Maternal and Child Care Nursing PDF

MATERNAL AND CHILD CARE NURSING 5 BRANCHES OF MATERNAL HEALTH  Nutrition OUTLINE...

MATERNAL AND CHILD CARE NURSING 5 BRANCHES OF MATERNAL HEALTH  Nutrition OUTLINE  The development of the baby depends on what I. Course Description the mother eats II. Prenatal Care  Prenatal Care III. Diagnostic and Laboratory Examinations  For the safety of the delivery of the baby IV. Medical Complications During Pregnancy  For the management and treatment of detected birth defects and other untowards complication COURSE DESCRIPTION  Safe Delivery  Breastfeeding  This course deals with the concept of disturbances and  Optional; depends on the mother’s perspective pre-existing health problems of pregnant women and the and level of understanding pathologic changes during intrapartum and postpartum  Family Planning periods.  Average gap of first pregnancy to succeeding COURSE OBJECTIVES pregnancy: 2-3 years At the end of the course, given actual or simulated situations/conidtions involving indiviudal client (mother, newborn baby, children) and family at risk/with problem, the student will be able to: 1. Utilize the nursing process in the holistic care of client for the promotion and maintenance of health in community and hospital settings 2. Assess with client his/her health condition and risk factors affecting health 3. Identify actual/risk nursing diagnosis 4. Plan with client appropriate interventions for identified problems 5. Implement with client appropriate interventions for identified problems 6. Evaluate with client the progress of their condition and Fig. 2 Breastfeeding Mnemonics outcomes of care PRENATAL CARE PRENATAL CARE 1. Regular prenatal care increases the chances of a healthy  The purpose of prenatal care is to ensure an mother and child after birth uncomplicated pregnancy and the delivery of a live and  Prenatal check up should be completed healthy infant 2. Early detection of congenital and birth defects  Problem arises even before conception if the mother has  Through ultrasound as early as 8 weeks, then 20 any pre-exisitng health conditions weeks, then 38-36 weeks (to check if umiikot si BALANCES OF FORCES IN PREGNANCY baby, if breech position, if there’s any problem with fetal development, etc)  “Pag buntis ang babae, ang isang paa niya ay nasa 3. Prenatal immunization can prevent mother-to-child hukay.” Giving birth is a matter of life and death. transmission  Anti-tetanus and vitamin A  Tetanus Toxoid – 5 doses for lifetime immunity; will reach the baby since it circulates in the blood Fig. 1 Balances of Forces in Pregnancy 1 BULAWAN, CIVILES, DONALVO, GAGARRA, OBEJERO, ROMARATE, SANTOS BSN 2D  DOH STANDARDS FOR PRENATAL CARE HIGH RISK PREGNANCY 1. Weight  Poor maternal or fetal outcome due to:  There should be a 5 pounds increase in the mother’s  Medical weight every week  Reproductive  To ensure if weight gain is equal to the expected weight  Psychosocial gain of a pregnant woman (weight gain of fetus, placenta,  Obstetrical amniotic fluid) DIAGNOSTIC AND LABORATORY EXAMINATIONS 2. Height  For management and appropriate nursing care if patient 3. Blood Pressure has an abnormal result  Methyldopa is always the drug of choice COMPLETE BLOOD COUNT 4. FHT  Evaluate if the baby if baby is still alive and its movement  Hemoglobin – 120-160; 12-16 (female); 12-18 (male)  Audible in 5 months/20 weeks  Hematocrit – 36% - 48%  Leukocyte – 4-11 5. Fundic Height  Thrombocytes – 350,000 – 450,000/350-450  Symphysis pubis to the fundus  Blood Typing – a, b, ab, o 5th month 20 cm  Rhesus Factor – Rh (+) or (-) 6th month 21-24 cm  Erythrocytes – RBC: 4.5 – 6 7th month 25-28 cm What Does Low Hematocrit Mean? 8th month 29-30 cm 9th month 30-34 cm  Sickle cell anemia  RBC is cresent-shaped 6. Leopold’s Maneuver  There aren’t enough healthy RBC to carry  are non-invasive method of assessing fetal presentation, oxygen throughtout the body position, and attitude. This technique can also be used to  Leukemia locate the fetal back before applying the fetal monitor  Low WBC 1. Fundal grip – fetal presentation 2. Umbilical grip – fetal position (back and extremities)  Hemolytic anemia 3. Pawlick’s grip – engagement (relationship to ischial  Ruptured RBC spine)  Iron, Folate, or Vitamin b12 Deficiency 4. Pelvic grip – fetal attitude (degree of fetal position)  Influence the production and formation of RBC  Ex. good