CA 2 (OB) - Bleeding Disorders of Pregnancy PDF

BLEEDING DISORDERS OF PREGNANCY - Bleeding during pregnancy is a danger sign that requires immediate medical attention, except for a bloody show, which is a normal indication of true labor (acceptable) as the cervix dilates in preparation for childbirth. o A bloody...

BLEEDING DISORDERS OF PREGNANCY - Bleeding during pregnancy is a danger sign that requires immediate medical attention, except for a bloody show, which is a normal indication of true labor (acceptable) as the cervix dilates in preparation for childbirth. o A bloody show is a small amount of blood-tinged mucus discharged from the vagina, signaling the cervix's dilation and the onset of labor. First Trimester (Weeks 1–12) 1. Abortion - Refers to the loss of pregnancy during the first trimester. 2. Ectopic Pregnancy - Occurs when the fertilized egg implants outside the uterine cavity, most commonly in the fallopian tube. - Signs include sharp, unilateral abdominal pain, vaginal bleeding, and if ruptured, severe internal bleeding leading to shock. Second Trimester (Weeks 13–27) 1. Abortion Before Viability - Loss of pregnancy before 20 weeks of gestation is still classified as abortion. Viability is the age at which the fetus has a chance of survival outside the womb, typically 20 weeks or more. - Causes include infections, uterine abnormalities, or chromosomal defects. 2. Hydatidiform Mole (H. Mole) - A molar pregnancy is a type of gestational trophoblastic disease caused by abnormal fertilization. - Instead of forming a normal placenta and fetus, a cluster of grape-like vesicles forms. - H. mole does not lead to a viable pregnancy or premature labor. - Symptoms include excessive nausea, uterine enlargement disproportionate to gestational age, and vaginal bleeding. 3. Incompetent Cervix - A structural weakness of the cervix leads to its premature dilation and thinning, often without pain or contractions. - This condition can cause second-trimester pregnancy loss or preterm birth. Management includes cervical cerclage (a surgical procedure to close the cervix). H. Mole and Incompetent Cervix - Commonly occur around 5 ½ months (approximately 22 weeks). These conditions can complicate pregnancies during this stage. Third Trimester (Weeks 28–40) 1. Placenta Previa - The placenta implants in the lower uterine segment, partially or completely covering the cervix. - Symptoms include painless, bright red vaginal bleeding, often occurring in late pregnancy.  - Management involves monitoring, bed rest, or delivery via cesarean section if bleeding is severe. 2. Abruptio Placenta - The placenta separates from the uterine wall before delivery, causing painful vaginal bleeding, uterine tenderness, and contractions. - This is a medical emergency as it endangers both the mother and fetus. - Risk factors include hypertension, trauma, smoking, or previous history of abruptio placenta. Primary Question To The Mother - Age of gestation - How many months pregnant? Gestational Age Classifications 1. Preterm Pregnancy - Spans from 20 to 36 weeks. 2. Full-Term Pregnancy - Spans from 37 to 42 weeks. 3. Post-Term Pregnancy - Refers to pregnancies that extend beyond 42 weeks.  ABORTION - Abortion refers to the termination of pregnancy before the fetus reaches the period of viability, typically defined as 20 weeks of gestation or a fetal weight of less than 500 grams. SPONTANEOUS (NALAGLAG) ABORTION - A miscarriage that occurs unintentionally. Types 1. Threatened Abortion - The only type of abortion where the pregnancy is still viable. - Threatened abortion is unique compared to the other six types, as it involves a pregnancy that is at risk but may still be saved with proper medical intervention. In such cases, the doctor might administer tocolytic drugs to help manage the condition. Cervix BOW Uterine Contraction Bleeding POC Closed and not Intact Mild Mild Intact dilated - Presenting Signs o Abdominal cramping. o Spotting or light bleeding. - Management o Tocolytics: Administer drugs to suppress uterine contractions. o Sedation: Reduce stress or anxiety to prevent contractions. o Complete Bed Rest (CBR): Most important; strict bed rest to avoid activity-induced contractions. o Avoid Internal Examinations (No IE): Use external fetal monitoring instead to avoid stimulating uterine contractions and bleeding. o Sanitary Pad Inspection: Save used pads to inspect for tissues or abnormal bleeding. 2. Imminent (Inevitable) Abortion - This type of abortion cannot be prevented once it has started. Cervix BOW Uterine Contraction Bleeding POC Open and dilated Ruptured Moderate to strong Mild to strong Intact - Management o Immediate hospitalization is required. o Monitor for progression to either a complete or incomplete abortion. 3. Complete Abortion - All Products of Conception (POC) have been expelled from the uterus. - This must be confirmed as the final diagnosis. Cervix BOW Uterine Contraction Bleeding POC Closed and not Absent None to mild None to mild None dilated - Management o Conduct routine check-ups to ensure complete expulsion. o Administer oxytoxic to promote uterine contraction and reduce the risk of hemorrhage. o Provide antibiotics to prevent infection and analgesics for pain relief. o Perform vital signs monitoring and maintain meticulous perineal care. 4. Incomplete Abortion - Some POC, often the placenta, remain in the uterus, leading to complications. Cervix BOW Uterine Contraction Bleeding POC Open and dilated Ruptured Moderate to strong Moderate to strong Placenta - Management o Immediate hospitalization is required. o Perform dilation and curettage (D&C) to remove any retained POC. o Administer oxytoxic to promote uterine contraction and reduce the risk of hemorrhage. o Provide antibiotics to prevent infection and analgesics for pain relief. - The initial diagnosis should be "incomplete abortion," as making it a final diagnosis could be legally self- incriminating, implying negligence since retained products of conception remain and were not removed by the doctor. 5. Missed Abortion - A type of abortion where intrauterine fetal demise or death (IUFD) occurs, but the fetus and products of conception (POC) remain in the uterus and may stay until 1 month without causing any infection. - The pregnancy may persist for 4 to 6 weeks without signs of infection. - The first noticeable sign is absence of fetal movement, followed by absence of fetal heart tones. - Diagnostic Procedures o Urinary pregnancy test: Confirms pregnancy status. o Leopold's maneuver: Checks for fetal outline and size. o Doppler: Used to detect fetal heart rate; absence confirms suspicion (must be referred). o Ultrasound: Definitive test to confirm IUFD and the absence of fetal activity. - No infection yet Cervix BOW Uterine Contraction Bleeding POC Closed and not Intact None None Intact dilated - The patient remains pregnant but shows no signs of fetal life. - A missed abortion is typically identified around the 4th month of pregnancy, when the baby is about 16 cm in length and has assumed a more human-like form. - Management  o If IUFD is confirmed, remove POC to prevent infection. 1. Start with oxytoxic IV incorporation to induce uterine contractions and expel POC. 2. Follow with dilation and curettage (D&C) to ensure complete removal. 