitate delivery Large infant over 9 lbs %ultiple pregnancy Primigravidas ‘bnormal fetal presentation & position
Õeturn woman to delivery room for inspection & repair, if laceration is suspected. Vaginal packing to maintain pressure on suture line. Ée sure to remove packing after 24 to 4 hrs 3rd & 4th degree lacerations no enema or rectal suppository. Constipation should be avoided & temp should not be taken rectally.
terus will not be able to contract effectively if placental fragments are retained resulting in uterine atony & hemorrhage. %ost common cause of L‘TE postpartum hemorrhage.
Partial separation of a normal placenta %anual removal of the placenta Entrapment of placenta in the uterus ‘bnormal adherent placenta acreta, increta, percreta
D & C to remove adherent placenta Hysterectomy for severe cases
Occurs when there is a delay in the return of the uterus to its prepregnant size, shape & function Causes: Õetained placental fragments Infection Endometritis terine tumors
SSx: Enlarged & boggy uterus Prolonged lochial discharge persistent lochia rubra Éackache %anagement: %ethergin to stimulate uterine contractions .2 mg 4x/day for 3 days ‘ntibiotics to prevent or treat infection D & C if there are retained fragments Instruct woman to report the following signs fever, vaginal bleeding, age of tissue
This is due to injury to blood vessels during delivery or during repair of episiotomy resulting in blood escaping to the connective tissue under the skin. Causes: 1. Vulvar varicosities 2. Precipitate labor 3. Forceps delivery 4. Inadequate suturing of episiotomy or lacerations
Signs and Symptoms: Perineal pain Swelling Discoloration of skin over the swollen area Feeling of pressure over the vagina
‘pplication of ice packs wrapped with towel to stop bleeding by vasoconstriction Large hematomas are potentially dangerous because they may rupture & cause severe bleeding & infection. The woman is brought back to the DÕ for incision & ligation of bleeding vessels.
‘nalgesics for pain Éroad spectrum antibiotics to prevent or treat infection Élood transfusion to combat hypovolemia
´Childbed feverµ Infection of the genital tract after delivery. Predisposing factors: PÕO% Prolonged labor Postpartum hemorrhage ‘nemia %alnutrition Õetained placental fragments CS Excessive vaginal manipulation Sexual intercourse near labor or after membranes have ruptured
Fever Foul smelling lochia Õapid pulse, chills ‘bdominal pain or tenderness Éody malaise Lack of appetite Perineal discomfort Nausea & vomiting
„ood prenatal nutrition Prevention of anemia & hemorrhage „ood maternal hygiene Strict adherence to aseptic technique by hospital personnel Well balanced diet to promote healing Increased Vit. C, Chon, adequate calories
%ost common during puerperium because of trauma to the bladder after delivery, urinary retention, & overdistention of the bladder due to anesthesia or infection may be introduced during catheterization. SSX: Painful urination, frequency & urgency of urination Flank pain Fever Hematuria
Increase fluid intake ( 3,000cc/day) to flush away infection from the bladder. Õegular emptying of the bladder to prevent stasis of urine ‘nalgesics for pain, antibiotics for infection Collect urine specimen ( clean catch) for examination
Infection of the breast tissue commonly occurring in breastfeeding mothers. sually appears during the 2nd & 3rd week postpartum when milk supply is already established Staphylococcus aureus most common causative agent found in the oral nasal cavity of the infant ( acquired from health care personnel in the nursery or from cracks & fissures in the nipples)
Engorgement or swelling of affected breast & chills are usually the first signs Fever, tachycardia,body malaise Hard & reddened breast Õeduced milk supply as edema & engorgement obstruct milk flow Éreast abscess about 10% of women with mastitis develop breast abscess.
1. Prevention: Prevent nipple cracks & fissures by correct placement of infant·s mouth on the nipple ( latchin) not feeding the baby too long, using correct technique when releasing the baby from the nipple after feeding , proper breast care . Express excess milk after feeding the baby to prevent milk stasis which is a good medium for bacterial growth
Isolation of infants with cord or skin infections Persons with known or suspected staphylococci infections should not be allowed to care for newborn in the nursery Proper handwashing technique in between handling of newborns. Observance of strict aseptic technique.
Wash hands before and after changing perineal pads, good personal hygiene on the part of the mother 2. Comfort %easures:
Instruct mother to wear ive brassiere ‘pplication of heat to the breast to promote comfort & relieve engorgement Discontinue breastfeeding from the affected breast. Express milk every 4 hours to maintain lactation
3. ‘ntibiotic therapy to fight infection 4. If abscess develops, the affected area is incised & drained.
Inflammation in the lining of the blood vessels with formation of blood clots or thrombi. Causes: Stasis of circulation Increased fibrinogen during pregnancy
Types: 1. Femoral Thrombophlebitis: infection of the veins of the legs ( femoral, saphenous, popliteal veins) SSx: Homan·s sign calf pain when the foot is dorsiflexed %ilk leg or Phlegmasia alba dolens leg is shiny white Swelling of affected leg, pain & stiffness Fever
2. Pelvic Thrombophlebitis infection of the ovarian, uterine and pelvic veins SSx: Fever & chills Pain in the lower abdomen or flank Palpable parametrial mass in some cases
1. Prevention: > Early ambulation after delivery > se of stocking in women with varicosities to promote circulation & prevent stasis put on stocking before rising from bed in the morning 2. Éedrest until signs & symptoms disappear
3. ‘nticoagulant medications to prevent further clot formation. Heparin not ed to breastmilk Protamine Sulfate antidote of heparin
Dicumerol ed to breastmilk so mother must stop breastfeeding
4. Do not give ‘spirin or ‘S‘ if patient is receiving anticoagulant drugs because aspirin increases coagulation time. Watch for signs of bleeding: bleeding gums, ecchymotic skin, increased lochial discharge. 5. ‘ntibiotic therapy to combat infection, analgesics for pain.
6. „radual ambulation after symptoms disappear 7. Never massage the affected leg . Warm wet compress dressings to promote circulation & for comfort
ž ž
Õ Õ ! Second Trimester !" "# $ %& Third Trimester '/$ $
$ %
Õ ( Õ Õ Õ $ ! ) !
! "'" !
$ $ Õ Õ Õ $ $$'
Õ #$!
$ # Teenage pregnancy of 16 yrs. and below is considered a high risk pregnancy from both physical and psychosocial standpoint ˜
Physical
Éecause of the physical task of adolescence Æ Æ
˜
Õapid growth during adolescence Õapid growth of the fetus
Psychosocial Æ Æ Æ Æ Æ Æ Æ Æ Æ
ack of motivation Denial Ignorance Õebellion against authority Failure to complete education Dependence on others for Failure to establish a stable family life High rate of marital failure High incidence of repeated out of wedlock pregnancy
‘dvanced age of 35 yrs and above is a high risk of pregnancy because of increased incidence of : Æ Æ Æ Æ Æ Æ
Placenta previa Chromosomal abnormalities ‘bruptio / ‘blatio placenta Hypertension Toxemia Low birth weight babies
! ! is the period of highest risk "*)" "') ! the risk of death for the mother is at its lowest #) ! marked increase especially when the pregnant mother is over 40 years of age.
ª
ª •
•
•
ªª ª •
!
ª
ª • ! !
" ª ª # $ ª
{ % & ''
ª¯ #
#
&
&&
¯ ‘ ‘ ‘ ‘‘‘
# ( ! (
" ( ! !