attitude; flexion (neck is flexed) = Anemia if kulang  vertex presentation – neck is flexed,  Bone marrow disease chin is touching the chest  Unable to produce healthy blood  cephalobregmatic position – maganda  Chronic inflammatory disease ang vertex; perfect for NSVD  An organ swells when there is inflammation 7. TT Immunization which causes the capillaries to dilate. The capillaries will eventually rupture, causing Tetanus Toxoid When to Give bleeding and a low hematocrit.Internal bleeding TT1 Anytime during pregnancy  Low platelet TT2 4 weeks after TT1  Kidney failure TT3 6 months after TT2  Erythropoietin (released by kidney) stimulates TT4 1 year after TT3 bone marrow to produce blood TT5 1 year after TT4  Kidney failure = no stimulation to produce healthy blood since walay erythropoietin 8. Diet  Lymphoma  If possible: adquate calorie, low carbs, more protein  Cancer on the lymphatic vessel (fluid and blood (muscle and bone development of baby) becomes trapped) 9. Danger Signs of Pregnancy What Does a High Hematocrit Mean?  Assess: elevated blood sugar, unusual bleeding, premature uterine contraction, hypertension, PROM,  Polycythemia Vera dizziness, headache  Poly – madami; cythemia - cell and blood = maraming cell sa blood 10. Breastfeeding  Excessive increase of RBC, WBC, and platelet  Unang Yakap  Kidney tumor  Edema formation = more fluids and plasma 11. Family Planning  Congenital heart disease  Left side, right side shunting 12. Postpartum Care 2 BULAWAN, CIVILES, DONALVO, GAGARRA, OBEJERO, ROMARATE, SANTOS BSN 2D  Dehydration Transvaginal ultrasound  More water = More hematrocrit = Excessive vomiting  A probe is inserted inside the vagina  Excessive Diarrhea may lead to dehydration that makes our haematocrit high due to the loss of plasma  Lung disease  pneumonia, lung disease that causes increase in hematocrit URINALYSIS  Pus cells -  Bacteria –  Protein/albumin – PIH (if +)  +1, +2, +3, +4 (highest, boiled egg)  Sugar – GDM - (-) glucose = no GDM Fig. 5 Transvaginal ultrasound - (+) glucose = GDM BLOOD GLUCOSE TEST  Squamous epithelial cells - normal  FBS PAP SMEAR  100-120 mg/dl  HGT/CBG  Check cervical secretion  80-120 mg/dl  Get sample for cervical biospy  OGTT  Get smaple for STI  Oral Glucose Tolerance Test  Get sample to check for RBOW or LBOW  OGCT  Oral Glucose Challenge Test  2 hrs. Post Prandial Additional Notes: OGTT  Needs flavored juice 75g sugar  Blood is extracted prior the test (1). Patient drinks the juice after obtaining the first sample. Blood is extracted again after 1 hour (2). This is done 2 more times with 1 hour interval each (3 then 4).  Blood is extracted 4 times.  First extraction: baseline  Result: 2/3 elevated result = GDM Fig. 3 Pap smear  OGTT and OGCT difference: gram of juice OGCT ULTRASONOGRPAHY  Needs flavored juice 50g sugar  Done to check baby’s status inside, bag of water, fetal  Blood is extracted prior the test (1). Patient drinks features, heart rate, placenta the juice after obtaining the first sample. Blood is Transabdominal ultrasound extracted again after 2 hours (2).  Blood is only extracted twice  Over the fundus or abdomen Fig. 4 Transabdominal ultrasound 3 BULAWAN, CIVILES, DONALVO, GAGARRA, OBEJERO, ROMARATE, SANTOS BSN 2D  AMNIOCENTESIS  Aspiration of bag of water  To detect congenital anomalies, trisomy problem, fetal defects Fig. 8 Anencephaly Fig. 9 Gastroschisis Fig. 6 Amniocentesis Fig. 10 Spina bifida CHORIONIC VILLI SAMPLING DOPPLER VELOCIMETRY  Check for possible problem/defect  uses ultrasound to check blood flow in the umbilical cord or between the uterus and the placenta  To see the contractions if the waves are strong while the baby is inside the mother’s womb. Fig. 7 Chorionic Villi Sampling MATERNAL ALPHA-FETO PROTEIN  To checks the level of AFP in a pregnant woman's blood  AFP – substance made in liver of fetus  Detect neural tube defects  Spina bifida  A condition that affects the spine and is usually apparent at birth. It is a type of neural tube defect (NTD). Spina bifida can happen anywhere along the spine if the neural tube does not close all the way.  