3. Administer antibiotics, analgesics, and anti-inflammatory medications. - Bartholomew’s Rule o At 4 months of pregnancy, the uterus is palpable midway between the symphysis pubis and the umbilicus. o At 5 months, the uterus reaches the level of the umbilicus. - Haase’s Rule (Fetal Length Estimation) o For months 1–5, fetal length is approximated by squaring the month of pregnancy (e.g., 4 months = 16 cm). o For months 6–9, multiply the month by 5. o Example: A fetus at 16 cm is 6.3 inches long (16 ÷ 2.54 cm/inch). 6. Septic Abortion - A serious infection that occurs due to retained POC following incomplete or missed abortion. Cervix BOW Uterine Contraction Bleeding POC Baby and/or Open and dilated Ruptured Strong Strong placenta - Discharge: Foul-smelling vaginal discharge, a hallmark sign of infection. - Fever: Indicates systemic infection. - Management o Immediate hospitalization is required. o Administer oxytoxics to contract the uterus. o Remove POC through D&C to prevent further infection. o Prescribe antibiotics, analgesics, and antipyretics to manage infection, pain, and fever. o Ensure meticulous perineal care to prevent secondary infections. 7. Habitual or Recurrent Abortion - Defined as three or more consecutive spontaneous abortions (naturally caused miscarriage, nalaglag). - Cause o The number one cause is incompetent cervix, where the cervix cannot remain closed during pregnancy. § Occurs in the second trimester, often around the 4th month of pregnancy. § Presents as painless vaginal bleeding without uterine contractions. Outcomes o If pregnancy is less than 5 months, abortion occurs.  o If pregnancy is more than 5 months but less than 9 months, preterm labor ensues. - Management o Kegel exercises: Done during urination to strengthen pelvic floor muscles and aid in maintaining cervical closure. o Cerclage (Cervical Stitching, Purse String Suture): A surgical technique used to prevent cervical opening. § McDonald’s Cerclage: Temporary stitch, removed at 37 weeks or when signs of true labor occur (or without signs of true labor, whichever comes first). This allows for a normal spontaneous delivery (NSD). § Shirodkar Cerclage: Permanent stitch requiring cesarean delivery (CS). It allows slight cervical dilation for pregnancy but prevents abortion or incompetent cervix. More Lochia during NSD - Lochia is the vaginal discharge that occurs after childbirth, consisting of blood, mucus, and uterine tissue. It can be heavier after a normal spontaneous delivery (NSD) because the body is expelling the remnants of the uterine lining and blood that supported the pregnancy. It’s common to have increased lochia in the first few days postpartum, but the amount should decrease over time. Chromic 2O Suture - A chromic 2O suture is a type of absorbable surgical suture used for suturing tissues, commonly in procedures like episiotomies or cesarean sections. "Chromic" refers to the suture being treated with chromic acid to make it more durable and slower to absorb by the body, allowing for better tissue healing. "2O" indicates the thickness of the suture. Before Closing the Endometrium, Give Wet Gauze or Sponge (Not Dripping), Wipe to Remove Remnants of Decidua - Before closing the uterus (endometrium) after childbirth, it's essential to remove any leftover tissue from the inner uterine lining (decidua). Decidua refers to the modified endometrium during pregnancy, which is shed postpartum. Using wet gauze or a sponge (moistened but not dripping) to gently wipe the area helps clear out any tissue remnants to prevent infection or complications. This step ensures the uterus is clean before it is closed, reducing the risk of infection and promoting healing. Blood Transfusion Post-Abortion - Steps Before Transfusion 1. Blood Typing: Determines compatibility. 2. Crossmatching: Ensures no adverse reactions between donor and recipient blood. 3. CBC: Monitors blood levels and need for transfusion. 4. Verify the name, type, serial number, and expiration date of the blood unit. - Methods of Transfusion  1. Direct method: Blood transferred directly from donor to recipient. 2. Indirect method (done by the nurse): Blood is processed and stored before use. § Side drip with PNSS: Normal saline solution prevents hemolysis of donor RBCs. - Check VS 15 minutes before and 15 minutes after transfusion. Compare results for any adverse reactions. - Blood Types 1. Type A: Antigen A, agglutinin B. 2. Type B: Antigen B, agglutinin A. 3. Type AB: Antigen A and B, universal receiver (no agglutinins). 4. Type O: Agglutinin A and B, universal donor (no antigens). § An antigen (same letter) is a substance that triggers an immune response, while an agglutinin (opposite letter) is an antibody that causes clumping of antigens. Nasogastric Tube (NGT) Placement - Measure the insertion length o Start at the tip of the nose. o Extend to the earlobe. o Finish at the xiphoid process. Catheterization 1. Indwelling Catheter - 2-way Foley: Standard for urine drainage. - 3-way Foley: Used for bladder irrigation (e.g., post-surgical or bleeding cases). 2. Non-Indwelling Catheter - 1-way straight catheter: Single-use, typically orange in color. - Commonly used for laboring clients who require temporary bladder drainage. DRUGS Oxytoxic (Pampahilab or Uterotonic) - These drugs stimulate uterine contractions, typically used to aid labor or manage postpartum bleeding. o Syntocinon/Pitocin: Synthetic oxytocin given intravenously (IV incorporation at airvent [upper part]) to stimulate contractions. It can be administered with fluids like D5LR (Dextrose 5% in Lactated Ringer's) combined with 10 units and absorbed once all the fluid is consumed. o Oxytocin: Administered intramuscularly (IM) to the mother one minute after the baby is delivered to help the uterus contract and prevent bleeding. o Methergine: Given IM to the mother after placenta delivery to promote uterine contraction. If administered before the placenta is out, it may cause powerful contractions and a closed cervix, resulting in a retained placenta. Tocolytic (Tanggal Hilab or Uterine Relaxants) - These medications inhibit uterine contractions and are used to prevent premature labor or uterine irritability. - Duvadilan, Yutopar, Dactyl OB, Bricanylnor Terbutaline, Magnesium Sulfate: All are smooth muscle relaxants that help prevent early uterine contractions by relaxing the myometrium. INTENTIONAL OR INDUCED (NILAGLAG) ABORTION 1. Therapeutic or Legal Abortion - This is a medically performed abortion in the Philippines with the goal of saving the life of the mother or addressing medical complications like: o Ectopic pregnancy: Where the fertilized egg implants outside the uterus. o Gravidocardiac patients: Pregnant women with heart disease who are at risk of dying from a heart attack due to the strain of pregnancy. 2. Non-Therapeutic or Criminal Abortion - This is done to end an unwanted pregnancy and is illegal in the Philippines. There are bills seeking to legalize it, but no law has passed yet. Divorce was passed before abortion bills. Who May Perform Abortion? - A Hilot is a traditional birth attendant or healer, the number one abortionist, and often called upon in rural areas, including for performing abortion procedures illegally. Though not formally trained in medicine but just a skill within the family. - Midwives and doctors may also perform actual abortive procedure when medically necessary. Nurses' Role in Abortion - Nurses may suggest the use of Cytotec, an anti-ulcer medication known to induce uterine contractions. This drug can be taken orally or administered vaginally by inserting 4 to 5 tablets, often followed by sexual intercourse to aid dissolution. However, this method can disrupt the normal vaginal pH (4-5), promoting microbial growth that may lead to chorioamnionitis—an infection of the chorion and amnion. This infection can affect the placenta, trigger uterine contractions, and result in abortion. Additionally, an overdose of Cytotec can cause congenital defects, such as anencephaly. o Anencephaly is a severe neural tube defect where a baby is born without parts of the brain and skull, leading to incompatibility with life. Other Abortion Methods - Wire for bleeding induction: A method involving mechanical injury to induce bleeding. - Saline infusion: Hypertonic saline (NSS) [with sodium] may be used intraabdominally to irritate the uterus, inducing contractions and potentially an abortion.  