$
{
( {
( "
( " ( &
!"#$%& •
ª (
) ¯ * *
%anagement: Éed rest Save all pads No coitus up to 2 weeks after bleeding has stopped
INEVITABLE OR IMMINENT ABORTION is a loss of pregnancy that cannot be prevented. Clinical Manifestations: Moderate to profuse Bleeding Moderate to severe uterine cramping Cervix dilated Membranes rupture
%anagement: Hospitalization D&C Oxytocin after D & C Emotional
TYPES OF INEVITABLE ABORTION: Complete ² all products of conception are expelled. Sxs of complete abortion: Moderate bleeding Mild uterine cramping age of tissue 1)
Management: Sympathetic understanding & emotional 2) Incomplete ² not all products of conception are expelled from the uterus. Signs and Sxs: Profuse vaginal bleeding Severe uterine cramping Open cervix age of tissue Other products are retained
Treatment and MX: D and C Oxytocin after D & C Emotional
%issed ‘bortion Õetention of all products of conception after the death of the fetus in the uterus S/Sx: No FHT Signs of pregnancy disappear %anagement: D&C
Septic ‘bortion ‘bortion complicated by infection S/Sx: Foul smelling vaginal dischrage terine cramping Fever %anagement: Treat abortion ‘ntibiotics
î
Induced Abortion ² is an intentional loss of pregnancy through direct stimulation either by chemical or mechanical means. Types of induced abortion: 1) Therapeutic abortion ² to preserve the life of the mother 2) Elective abortion B.
Õeasons for Induced ‘bortion: Therapeutic to end a pregnancy that is life threatening to the mother To end a pregnancy of a fetus found to have severe congenital abnormalities that may be incompatible with life To end an unwanted pregnancy that is a result of rape or incest To end a pregnancy because of woman·s choice not to have a child yet
Prevention of abortion: Prepregnancy correction of maternal disorders Immunization against infectious diseases Proper early antenatal care Treatment of pregnancy complications Correction of cervical incompetency
Complications: Hemorrhage Sepsis Rh sensitization
#
###
&
" ': $ ' $ ") %' ! %'' $'! '$$%' ') ")' & $ #)%' '"%+ , -
"&.
( $$" '$ " # ) $' #$$/"!$)'$"
#' $''. %) 0#$0 )$/ 1' " #) " " $"! ' "% /)2")2 ) $ $3" )%& $ & +/$-
#)) . 4 '$$5 6 $')"$ #) '$'"')#$") $ %! 4 "" "$0 " 2#)0. 4 $$ 7 "'$ 4 )) "" 4 $$ 4 ! $" 4 $"$ !0
Culdocentesis aspiration of bloody fluid from Cul de sac of Douglas ltrasound reveals presence of the gestational sac outside of the uterine cavity
" . #!''". $! 6 % $# ' $ ) 8$ " )" $#) # $$ '!# $ %) !2)' /$$ &'"#)9%" ' $$!2 $! 6 $'" $ " %) !9)' %"'#$' $ % ' 6 % $#)' !$09'#)# $$ '
#''". 4 % $#)''"' ' )# #' " 9$# $ " )' $ !2 ' $ . 4 $! 4 $! 6 % $#) %"'
Prevent and treat hemorrhage which is the main danger of ectopic pregnancy. Élood transfusion Place patient flat in bed with legs elevated %onitor Vital signs, I & O, & amount of blood loss
Prevent infection as the woman who lost so much blood is susceptible to infection
Contraception must be started upon discharge from hospital. Ovulation begins as early as 19 days or 3 weeks after resection of ectopic pregnancy.
ªª
ª ª ª ' (( ' $)*) )!%"*)+")$,+ -".$%-#"/!+)#$0 #$1$%./$0/ )2)01+)" 2$0+ +,-. /- .0,123/42 53678207
"# . ''0/ :;! $"$/ "<=!2% / ' / 0 %'$ )" /
&
(
î # "% 90 "%
¯ : : •"
&
: "
•"%
:
:
•"%
"&. Õ " '3 ) $ #)#' 0" >(.?@@7@@' &% ' "%"' $% " /)% $") '""
# $0$
!9)& # $ !# #8?)/0
BB"##2 4$94$ 4 #8@/0C $ 4 #8@/0'8/0 'C$
DX: ltrasound will identify the characteristic vesicles.
" . " 9 %)$2+ #) / ) ?@!$"7)!! ")) ))) #"%$ Õ Õ #:! + )$" % 84D/0 #% $# 4$2-
)E !%!< #D2)$' )# # ) )) !+)& -#. 4 "#< '% /0"'$ ! 4 $% "<4"$%!
The woman is advised not to get pregnant for 1 year, contraceptive method should NOT be the pills. Pills contain estrogen which promote regrowth of the chorionic villi. Hysterectomy is the method of tx for women above 40 yrs old because of the higher incidence of malignancies & to clients who have completed childbearing & require sterilization.
Prognosis: % $# "' # % ' #)$ ,# % $# $ !"%$ " ' "
„estational Trophoblastic Tumors persistent trophoblastic proliferation after Hmole. ** Choriocarcinoma most severe malignant complication that involve the transformation of chorion into cancer cells that invade & erode blood vessels & uterine muscles.
,-,.2;2-8 9< ,33 8091+9=3,78/5 86;907 /7
¯ '
3 4%,*(
5
ª & #
#
¯ ( 7+908 520>/? @ *
Signs and Sxs: $)% $$" #' " Õ''#) #/ &'$#)' # $% $"$ Õ$ &"% $$%&
¯ (
"
)ª ª6 ( 82;190,0A
'
= ª7 ( 120;,-2-8 #
‘fter suturing the cervix: Place woman on bed rest for 24 hours Observe for bleeding, uterine contractions, and rupture of ÉOW If ÉOW ruptures the sutures are removed If uterine contractions occur, the woman is given ritodrine to stop the contractions Postop care: Õestrict activities for the next 2 weeks including coitus
Cervix not dilated Intact membranes No vaginal bleeding & uterine cramping
# & ' (
(
(
(
Predisposing factors: '$ ! "% " $ 6 %<=! '$$ ! ,' 0 #%'%' "% '$ !#''
' 9
Signs and Sxs: $7)"% $$" "')<" "#7" ,$ '"% $$ %
¯ ! !
' B/8+968 @7 .= 58 ! ª' ¯ 8+2 /7 1021,02C <90 >,./-,3 2?,; ,-C <90 527,02,- =/08+ /- 5,72 8+2 2?,;/-,8/9- 1025/1/8,827 109<672 =322C/-.
! #
! ! "
# $$' '! %#
)) % )1'
Complications of placenta previa: ) # '!
& =25,672 9< 6820/-2 59-80,58/9-7 ! D
¯
E
!
# & &
(
(
¯ (
" $ {
) ¯
! ! ! #
"
‘ ‘‘ ‘‘
ª
&
ª8
!
9 ª !
!
!
ª9 ! !
!
ª: • ! ! !
5&
! ' ! !
(
"ª & ;; ª î
! ª ( !
& (
( (
Disorder of blood clotting ô Fibrinogen levels fall below effective limits ( Hypofibrinogenemia) Symptoms ô Éruising or bleeding ô massive hemorrhage initiates coagulation process causing massive numbers of clots in peripheral vessels (may result in tissue damage from multiple thrombi), which in turn stimulate fibrinolytic activity, resulting in decreased platelet and fibrinogen levels ô signs and symptoms of local generalized bleeding (increased vaginal blood flow, oozing IV site, ecchymosis, hematuria, etc) ˜ monitor PT, PTT, and Hct, protect from injury; no I% injections
Õesult from an imbalance between clot formation systems and clot breakdown systems that results in hemorrhage. This problem begins with the excessive triggering of coagulation mechanisms, most commonly encountered in abruptio placenta, PIH, amniotic fluid embolism. This overstimulation of the coagulation system leads to rapid formation of massive numbers of clots. In turn, the fibrinolytic system is overactivated & clots are broken down. ‘s a result, clotting factors are used up & generalized hemorrhage occurs leading to shock & death. Tx: Õeplacement of clotting factors _ Cryoprecipitate or fresh frozen plasma or platelet transfusion
ª < ª ' '
! &&& # && && &
•
!
¯ , (
!