Anencephaly Fig. 11 Doppler Velocimetry  The absence of skull  Gastroschisis PERCUTANEOUS UMBILICAL BLOOD SAMPLING  Intestines are found outside the body  They go straight to NICU and is scheduled for  Cordocentesis, also known as percutaneous umbilical surgery for their stomach to be close in order for blood sampling, is a diagnostic prenatal test. During them to survive. cordocentesis, an ultrasound transducer is used to show the position of the fetus and umbilical cord on a monitor. Then a fetal blood sample is withdrawn from the umbilical cord to test for fetal disorders 4 BULAWAN, CIVILES, DONALVO, GAGARRA, OBEJERO, ROMARATE, SANTOS BSN 2D  Hepatitis B Antigen (HBSAg)  Reactive – positive  Patient should be isolated  Nurses should double glove  Non-reactive – negative  Patient can stay in the labor room Hepatitis B Antibodies (HBSAb)  Test that looks for antibodies that your immune system makes in response to the surface protein of the hepatitis B virus.  Qualitative – reactive, non-reactive  Quantitative – with values (eg. 120 mg/dl interferes with normal embryonic development  Sign: hot and dry (skin, lips) the sugar is high ALCOHOL  Give Regular Insulin SQ  Hypoglycemia: CBG< 80 mg/ dl  CNS Depressant  Sedation  Signs: Cold & clammy need some candy  Reduce Anxiety  Respiratory Depressant  Give D50 water 50 ml IVTT Alcohol Effects on Fetus Additional Notes:  Fetal Alcohol Syndrome (FAS) How to Convert mg/dl To mmol/L? FAS Facial Characteristics Epicanthal Folds Upturned nose  CBG normal values: 80-120 mg/dl Small eye openings Smooth philtrum  Normal values: 4.44-6.66 mmol/L Flat mid face Thin upper lip  Formula: CBG results/18 o Eq. 120/18= 6.66 mmol/L = Normal  Intrauterine Growth Restriction o 200/ 18= 11.11 mmol/ L = high =  There is a decrease tissue perfusion which is the Hyperglycemia flow of blood or uteroplacental insufficiency because it interfere the growth and development HOW TO DEAL WITH GESTATIONAL DIABETES of the fetus that leads to an early delivery or early DURING PREGNANCY delivery  Preterm Delivery  Monitor blood sugar level regularly  The placenta would early separate from the  Sleep well uterine cavity because tissue perfusion isn’t good due to the teratogenic effect of alcohol that leads  Eat the right carbohydrates to preterm labor or preterm delivery once it detach  Eat a healthy breakfast from the uterine call  Take prescribed medicine as directed  Drink cinnamon tea  Opt for a sugar free diet 10 BULAWAN, CIVILES, DONALVO, GAGARRA, OBEJERO, ROMARATE, SANTOS BSN 2D  Fig. 5 Drug of Abuse Effects on the Fetus Stimulants Effects on Fetus  Preterm labor  Vasoconstriction less amount of blood flow to the fetal circulation fetal distress preterm labor  Labor than happens before term  Spontaneous abortion  Placeta abruptio  Fetal hypertension NICOTINE Fig. 3 & 4 FAS Facial Characteristics  Found in cigarettes Effects of Smoking TYPES OF TERATOGENS  Higher rates of spontaneous abortion OPIOIDS  Placenta previa  Preterm labor  Morphine  Low birth weight infant  Heroin  Disruption of blood flow to fetal circulation  Methadone  Fetal pulmonary hypertension  Analgesics o Ex. Mefenamic acid MARIJUANA STIMULANTS  Relaxant  Cocaine  Hallucination  Amphetamine  Short term memory loss  Ecstasy  Low birth weight infant  Caffeine LIFETIME EFFECTS OF SUBSTANCE ABUSE Effects of Stimulants  Mental retardation  Increase concentration  Physical deformities (FAS)  Alertness  Developmental problems  Paranoia  Hypertension  Stimulants can cause vasoconstriction  Psychosis Drug of Abuse Effects on the Fetus  Embryonic stage: o Teratogenic  Fetal Development Stage: Fig. 6 Baby born with severe defect due o Abnormal Growth to mother’s drug abuse o Alteration in neurotransmitters and receptors o Brain organization o Altered delivery of substrates/Nutrients 11 BULAWAN, CIVILES, DONALVO, GAGARRA, OBEJERO, ROMARATE, SANTOS BSN 2D  TERATOGENS: DRUGS HIV/AIDS  Prescription: Thaldomide (nausea), Valium WHAT IS HIV? (Tranquilizer), Accutane (Acne), Streptomycin & tetracycline (antibiotics), artificial hormones  Human Immunodeficiency Virus (HIV) is a virus that attacks cells that help the body fight infection  Caffeine: Increased rate of Spontaneous abortion and low birth weight  There’s no cure, but it is treatable with medicine  Marijuana: Low birth weight, premature delivery; infant PATHOPHYSIOLOGY OF HIV/AIDS startle more readily, have tremors, and experience sleep cycle problems  Caused by the human immunodeficiency virus o Retrovirus – single strand RNA virus that  Cocaine: More likely to be stillborn or premature, have replicated via reverse transcription low birth weight, have birth defects; infants more irritable, uncoordinated, slow learners A