ECTOPIC PREGNANCY - An ectopic pregnancy is a type of extrauterine pregnancy where the fertilized egg implants and grows outside the uterus, often in the fallopian tube, but it can also occur in other locations. Causes and Risk Factors 1. Pelvic Inflammatory Disease (PID): An infection of the female reproductive organs that can lead to scarring, which increases the risk of ectopic pregnancy. 2. Intrauterine Device (IUD): While IUDs are highly effective in preventing pregnancy, they can increase the risk of ectopic pregnancies if pregnancy occurs while using one. Salpingitis - Inflammation or infection of the fallopian tubes, often caused by PID, which can increase the risk of an ectopic pregnancy by obstructing the fallopian tubes and preventing the fertilized egg from reaching the uterus. Four Sites - The ampulla is the outermost third of the fallopian tube, the isthmus is the middle third and the widest, and the interstitial is the innermost third, narrowest, and passes through the three uterine layers. 1. Tubal: The most common site, usually occurring in the ampulla. It is particularly dangerous in the interstitial portion because it is narrow and connected to the uterine layers, often requiring exploratory laparotomy. o Ectopic pregnancies in the ampulla typically do not cause vaginal bleeding, while interstitial pregnancies are associated with vaginal bleeding. 2. Ovarian: Managed with exploratory laparotomy. 3. Abdominal: The most dangerous type, also requiring exploratory laparotomy. 4. Cervical: The rarest type, treated with methotrexate to terminate the implanted egg cell without surgery. - Rupture commonly occurs between the 10th and 12th week of pregnancy. Signs - Absence of Menstruation: Similar to a normal pregnancy, a woman with an ectopic pregnancy may miss her period. - Positive Urinary Pregnancy Test: Pregnancy hormones (HCG) are present, but the pregnancy is not in the uterus. - Ultrasound: Used in the first trimester to confirm the pregnancy's location. It can also detect complications such as placenta previa (where the placenta covers the cervix). Signs of Rupture (Complications) 1. Kehr’s Sign (earliest): Sharp, stabbing pain that radiates to the shoulder on the same side as the ectopic pregnancy, often due to blood accumulating in the abdominal cavity irritating the diaphragm. 2. Cullen’s Sign: A bluish discoloration around the belly button (periumbilical area), indicating internal bleeding. 3. Hypovolemic Shock: This occurs due to significant blood loss and includes symptoms like: - Low blood pressure (BP)  - Increased heart rate (HR) and respiratory rate (RR) - Low body temperature - Cold, clammy skin - Lethargy, confusion, or even loss of consciousness (conscious and coherent, lethargic, obtunded, stupor, coma) Treatment - Exploratory Laparotomy (Exlap): A surgical procedure used to explore the abdominal cavity. If the ectopic pregnancy is not yet ruptured (controlled bleeding), it is usually done electively. - Salpingectomy: If the ectopic pregnancy is in the fallopian tube, this may involve removing the tube. If the pregnancy is ruptured, emergency exlap with salpingectomy is performed to prevent further complications. o General Anesthesia: Used during emergency surgery for faster absorption of the anesthesia and to ensure patient comfort. - Surgical Tools o Kelly Clamp: A long tool used to clamp the damaged fallopian tube to control bleeding during surgery. o Suture Ligature (Sutlig): This consists of a needle, needle holder, suture, tissue forceps, and thumb forceps. These tools are used to close and secure the surgical site. - Stick Tie: A stick tie is a type of knot that involves using a needle and suture to ligate a vessel or tissue, while the surgeon holds the tissue with forceps. - Free Tie: A free tie involves using a length of suture (without the needle) to tie off a vessel or tissue. Post-Surgery Considerations - Future Pregnancy Potential o After a salpingectomy (removal of the affected fallopian tube), a woman can still conceive if the other fallopian tube and ovaries are healthy and functional. However, if the damage is on both sides, fertility may be affected. o The fallopian tube on the opposite side of the removed one can still be used for future pregnancies. o The ovaries can also still function and release eggs for future pregnancies.  HYDATIDIFORM MOLE (HMOLE) / MOLAR PREGNANCY / GESTATIONAL TROPHOBLASTIC DISEASE (GTD) / KAYAWA / KIYAWA - A Hydatidiform Mole (HMole), also known as Molar Pregnancy, is a form of Gestational Trophoblastic Disease (GTD) that occurs due to an abnormal fertilization process, leading to the development of abnormal placental tissue instead of a viable fetus. It involves issues with the trophoblast, the outer layer of cells that typically forms the placenta. Normal Fertilization Process - Normally, sperm fertilizes an egg, forming a zygote. The zygote undergoes cleavage, developing into a blastomere, then a morula, and eventually a blastocyst. o The trophoblast (the outer layer of cells in the blastocyst) forms the placenta, while the inner cells of the blastocyst become the embryo. - The decidua basalis and chorionic villi (projections from the trophoblast) develop to support the pregnancy by forming the placenta, which is responsible for secreting Human Chorionic Gonadotropin (HCG) at 50,000 to 400,000 units, a hormone that supports pregnancy. Predisposing Factors 1. Faulty Fertilization - Occurs when one egg is fertilized by two sperm cells. This results in an abnormal pregnancy, where the chorionic villi (placental tissue) grow but no viable embryo (blastocyst not formed) forms. - This can also happen when an empty egg is fertilized, leading to the development of only trophoblastic tissue. - The result is rapidly growing, fluid-filled vesicles that take up space in the uterus, making it grow larger than expected. 2. Low Socioeconomic Status - People with low socioeconomic status may experience nutritional deficiencies, contributing to abnormal fertilization and trophoblastic tissue growth. - Protein Deficiency o Protein deficiency occurs when the body doesn't receive enough protein, which is essential for tissue growth and repair, and good sources of protein include meat, such as beef, pork, lamb, and poultry, as well as fish, eggs, dairy products, legumes, and nuts. o Protein deficiency can increase the risk of developing HMole. Since proteins are essential for cell growth and tissue development, inadequate nutrition, especially in those following restrictive diets (e.g., vegan diets), can affect trophoblast development. o High progesterone levels can stimulate the formation of many temporary capillaries, increasing blood supply to support tissue growth and development. Additionally, amino acids, which are the building blocks of tissue, are essential for this process, helping to repair and build new cells and tissues. Pathophysiology - In HMole, the trophoblast tissue detaches, causing spontaneous abortion. However, the trophoblast tissue itself continues to develop abnormally, creating fluid-filled vesicles (the characteristic grape-like clusters). - The uterus becomes enlarged, but instead of carrying a fetus, it contains abnormal tissue. - HCG levels are elevated, as the trophoblastic tissue continues to produce it, even though no viable pregnancy exists. 