= ª (
) ¯ 5=! (
! ! ! E
ª ª¯
¯
¯
E '
! ! (
(
¯
¯ #
E
E
ª #
&& ¯
¯ , = 5 C 2
< ,
=
5
Or spurious pregnancy occurs in women nearing menopause & in women who have intense desire to become pregnant. These women develop the belief that they are pregnant when in fact they are not. The women often experiences all the subjective symptoms of pregnancy: fatigue, amenorrhea, tingling sensations & fullness of the breast, nausea & vomiting. Some of these women repost feeling fetal movements which are actually movement of air in the intestines or muscular contractions of the abdominal wall.
%anagement: Explain pregnancy test result, clarify misconceptions & false beliefs Provide referrals when necessary, psychologic counselling Provide emotional & understanding
Excessive nausea & vomiting that persists beyond 12 weeks gestation & which leads to complications like dehydration, weight loss, starvation & fluid & electrolyte imbalance. Etiology: nknown SSx: 1.Excessive nausea & vomiting not relieved by ordinary remedies persisting beyond 12 weeks 2. Signs of dehydration: thirst, dry skin, increased pulse rate, weight loss, concentrated & scanty urine.
)%)-*%#& ¯ &
&&& F F # (
ªª
¯ ¯ #
!
&
¿ ¿ ¯
‘ ‘ ‘ ‘ ‘
¿ ¿ ¯
‘ ‘ ‘‘ ‘
¿ ¯ ‘ ‘‘ ‘‘ ‘‘ ‘ ‘ ‘ ‘
‘ ‘
‘ ‘‘ ‘‘ ! ‘ "#$%&'(()*+,&-.+./,$0"('-$'-.-0(' ,$*( 1 '(2.$3-"#$%&'(()*+,&-.+
‘¯ ‘ !‘‘ ‘ ‘
‘4¯ ‘ ‘ 5/6 *(+6./7)+3-($%,+0('/+*6(+0" 5)".(%)+3-(-$%,+0('/+*6(+0"63(0$ ¯ )('(8'+*"(,$''"+7( )+'6.+)%+.*3'(9.0"&3*,$/+':(6(,+ '(/+ "(&+0.)$''(-&%+.*3'( $8-0(0'.)"(,$''"+7(+--$)9.0"+8'3&0.$
&*+)(/0+
‘ ‘ 63(0$6+,7(0$0"((/6$0"(*.3, ‘‘
‘
‘‘ ‘ ‘ ‘‘‘
‘ ‘
‘/) ‘
‘ ‘ ‘ ‘
‘ ‘
Warning Signs: Õapid weight gain, 45 lbs in a single week Sudden swelling Swelling of face & hands Swelling of ankles or feet that does not go away after 12 hours rest ‘ rise in ÉP Protein in the urine Severe headaches Élurry vision Seeing spots in the eyes Severe pain over the stomach, under the ribs Decrease in the amount of urine
¯
¿
¿
!;<=:-0$*.)(*(2+0.$/ 1; $%,,; 7 .+-0$*.)(*(2+0.$/$% ,,; 7
'$0(./3'.+
>0$> ,7;! "$3'3'./( )$**()0.$/
>0$>!./)*(+/)+0)" 7;! "$3'3'./( 3'./($'7;! 3'./($' )$**()0.$/
6(,+
.7.0+*(6(,+>> (&(/6(/0(6(,+
.00./7(6(,+>>! (/('+*.?(6(6(,+
(.7"0+./
*8;9((@
$'('+&.69(.7"07+./
'./+':30&30
$0*(--0"+/,*;! "$3'-
(--0"+/,*;! "$3'-=$*.73'.+ "$3'-= $*.73'.+
(+6+)"(
))+-.$/+*"(+6+)"(
(2('("(+6+)"(
(%*(#(-
$',+*0$>>
:&(''(%*(#.+ >>!
.-3+*.-03'8+/)(-
‘8-(/0
"$0$&"$8.+ 8*3''./7 -&$0-8(%$'(0"((:(-
&.7+-0'.) +./ *.2(' ./2$*2(,(/0
‘8-(/0
.7"03&&('A3+6'+/0 &+./+3'+0$ )$/23*-.$/
‘¯ >
‘ ‘ 4 > ‘‘ 4 ‘ > ‘ ‘ >! ‘‘‘‘‘‘
¿ ¯ ‘
‘ ‘ ‘ ! B ‘‘ ‘‘ ‘ ‘ ‘ ‘ ‘ ‘
1 ‘ B ‘ ‘ ¯ ‘
‘‘ ‘ ‘ ‘‘ ¿ ‘ ‘
‘ ‘‘‘ &/ $-+7( ,7; +6,./.-0('-*$9*:0$+2$.6 -366(/%+**./
+./0+./6.+-0$*.)&'(--3'(+0<,,; 70$ (/-3'(+6(A3+0(&*+)(/0+*%.**./7
7! ‘ +*-$+,3-)*('(*+#+/0 $+6./76$-(.-! 17+./0(/+/)(6$-(.- 7;" /%3-(*$+6./76$-(-*$9*:$2(' ,./ ‘*9+:-+6,./.-0('+-+&.77:8+)@./%3-.$/ ('3,7*(2(*-"$3*6'(,+./8(*$9,A;
¿ + 8 ¿ ¿ ¯ 4 >‘ ‘‘ ‘‘;
Diazepam ( Valium) Halt seizures 510 mg/IV ‘dminister slowly Dose may be repeated every 510 mins ( up to 30 mg/hr) Observe for respiratory depression or hypotension in mother & respiratory depression & hypotonia in infant at birth.
66 7!4 ‘ ‘ ‘
‘‘ ‘ ¿ ¿¿
‘ 7; ,*$%+C-$* "+2(&'(&+'(6+08(6-.6(9"(/+6,./.-0('./7 7! 66 7! ‘ ‘‘‘‘ ‘4‘
¿ ¯ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘
¯ ‘ ‘ ‘4 ‘‘‘ ¯ + !;< 8 ‘ ) ‘ ‘‘ 6 ‘‘
‘‘ ‘ ‘ ‘
‘‘
‘ ‘ ‘‘ ! ‘ ‘ ‘ ‘‘‘ 1 ‘‘ ‘¯ + ‘ ‘‘‘ 8 ‘ ‘ ) ‘‘
6‘‘ ‘‘‘¯ ‘ !;<,, 7 ‘ ‘ + ‘‘
‘‘
¿ ¯ ‘ ‘ ‘‘ ‘ 4 ‘
‘ ‘‘ ‘ ‘ ‘‘ ‘ ‘
‘ D‘ ‘ ‘ ‘‘4‘‘
‘‘ ‘ ‘‘ ‘ ‘ ‘ ! ‘
‘‘ ‘ ‘ ‘ ‘ ‘ ‘
¿ ‘‘ ‘ ¯ ‘ ‘
‘‘ ‘‘ ‘ ‘ ‘ ‘¯‘‘
‘‘‘ ‘ D ‘ ‘ ‘‘ ‘ ‘ ‘ ‘ ! ‘ ‘‘ ‘‘
‘ ‘ ‘ 1‘ ‘ ‘‘¯ ‘‘ ‘ ‘ ‘ ‘ ‘‘ ‘ ‘ ‘ ‘ E ‘ ‘ ‘‘‘ ‘
66 ‘‘ ‘ ‘ ‘ 66 ‘‘ 66 ‘ ‘ ‘ ‘‘
¿ ¯ ‘ 4!
‘ 7! ‘ ‘!