retrovirus unknown until early 1980’s:  Methadone & Heroin: Born addicted; likely to be 1. Cannot replicate outside living host cells premature, underweight, vulnerable to respiratory illness, 2. Contains only RNA; no DNA tremors, irritable; infants have difficulty attending, poor 3. Destroys the body’s ability to fight infections motor control 4. Infects CD4 cells – the primary traget of HIV infection COMPREHENSIVE MATERNAL TREATMENT Fig. 8 Pathophysiology of HIV/AIDS Fig. 7 Comprehensive Maternal Treatment NURSING CARE  Identify the type of substance the person has been using, the amount, frequency, method of administration & the length of time the substance has been abused  Note on any suicidal ideation or interest, with drained symptoms.  Assess for level of motivation for treatment Fig. 9 Structure of HIV Cell  Identify reason for admission PATHOPHYSIOLOGY  A baseline physical & Emotional nursing assessment is done to determine admission status & provide baseline  HIV attacks T cells from which to determine progress towards an expected  T cells are lymphocytes outcome  Have a special receptor on cell surface  Encourage Prenatal Care  Different subsets of T cells  Provide emotional support  CD4+ helper T Cells (release cytokines) instrumental in  Encourage to verbalize feelings initiating the immune response both with B lymphocytes,  Monitor Fetal heart rate macrophages, and NK cells.  Watch out for withdraw symptoms  If preterm labor occurs, give Duvadilan  If abortion occurs, D&C  Maintain optimum nutrition, fruits and vegetables  Family support  Exercise  Monitor drugs, alcohol or nicotine levels on the client’s blood 12 BULAWAN, CIVILES, DONALVO, GAGARRA, OBEJERO, ROMARATE, SANTOS BSN 2D  SYMPTOMS OF AIDS  Extreme weakness and fatigue  Rapid weight loss  Frequent fevers with no explanation  Heavy sweating at night  Swollen lymph glands  Minor infections that cause skin rashes and mouth, genital, and anal sores.  White spots in the mouth or throat  Chronic diarrhea  A cought that won’t go away  Short-term memory loss Fig. 10 Pathophysiology of HIV FROM INFECTION TO DISEASE: PATHOPHYSIOLOGY Fig. 11 Symptoms of HIV infection  Infected body fluids are introduced into the body of an FACT OR FICTION? uninfected person a) You can get AIDS from a mosquito bite  The HIV virus crosses into the T-4 Cell count  Fiction: HIV is not transmitted by insects  The virus uses the genetic mechanisms of the cell to b) You cannot get AIDS by having oral sex with an infected produce millions of new viruses person  The cell dies and the new viruses are released into the  Fiction: Any type of sexual activity (where bodily blood to infect new uninfected cells fluids are exchanged) with an infected person is at  The T-4 cells are killed and the patient becomes risk of HIV transmission immunodeficient c) HIV survives well in the environment, so you can get it  The person becomes susceptible to opportunistic from toilet seats and door knobs infections or AIDS related cancer  Fiction: Scientists and medical authorities agree that HIV does not survive well in the environment ACQUIRED IMMUNODEFICIENCY SYNDROME – so forget about those toilet seats! d) You can get AIDS by hugging a person with HIV who is  Caused by HIV sweating  Transmitted through:  Fiction: Contact with saliva, tears, or sweat has  Blood never been shown to result in transmission of HIV  Blood products e) You can get aids by kissing someone who is HIV infected  Semen  Fiction: It would be extremely unlikeley to get HIV  Vaginal fluid from kissing, even open-mouth deep kissing. HIV  Breast milk is transmitted through blood, semen, vaginal  Still encourage breastfeeding because the fluids, and breastmilk and these fluids are not benefit of breastmilk outweighs the risk of usually present during kissing. (unless the person transmission has mouth sores or bloodied wounds)  Diagnosed by enzyme-linked immunosorbent assay f) Condoms are really effective in preventing HIV (ELISA) transmission  (2X ELISA+) = confirmed by western blot test  Fiction: Latex condoms have pores measuring  ELISA detects HIV antibodies.5mm3, while HIV virus measures only.005mm3.  