Documente Academic
Documente Profesional
Documente Cultură
GOAL
Improve the survival, health and
well being of mothers and the
unborn through a package of
services for the:
pre-pregnancy
prenatal
natal
postnatal stages
2a.2
2a.3
It is the poorest
Filipinos (57.1%) who
are not using family
planning because of
poor access and
ineffective outreach
20.5% of married
women say they need
family planning but
are not using any
method
3.1 million pregnancies occur each year. Half of these pregnancies are
unintended and one third ends in abortion
About 473,000 abortions annually with induced abortion as 4th
leading cause of maternal deaths
Every mom who dies leaves 3 orphans. In effect, 30 children are orphaned
every day
Note: To show progress of MMR based on MDG, UNFPA estimated MMR based on the
average rate of progress in 2003.
Health
Indicators
Selected Asian Countries
Japan
So.Korea
Malaysia
Thailand
Philippines
Life Expectancy
81
75
73
70
70
Infant Mort.
Rate
24
29
Underfivemortal
ity
28
40
Maternal
Mortality
20
41
44
160
Population
Growth
0.3
0.8
2.2
1.4
2.3
70 %
home
7 Direct Obstetric
Complications
Social
Physical
a. history of drug
dependence
b. History of mental
illness
c. History of poor
coping mechanism
a. Occupation handling
of toxic substances
b. Environmental
contaminants at home
c. Isolated
d. Lower economic
level
e. Poor access to
transportation for care
f. Poor housing
g. Lack of support
people
a. Visual or hearing
challenges
b. Pelvic inadequacy
(CPD)
c. Secondary major
illness (heart disease,
DM, kidney disease,
hypertension etc.)
d. Poor gynecologic or
obstetric history
Psychological
Social
Physical
e. History of previous
poor pregnancy
outcome(miscarriage,
stillbirth, intrauterine
fetal death)
f. Pelvic inflammatory
disease
g. Obesity
h. Small stature
i. Younger than age
18 years or older than
35 years
j. Cigarette smoker
k. Substance abuse
B. Pregnancy
Psychological
Social
Physical
a. Loss of support
b. Illness of a family
member
c. Decrease selfesteem
d. Poor acceptance of
pregnancy
a. Refusal of or
neglected prenatal
care
b. Exposure to
environmental
teratogens
c. Decreased
economic support
d. Conception less
than 1 year after last
pregnancy or
pregnancy within 12
months of the first
pregnancy
a. Intake of teratogen
b. Multiple gestation
c. Poor placental
formation or
position
d. Gestational
diabetes
e. Nutritional
deficiency
f. Poor weight gain
g. PIH
h. Infection
i. Amniotic fluid
abnormality
j. post maturity
Social
Physical
a. Severely
frightened by labor
and delivery
experience
b. Inability to
participate due to
anesthesia
c. Lack of preparation
for labor
d. Birth of infant who
is disappointing in
some way
a. Lack of support
person
b. Unplanned CS
c. Lack of access to
continued health care
d. Lack of access to
emergency personnel
or equipment
a. Hemorrhage
b. Infection
c. Dystocia
d. Precipitate birth
e. Lacerations of
cervix or vagina
f. CPD
h. Retained placenta
Renal failure
- a spontaneous miscarriage is an
early miscarriage if it occurs week 16
of pregnancy and a late miscarriage if
it occurs between weeks 16 and 24.
Causes:
2. Threatened Abortion
- limiting activity to no strenuous activity for 2448 hours is the key intervention to stop vaginal
bleeding. complete bed rest is usually not indicated
4. Complete Abortion
5. Incomplete Abortion
6. Missed Abortion
Complication of Abortion:
1. Hemorrhage
2. Infection
3. Isoimmunization
- happens when the mother s blood is Rh negative, while the
fetus is Rh positive.
- after spontaneous abortion or D & C. some Rh positive fetal
blood may enter the maternal circulation and mother will develops
antibodies against Rh positive fetus blood.
- during the succeeding pregnancies when the fetus is Rh
positive again, those antibodies would attempt to destroy the
fetus RBC
- so after miscarriage, because the blood of the fetus is not
known, all women with Rh negative blood should receive Rhogam
(Rh Immune Globulin) to prevent the build up of Rh antibodies
4. Powerlessness
- emotional support
- aka.