‘ ‘‘‘ ‘ ‘ ‘ ‘ ‘
‘‘ ‘ ‘ B ‘
Serious complication of pregnancy induced hypertension & the client develops multiple organ damage. sually develops before delivery but may occur postpartum as well. HELLP syndrome consists of the following problems: Hemolysis red blood cells break down Elevated liver enzymes damage to liver cells cause changes in liver function lab tests Low platelets cells found in the blood that are needed to help clot the blood to control bleeding
HELLP syndrome can cause other problems ‘nemia breakdown of ÕÉC·s may cause anemia DIC may lead to severe bleeding Placenta abruptio may also occur
SSx of HELLP syndrome: syndrome Õight sided upper abdominal pain around the stomach ( epigastric area) Nausea & vomiting Headache Increased ÉP Protein in the urine edema
How is HELLP diagnosed? ÉP measurement ÕÉC count ( hemolysis) Éilirubin level substance produced by the breakdown of ÕÉC Liver function tests ( ‘LT & ‘ST) Platelet count ( thrombocytopenia ) rine tests for protein
Treatment: Éedrest Élood transfusion %gSO4 ( as anti convulsant) ‘ntihypertensive medications Lab testing of liver, urine & blood ( for changes that may signal worsening of HELLP syndrome Corticosteroids to help in the maturity of fetal lungs Delivery ( if HELLP syndrome worsens & endangers the well being of the mother or fetus)
+2- 8B/-! 80/1328! G6,C061328 90 2>2- G6/-861328 <286727 C2>2391 /- 8+2 682067 ,8 8+2 7,;2 8/;2 ¥ 7795/,82C B/8+ ;902 0/747 8+,- , 7/-.3289102.-,-5A ¥
¯ ¥ ' 90 ¥
¾ 2>2391 <09; 9-2 9>6; 9-2 7120; 5233 8+,8 6-C20.9 0,1/C 5233 C/>/7/9- ,<820 <208/3/H,8/9- 8+,8 0276382C /- 8B9 90 ;902 /-C/>/C6,37 /-52 8+2A 59;2 <09; 9-3A 9-2 7120; ,-C 9-2 9>6;! 8+272 /-C/>/C6,37 1977277 8+2 7,;2 .2-28/5 80,/87 ,-C ,02 ,3B,A7 9< 8+2 7,;2 72?
¥
< 8B/--/-. 9556002C B/8+/- $ +9607 ,<820 <208/3/H,8/9-! 8+202 B/33 =2¯ ¾ ,;-/9-7 C/,;-/9-/5 ¾ 5+90/9-7 C/5+90/9-/5 ¾ 2;=0A97
¥
< 8B/--/-. 9556002C =28B22- 8+2 8+ {8+ C,A ,<820 <208/3/H,8/9-! 8+202 B/33 =2 ¯ ¾ ,;-/9-7 ¾ 5+90/9- ;9-95+90/9-/5 ¾ 2;=0A97
¥
< 8B/--/-. 9556002C ,<820 { C,A7! 8+202 B/33 =2 ¯ ¾ ,;-/9- ;9-9,;-/9-/5 ¾ 5+90/9¾ 2;=0A97
¥
< 8B/--/-. 9556002C ,<820 8+2 2;=0A9-/5 C/75 /7 <90;2C! I B/33 C2>2391 9-J9/-2C 8B/-7 ,02 53,77/
-820/90 ( +90,591,.67 97820/90 ( 1A91,.67 21+,3/5 ( 50,-/91,.67 ,6C,3 ( 75+/91,.67
¥
' 90
¾ 2>2391 <09; 90 ;902 9>, ,-C 7120; 52337 8+,8 B202 <208/3/H2C ,8 8+2 7,;2 8/;2 +2A +,>2 8+2 7,;2 .2-28/5 80,/87! ;,A 90 ;,A -98 =2 9< 8+2 7,;2 72? ,-C ,3B,A7 +,>2 5+90/9-7 ,;-/9-7
902 <2;,327 8+,- ;,327 =25,672 <2;,32 HA.982 +,7 , +/.+20 82-C2-5A 89 C/>/C2 /-89 8B/-7 2;,32 HA.9827 +,>2 +/.+20 0,82 9< 760>/>,3 8+,;,32 HA.9827
¥
02C/7197/-. <,58907 9< /HA.98/5 B/--/-. ¾ ,52 ( +/.+278 /- =3,54 B9;2¾ 202C/8A ( ;902 59;;9- /- B9;2- B/8+ <,;/3/,3 ¾ ¾ ¾ ¾
+/7890A 9< 8B/--/-. .2 1,0/8A ( /-502,72C /-5/C2-52 /- +/.+ 1,0/8A ,C>,-52C ;,820-,3 ,.2 /.+20 /-5/C2-52 /- B9;2- 8,4/-. <208/3/8A C06.7 8+,8 109;982 9>63,8/9- 0232,72 9< 72>20,3 9>, ,8 8+2 7,;2 8/;2 /.+20 /-5/C2-52 B/8+/- 8+2 27 =25,672 9< 8+2 76CC2- .02,820 ,;96-8 9< 1/86/8,0A .9-,C98091/- 0232,72C ,8 8+/7 8/;2 - >/809 <208/3/H,8/9- ( 78/;63,8/9- 9< <90;,8/9- 9< -6;20967 <933/5327! +,0>278/-. 8+2; /- 8+2 9>,0A <208/3/H/-. 8+2; /- >/809 33 HA.9827 8+,8 B202 <208/3/H2C ,02 02860-2C 89 8+2 682067 89 .09B C2>2391
¥
9;13/5,8/9-7 9< 638/132 286727¯ ¾ ¾ ¾ ¾ ¾ ¾ ¾ ¾ ¾ ¾ ¾ ¾
=908/9 2,8+ 9< 9-2 <2867 20/-,8,3 ;908,3/8A 02820; 3,=90 ( ,7 8+2 -6;=20 9< <286727 /-502,727! 8+2 C60,8/9- 9< 102.-,-5A C2502,727 9B =/08+ B2/.+8 9-.2-/8,3 ;,3<90;,8/9-7 AC0,;-/97 ,820-,3 +A12082-7/93,52-8, 102>/, =0618/9 13,52-8, -80,6820/-2 .09B8+ 028,0C,8/990C 2-8,-.32;2-8! 1093,172 59;10277/9,820-,3 ,-2;/,
¥
) ? ¾ 82067 3,0.2 <90 .278,8/9-,3 ,.2 ¾ 675638,8/9- 9< 8B9 90 ;902 <28,3 +2,08 89-2 ¾ ? 9< 8B/-7 /- 8+2 <,;/3A ¾ ,31,8/9- 9< 8+022 90 ;902 3,0.2 <28,3 1,087 ¾ 380,796-C 02>2,37 8B9 90 ;902 .278,8/9-,3 7,5
3/-/5 /7/8¯ ¥ /078 0/;27820 ( 2>20A ;9-8+ ¥ 259-C 0/;27820 ( 2>20A B2247 ¥ +/0C 0/;27820 ( 2>20A B224 ¥ 680/8/9- ( ,CC/8/9-,3 && 45,3 89 8+2 -90;,3 102.-,-5A 02G6/02;2-8 ¥ " 7;,33 ;2,37 0,8+20 8+,- 3,0.2 ;2,37 89 C2502,72 C/759;<908 9< , 3,0.2 682067 59;10277/-. , <633 789;,5+ ¥
,=90 ,-C 23/>20A¯ ¥ +2 590C /7 568 0/.+8 ,<820 C23/>20A 9< 8+2 ,3 9< C23/>20A 9< 8+2 202C >,./-,33A =25,672 9< ,=-90;,3 197/8/9-! /7 C9-2
27,02,- C23/>20A ( C23/>20A 9< 5+9/52 /< 8+2 8B/-7 90 9-2 9< 8+2; 5,--98 =2 C23/>202C -90;,33A 90 /< 59;13/5,8/9-7 ,0/72 8+,8 -25277/8,82 /;;2C/,82 C23/>20A ¥ 978 1,086; 120/9C ( B,85+ 968 <90 2;900+,.2 C62 89 9>20C/782-8/9- 9< 8+2 682067 ¥