Western Blot Test is a confirmatory test for HIV  Virus is smaller compared to condom’s pores, but there are condoms specifically made for HIV patients (pores of HIV condoms are smaller) 13 BULAWAN, CIVILES, DONALVO, GAGARRA, OBEJERO, ROMARATE, SANTOS BSN 2D g) There is a connection between other STD’s and HIV 3. Seroconversion infection  Point at which HIV test becomes positive  Fact: Having a sexually transmitted disease (STI)  Body starts making antibodies to HIV a few weeks can increase a person’s risk of becoming infected after infection with HIV up to 10x  HIV test becomes positive  Person may have a mild flu-like illness, lasting a week HOW A HEALTHY IMMUNE SYSTEM WORKS or two  Afterwards, the person is well again  Physical Barriers  These barreirs provide a physical block against 4. Asymptomatic Period pathogens from entering the immune system  Time period between seroconversion and onset of  Skin HIV/AIDS-related illness  Innate Immune System  Duration variable: 15 years  Immune system cells that attack foreign cells in  Most people remain healthy (asymptomatic) for the body occurs naturally due to genetic factors or about three years physiology  Duration may depend on socio-economic factors  WBC  The CD4 count is above 500 cells/ml  Acquired Immune System 5. HIV/AIDS – Related Illness  (adaptive or specific) immunity is not present at  Time period between onset of illness and diagnosis of birth AIDS  Natural Acquired: chicken pox, mumps, measles  Duration is variable: average about 5 years  Artifical Acquired: all forms of vaccines  Illnesses initially mild, with gradual increase in HOW DOES HIV INTERRUPT THE NORMAL frequency and severity  CD4 count is between 500 & 200 cells/ml FUNCTIONAL OF THE IMMUNE SYSTEM? 6. AIDS HIV INFECTED T-CELL  Final phase of HIV/AIDS  Duration  HIV infects a type of white blood cell in the body’s immune  without antiretroviral drugs, less than 2 years system called a T-helper cell (also called CD4 cell).  with antiretroviral drugs, potentially many years  These vital cells keep us healthy by fighting off infections and diseases  CD4 count is below 200 cells/ml  Decrease t-cell means the person’s health is starting to  Viral load is high and the person is very infectious deteriorate Additional Notes: CD4 Counts  Western blot test: confirmatory test for HIV  A measure of the number of helper T-cells per cubic  The lower the CD4 count, the higher the virus millimeter of blood used to analyze the prognosis of number patients infected with HIV.  Number of CD4 cells in blood provides a measure of immune system damage IMPORTANT FACTS  CD4 counts reflects phase of disease  CD4 count  Duration of different phases of HIV/AIDS will vary in  500 – 1200: Normal different people  200 – 500: Beginning of HIV illness  Factors affecting the course of HIV/AIDS include nutrition, emotional stress, and access to health care  10/100 WBCs)  Thrombocytopenia  Leukopenia  Positive Direct Antiglobulin Test  Hypoalbuminemia  Rh negative blood type or ABO incompatibility  Smear: polychromasia, anisocytosis, no spherocytes Fig. 21 Hydrops Fetalis Symptoms HYDROPS FETALIS PATHOPHYSIOLOGY  The precise pathophysiology of hydrops remains unknown  Theories include o Heart failure form profound anemia and hypoxia o Portal hypertension due to hepatic parenchymal disruption caused by extramedullary hemopoiesis o Decreased colloid oncotic pressure resulting from liver dysfunction and hypoproteinemia Fig. 23 Interpretation of the anti-human globulin test Fig. 24 Direct and Indirect Coomb’s Test TREATMENT Fig. 22 Hydrops Fetalis Pathophysiology INTRAUTERINE FETAL BLOOD TRANSFUSION RH INCOMPATIBILITY DIAGNOSTIC TESTS  To avoid fetal death  Replace fetal RBCs (for oxygen) – needle to placenta Maternal Blood  RBC maturation – 2 days  Keep the fetus healthy until he or she is mature enough 1. CBC to be delivered 2. Blood typing  Management for Erythroblastosis Fetalis 3. Kleihauer-Betke Test (Flow Cytometry) o Blood test to measure the manount of hemoglobin transferred from the fetus to the mother’s blood stream o Used to determine the required dose of Rh immune globulin o Used for detecting fetal-maternal hemorrhage 4. Indirect Coomb’s Test Fetal Blood 1. Direct Coomb’s Test Fig. 25 Intrauterine Fetal Blood Transfusion 2. CBC 3. Bilirubin Test (B1, B2, Total Bilirubin) 18 BULAWAN, CIVILES, DONALVO, GAGARRA, OBEJERO, ROMARATE, SANTOS BSN 2D  PHOTOTHERAPY  Aka light therapy to treat jaundice  Exposure to light using LED/polarized light @ a specific time of the day  Goal: to treat neonatal hyperbilirubinemia and prevent related neurotoxicity  Decreases the need for exchange transfusion Fig. 27 