4 Classical Signs in the Second Trimester 1. Uterus Larger than Expected - When the uterus is larger than expected for the gestational date, Bartholomew's rule can be used to assess the growth. According to this rule, the uterus is typically at the level of the umbilicus around the fifth month of pregnancy, and near the xiphoid process during the early ninth month. - A larger-than-expected uterus could indicate conditions such as hydatidiform mole (hmole), multiple pregnancy, large for gestational age (LGA) fetus, or polyhydramnios (excess amniotic fluid). - Ultrasound is essential for further evaluation to confirm the cause of the uterine enlargement. 2. Abnormally High HCG Levels - HCG levels can rise dramatically, sometimes reaching 1 million to 2 million units, much higher than typical pregnancy levels. 3. Absence of Fetal Signs - No fetal heartbeat or development is observed, confirming that the pregnancy is non-viable. 4. Passage of Vesicles - The classic sign of HMole is the passage of vesicles (the fluid-filled clusters of tissue from the molar pregnancy), which further confirms the diagnosis. Symptoms - No menstruation: The woman misses her period, which would be expected with pregnancy. - Nausea and vomiting: Due to high levels of HCG, leading to hyperemesis. However, Hyperemesis Gravidarum (severe nausea and vomiting in pregnancy) is not necessarily associated with HMole. - Urinary frequency: Common during pregnancy, though it may also occur in HMole. - Positive pregnancy test: A standard pregnancy test will be positive due to high levels of HCG. Ultrasound - Is used to determine the cause of symptoms like excessive nausea and vomiting during pregnancy, which can be due to hyperemesis gravidarum (HG) caused by high levels of Human Chorionic Gonadotropin (HCG). While HG is linked to high HCG levels, it is not specifically associated with hydatidiform mole (hmole). HG could also be influenced by pregnancy-induced hypertension, emotional factors or attention-seeking behaviors. In cases of hmole, ultrasound helps to confirm the diagnosis. Complications  - Rupture of Vesicles: Vesicles may begin to rupture between 16-20 weeks of pregnancy, causing complications that require immediate attention. If left untreated, it can lead to severe bleeding and the need for surgical intervention. Management - Dilation and Curettage (D&C) o This is the primary method of treatment. Curettes (surgical instruments) are used to remove the abnormal tissue from the uterus. There are various types of curettes used in the procedure, such as the loop curette and sharp curette. o During a D&C, a curette with loop or sharp edges and an ovum forcep (transfer forcep) are used to remove the tissue. - Suction and Curettage o In this procedure, suction is used to remove the abnormal tissue, and a large-bore catheter is employed for low-pressure suction to avoid damaging the endometrium. - Post-Procedure Monitoring o After the molar pregnancy is evacuated, HCG titers are measured. If the levels remain high, it indicates that some trophoblastic tissue may have been left behind, and another D&C may be necessary. o If the HCG levels drop and become negative, it indicates that the pregnancy has been successfully cleared. - Avoid Pregnancy for One Year o It’s recommended that women avoid pregnancy for at least one year after treatment for a molar pregnancy to reduce the risk of another molar pregnancy or the development of choriocarcinoma (a cancer of the uterus). - Methotrexate o Methotrexate is the drug of choice (DOC) for choriocarcinoma, which can develop if trophoblastic tissue continues to grow abnormally after the molar pregnancy.  PLACENTA PREVIA (BUKANAN) - Placenta previa is a condition where the placenta is located in the lower part of the uterus, instead of the usual upper posterior position. This abnormal placement can lead to complications during pregnancy and delivery. - The placenta is positioned at the lower part of the uterus, blocking the cervix (the opening of the uterus). Symptoms - Painless vaginal bleeding: This bleeding typically occurs in the third trimester, and the blood is usually bright red. - No uterine contractions: The uterus and abdomen remains soft, and there are no strong contractions associated with the bleeding. - Overt bleeding: The bleeding is visible, rather than concealed. - Absent engagement of the fetal head: The fetal head does not engage in the pelvis as it should for a normal delivery, making vaginal delivery more challenging or risky. Causes and Risk Factors - Unknown cause: The exact cause of placenta previa is not fully understood, but several factors can contribute, including high parity (having had multiple previous pregnancies. Diagnosis - Placenta previa is often detected during a first-trimester ultrasound, though it may not cause symptoms until third-trimester. Management - If diagnosed early, placenta previa may resolve as the pregnancy progresses, with the placenta moving away from the cervix. However, if it persists into the third trimester, it can pose significant risks for bleeding during delivery, and cesarean section (C-section) is often required to avoid complications.  ABRUPTIO PLACENTA (KALOOB-LOOBAN) - Abruptio Placenta (Placental Abruption) is a serious pregnancy complication where the placenta prematurely detaches from the uterine wall, causing bleeding and potentially affecting both the mother and fetus. It typically occurs suddenly and can result in significant complications. - Abrupt and premature (sudden) detachment of the placenta (maaga at bigla). Symptoms - Fetal distress: The baby may show signs of stress due to disrupted blood flow. - Bleeding: The amount of bleeding can vary; it may be overt or covert. - Damaged Placenta: In abruptio placenta, the placenta becomes damaged due to the premature separation, which can compromise the supply of oxygen and nutrients to the baby. This damage can result in fetal distress, and if severe, may lead to fetal death. - Rh Incompatibility: If the mother is Rh-negative and the baby is Rh-positive, Rh incompatibility can cause immune reactions, increasing the risk of complications like placental abruption. The maternal immune system may attack the baby’s red blood cells, leading to hemolytic disease of the newborn, which can also contribute to premature placental detachment. - Board-like or rigid abdomen: The abdomen feels tense and hard due to the bleeding behind the placenta. - Uterine contractions: Strong and long contractions that don't subside. - Painful: The mother experiences strong, painful uterine contractions. - Dark red blood: The blood is typically dark, indicating older blood. - Overt or obvious bleeding: The bleeding is visible when the placenta detaches from the uterine wall, and blood leaks through the cervix. - Covert or concealed bleeding: The bleeding is hidden, and blood remains behind the placenta as it detaches. o Depending on § Duncan: The placental separation starts from the maternal side, leading to overt bleeding. § Schultz: The placental separation begins from the fetal side, often leading to covert bleeding. - Engagement of the fetal head: The fetal head may or may not be engaged at the time of placental abruption: Risk Factors - Hypertension: High blood pressure increases the risk of placental abruption. - Short umbilical cord: A short cord can be pulled on by the baby, causing the placenta to detach. - Double cord coil: This refers to the umbilical cord being twisted around the baby's neck or body. A double coil can cause umbilical cord compression, which may lead to fetal distress and increase the risk of placental abruption. - Trauma: Physical injury to the abdomen can trigger placental detachment. - Low nourishment: Poor maternal nutrition increases the likelihood of placental problems.  - Rh incompatibility: The mother and baby have incompatible blood types, leading to immune reactions that may contribute to abruption. Cannot Be Diagnosed Early - Abruptio placenta often cannot be predicted or diagnosed until it actually occurs, making it a sudden and urgent medical emergency. Close monitoring is necessary if any risk factors or signs of early detachment are present. Management - Preterm delivery: If the pregnancy is preterm, dexamethasone may be administered to help mature the baby's lungs. - Cesarean Section (CS): In severe cases, CS is often required to safely deliver the baby. The decision to perform a vaginal birth after cesarean section (VBAC) depends on the type of incision from the previous C-section and the overall condition of the uterus. o Types § Classical incision (above the umbilicus): This incision is made across vertically and is an absolute contraindication for VBAC because it involves the upper part of the uterus, which may lead to uterine rupture during labor. § Low vertical incision (below the umbilicus): A vertical incision made across and below the umbilicus can be used when a classical incision is not recommended. § Low transverse incision (across the lower abdomen): The most common and preferred incision for CS because it has better healing and lower risk for future pregnancies. It’s suitable for VBAC in some cases depending on the uterine healing.  MEDICAL CONDITIONS PREGNANCY-INDUCED HYPERTENSION (PIH) Definition - PIH is high blood pressure that develops during pregnancy, typically after 20 weeks of gestation, in a person who previously had normal blood pressure. Cause - It is directly linked to pregnancy and is not a pre-existing condition. The exact cause is unclear but may involve factors like hormonal changes, stress on blood vessels, or the body’s response to the growing fetus. Gone After Delivery - PIH usually resolves after the baby is born because the pregnancy—the triggering factor—is no longer present. Blood pressure often returns to normal within 12 weeks postpartum. Monitoring is still required during this period. Family History - If there’s a family history of hypertension, there’s an increased likelihood of developing PIH. In these cases, high blood pressure may persist even after pregnancy, evolving into chronic hypertension. Chronic Hypertension - High blood pressure that existed before pregnancy or that appears earlier than 20 weeks of gestation is called chronic hypertension. - This is not pregnancy-induced because the condition pre-dates the pregnancy or develops earlier than typical PIH onset. It also requires long-term management even beyond the postpartum period. Three Important Signs 1. Proteinuria - Presence of protein in the urine, indicating kidney damage or dysfunction caused by high blood pressure. - Proteinuria is a key diagnostic marker for preeclampsia, a severe form of PIH. 2. Edema - Swelling, especially in the hands, face, and legs, due to fluid retention caused by poor circulation and increased pressure in blood vessels. - While some swelling is normal during pregnancy, significant or sudden swelling is concerning. 3. Hypertension - Persistent elevation of blood pressure above 140/90 mmHg. - This is the primary feature of PIH and can lead to complications if left untreated. Primigravida (Young Mothers) as the Number One Predisposing Factor - Refers to a woman experiencing her first pregnancy. - Why High Risk  o The body encounters pregnancy hormones like hCG (human chorionic gonadotropin), hPL (human placental lactogen), and fetal cortisol for the first time. o In some cases, the body reacts abnormally, leading to massive vasoconstriction, which increases blood pressure. Multipara or Advanced Age - Refers to women who have had two or more pregnancies. - Why High Risk o Advanced maternal age (35+ years) is associated with arteriosclerosis (hardening of arteries), making blood vessels less elastic. o This leads to an increased likelihood of hypertension during pregnancy. Medication: Hydralazine (Apresoline) - Drug of Choice (DOC): Hydralazine is commonly used to lower blood pressure (antihypertensive) in pregnant women with severe hypertension. - Mechanism: It works by converting vasoconstriction (narrowing of blood vessels) into vasodilation (widening of blood vessels), reducing blood pressure and improving blood flow to the placenta. Protein in the Diet - Slightly High Protein Diet o A diet with slightly high protein diets supports the body’s increased metabolic demands during pregnancy and helps repair tissues affected by PIH. Main Goal: Promote Safety During Pregnancy, Labor, and Delivery - Regular monitoring of blood pressure, urine protein levels, and fetal growth. - Educating the mother about warning signs like severe headaches, visual disturbances, or sudden swelling. - Safe delivery planning, sometimes involving early induction or cesarean section if needed to protect the mother and baby. Types 1. Gestational Hypertension (GHPN) - High blood pressure (≥140/90 mmHg) that develops early in the 20th week or 5th month of pregnancy or above without signs of proteinuria or edema. - Blood pressure is manageable with proper care. 2. Preeclampsia - High blood pressure (≥140/90 mmHg) that begins early in the 20th week or 5th month of pregnancy or above and is accompanied by proteinuria (≥300 mg protein in 24-hour urine) or edema. - May also include symptoms like severe headache, visual disturbances, and edema. 3. Eclampsia  - A severe progression of preeclampsia marked by seizures that are not caused by any neurological condition and is accompanied by proteinuria (≥300 mg protein in 24-hour urine) or edema. - Begins early in the 20th week or 5th month of pregnancy or above. 4. Chronic Hypertensive Disease - High blood pressure (≥140/90 mmHg) that preexists before pregnancy or is diagnosed before the 20th week of gestation. - Indicates pre-pregnancy hypertension. - May worsen during pregnancy or lead to superimposed preeclampsia. - Requires careful monitoring throughout pregnancy. Mild Preeclampsia - Blood Pressure: 140/90 to less than 160/110 mmHg. - Proteinuria o Urinalysis: +1 to +2. o 24-Hour Protein in Urine: 300 mg to less than 500 mg. - Edema o Mild to moderate swelling, sometimes noticeable in the hands (e.g., tightening of a wedding ring). o Lower Extremities (LE) Indentation Grading § +1: 2 mm indentation. § +2: 4 mm indentation. § +3: 6 mm indentation. § +4: 8 mm indentation. (x 2 the positive indention) o Edema Nail Test § +1: 1/4 of the nail submerged. § +2: Half of the nail submerged. § +3: 3/4 of the nail submerged. § +4: Entire nail submerged. Severe Preeclampsia - Blood Pressure: 160/110 mmHg or higher. - Proteinuria o Urinalysis: +3 to +4. o 24-Hour Protein in Urine: 500 mg or higher. - Edema o Generalized edema, including facial edema.  