B.
ECTOPIC PREGNANCY
Risk Factors:
Before Rupture
During rupture
Diagnostics:
Culdocentesis
Transvaginal UTZ
Laparoscopy
Management:
1. once an ectopic pregnancy ruptures, it is an
emergency situation and the womans conditions
must be evaluated quickly (monitor for the symptoms
of shock)
2. therapy for a ruptured ectopic pregnancy is
laparoscopy to ligate the bleeding vessels and to
remove or repair the damaged fallopian tube
3. women with Rh negative blood should receive Rh
immune globulin (Rhogam) after an ectopic pregnancy
for isoimmunization protection in future childbearing
Causes:
- unknown
Risk Factors:
Types;
- there are two distinct types of hydatidiform mole
complete/partial
Management:
1. suction curettage to evacuate the mole
2. after extraction, women should have a baseline serum
test for the beta subunit of hCG
3. educate on avoiding pregnancy for at least one year
4. hCG is analyzed every 2-4 weeks for 6-12 months
(gradually declining hCG suggest no complications)
5. prophylactic course of Methotrexate is the drug of choice
for choriocarcinoma. This must be weigh carefully because
it interferes with WBC formation which can lead to
leucopenia
6. observe for bleeding and hypovolemic shock
Causes:
- unknown
Risk factors
Management:
1. bed rest in trendelenburg position
2. monitor FHT
3. observe for the rupture of BOW
4. avoid coitus and limit activities
5. avoid vaginal douche
6. Surgical Operation termed as Cervical Cerlage is
performed
- types:
A. PLACENTA PREVIA
- is low implantation of the placenta
- it occurs in four degrees:
1. Low- lying placenta implantation in the lower rather than in the
upper portion of the uterus
2. Partial placenta previa implantation that occludes a portion of
the cervical OS
3. Marginal placenta edge approaches the cervical OS. Lower
border is within 3 cm from internal cervical OS but does not cover
the OS
4. Total placenta previa implantation that totally obstructs the
cervical OS
- incidence is approximately 5 per 1000 pregnancies
Risk Factors
- increased parity
Complication:
1. postpartum hemorrhage
2. hypovolemic shock
3. preterm labor
4. fetal distress
Note:
Management;
1. bleeding is an emergency. (fetal oxygen may be compromised
and preterm birth may occur)
2. assess the amount of blood loss (duration, time of bleeding
began, accompanying pain, and color of the blood)
3. bed rest with oxygenation prescribed
4. side-lying or trendelenburg position (for 72 hours)
5. NO internal exams (IE) or rectal exams, may initiate massive
hemorrhage (if necessary, must have double set up; OR/ DR)
6. keep IV line and have blood available (X-matched and typed)
7. Apt or Kleihauer- Betke test (test strip procedure to determine if
blood is fetal or maternal in origin)
Fetal Assessment:
1. monitor fetal status; heart tone and
movement
2. determine fetal lung maturity;
amniocentesis L/S ratio
3. Bethamethasone may be prescribed
(encourage maturity of fetal lungs; if fetus is
less than 34 weeks gestation)
B. ABRUPTIO PLACENTA
- premature separation of a
normally implanted placenta either
partial/marginal or complete/total
Causes:
-unknown
Risk Factors
- high parity
- PIH
Complications:
1. fetal distress (altered HR)
2. Couvelaire uterus or Uteroplacental apoplexy
3. disseminated intravascular coagulation (DIC)
Signs and symptoms:
1. vaginal bleeding (may not reflect the true amount of blood loss)
2. abdominal and low back pain (dull or aching)
3. sharp stabbing pain high in the fundus
4. uterine irritability (frequent low intensity contractions)
5. high uterine resting tone
6. uterine tenderness
0
- no symptoms of separation. Slight separation
occurs after birth. When placenta is examined, a segment
shows recent adherent clots
1
- minimal separation, enough to cause bleeding
and changes in vital signs. However, there is no
occurrence of fetal distress and hemorrhagic shock
2
- moderate separation. There is evidence of fetal
distress, and the uterus is tense and painful on palpation
3
- extreme separation, and maternal shock or
fetal death will result
Management:
1. keep the client in lateral position, not supine
2. oxygen therapy (limit fetal anoxia)
3. monitor FHT and record maternal vital signs
every5 to 15 minutes
4. baseline fibrinogen(if bleeding is extensive.