Jaundice and Kernicterus Fig. 26 Phototherapy Effects of Phototherapy  Exposure of the skin of the jaundiced baby to blue or cool white light of wavelength 425-475nm  Toxic bilirubin molecule isomerizes to non-toxic product  The mainstay of treating hyperbilirubinemia in neonates  Acts by converting insoluble bilirubin (unconjugated) into soluble isomers; excreted in urine and feces  Uses blue-green (460-490nm)  The product is harmless isomers  Acts only on bilirubin present in skin Jaundice  Neonatal Hyperbilirubinemia  Jaundice is an excess of bilirubin in the blood, which causes yellow coloration of the eyes and skin. Medical staff must quickly diagnose and treat infant jaundice in order to avoid kernicterus and permanent brain injury.  Untreated jaundice can cause kernicteru, resulting in brain injury and permanent disability. Kernicterus  Schmorl (1904) described yellow staining of the basal Fig. 28 Effects of Phototherapy ganglia in the brain of infants who died with severe Nursing Care on Phototherapy jaundice and called it “kernicterus”. Also noted by Orth in 1875.  Place newborn on Phototherapy only when there is a  Extreme hyperbilirubinemia causes bilirubin doctor’s order encephalopathy and toxicity to basal ganglia and  Undress the baby, cover the eyes with OS/cloth and put brainstem nuclei diapter on genitals (as heat will harm the eyes and  Rare but preventable cause of severe morbity in genitals of the newborn) otherwise normal infants  Change position of the newborn every two hours (supine,  AAP Recommendation: side, prone, side, supine, repeat) o Acute manifestations: acute bilirubin  Observe for yellow concentrated urine and feces encephalopathy  Monitor vital signs, check for warm temperature o Kernicterus: chronic and permanent clinical  Continue breastfeeding while on phototherapy sequelae of bilirubin toxicity  Teach mother that baby can be exposed to sunlight every Stages of Kernicterus morning from 6am to 8am only  Acute Bilirubin Encephalopathy: 3 distinct clinical phases o First phase (first few days): stupor, hypotonia, and Additional Notes: poor sucking Other Treatments: o Second phase: Hypertonia (retrocollis – backward arching of the neck; opisthotonus – arching of the  Elect time of delivery trunk) and fever. All infants who develop this will  Exchange transfusion after delivery develop chronic encephalopathy.  Top-up transfusion (Hb falls below 7/dl, o Third phase (after 1st week): disappearance of prophylactic: oral folate) hypertonia  Muscle rigidity, paralysis of upward gaze, periodic oculogyric crisis, and irregular respirations are present in the terminal phase. 4% die in acute phase (data from USA). 19 BULAWAN, CIVILES, DONALVO, GAGARRA, OBEJERO, ROMARATE, SANTOS BSN 2D  MANAGEMENT OF SENSITIZED MOTHER ANEMIA IN PREGNANCY  Measurement of antibody levels in titers at regular Normal Values intervals Red Blood Cells 4.5 – 6.10  Amniocentesis for bilirubin levels Hemoglobin 120 – 180  Serial ultrasound for detection of hydrops and White Blood Cells 4.8 – 10.8 management of neonatal anemia and hyperbilirubinemia Platelets 150,000 – 350,000  Therefore, referral of these women is the correct approach at health center level. PREVENTION OF Rh INCOMPATIBILITY  Premarital counseling  Proper matching of blood in transfusions particularly in women before childbearing  Blood grouping must for every woman, before 1st pregnancy  On exposure to Rh(+) Blood Anti Rh Immunoglobulin should be given as early as possible  Proper management of unsensitized Rh negative pregnancies RHOGAM Fig. 30 Anemia  Anti-D antibodies (RhoGam) Component of Blood injection given to Rh(-) Blood 45% Blood Cells WBC, platelet & mothers after delivery of RBC Rh(+) baby  Contains IgG anti-D (anti Rh0) Hemoglobin 55% Plasma  IM medication (white part)  Anti D Immunoglobulin Heme Globin  After 28 weeks AOG Fig. 29 RhoGam (colorless protein)  Within 72 hours after birth (sub unit of HGB) Iron  Prevents Rh alloimmunization  Manufactured from human plasma that contains anti-D  A single 300mcg dose will suppress the immune Oxygen response to 15ml of Rh(+) RBCs (approx 30mL whole NUTRITIONAL INFLUENCE OF RBC PRODUCTION blood)  Suppress immune system of mother not to produce  Folic Acid antibodies  Green leafy vegetables  Rhogam prevents fetal death on succeeding pregnancy  Vitamin B12 or cobalamine  Rhogam will be given each and every after delivery  