Is labor that occurs between 20 weeks to 37 weeks gestation characterized by regular uterine contraction that lasts more than 30 seconds & result in cervical dilatation & effacement. It is the greatest cause of neonatal mortality & morbidity. morbidity
'. PÕO% most often associated with infection Infection of amniotic fluid Õetained I D Fetal death History of premature labor & abortion Overdistention of the uterus caused by multiple pregnancy, hydramnios ‘bnormal placentation terine abnormalities Incompetent cervix Serious maternal conditions
SSx: Dx is made when there is regular uterine contractions occuring 5 minutes apart accompanied by: Progressive cervical changes Cervical dilatation of more than 2 cm Cervical effacement of 0% or more Duration of at least 30 secs 10 mins apart
%enstrual like cramping Watery or bloody vaginal discharge Low back pain
¯ 02>2-8/9- ( 02.63,0 102-,8,3 5+254 61 < <2867 /7 3277 8+,- # B2247! ,-C 78/33 102;,8602 89 =2 C23/>202C! 3,=90 ;678 =2 ,002782C¯ 2C0278 9- 89 109;982 =399C <39B 89 8+2 13,52-8, AC0,8/9- ( <36/C7 9593A8/57 ( ;2C/5,8/9-7 89 7891 6820/-2 59-80,58/9-7 023,?27 7;998+ ;675327 /89C0/-2 53 20=68,3/-2 ( 5+254 16372 0,82 =25,672 /8 5,5,672 8,5+A5,0C/, 0978,.3,-C/- /-+/=/8907 -C9;28+,5/-
06.7 89 +,782- <28,3 36-. ;,860/8A¯ # 8+20,1A /< 3,=90 5,- =2 C23,A2C <90 { +9607 ( ,C;/-/780,8/9- 9< ,552320,82 <28,3 36-. ;,860/8A 102>2-87 0271/0,890A C/780277 +A,3/-2 ;2;=0,-2 C/72,72 ;978 59;;9- 109=32; 9< 8+2 102;,8602 -29-,82 #
%
%
¿
¿ ¿
!‘ 5‘ ‘ ‘
‘ ‘ ¿
5 ‘ ‘ ‘ ‘ ‘ ‘ ‘
‘ ‘
¿
5‘‘ ‘ ‘‘ ‘ 4 ‘=
‘ ‘ ‘ ‘ !¿
5 ‘= ‘ 4 ‘=‘ ‘
‘‘
¯ ‘ ‘ ‘ ¿ ‘ 4 ! ‘ ‘
E <‘
¯ 66 ‘ ‘‘
‘‘ ‘ ¿ ¿
‘ ‘ ‘ ‘
4¯ ‘ ‘‘‘¯ ‘‘ 6E
‘ B ‘ 6 ‘ ‘ ‘ 4 ‘ 6 ‘ ‘
‘ ‘ ‘‘ ‘ ‘‘ ‘‘ ‘ ‘ ! 6‘ ‘ 6‘‘ ‘
‘ ‘¯ 6 ‘‘ ‘ ‘ ‘
6‘ ‘ ‘ ‘‘ ‘ ‘
‘¯
‘ ‘‘ ‘ ‘‘ ‘‘ ‘‘ ‘ ‘ ‘‘ ‘ ‘
‘ ‘
¿ ‘ ‘‘ ‘ ‘ ‘ ‘ ‘‘ F ‘‘ ‘ ‘‘ ‘ ‘‘‘ ‘ ‘ ‘!‘ ‘‘ ‘ ‘ ‘ ‘ B ‘
! ‘‘ ‘
‘‘ ‘ ‘‘ ‘‘‘ ‘‘ ‘
‘ 6 ‘
‘‘ ‘ ‘
‘ ‘ ‘ ‘
‘ ‘
‘ ‘‘
‘ ‘‘‘ ‘ ‘ !‘ ‘‘‘ ‘
‘ 6‘ 6 ‘‘ ‘ ‘‘ ‘
1 ‘ ‘ ‘ ‘‘ ‘
‘ ‘ ‘
Hemoglobin level of less than 11g/dl in the first and third trimester and less than 10.5g/dl in the second trimester.
%ost common type of anemia during pregnancy. %ost women enter pregnancy without enough iron reserve so that deficiency develops particularly on the 2nd and 3rd trimester when iron requirements increases.
Predisposing Factors: Poor diet and poor nutrition Heavy menses Pregnancies at close intervals, successive pregnancies nwise reducing programs
**Nurse ‘lert** ´ The newborn of the severely anemic mother IS NOT ‘FFECTED by iron deficiency anemia. This is because the amount of iron transported to the fetus of an anemic mother is almost the same as the amount transported to the fetus of a mother without anemiaµ
Signs and Symptoms Easy fatigability Sensitivity to cold Proneness to infection Dizziness Laboratory findings will reveal low hgb
Decreased resistance to infection ‘ssociated with prematurity & low birth weight infants Predispose to heavy bleeding during labor & puerperium %ay increase digestive discomfort of pregnancy
1. Oral iron supplementation 200 mg of elemental iron daily in the form of: Ferrous Sulfate the most absorbable form of iron Ferrous Fumarate Ferrous „luconate ˜ Inform the mother about the possible side effects. Tarry
stool, constipation, „I discomfort
˜ Never take with milk but with citrus juice ˜ If given in liquid form, use straw to prevent
staining the teeth. Tell patient to rinse mouth. ˜ If iron is to be given parenterally, give I% by Z tract technique to prevent tissue staining. Do not massage after injection.
Oral iron should be continued until 3 months after anemia has been corrected. Increase intake of iron rich foods: lean meat, liver, dark green leafy vegetables. „ood food sources of iron include the following: %eats beef, pork, lamb, liver,& other organ meats Poultry chicken, duck, turkey, liver ( especially dark meat) Fish shellfish, including clams, mussels, oysters, sardines and anchovies
Leafy greens of the cabbage family such as broccoli Legumes such as lima beans & green peas; dry beans & peas Yeastleavened whole wheat bread & rolls Iron enriched, white bread, pasta, rice & cereals
Folic acid is necessary for the normal formation and nutrition of red blood cells. Deficiency in folic acid leads to the formation of large and immature blood cells that have shorter life span than normal red blood cells. Women who have folic acid deficiency during pregnancy are more at risk of giving birth to babies with neural tube defects.