Fibrinogen reserve may be used up in the bodys
attempt to accomplish effective clot formation)
5. NO IE or rectal exam. No Enema
6. keep IV line open (possible BT)
PRETERM LABOR
- aka. Premature Labor
- labor that occurs after 20 weeks and before
the end
- approximately 9-10% of all pregnancies
- labor contractions that happens every 10-20
minutes
-usually leads to progressive cervical dilatation
of >2 cm and effacement of >80%
Causs:
- unknown
Risk Factors
2. UTI
2. vaginal spotting
3. cramping
5. uterine contractions
6. Pelvic pressure or a feeling that the
fetus is pushing down
7. Pain or discomfort in the vulva or
thighs
Management:
FOCUS: Prevention of the delivery of premature fetus
1. The woman should first admitted to the hospital
2. Place in Left lateral position
3. BEDREST to relieve the pressure of the fetus on the
cervix
4. Intravenous fluid therapy to promote hydration
5. Medical Management
a. Bethamethasone/Glucocorticoids steroid, given in
an attempt to hasten fetal lung maturity
- given in 2 dose, 12 mg IM 24 hours apart
Complication:
1. Fetal infections after the rupture of BOW, the seal
to the fetus is lost
2. Cord Compression pressure on the umbilical cord
because of the loss of the amniotic fluid, which can
cut off the nutrient supply to the fetus (fetal distress)
3. Cord prolapsed the extension of the umbilical
cord into the vagina which can also interfere with
fetal blood circulation
Management:
1. Strict Bed Rest
2. Observe, document and report maternal temperature above
38C, fetal tachycardia
3. Monitor for signs of infections (fever, uterine tenderness)
4. Avoid sexual intercourse/Orgasm
5. avoid vaginal exams (risk of infection)
6. avoid breast stimulation
7. record fetal movements daily and report fewer than 10 in a
12 hour period
8. administer broad spectrum ATBC to reduce the risk of
infection e.g. Penicillin/Ampicillin
Cause:
- Unknown
Risk Factors:
4. Multiple pregnancies
5. Hydramnios (pre-exisiting)
6. Underlying HPN/DM
8. H-mole
Pathophysiology:
Pregnancy Induced Hypertension
Peripheral Vascular Spasms (Vasospasm)
Vascular Effects
Vasoconstriction
Kidney Effects
Interstitial Effects
Increased BP
Increase Serum BUN, uric acid and
Creatinine
Edema
Kidney Effects:
Interstitials Effects:
Classification of PIH:
1. Gestational HPN aka, Transcient HPN
2. Mild Pre-Eclampsia
b. Protenuria
- weight gain of >2 lb/wk in the second semester or > 1 lb/wk in the
3rd trimester (abnormal)
Normal Weight Gain; 1st Trimester 1 lb/month, 2nd/3rd trimester 4
lbs/mos
Nursing management:
- facilitate Na excretion
- Na restriction may activate the RAAS (rennin-angiotensinaldosterone system) which can result in increase BP
4. if symptoms progress to Severe Pre-Eclampsia REFER immediately to
HOSPITAL.