o Indentions and nail submersion similar to the grading system above, with more pronounced swelling. Eclampsia - Blood Pressure: 160/110 mmHg or higher. - Proteinuria: o Urinalysis: +3 to +4. o 24-Hour Protein in Urine: 500 mg or higher. - Edema: Generalized edema. - Seizures: Presence of seizures unrelated to any neurological condition marks progression to eclampsia, making it a medical emergency. Predisposing Factors 1. Hormonal Changes and Vasoconstriction - Exposure to New Hormones o Pregnancy introduces hormones like hCG, hPL, and fetal cortisol, triggering vasoconstriction (narrowing of blood vessels). o This leads to § Reduced blood flow throughout the body. § The heart compensates by working harder, increasing its pumping action, which results in elevated blood pressure (hypertension). 2. Renal Blood Supply and Proteinuria - Vasoconstriction → Renal Hypoxia o Reduced blood flow to the kidneys causes renal hypoxia (lack of oxygen). o Damage to the glomeruli (tiny kidney filters) increases glomerular permeability, allowing protein to leak into the urine (proteinuria). - Protein Loss and Edema o Proteins in the blood attract water, maintaining fluid balance between compartments (intravascular and interstitial). o Loss of protein in urine lowers intravascular protein levels, causing fluid to shift from blood vessels (intravascular) into tissues (interstitial), leading to edema. 3. Hepatic Blood Supply and Epigastric Pain - Vasoconstriction → Hepatic Hypoxia o Decreased blood flow to the liver results in hepatic hypoxia and inflammation of liver tissue. This causes epigastric pain, a classic sign of liver involvement and a warning of an impending seizure. 4. Cerebral Hypoxia and Neurological Symptoms - Vasoconstriction → Cerebral Hypoxia  o Reduced oxygen supply to the brain leads to § Severe headache: Pounding, unrelenting (persistent), excruciating, and resistant to analgesics. § Visual disturbances: Blurring or flashing lights. § Hyperactive reflexes: Increased sensitivity in neurological exams. o These symptoms are warning signs (auras) of an impending seizure. o Among these, epigastric pain often appears earliest. 5. Uteroplacental Insufficiency (UPI) - Inadequate blood flow to the uterus and placenta, leading to poor oxygen and nutrient delivery to the fetus. - Complications o IUGR (Intrauterine Growth Restriction): Fetal growth is restricted, leading to a small-for-gestational- age (SGA) baby. o Fetal Distress: Signs of fetal oxygen deprivation. o Increased Uterine Irritability: The uterus may contract abnormally. o Abruptio Placenta: Premature separation of the placenta, a life-threatening emergency for both mother and baby. Two Types of Intrauterine Growth Restriction (IUGR) 1. Chronic IUGR - Cause: Chronic hypertension or early vasoconstriction during the first trimester. - Timing: Occurs early in pregnancy, affecting fetal development during the initial stages. - Characteristics o Fetus is small but proportional (all parts of the body are uniformly small). o The brain size is also small, which increases the risk of mental retardation and long-term developmental delays. - Risks: This type is more dangerous because it affects critical stages of organ and brain development. 2. Sub-Acute IUGR - Cause: Develops later in pregnancy, typically during the 7th or 8th month. - Timing: Fetal growth was initially normal but slows or stops later in pregnancy. - Characteristics: o The fetus has an unproportional body (thin or wasted appearance due to loss of fat and muscle mass). o The brain size remains normal, so the risk of mental retardation is lower. - Risks: May lead to complications during delivery but is generally less dangerous than chronic IUGR. Triad Signs 1. Hypertension  - Persistently elevated blood pressure, indicating increased cardiac workload due to vasoconstriction. 2. Proteinuria - Protein leakage into urine caused by kidney damage (glomerular permeability). 3. Edema - Swelling caused by fluid shifting into interstitial spaces due to low protein levels in the blood (secondary to protein loss). o All are increasing - Primarily due to protein loss (hypoproteinemia), which reduces oncotic pressure, leading to fluid retention in tissues. - Commonly observed in the lower extremities but can progress to generalized edema. - Slightly High Protein Diet: To compensate for protein loss and maintain oncotic pressure, a diet slightly higher in protein is recommended. - No Total Sodium Restriction: A complete sodium restriction is avoided because it may lead to fluid and electrolyte imbalances, which can worsen the mother’s condition. Sodium intake should be moderate, enough to prevent fluid overload while avoiding deficiencies. Management: Pharmacological Approach A. Hydralazine (Apresoline) - Purpose: First-line antihypertensive due to its vasodilating effects. - Mechanism: Relaxes vascular smooth muscles, reducing peripheral resistance and lowering blood pressure. B. Magnesium Sulfate (MgSO₄) - Purpose: Drug of choice (DOC) for seizure prophylaxis and management (anticonvulsant). - Administration o Loading Dose: 6–10 g administered via IV or IM (as prescribed). o Special Considerations § Light Sensitivity: Ampule is brown to protect it from light; avoid storing in direct sunlight. § IM Injection Z-track technique: Prevents irritation of the subcutaneous tissue and backflow of magnesium sulfate from muscle to subcutaneous layers. Site: Administer in a large muscle mass (e.g., dorsogluteal in the upper outer quadrant of the buttock). Needle Technique: Hold skin taut and twist during administration to ensure proper placement. o Dosage Note: 1 g = 1 ml. - Actions o Central Nervous System (CNS) Depressant: Reduces CNS irritability to prevent seizures.  o Decreases Neuromuscular Irritability: Stabilizes overactive nerve impulses, further reducing seizure risk. - Monitoring Parameters (Before Second Dose) and Signs of Hypermagnesemia Toxicity o Deep Tendon Reflexes (DTR) § Earliest sign of hypermagnesemia toxicity is decreased reflexes or hyporeflexia. o Respiratory Rate (RR) § Hold the drug if RR drops below 12 breaths per minute (indicates bradypnea or apnea). § CNS related o Urinary Output (UO) § Monitor for oliguria (500mL. o After C-Section (CS): >1000mL. - Check o For vaginal bleeding or pad saturation. o After CS, check vaginal or abdomen surgical wound dressing for any signs of bleeding. Categories of Postpartum Bleeding 1. Early PPH (Within 24 hours postpartum) - Causes: Uterine atony, lacerations, and retained placental fragments. 2. Late PPH (Beyond 24 hours postpartum) - Causes: Subinvolution, particularly from puerperal sepsis. Causes of Postpartum Bleeding 1. Uterine Atony - Uterine atony occurs when the uterus does not contract effectively after delivery, leading to postpartum hemorrhage. - Most Common Predisposing Factor o Overdistension of the uterus: This can be caused by multiple pregnancies, large for gestational age (LGA) infants, polyhydramnios, or malpresentation (such as breech or transverse positions) multiple pregnancies. o Lower uterine segment overdistension may result to possible uterine rupture - Prolonged labor (exceeding 24 hours) o Hypotonic uterine contractions (weak or ineffective contractions). o Prolonged use of oxytocin (for inducing or augmenting labor) can contribute to uterine atony. o Sources of power are contraction and pushing. o Maternal exhaustion from prolonged or intense labor, which leads to ineffective contractions. - Precipitous labor (less than 3 hours). o Precipitate has hypertonic contraction so do not push. Do panting only. - Prolong and precipitate leads to fetal distress. CS if there are signs of fetal distress. - Cesarean section (C-section) can contribute to uterine atony postpartum due to the effects of anesthesia and uterine manipulation.  - Grand multiparity (e.g., G8P7) weakens the myometrium over time, making it more prone to atony. Must be hospital-bound. 2. Retained Placental Fragments - Normal placental separation (Schultz) should occur from the center to the periphery. - Retained fragments may occur if the placenta separates in a Duncan pattern (from the periphery to center separation). - Check: Inspect the back of the placenta to ensure all cotyledons are intact. 3. Lacerations - Risk factors o LGA (Large Gestational Age) babies o Macrosomia (very large babies) o Hypertonic uterine contractions (strong, ineffective contractions) o Improper pushing technique (too forceful pushing) o Forceps delivery o Fundal pushing o Malpresentation (e.g., breech presentation) Symptoms and Management 1. Uterine Atony - Signs/Symptoms: The uterus is relaxed, with dark red blood accumulating inside the uterus. - Management o Massage the uterus (except after a C-section due to the surgical wound). o No early ambulation due to active bleeding. o Bladder emptying to prevent displacement of the uterus. o Breastfeeding can help release oxytocin from the posterior pituitary gland, aiding in uterine contraction. o If irreversible, consider hysterectomy to control bleeding. 2. Retained Placental Fragments - Signs/Symptoms: The uterus is initially contracted but eventually relaxes, with dark red bleeding from the uterus. - Management o Dilation and Curettage (D&C) or manual exploration of the uterus to remove retained placental fragments. o Use the same medications as for uterine atony (antibiotics, analgesics, anti-inflammatories). o Monitor the postpartum discharge (lochia) for changes § Rubra (bright red): immediate postpartum.  § Serosa (pink or brownish): after a few days. § Alba (white or yellowish): after one to two weeks. 3. Lacerations - Signs/Symptoms: The uterus is contracted, but there is bright red blood from the birth canal. - Management o Repair and suturing by a doctor to fix any lacerations. o Administer antibiotics to prevent infection, analgesics for pain relief, and anti-inflammatory medications. o Provide pericare (care for perineal hygiene) to prevent infection.  NEONATAL HYPOGLYCEMIA - A sudden drop in the baby's glucose supply after birth can lead to neonatal hypoglycemia, characterized by lethargy and tremors. - Normal blood glucose levels in newborns: 40 to 60 mg/dL. o If the blood glucose is 40 mg/dL, administer breastmilk as it is within normal limits (WNL) and helps maintain stable glucose levels. § Avoid water (which can cause hypoglycemia) and excessive oral glucose (which may cause hyperglycemia). o If the blood glucose is 35 or 36 mg/dL, assess the newborn's ability to suck: § If the Apgar score is 7 (minimum normal) and the sucking reflex is present, give oral glucose solution. § If the Apgar score is 5, administer glucose intravenously.  NON-STRESS TEST AND CONTRACTION STRESS TEST 1. Non-Stress Test (NST) Purpose - To assess the reaction of the fetal heart rate (FHR) to fetal activity. - Performed between the 30th to 32nd week of pregnancy. - Do not stress the baby. Normal Result - Reactive: FHR increases by 15 bpm from the baseline during a 10-minute window of fetal activity. o A positive result in the context of a Non-Stress Test (NST) means FHR acceleration, indicating that the fetal heart rate increased by at least 15 bpm from the baseline in response to fetal movement. This is a reactive and normal finding, suggesting that the baby is not under stress. Preparations (for a 9:00 AM test) - 8:30 AM: The mother should already be at the hospital. o Ensure the baby is awake by instructing the mother to eat breakfast before leaving home (increased glucose supply wakes the baby). o If the mother did not eat, give juice at the hospital to boost glucose levels quickly. - Allow the mother to rest for 30 minutes. - Before 9:00 AM o Check vital signs (VS), especially BP. o Determine the baseline FHR (e.g., 140 bpm). Procedure - Position the mother in a left lateral or semi-Fowler’s position. - Attach the external fetal monitor over the fundus. - Provide the mother with a call bell or buzzer, and instruct her to press it when she feels fetal movement. Monitoring Fetal Movement - 9:00 AM: If the mother presses the call bell, monitor FHR for 10 minutes. - If the baby does not move (e.g., no buzzer by 9:10 AM or 9:20 AM), the baby might be sleeping. o Use a bell or a high-frequency sound (e.g., ringtone) above the abdomen to wake the baby. - Once the baby moves, monitor FHR for 10 minutes and compare to the baseline. Results Interpretation - Reactive: FHR increases by 15 bpm or more. Example: Baseline 140 bpm, second FHR should be at least 155 bpm. - Non-Reactive: If FHR increases by less than 15 bpm, wait another 10 minutes and test again. o If still non-reactive, suspect fetal distress, and proceed with a Contraction Stress Test (CST) to further assess fetal well-being.  2. Contraction Stress Test (CST) Purpose - To assess the fetal heart rate (FHR) response to uterine contractions. - Done between the 34th to 36th week of pregnancy. - Stress baby contraction. Normal Result - Negative: No FHR deceleration in response to uterine contractions, indicating that the baby is tolerating contractions well. Abnormal Result - Positive: FHR deceleration occurs with contractions, which is abnormal and suggests fetal distress, indicating that the baby may not tolerate labor well. Preparations (for a 9:00 AM test) - 8:30 AM: The mother arrives at the hospital and rests for 30 minutes. - Provide a hospital gown and ensure privacy. - Obtain vital signs (VS), including BP, and baseline FHR (e.g., 140 bpm). - Position the mother in a left lateral or semi-Fowler's position. - Instruct the mother to perform self-nipple rolling on both nipples for 10 minutes to stimulate uterine contractions. - Ensure the contractions are mild and do not affect FHR. The goal is for the FHR to remain normal without any deceleration. Interpretation - After 10 minutes of nipple rolling o If FHR is 110 bpm, it is abnormal because a decrease in FHR, even without labor, suggests that mild contractions can already cause a drop in FHR. This could lead to fetal distress during actual labor. o If FHR decelerates below 100 bpm, it indicates more significant fetal distress. o Prolonged nipple rolling beyond 10 minutes may cause moderate to strong contractions, potentially resulting in rupture of membranes. - When explaining to the patient, focus on the contractions induced by the CST and how they affect the fetal heart rate (FHR), rather than emphasizing the nipple rolling technique used to trigger the contractions. The key point is that the contractions from the CST are intended to mimic the stress of labor, and it is the contraction intensity and its impact on FHR that is most important, not the method of stimulation (nipple rolling). Make sure the patient understands that actual labor contractions are stronger and can cause more significant FHR changes, which could indicate fetal distress. Management - Positive CST: A positive result requires Caesarean Section (CS) due to fetal distress risk.  - CST cannot be done at home because it may lead to premature rupture of membranes. Example Scenario - If the CST at 34 weeks is positive, indicating fetal distress, a scheduled CS is planned. - The test may be repeated at 35 weeks. If negative, the result is normal, and a normal spontaneous delivery (NSD) is considered. - At 36 weeks, another negative CST confirms NSD, but a double setup is prepared (both OR and DR) in case the situation changes during labor. o If fetal distress signs are not observed during labor, the OR setup is cancelled, but the anesthesiologist is still compensated for being on standby, even if only the DR is used.  ULTRASOUND AND AMNIOCENTESIS 1. Ultrasound (UTZ) Purpose - For visualization of the uterus, placenta, fetus, and amniotic fluid. - Non-invasive procedure requiring no puncture. Preparation - Increase fluid intake (OFI) to improve visualization. - Administer a maximum of 1.5L of water. - Give 1 cup (240 ml) of water every 15 minutes starting 1½ hours prior to the ultrasound. - Total intake: 6 cups (1,140 ml). Indications for Increased OFI - Necessary for pregnancies less than 20 weeks (5 months). - At 5 months, the fundus is at the umbilicus (Bartholomew's rule). - Before 5 months or in cases of Small for Gestational Age (SGA) or reduced amniotic fluid, OFI is required to improve imaging. - Polyhydramnios and multiple pregnancy can cause the pregnancy to appear larger than expected for gestational age, such as at the 5th month appearing to be at the 7th month due to excessive amniotic fluid and the presence of more than one fetus. Uses - Locate the placenta. - Determine the number of babies. - Assess size of the baby. - Measure the amount of amniotic fluid. - Assess calcium deposits at the placenta base (important at 7th month due to calcium transfer from mother to baby for bone ossification). o Leg cramps (pulikat) may occur due to low calcium stores in the mother before pregnancy. Fetal Assessment - Determine the lie (longitudinal, transverse, or oblique). - Assess position (e.g., cephalic or breech). - Identify presentation (part of the fetus closest to the cervix). - Evaluate fetal attitude (degree of flexion or extension of the fetal body). 2. Amniocentesis Purpose - Aspiration of amniotic fluid to detect o Chromosomal defects  o Neural tube defects o Alpha-fetoprotein levels (can also be tested in maternal blood). o Fetal lung maturity through the Lecithin-to-Sphingomyelin (LS) ratio in surfactant, which should be 2:1 for maturity. Procedure Characteristics - Invasive and involves puncture of the lower abdomen near the bladder. - Requires informed consent due to the risks involved. Preparation - Bladder emptying is necessary to avoid injury during the procedure. - Use a French catheter (orange, size 14–16) for bladder emptying. Procedure Details - Only 15–30 ml of amniotic fluid is aspirated for testing.  MEASUREMENT EQUIVALENTS Volume Conversions 1. 1 tsp = 5 ml 2. 1 tbsp = 15 ml, 3 tsp 3. 1 oz = 30 ml, 2 tbsp or 6 tsp 4. 1 cup = 240 ml, 8 oz 5. 1 pint = 480 ml, 2 cups or 16 oz 6. 1 dram = 5 ml or 1 tsp Drop Conversions 1. 1 ml = 60 microdrops or 15 macrodrops 2. 1 macrodrops = 4 microdrops Weight and Volume Equivalents 1. 1 ml = 15 minims or 1 g - ml is for volume, g is for weight 2. 1 kg = 1 L  INDUCTION AND AUGMENTATION OF LABOR Definitions - Induction: The process of forcing labor to start intentionally, typically when labor has not begun by the 9th month or in cases like post-term pregnancy. - Augmentation: Assisting labor that has already begun but is progressing slowly or ineffectively, often due to hypotonic uterine contractions. Prolonged labor caused by hypotonic uterine contractions. Medications - Oxytoxic drugs, such as Pitocin (10 units IV), to stimulate contractions. Indications - Number 1 indication for induction: Post-term pregnancy (beyond 42 weeks). Bishop Scoring - Purpose: Evaluates cervical readiness for labor induction and augmentation. - Five parameters, each scored from 0 to 3. 1. Cervical Dilatation (Highest: 3) - 0: Not dilated - 1: 1 to 2 cm - 2: 3 to 4 cm - 3: 5 to 6 cm 2. Cervical Effacement (Highest: 3) - 0: 0–30% - 1: 40–50% - 2: 60–70% - 3: ≥80% 3. Fetal Station (Highest: 3) - 0: -3 - 1: -2 - 2: -1 to 0 - 3: +1 to +2 4. Cervical Consistency (Highest: 2) - 0: Firm - 1: Medium - 2: Soft 5. Cervical Position (Highest: 2) - 0: Posterior (external OS facing backward) - 1: Middle  - 2: Anterior Interpreting Bishop Score - Highest possible score: 13 - Minimum score for induction: 8 o ≥8: Labor can proceed. Start IV incorporation Pitocin (10 units). o 5h, notify OB 1. Cervical Dilatation: x - Degree o Primigravida: 1cm/hr o Multigravida: 1.5-2cm/hr § In the partograph, the degree of cervical dilation is expected to progress at a rate of 1 cm per hour, regardless of whether the patient is a primigravida or multigravida. 2. Descent of Head: o 3. Contractions per 10 Minutes - Progress or improved to… - Shaded: more than 40 seconds - Diagonal: 20-40 seconds - Dots: 20 seconds Maternal Parameters 10U 30-31gtts/min D5LR 36.5 1 1. Oxytocin 2. Drugs given and IV fluids 3. Pulse 4. BP 5. Temperature 6. Urine: how many times?  SIMPLE PARTOGRAPH - Latest go, normal warning danger alert action normal abnormal abnormal X X X X 8 9 10 11 12 1 2 3 + + + ++ I I C C 2 2 3 3 145 140 145 150 0 0 0 0 36.5 36.5 36.5 36.5 80 80 80 85 110/70 110/70 110/70 110/70 4 5 6 7 normal Q2 Q4 (original progress of schedule) labor improved, 2cm dapat, so 2 cm delayed, 2 kulang kasi 1cm hours Amniotic Fluid lang nadagdag = ALERT delayed due to no urine - CIMBA problem: progress of o C: Clear labor (cervical dilatation and uterine o I: Intact contractions) o M: Meconium o B: Bloody o A: Absent Vaginal Bleeding - 0: None - +: Mild - ++: Moderate - +++: Strong, heavy, profuse Nursing Responsibilities if no Urine is Excreted 1. Stimulate 2. Catheter  - To promote fetal descent, empty the bladder. Nursing Responsibilities at Alert 1. Notify the doctor. 2. NPO for food but not fluid. 3. Contact CEMONC 4. Prepare referral letter: Done by the doctor of who will refer. 5. Prepare emergency transport service - Ambulance - Transport patrol - ✅ Gas - ❌ Alcohol - Notify the driver 6. Perform bladder emptying. 7. Continue monitoring mother and baby. Nursing Responsibilities at Action 1. Transport to CEMONC together with the doctor and nurse. BEMONC (Basic Emergency Obstetric and Newborn Care) and CEMONC (Comprehensive Emergency Obstetric and Newborn Care) - BEMONC o Costs 250,000 to less than 500,000 pesos. o Provides basic life-saving care. o Includes procedures like management of normal labor, assisted vaginal delivery, administration of oxytocics, prevention and treatment of infections, newborn resuscitation, and basic neonatal care. o Does not include cesarean sections or advanced neonatal care. o ❌ Operating room o ❌ Blood bank - CEMONC o Costs more than 500,000 pesos. o Provides a more advanced level of care compared to BEMONC. o Includes all BEMONC services and adds more complex procedures like performing cesarean sections, blood transfusions, and the ability to handle more severe maternal and neonatal complications. o Has facilities for neonatal intensive care and more specialized interventions. o ✅ Operating room o ✅ Blood bank