Effects on Pregnancy: ‘ÉOÕTION, ‘bruptio placenta, Neural defect in fetus
Predisposing Factors: 1. Long term use of oral contraceptives 2. Poor nutrition 3. %ultiple pregnancies 4. Successive pregnancies
Signs and Symptoms 1. Nausea 2. Vomiting 3. ‘norexia lack of appetite
Folic acid supplementation of 1 mg/day accompanied oral iron. ÕD‘ for all women 0.4mg/day Vit supplements containing 400 micrograms of folic acid are now recommended for all women of chilbearing age and during pregnancy. These supplements are needed because natural food sources of folate are poorly absorbed and much of the vitamin is destroyed in cooking. Food sources of folate include the ff: Leafy dark green vegetables, dried beans & peas, nuts, citrus fruits & juices & most berries, fortified breakfast cereals, enriched grain products
"#$%&'() (*"+*" , ¿ ‘ ‘ ‘‘ ‘‘ ‘ ‘
6
‘
C F >
‘ > ‘ ‘
‘‘ ‘
‘ > ‘ ‘ ‘ ‘ ‘ ‘ ‘‘ ‘
‘‘ ‘
‘‘ ‘ ‘‘ ‘+*-$ ‘ ‘ ‘ ‘ ‘ ‘‘ ‘ ‘‘ ‘‘‘ ‘‘‘ ‘‘ ‘ ‘4 ‘ ‘‘ ‘ ‘ ‘‘
B
‘ > ‘ ‘‘ ‘ ‘‘‘‘ ‘ F ‘ ‘ ‘ ‘‘ G ¿ H
¯ ¿ ¿- ‘ ‘‘ ¿ ¿-
‘ ‘
‘dministration of Õh ( anti D) globulin (Õhogam) at 2 weeks gestation and within the first 72 hours after delivery to a woman who: Have delivered Õh positive fetus Have had untypeable pregnancies such as ectopic pregnancies, stillbirth & abortion Have received ‘ÉO compatible Õh positive blood Have had invasive diagnostic procedure such as amniocentesis, P ÉS ( cordocentesis)
‘ÉO INCO%P‘TIÉILITY Occurs when maternal blood type is O and fetus is: ˜ Type ‘ most common ˜ Type É most serious ˜ Type ‘É rare
4$% ‘¯ ‘ ! ‘ 4 ‘ D‘
‘ F ‘ ‘ 4 ‘‘ ‘ ‘‘
+
./ 01¿ ‘ ‘ ¿ ‘ 4 4 4 ‘
! ‘ ‘ ‘ ‘ 4 ‘ ‘ ‘ 1‘ ‘= ‘‘ ‘ ‘ ‘ ‘ ‘
‘ E‘‘ 1
¿ ¯ ‘‘ ¯ D F‘ ‘ ‘‘ ‘ B ‘ F ‘ ‘ ‘ F ‘
‘‘ ‘ ‘ ‘‘ ‘ ‘ ‘ ‘ ‘ ‘‘ ‘ ‘"D "$‘‘ ‘ ‘ ‘ ‘‘ ‘‘ ‘ ¯‘¯
¯ ‘"$‘‘" ‘‘E‘ ‘ ‘ ‘"> 66
‘ ‘‘B ‘4 ‘‘
‘ ‘ $0.%::$3'"(+*0")+'(&'$2.6('.%:$3'8+8:"+- +/:$%0"(%$**$9./7-;-+%0(''(03'/./7"$,(¯ (2(' D+3/6.)( $$'+&&(0.0($'&$$'9(.7"07+./ #)(--.2()':./70"+06$(-/$0-0$&9"(/ 0"(8+8:.-"(*6
Signs in the newborn: Paleness Jaundice that begins within 24 hours after delivery ( pathologic jaundice) nexplained bruising or blood spots under the skin Tissue swelling ( edema) Seizures Lack of normal movement Poor reflex response
(-0+0.$/+*.+8(0(-(**.03.-+"('(6.0+':(/6$)'./(6.-$'6('63(0$ ./+6(A3+0( $'*+)@$%./-3*./ &'$63)0.$/0"+0 '(-3*0-./.,&+.'(67*3)$-(+8-$'&0.$/ ,(0+8$*.-, +**9$,(/+&&(+'0$6(2(*$&+/./-3*./ '(-.-0+/)(+-&'(7/+/):&'$7'(--(-./-3*./6$(- /$0-((,/$',+**:(%%()0.2(63'./7&'(7/+/):+ &"(/$,(/$/0"+0.-&'$8+8*:)+3-(68:0"( &'(-(/)($%0"("$',$/( 3,+/ *+)(/0+* +)0$7(/
#¯ :&('7*:)(,.+ &+/)'(+-6$(-/$0&'$63)( (/$37"./-3*./ 0"3-7*3)$-(.-3/+8*(0$(/0(' 0"()(**-+))3,3*+0(-./0"(8*$$6-0'(+, '(-3*0./7./":&('7*:)(,.+
%&)$*23(+ 9"(/8*$$67*3)$-(*(2(*-7$(- 8(:$/60"('(/+*0"'(-"$*6%$'-37+' 7*3)$-(-&.**-$/ 0"(3'./( $%&23(+ / 7*3)$-(+00'+)0-9+0('-$0"+09"(/.0.- (#)'(0(6./0"(@.6/(: .08'./7-+*$/79.0".0*+'7( +,$3/0-$%9+0(''(-3*0./7./0"(9$,+/(#)'(0./7 *+'7(+,$3/0-$%3'./( +)$/6.0.$/)+**(6 !$%&4(5*(+ 0"((#)'(0.$/$%*+'7(+,$3/0-$%%*3.6 %'$,0"(8$6:*(+6-0$6(":6'+0.$/#)(--.2(0".'-0$' &$*:6.&-.+.-+/.,&$'0+/0-:,&0$,$%6(":6'+0.$/
"(6'%$** -./)(7*3)$-()+//$08(30.*.?(6+- +-$3')($%(/('7: 0"(8$6:3-(-.0-&'$0(./%+0- -0$'(-./0"(,3-)*(-+6.&$-(0.--3('(-3*0./7./ 9(.7"0*$-- 1"'$+)(4$*(* 8'(+@6$9/$%&'$0(./-%+0- '(-3*00$(#)(--.2(%$',+0.$/$%@(0$/(8$6.(-0"+0 0"(8$6:)+//$0(#)'(0('.7"0+9+:)+3-./70"(,0$ +))3,3*+0(
77")'*$7 (+8"'"*¯ $'6"3¯ /)'(+-(60(/6(/):0$&'( ()*+,&-.+ ()*+,&-.+ )+/6.6.+-./)'(+-(6'.-@%$'&$-0&+'03,"(,$''"+7(6;0 $2('6.-0(/0.$/$%0"(30('3- +0('/+*,$'0+*.0: ! '(0(',6(*.2(':
/%+/0¯ +)'$-$,.+ :6'+,/.$ '(,+03'.0: !/0'+30('./(7'$90"'(0+'6+0.$/ :&$7*:)(,.+*$9('(6-('3,7*3)$-(*(2(*- 1 '(6.-&$-.0.$/0$6.+8(0(-,(**.03-*+0('./*.%(+- 0"(6.-(+-(.-"('(6.0+':
$,&*.)+0.$/-¯ +)'$-$,.+ /%+/0-$%9$,(/9.0"&$$'*: )$/0'$**(66.+8(0(-0(/60$8(*+'7(,$'(0"+/ *8-8()+3-(7*3)$-()+/)'$--0"(&*+)(/0+* 8+''.(' .0+)0-+)0-+-+7'$90" -0.,3*+/0 "( ./)'(+-(67*3)$-(+66--38)30+/($3-%+0 6(&$-.0-‘**0"(/30'.(/0-0"+00"(%(03-'()(.2(- )$,(-6.'()0*:%'$,0"(,$0"('F-8*$$6 .'0"/I3': ,+:$))3'63(0$0"(8+8:F-*+'7( -.?(+/66.%%.)3*0:8(./78$'/,+:)+3-( 9".)",+:/()(--.0+0(8(./78$'/8:
3. refers to low blood sugar in the baby immediately after delivery delivery. This problem occurs if the mother·s blood sugar levels have been consistently high, causing the fetus to have a high level of insulin in its circulation. ‘fter delivery, the baby continues to have a high insulin level, but no longer has the high level of sugar from its mother, resulting in the newborn·s blood sugar level becoming very low. The baby·s blood sugar level is checked after birth, and if the level is too low, it may be necessary to give the baby glucose intravenously
4. Õespiratory distress (difficulty breathing) too much insulin or too much glucose in a baby·s system may delay lung maturation and cause respiratory difficulties in babies. This is more likely if they are born before 37 weeks of pregnancy.
Prenatal %anagement: 1. Diagnosis; Suspect D% in a woman a. b. c. d. e.
With family history of D% With history of unexplained repeated abortions and stillbirth With glycosuria Who are obese Who have history of giving birth to large infants, over 10 lbs. and infants with congenital anomaly
2. Screening tests a.
niversal screening screening 50 gram oral glucose tolerance test ( O„TT) between 24 242 weeks gestation irregardless of the time of the day and meals taken for all pregnant women. If the plasma value is more than 140 mg/dl after one hour, 100 gram three hour oral glucose tolerance test is performed to confirm if the woman is having hypergycemia.
Criteria of 100 gram Oral „lucose Tolerance Test (Instruct not to eat after midnight) /;2 9< 278
2-967 2>23
3,7;, 2>23
,78/-.
%&;.)C3
&;.)C3
#+960
";.)C3
%&;.)C3
#+960
;.)C3
";.)C3
#+960
;.)C3
;.)C3
b.
c.
Élood tests for sugar by Testape and Clinistix. Éenedict·s test and Clinitest are inaccurate when testing sugar during pregnancy because these test measure all kinds of sugar including lactose which is normally present in the urine of pregnant women, thereby, giving false positive result. rine test for acetone by acetest.
3.
Diet a.
b.
c.