3. Severe Pre-Eclampsia
a. increase BP >160/110 mm Hg
on at least 2 occasions 6 hours apart at
bed rest (the position in which BP is
lowest)
b. marked protenuria 3+ or 4+
on a random urine sample
Nursing Management:
a. sudden rise of BP
- placed in External fetal Monitors to asses for FHR and fetal movements
Medical Management:
- to prevent Eclampsia
1. Hydralazine (Apresoline) antihypertensive to reduce HPN by peripheral
dilatation
- side effects Tachycardia
- check for PR and BP before and after administration
2. Magnesium Sulfate
- DOC to prevent eclampsia
- action:
a. Cathartic reduces edema by causing fluid shifting from extracellular
spaces into the intestine (removed by bowel elimination)
b. CNS depressant (anti-convulsant) lessens the possibility of seizure activity
c. decrease neuromuscular irritability (muscle relaxant effect)
d. Promotes maternal vasodilatation promotes better feto-placental
circulation or tissue perfusion
c. decrease DTR
d. decrease LOC
4. Antidote: Calcium Gluconate a solution of 10 ml of 10% calcium
gluconate solution given for MGSO4 toxicity
a. Tonic phase all body contracts, arching of back, arms and legs
are stiff
b. Clonic phase = all of the muscle of body will contract and relax
Nursing Management:
- turning the mother to the side to allow the secretions to drain in the mouth
(preventing aspiration)
3. avoid placing a tongue depressor (during the seizure activity) because it can
obstruct the airway
8. mother can deliver via NSD, CS is very hazardous because hypotension might
result secondary to anesthesia
9. IV therapy as ordered
HELLP SYNDROME
Cause: Unknown
Associated Factors
primipara/Multipara mothers
Signs and Symptoms:
- nausea
- epigastric pain
- general malaise
Laboratory data:
a. hemolytic RBC
MULTIPLE PREGNANCIES
- a pregnancy in which there is more
than one fetus in the uterus at the
same time
- Incidence rate is 2% of
pregnancies
Types:
1. Monozygotic twins
2. Dizygotic Twins
Associative Factors:
a. more frequent in non-whites
than in whites
b. increase in parity
c. advance maternal age
d. familial inheritance
Diagnostic procedure:
Sonogram/Ultrasound
Signs and Symptoms:
Management:
HYDRAMNIOS (Polyhydramnios)
- Excessive fluid formation of >2000ml or an
amniotic fluid index of above 24 cm (normal 5001000ml)
Complication:
1. Fetal Malpresentation (because of extra-uterine
space)
2. Premature rupture of membranes that leads
to infection and prolapsed cord
3. Preterm labor (because of increasing pressure,
prostaglandin release)
Risk Factors:
1. Maternal diabetes hyperglycemia in
the fetus causes increase urine production
leading to increase urine output
2. Anencephaly
3. Esophageal atresia fetus becomes
unable to swallow the amniotic fluid
because of intestinal anomalies or
obstruction
Esophageal Atresia
Anencephaly
Management:
1. maintain bed rest to reduce pressure on
cervix and to prevent premature labor
2. monitor for rupture or uterine contraction
3. avoid constipation (it will increase uterine
pressure and rupture of membranes)
4. amniocentesis (slow and controlled release
of fluid to prevent premature separation of
the placenta) guided by ultrasound
POST-TERM PREGNANCY
- a pregnancy that exceeds 42 weeks
of gestation (term pregnancy 37-42
weeks)
Risk Factors:
1. Women who have long menstrual cycles (40-45 days)
Complication:
1. meconium aspiration
2. macrosomia fetus continues to grow
3. fetal distress due to placental aging it causes decreased
blood prefusion and inadequate supply of oxygenated blood and
nutrients to fetus
Management:
1. Induction of labor prostaglandins or inoprostol (cytotec)
applied to cervix to stimulate ripening or stripping of membranes.
Followed by oxytocin infusion to stimulate contraction
2. CS delivery
RH INCOMPATIBILITY
(Isoimmunization)
- occurs when the mother is Rh negative (-)
who carries a fetus with an Rh positive (+)
blood
Diagnosis:
1. Indirect Coombs test to check if Rh
antibodies are present within RBC
surface
2. Antibody titer determine at first
pregnancy visit and then again at 28
weeks AOG and after delivery (normal
is 0)
Management:
1. Rh Immune globulin (Rhogam) is administered at 28 weeks of
pregnancy and in the 1st 72 hours after delivery
2. Determine blood typed of infants after birth from a sample of
the cord blood
3. Blood transfusion through Intrauterine Transfusion
- done to give restore fetal RBC
- 75-150ml of RBC is administered