Eggs, meat, poultry, shellfish, milk and milk  Rhogam prevents development of antiRh-antibodies for products second baby, and the rest of succeeding babies  Iron NURSING CARE  Red meat, chicken, turkey, eggs, and cereals  Monitor uterine contraction  Monitor FHT  Monitor for progress of labor  Monitor for bloos test results  Prepare for delivery (NSVD/CS)  Prepare for Rhogam  Give Rhogam with 72 hours post delivery NURSING DIAGNOSIS Fig. 31 Nutritional Influence of RBC Production  Ineffective tissue perfusion (fetal) r/t  Increase cardiac output (fetal) r/t  Iron rich food intake then it becomes Transferin  Fluid volume decifit (fetal) r/t  Transferin – Iron Metabolism – responsible for Ferric-ion  Fluid volume excess (fetal) r/t Delivery to the cells  Risk for fetal injury r/t  Ferritin – primary form of iron stored in cells  Fear (maternal) r/t  Anxiety (maternal) r/t 20 BULAWAN, CIVILES, DONALVO, GAGARRA, OBEJERO, ROMARATE, SANTOS BSN 2D  CLASSIFICATION OF ANEMIA  the red cell destruction is usually removed extravascular by macrophages of reticuloendothelial system (RE) [BM,  PHYSIOLOGIC liver & spleen]  PATHOLOGIC  acute destruction or chronic destruction a) Deficiency: Iron, Folic A., Vitamin B12  extravascular or intravascular hemolysis b) Hemorrhagic: APH, Hookworm  heredotary or acquired hemolytic anemia c) Hereditary: Thalassema, Sickle, H. Hemolytic Anemia d) Bone Marrow Insufficiency: Aplastic Anemia e) Infections: Malaria, TB f) Chronic Renal Disease or Neoplasm DIFFERENT TYPES OF ANEMIA 1. Iron Deficiency Anemia  As the name implies, iron deficiency anemia is due to insufficient iron Fig. 32 Hemolytic Anemia  d/t insufficient dietary intake 7. Sickle Cell Anemia  without enough iron, the body can’t produce enough hemoglobin, a substance in red blood cells that enables  abnormal shaped RBCs d/t organ damage them to carry oxygen  in sickle cell anemia, the red blood cells become rigid  as a result, iron deficiency anemia may leave an and sticky and are shaped like sickles or crescent moons individual tired and short of breath  these irregularly shaped cells can get stuck in small blood vessels, which can slow or block blood flow and 2. Megaloblastic Anemia oxygen to parts of the body  large RBC produce fewer cells and die 3. Pernicious Anemia  same as megaloblastic anemia  a decrease in red blood cells when the body can’t absorb enough vitamin B12  it is an organ specific autoimmune disease in which the body’s immune system attacks the lining of the stomach  it was considered as a deadly disease due to the lack of available treatment Fig. 33 Sickle Cell Anemia  pernicious anemia is most common in caucasian persons 8. Physiologic Anemia of north Europe ancestry than in other racial groups  low HgB level from 6-8 wks (newborn)  during pregnancy, there is disproportionate increase in 4. Folic Acid Deficiency Anemia plasma volume, RBC volume and hemoglobin mass  lack of folate B9 that makes RBC  there is all time a physiological iron deficiency state  RDA: 400 mg/day during pregnancy o Requirements double during pregnancy  the above factors result in less hemoglobin  Cause: inadequate absorption, increased excretion, concentration in pregnancy which is calld increased requirement, destruction of folic acid physiological anemia of pregnancy o Folic acid and B12 have interrelated role in  plasma volume – 40-50% synthesis of DNA  RBC mass – 30%  At risk: pregnant women, alcoholics, low economic  As a result Hb concentration decreases by 2g/dl status, women over 30, infants born to folic acid deficient  Decreased Hb concn. is due to haemodilution mothers  Criteria of Physiological Anemia 1. Hb 10 gm% 5. Aplastic Anemia 2. RBC 3.2 million cells/cu mm  bone marrow defect; can’t make enough RBCs 3. PCV 32%  a bone marrow failure syndrome characterized by 4. Peripheral Smear – Normal morphology peripheral pancytopenia and marrow hypoplasia 9. Pathologic Anemia  bone marrow failure is a term with a larger meaning,  low erythrocytes d/t bleeding referring to disorders of the hematopoietic stem cell which involves either one cell line or all of the myeloid cell line 6. Hemolytic Anemia  d/t RBCs destruction  defined as those result from an increase in the rate of red cell destruction 21 BULAWAN, CIVILES, DONALVO, GAGARRA, OBEJERO, ROMARATE, SANTOS BSN 2D Pregnancy Increased blood volume by 40-50% MANAGEMENT OF PHYSIOLOGIC ANEMIA  Meet increased demand  