Caloric intake should be enough to meet needs of pregnancy, fetus and mother (1,00 to 2,400 cal/day) but not too much to promote excessive weigh gain. 20% of caloric intake should come from protein foods, 50% from carbohydrates, 30% from fats. Weight gain should be about 24 lbs. Too much weight gain can lead to large infants and cephalopevic disproportion. disproportion Teach and instruct to: ˜ ˜ ˜ ˜
Õeduce saturated fat Õeduce cholesterol Increase dietary fiber ‘void fasting and feasting
d.
e.
Have the woman become familiar with food exchange list and caloric values of foods she usually eats to enable her to plan her diet properly and estimate her caloric intake accurately. The goal is to maintain a fasting blood sugar level of 0 mg/dl and postprandial blood sugar level of 110mg/dl
Exercise
4.
‡
‡ ‡ ‡
‘ liberal cardiovascularconditioning exercise and diet therapy is the management for „estational Diabetes %ellitus Exercise lowers blood glucose levels and decreases the need for insulin. insulin The exercise regimen should be individualized, performed regularly and under supervision. ‘dvise woman to eat complex carbohydrates before exercising to prevent hypoglycemia.
Õemember that hypoglycemia could occur in persons undergoing insulin therapy during peak action hour of insulin: Short acting or regular insulin after 23 hours of injection Intermediate or Lente insulin after 6 hours of injection Longacting or ultralente after 16 1 hours of injection The sign of hypoglycemia are: dizziness, diaphoresis, weakness, blurring of vision „ive a hypoglycemic person a glass of orange juice.
Insulin therapy
5.
‡ ‡
‡
‡ ‡
Insulin requirements increase during pregnancy Oral hypoglycemics such as Tolbutamide and Diamicron are contraindicated during pregnancy because they are teratogenic for they can cross the placenta and may cause fetal and new born hypoglycemia. Combined fast acting and intermediate insulin made up of human derivative/humulin. Humulin is the insulin of choice during pregnancy because it is the least allergenic 2/3 in the morning, 1/3 at dinner istered subcutaneously ½ hour before meals. Insulin requirement is decreased on the first trimester due to nausea & vomiting and highest during the third trimester.
6.
Home blood glucose monitoring a. b. c.
Dextrometer 4x a day, upon rising in the morning, before breakfast, lunch, dinner Normal fasting 0 mg/dl, postprandial 110mg/dl
7. Observe for urinary and vaginal tract infections particularly candidiasis . Fetal wellbeing assessment teroplacental Function Tests NST and CST b. ‘mniocentesis to determine fetal lung maturity
a.
Delivery: 1.
2. 3.
Delivery is effected when the fetus is mature enough after 3 weeks gestation, but not too large so as to cause cephalopelvic disproportion. Thus, early hospitalization and labor induction is performed to deliver the baby before it becomes too large to the birth canal If cervix is not yet ripe, baby is macrosomic and fetal distress occurs, CS is performed Õegular insulin is given on the day of delivery not long acting insulin because insulin requirement drop immediately after delivery. delivery The woman may not require insulin during the first 24 hours postpartum and her insulin requirements usually fluctuates during the next few days.
Postpartum: 1. 2.
3.
Õecurrence of diabetes may occur in subsequent pregnancies. Women who develop gestational diabetes have higher tendency to develop overt diabetes later in life. Newborn Care: ô ô
ô ô ô
Keep warm because of poor temperature control mechanisms Observe respiration (stomach aspiration necessary at time of birth, since hydramnios inflates stomach which pushes up and interferes with diaphragm and lung expansion) Observe for signs of hypoglycemia (shrill cry, weakness) give glucose water Observe for signs of hypocalcemia (tetany, tremors) give calcium gluconate Observe for congenital anomalies: esophageal atresia, neural tube defect
4. Contraception: a.
a.
I D and combined oral contraceptives are contraindicated *Progesterone interferes with insulin activity therefore increases blood glucose levels. *Estrogen increases lipid & cholesterol levels & risk for increased blood coagulation Norplant (subcutaneous progestin implant system) or Depo provera may be good choices & safely used by diabetic women
¿¿ ¿ ‘ ‘ ‘‘ ‘!
¿ ¯ ‘‘ ‘ ; + ¿ ¿ ¿ ‘ B‘ ‘ ‘ 4 ‘ ‘
‘
‘¯ ‘ 4 !‘‘‘
4¯ ‘‘ ‘ ‘‘ ‘‘ 4 ‘‘ ! ‘ ‘
8 ¿ ¿ ¿
‘ ‘‘ B ‘ ‘4 ‘‘‘
‘ 4¯ ‘ ‘‘
‘
‘ ‘
‘‘‘‘ ‘‘ ‘ ‘4 ‘‘
82 Õ Õ*
Õ Õ . 4$ $ F<)#)# ))## Õ . :2 0#''' 82$ #%&7% " ' <2 ')) . :2)!&
: <<( ¯
¯
¯
&
: ª ª ª ª
2 Õisks associated with ruptured membranes : 1. Intrauterine infection 2. Cord Prolapse
:: >>
" ª ªª
( ;; ! & !
! #& !
$&#$ &
¯
‘ ‘ ‘ ‘ ‘ ¯ + ‘ ‘¿ 8 4 ‘ ‘ ¿
) ‘ ‘ ‘‘‘
6‘‘4 ( ‘ ‘‘
66 4 ‘ ‘ 66¿ ¿ 4 ‘ ‘
:: >>
!
!
Tearing of the muscles of the uterus. This occurs when the uterus can no longer withstand the strain placed upon it. It is a serious complication of labor that can lead to maternal & fetal death.
Õupture of scar from previous cs %ultiple gestation Injudicious use of oxytocin Forceps & vacuum extraction Overdistention of the uterus External trauma sharp or blunt „estational trophoblastic neoplasia
Impending uterine rupture is often manifested by a pathologic retraction ring or Éandl·s ring During the peak of a contraction, the woman suddenly complain of a sharp tearing pain after which, relief will be felt as the uterus will no longer contract.
Complete rupture when the uterus ruptures, the woman experiences a S DDEN EXCÕ CI‘TIN„ P‘IN at the peak of a contraction, cessation of fetal heart tones, then contractions stop. Internal hemorrhage follows & vaginal bleeding may or may not be present. Two swellings will be visible in the abdomen, the uterus & the extrauterine fetus. Õupture results in separation of the placenta from the uterus cutting blood supply to the fetus resulting in hypoxia & fetal death.
ÉT & IVF to correct shock ‘dminister mask O2 ´Eµ laparotomy to deliver the baby Postop care: Explain need to avoid driving for 36 weeks Explain need to avoid jogging, sexual intercourse, dancing & lifting heavy objects for 6 weeks
Or Pathologic retraction ring seen as a horizontal indentation running across the abdomen
%orphine SO4 to relax the uterus CS section for immediate delivery of the fetus & prevent uterine rupture if %orphine SO4 is ineffective If Éandl·s ring develop during the placental stage, woman is placed under anesthesia & the placenta is removed manually.
terus is completely turned inside out Causes: Pulling of the umbilical cord ‘pplying pressure on uncontracted uterus Placenta accreta Sudden increase in intraabdominal pressure such as when coughing, sneezing or straining
Fundus is no longer palpable Sudden gush of blood from the vagina terus appear in the vulva
1.
Prevention: 1. 2.
Never apply pressure on an uncontracted uterus Never pull the cord to hasten placental delivery
2. Lower uterine segment is inserted first manually & fundus last. 3. ÉT & IVF to combat shock 4. Do not attempt to remove the placenta if it still attached to the uterus as this will only enlarge the bleeding area 5. „ive oxytocin only after the uterus is properly replaced 6. If the placenta is still attached to the uterus, remove it when the uterus is replaced & contracted
1. Postpartum Hemorrhage is the leading cause of maternal mortality. Élood loss of more than 500 ml is considered hemorrhage. The most dangerous time at which hemorrhage is likely to occur is during the first hour postpartum
terine atony Lacerations & episiotomy Placenta previa complication Inversion of the uterus Õupture of the uterus DIC Overdistention of the uterus twins, hydramnios Prolonged & rapid labor
Early postpartum hemorrhage occurs during the first 24 hrs after delivery Causes: ˜.
terine atony ˜ Laceration of the birth canal ˜ Inversion of the uterus
Late postpartum hemorrhage occurs from 24 hrs after birth until 4 weeks postpartum
%ost common cause of E‘ÕLY postpartum hemorrhage. When the uterus fails to contract, open blood vessels in the placental site continue to bleed resulting in hemorrhage.