- after BT, the mother is encouraged to rest for 30 min. while
FHT and uterine activity are monitored
4. As soon as fetal maturity is reached, induction of labor is
followed
Pathophysiology of DM
Pancreas produces no insulin or inadequate insulin
Inadequate insulin
Inability to move glucose from the blood to body cells
Cellular
starvation
Polyphagia
Hyperglycemia
Glycosuria
Polydipsia
Attracts more water
Polyuria
Metabolic
acidosis
Glucometer
Fetal Effects of DM
1. Hypoglycemia during the 1st
trimester
2. Hyperglycemia during the 2nd/3rd
trimester
3. Macrosomia abnormally large for
gestational age(baby is delivered
>4000 g or 4kg)
Macrosomia
Newborn Effects:
1. Hyperinsulinism because insulin from the mother does not
cross the placenta which lead to increase insulin production
from the baby
2. Hypoglycemia when the umbilical cord is cut the supply
of glucose from the mother also stops which results in very
hypoglycemia newborn (normal glucose in NB 45-55mg/dl)
Signs and Symptoms: (newborn)
1. High pitched shrill cry
2. tremors
3. jitteriness
Diagnosis: Heel Stick Test to check glucose level
Management:
1. Frequent prenatal visits for close monitoring]
2. Insulin (regular/Intermediate acting insulin) given
subcutaneously (slow absorption)
Heart Disease
- Origin: 90% Rheumatic (incidence expected to
decrease as incidence of rheumatic fever
decreases), 10% congenital lesions or syphilis
- Normal hemodynamics of pregnancy that adversely
affect the client with heart disease:
- a. oxygen consumption increased 10% to 20%;
related to the needs of the growing fetus
- b. plasma level and blood volume increase; RBCs
remain the same (physiologic anemia)
3. Nursing Interventions
A. Prenatal period
1. teach importance of rest and avoidance of stress
2. instruct regarding use of elastic stockings and
periodic evaluation of legs
3. teach appropriate (dietary intake; adequate
calories to ensure appropriate, but not excessive,
weight gain; limited, not restricted salt intake
4. administer medications as ordered; heparin,
furosemide (lasix), digitalis, beta blockers (inderal)
5. monitor for signs of heart failure such as
respiratory distress and tachycardia; may be
precipitated by severe anemia of pregnancy
B. Intrapartal period
1. encourage mother to remain in semi Fowlers
position or left lateral position
2. provide continuous cardiac monitoring
3. provide electronic fetal monitoring
4. assist mother to cope with discomfort; minimal
analgesia and anesthesia are used
5. assist with forceps delivery in second stage of
labor to avoid work of pushing
6. monitor for signs of heart failure, such as
respiratory distress and tachycardia
INTRAPARTUM COMPLICATIONS
occur in as many as 31% of all births
- broad term for abnormal or difficult labor and
delivery
- arise from 3 main components of the labor
process
Common Causes:
a. inappropriate use of analgesia (excessive or too early
administration)
b. unusually large baby/multiple gestation
c. poor fetal position (posterior rather than anterior position)
d. pelvic bone contraction (leads to narrowing of the pelvic
diameter so the fetus cant pass)
e. primigravida
f. hypotonic, hypertonic and prolonged labor
2 types:
1. Primary occurring at the onset of labor
2. Secondary occurring later in labor
Management:
1. Monitor uterine contractions by palpation and with the
use of electronic monitor
2. Prevent unnecessary fatigues check the client level of
fatigue
3. Prevent complications of labor
b. assess maternal VS
b. walking
c. quiet/calm environment
d. breathing/relaxation technique
Risk Factors
- bowel/bladder distention prevents
descent/engagement
- multiple gestation
-large fetus
- hydramnios
- multiparity
2. Hypertonic Contractions
Management:
1. assess quality of contractions by uterine/fetal
external monitor applied at least 15 minutes
interval
2. adequate rest
3. pain relief with morphine sulfate
4. changing linen/gowns
5. darkened room lights
6. decreasing environmental stimuli
7. CS delivery
PRECIPITATE LABOR
- define as labor that is completed in fewer than 3 hours
(normal length of labor; Primipara 14-20 hours, Multi 8-14
hours)
Complications
1. hemorrhage
2. Intracranial hemorrhage in fetus
3. lacerations (because of forceful birth)
4. Fetal distress
Nursing Management:
1. Inform mother at 28 weeks of pregnancy that labor
may be shorter than normal
2. Tocolytic agent administration to reduce the force
and frequency of contractions
3. Cold applications to limit bruising, pain and edema
4. In time of hemorrhage position the mother in
modified trendelenburg position
5. IVF replacement fast drip
UTERINE RUPTURE
- rupture of the uterus during labor
- prolong labor
- faulty presentation
- multiple gestation
- use of oxytocin
- traumatic maneuvers
3. hemorrhage from a torn uterus into the abdominal cavity and into the
vagina
4. signs of shock (rapid, weak pulse, falling blood pressure, cold clammy
skin)
7. fetal distress
Nursing Management:
1. Administer emergency fluid replacement therapy as
ordered
2. Anticipate use of intravenous oxytocin to attempt to
contract the uterus and minimize bleeding
3. prepare mother from a Laparotomy as an emergency
measure to control bleeding and effect a repair
4. Physician may perform hysterectomy (removal of a
damaged uterus) or BTL at the time of Laparotomy
5. monitor VS and FHR
6. administer BT as ordered
UTERINE INVERSION
- uterus turns completely or partially inside out, it occurs
immediately following delivery of the placenta or in the immediate
postpartum period
Causes:
Nursing Management;
1. recognize signs of impending inversion and immediately notify
the physician
2. never attempt to replace the inversion because handling may
increase the bleeding
3. never attempt to remove the placenta if it still attached
Nursing Management:
1. immediate management is oxygen administration by face mask
or cannula
2. prepare the mother for CPR (may be ineffective because these
procedures do not relieve the pulmonary constriction)
3. Endotracheal intubation to maintain pulmonary function
4. The mother should be transferred to ICU
Complication:
1. DIC disseminated intravascular
coagulation
Associative Factors:
1. premature rupture of membranes (the fetal fluid may rush and carry the
cord along toward the birth canal)
2. breech presentation
3. placenta previa
4. intrauterine tumors preventing the presenting part from engagement
5. small fetus
6. CPD preventing engagement
7. hydramnios
8. multiple gestation
Signs and Symptoms;
1. the umbilical cord seen or felt during vaginal exam
2. reports feeling of cord into the vagina
Risk Factors:
1. Women with android/anthropoid pelvis.
Risk Factors:
1. gestational age under 40 weeks
2. abnormality in the fetus such as anencephaly, hydrocephalus
3. hydramnios (allows for free fetal movement)
4. congenital anomaly of the uterus
5. multiple gestation
Nursing Management;
1. External version is being used to avoid some CS
deliveries for a breech presentations
VERSION is a method of changing the fetal presentation
usually from breech to cephalic.
- done after 37 weeks of gestation but before the onset of
labor
- begins with non-stress test and BPF to determine of the
fetus is in good condition and if there is adequate amount
of amniotic fluid
- mother is given tocolytic drug to relax her uterus during
version
Indications;
1. pre-eclampsia
2. eclampsia
3. severe hypertension/DM
4. Rh sensitization
5. prolong rupture of membranes
6. post maturity
Pharmacological Methods:
1. Cervical Ripening softening of the
cervix/consistency
Scoring
Factor
Dilatation (cm)
1-2
3-4
5-6
40-50
60-70
80
Station
-3
-2
-1, 0
+1, +2
Consistency
Firm
Medium
Soft
Position
Posterior
Mid-Posterior
Anterior
Nursing Considerations;
1. Place women in flat position to prevent leakage of medication
2. the woman remains on bed rest for 1 to 2 hours and is
monitored for uterine contractions
3. monitor FHR continuously for at least 30 minutes after each
application up to 2 hours
4. IV line with saline is initiated in case uterine hyperstimulation
occurs such as contractions longer than 90 seconds or more than
5 contraction in 10 minutes
5. explain the side effects vomiting, fever, diarrhea and
hypertension
6. oxytocin induction can be started 6-12 hours after the last
prostaglandin dose
needs to be diluted
- no fetal abnormality
associated with it
Postpartum Complications
According to time:
1. Early Postpartum hemorrhage occurs within 24 hours of birth
2. Late postpartum hemorrhage occurs after 24 hours until 6 weeks
after birth
Major Risk: Hypovolemic Shock (low volume)
- occurs when the circulating blood volume is decreased which interrupts
blood flow to body cells
- manifested as:
a. Tachycardia (first sign)
b. hypotension
c. cold and clammy skin
d. mental changes such as anxiety, confusion, restleness
e. decrease urine output
2.
3.
4.
5.