Overdistention of the uterus hydramnios, multiple pregnancy Complication of labor precipitate, prolonged labor High parity & advanced maternal age Presence of fibroid tumors Overmassage of the uterus Õetained placental fragments
First action taken when uterus is relaxed & boggy is to %‘SS‘„E IT „ENTLY. Keep bladder empty since a full bladder interferes with effective uterine contractions %onitor vital signs & amount of blood loss during the early postpartal period ‘dminister oxytocin if uterus is not contracted ÉT & IVF to replace blood loss If retained placental fragments is the cause, curettage is performed If bleeding cannot be controlled by the above measures, HYSTEÕECTO%Y is performed as the last resort.
When bright red blood continue to gush from the vagina & the uterus is firmly contracted, lacerations of the birth canal are usually the cause of bleeding. Lacerations can occur anywhere in the cervix, vagina, & perineum.
ª ( !
ªª ( ªª ( (
Operative delivery forceps delivery Precipitate delivery Large infant over 9 lbs %ultiple pregnancy Primigravidas ‘bnormal fetal presentation & position
Õeturn woman to delivery room for inspection & repair, if laceration is suspected. Vaginal packing to maintain pressure on suture line. Ée sure to remove packing after 24 to 4 hrs 3rd & 4th degree lacerations no enema or rectal suppository. Constipation should be avoided & temp should not be taken rectally.
terus will not be able to contract effectively if placental fragments are retained resulting in uterine atony & hemorrhage. %ost common cause of L‘TE postpartum hemorrhage.
Partial separation of a normal placenta %anual removal of the placenta Entrapment of placenta in the uterus ‘bnormal adherent placenta acreta, increta, percreta
D & C to remove adherent placenta Hysterectomy for severe cases
Occurs when there is a delay in the return of the uterus to its prepregnant size, shape & function Causes: Õetained placental fragments Infection Endometritis terine tumors
SSx: Enlarged & boggy uterus Prolonged lochial discharge persistent lochia rubra Éackache %anagement: %ethergin to stimulate uterine contractions .2 mg 4x/day for 3 days ‘ntibiotics to prevent or treat infection D & C if there are retained fragments Instruct woman to report the following signs fever, vaginal bleeding, age of tissue
This is due to injury to blood vessels during delivery or during repair of episiotomy resulting in blood escaping to the connective tissue under the skin. Causes: 1. Vulvar varicosities 2. Precipitate labor 3. Forceps delivery 4. Inadequate suturing of episiotomy or lacerations
Signs and Symptoms: Perineal pain Swelling Discoloration of skin over the swollen area Feeling of pressure over the vagina
‘pplication of ice packs wrapped with towel to stop bleeding by vasoconstriction Large hematomas are potentially dangerous because they may rupture & cause severe bleeding & infection. The woman is brought back to the DÕ for incision & ligation of bleeding vessels.
‘nalgesics for pain Éroad spectrum antibiotics to prevent or treat infection Élood transfusion to combat hypovolemia
´Childbed feverµ Infection of the genital tract after delivery. Predisposing factors: PÕO% Prolonged labor Postpartum hemorrhage ‘nemia %alnutrition Õetained placental fragments CS Excessive vaginal manipulation Sexual intercourse near labor or after membranes have ruptured
Fever Foul smelling lochia Õapid pulse, chills ‘bdominal pain or tenderness Éody malaise Lack of appetite Perineal discomfort Nausea & vomiting
„ood prenatal nutrition Prevention of anemia & hemorrhage „ood maternal hygiene Strict adherence to aseptic technique by hospital personnel Well balanced diet to promote healing Increased Vit. C, Chon, adequate calories
%ost common during puerperium because of trauma to the bladder after delivery, urinary retention, & overdistention of the bladder due to anesthesia or infection may be introduced during catheterization. SSX: Painful urination, frequency & urgency of urination Flank pain Fever Hematuria
Increase fluid intake ( 3,000cc/day) to flush away infection from the bladder. Õegular emptying of the bladder to prevent stasis of urine ‘nalgesics for pain, antibiotics for infection Collect urine specimen ( clean catch) for examination
Infection of the breast tissue commonly occurring in breastfeeding mothers. sually appears during the 2nd & 3rd week postpartum when milk supply is already established Staphylococcus aureus most common causative agent found in the oral nasal cavity of the infant ( acquired from health care personnel in the nursery or from cracks & fissures in the nipples)
Engorgement or swelling of affected breast & chills are usually the first signs Fever, tachycardia,body malaise Hard & reddened breast Õeduced milk supply as edema & engorgement obstruct milk flow Éreast abscess about 10% of women with mastitis develop breast abscess.
1. Prevention: Prevent nipple cracks & fissures by correct placement of infant·s mouth on the nipple ( latchin) not feeding the baby too long, using correct technique when releasing the baby from the nipple after feeding , proper breast care . Express excess milk after feeding the baby to prevent milk stasis which is a good medium for bacterial growth
Isolation of infants with cord or skin infections Persons with known or suspected staphylococci infections should not be allowed to care for newborn in the nursery Proper handwashing technique in between handling of newborns. Observance of strict aseptic technique.
Wash hands before and after changing perineal pads, good personal hygiene on the part of the mother 2. Comfort %easures:
Instruct mother to wear ive brassiere ‘pplication of heat to the breast to promote comfort & relieve engorgement Discontinue breastfeeding from the affected breast. Express milk every 4 hours to maintain lactation
3. ‘ntibiotic therapy to fight infection 4. If abscess develops, the affected area is incised & drained.
Inflammation in the lining of the blood vessels with formation of blood clots or thrombi. Causes: Stasis of circulation Increased fibrinogen during pregnancy
Types: 1. Femoral Thrombophlebitis: infection of the veins of the legs ( femoral, saphenous, popliteal veins) SSx: Homan·s sign calf pain when the foot is dorsiflexed %ilk leg or Phlegmasia alba dolens leg is shiny white Swelling of affected leg, pain & stiffness Fever
2. Pelvic Thrombophlebitis infection of the ovarian, uterine and pelvic veins SSx: Fever & chills Pain in the lower abdomen or flank Palpable parametrial mass in some cases
1. Prevention: > Early ambulation after delivery > se of stocking in women with varicosities to promote circulation & prevent stasis put on stocking before rising from bed in the morning 2. Éedrest until signs & symptoms disappear
3. ‘nticoagulant medications to prevent further clot formation. Heparin not ed to breastmilk Protamine Sulfate antidote of heparin
Dicumerol ed to breastmilk so mother must stop breastfeeding
4. Do not give ‘spirin or ‘S‘ if patient is receiving anticoagulant drugs because aspirin increases coagulation time. Watch for signs of bleeding: bleeding gums, ecchymotic skin, increased lochial discharge. 5. ‘ntibiotic therapy to combat infection, analgesics for pain.
6. „radual ambulation after symptoms disappear 7. Never massage the affected leg . Warm wet compress dressings to promote circulation & for comfort
ž ž
Related Documents 3m3m1z
Abnormal Obstetrics f2o6u
January 2022 0
Obstetrics m3x1y
July 2020 0
Obstetrics Mnemonics 6n1s5t
November 2019 150
Abnormal Loss 175g4x
December 2019 46
Abnormal Pressure e3h5j
March 2021 0
Abnormal Psychology f5m3o
January 2021 0More Documents from "Jen Ilagan" 655226
Abnormal Obstetrics f2o6u
January 2022 0
Everything About Her Movie Summary.docx 174b19
October 2019 72
Essay - Education With A Heart 4m1zu
December 2019 56
6l6m1j
November 2021 0
Grade 9 Science Book Free 473s3r
October 2019 4,195