Risk Factors:
1. Deep anesthesia
2. >30 years old
3. prolonged use of magnesium sulfate
4. previous uterine surgery
5. Over exhaustion
Symptoms:
1. uterus is difficult to feel and is boggy (soft)
2. lochia is increased and may have large blood clots
3. Blood may gush or come out slowly
Nursing Management:
1. Massage the uterus until firm
2. have mother to urinate or catheterize because bladder
distension pushes the uterus upward or in the side and
interferes with the ability of the uterus to contract
3. Encourage mother to breastfeed because sucking
stimulation causes the release of oxytocin from PPG
4. Administration of IV oxytocin or Methylergonovine
(Methergine) to control uterine atony
5. Hysterectomy is performed to remove the bleeding
uterus that does not respond to other measures
Sites of lacerations:
1. Cervical Lacerations
- characterized by gushes of bright red blood from
the vaginal opening if uterine artery is torn
- difficult to repair because the bleeding may be so
intense that it can obstruct visualization of the area.
2. Vaginal Lacerations
- rare case but easier to assess
- oozing of blood after repair, vaginal packing is
necessary to maintain pressure from the suture line
- catheterize the mother because packing causes
pressure on urethra
- packing is removed after 24-48 hours (at risk for
infection)
3. Perineal Lacerations
- usually occurs when mother is placed on lithotomy
positions (increases pressure on perineum)
Classifications:
a. First Degree vaginal mucous membranes and
skin of the perineum to the fourchette
b. Second Degree vagina, perineal skin, fascia and
perineal body
c. Third Degree entire perineum and reaches the
external sphincter of the rectum
d. Fourth Degree entire perineum, rectal sphincter
and some of the mucous membrane of the rectum
Management (Perineal)
1. sutured and treated using episiotomy repair
2. diet high in carbohydrate and a stool softener is
prescribed for the first week postpartum to prevent
constipation which could break the sutures
3. do not take rectal temperatures because the
hard tips of equipment could open sutures
Management:
1. Dilatation and Curettage (D&C) will be
performed to remove placental fragments and to
stop bleeding
2. administration of Methotrexate to destroy the
retained placental tissue
3. instruct the mother to observe the color of lochia
discharge
4. check the completeness of the placenta after
birth
Management:
1. assess the size by measuring it in
centimeters
2. administer a mild analgesic as pain relief
3. apply an ice pack (covered by towel to
prevent thermal injury to the skin)
4. incision and drainage of the site of
hematoma and is packed with gauze
Puerperal Infection
- Infection of the reproductive tract associated with
giving birth
- Usually occurs within 10 days of birth
- Another leading cause of maternal death
- Predisposing factors:
a. Prolonged rupture of membranes (>24 hours)
b. C-section
c. Trauma during birth process
d. Maternal anemia
e. Retained placental fragments
Nursing interventions
1. Force fluids; may need more than 3L/day
2. Administer antibiotics after culture and sensitivity of
the organism (Group B streptococci and E. Coli) and
other meds as ordered
3. Treat symptoms as they arise
4. Encourage high calorie, high protein diet
5. Position patient in a semi-Fowlers to promote drainage
and prevent reflux higher into reproductive tract
6. Use of sterile equipments on birth canal during labor,
birth and postpartum
7. Educate the mother about proper perineal care
including wiping from front to back
Endometritis
- refers to the infection of the endometrium, the lining
of the uterus at the time of birth or during Postpartal
period
Signs and Symptoms:
1. fever on the third or fourth day postpartum(increase
in oral temperature above 38C for 2 consecutive 24
hour periods, excluding the first 24 hours period after
birth)
2. chills, loss of appetite and general body malaise
3. uterine tenderness
4. foul smelling lochia
Management:
1. ATBC administration such as Clindamycin after culture
2. oxytocin is given to encourage uterine contraction
3. encourage increase fluid intake to combat fever
4. analgesic as ordered for pain relief due to after pains
and abdominal discomforts
5. encourage client to ambulate or in Fowlers position to
promote lochia drainage and prevent pooling of infected
secretions
6. IV therapy
Perineal Infection
- localized infection of the suture line from an episiotomy
site
Signs and Symptoms:
1. feeling of heat, pain and pressure on the suture line
2. 1 or 2 stitches are sloughed away
3. purulent discharges on suture lines
Management:
1. removal of perineal sutures to open and allow for
drainage