Rest  Nutrition  Protect from impaired venous  Monitor CBC often  Blood transfusion return  Folic Acid Supplement  Prepare for blood loss  Vit B12, 6 (NSVD – 500) (CS – 1000)  Prenatal check-up regularly  Report should vaginal bleeding occurs  Oxygen therapy  Encourage client to eat iron-rich food such as organ Decrease Hemoglobin Concentration meats, liver, green leafy vegetables, sweet potato olives PRIORITY NURSING DIAGNOSIS OF ANEMIA  Altered Tissue Perfusion PHYSIOLOGIC ANEMIA  Altered Nutrition Less than Body Requirements  Activity Intolerance HYPEREMESIS GRAVIDARUM  Defined as unexplainable intractable nausea, retching, or vomiting beginning in the first trimester, incapacitates her in day-to-day activities or sufficient to warrant hospital admission resulting in dehydration, ketonuria, and typically a weight loss of more than 5% of prepregnancy weight ETIOLOGY  HORMONAL o High human chorionic gonadotrophina (hCG) stimulates the chemoreceptor trigger zone in the brain stem including the vomiting center in the Fig. 34 Hemoglobin Count Graph During Pregnancy conditions where the hCG is high as in: SIGNS AND SYMPTOMS OF ANEMIA a) Early in pregnancy b) Vesicular mole and  Pallor c) Multiple pregnancy  Fatigue  High levels of Beta-hCG  Shortness of breath  High placenta weight  Impede lungs of gravid uterus  Psychological and family aspects  Hypotension  Excessive vomiting that persists beyong 1st trimester  Vasospam occurs because of increase blood  Contains: volume and/or underlying conditions  Previous food intake  Asymptomatic  Mucus  Bile EFFECTS OF ANEMIA ON PREGNANCY  Finally blood FETUS MOTHER Additional Notes: Neural Tube Defects (esp. Susceptibility to infection folate def.)  Nausea and Vomiting - due to the increase level Miscarriage Hearts decompensation of progesterone during pregnancy on the 1st and heart failure trimester OIUGR/ Low birth weight Preterm labor and preterm delivery Predisposing Factors Precipitating Factors Prematurity Post-partum hemorrhage Pancreatitis Pregnancy Anemia in Infanct Mental lassitude & loss of Biliary tract disease Multiple pregnancy working hours Decrease Vit B6 Hydatidiform mole IUFD Death Psychological Heredity DIAGNOSTIC EXAMINATIONS OF ANEMIA Drug toxicity Female  Hemoglobin count – 12-14 grams/dl  Iron – 50-150 grams/dl  Transferin – 250-430 mg/dl  Ferritin – 11-20 g/ml  Folate – 7-20 g/ml  Vit B12 – 200-800 g/ml 22 BULAWAN, CIVILES, DONALVO, GAGARRA, OBEJERO, ROMARATE, SANTOS BSN 2D  Fig. 36 Ways to Relieve Morning Sickness Fig. 35 Increase Hcg Hormone DIAGNOSTIC TESTS Additional Notes:  CBC  Serum Creatinine  Serum Electrolytes Test  BUN  Hcg is a placental hormone 1. Serum Potassium  ABG  Hcg triggered the woman to vomit 2. Serum Sodium  UA  The formation of placenta into the abdomen or 3. Serum Calcium metabolic that causes reflux and excessive 4. Serum Magnesium vomiting NAUSEA AND VOMITING IN PREGNANCY SYMPTOMS OF HYPEREMESIS GRAVIDARUM Hyperemesis Nausea + Vomiting Gravidarum of Pregnancy  A dry mouth Less common than Nausea and vomiting  Extreme thirst nausea/vomiting alone Very common in  Faster heartbeat Intractable vomiting pregnancy Weight loss First 12 weeks usually  Excessive weight loss Volume depletion worse  Less urination Hypokalemia or  Low blood pressure ketonemia/ketonuria Diagnosis Clinical Clinical MANAGEMENT OF HYPEREMESIS GRAVIDARUM Ketones in blood or urine No ketosis or severe weight loss  May need hospitalization Workup Urinalysis for ketones  IVF infusion for hydration Consider: electrolytes, renal function  Parenteral nutrition If patient has abdominal pain, consider/workup  Antiemetics: Metoclopromide, Plasil other etiologies:  Progress diet – clear liquid, full liquid, soft, small frequent,  Ectopic or molar pregnancy full diet  Cholecystitis/cholelithiasis (more common in  Midnight snacks pregnancy)  HELLP (hemolysis, elevated liver enzymes, low  Parenteral vitamins and electrolyte replacement (K, Na, platelets) syndrome Cl, Ca, Mg)  Pancreatitis or hepatitis  Hydration: Increase OFI, IVFs  Appendicitis  Hydration rounds: eyes, skin, mucous membranes,  Pyelonephritis/cystitis mouth Treatment Fluids w/ dextroes (D5 Avoid trigger odors  Ice chips, crackers 0.9% NaCl or D5LR)  Small frequent feedings: ideal for nutritional replacement Anti-emetics  Do not get up immediately after waking up Anti-emetics Class A (First Line)  Avoid nauseous food Admission if:  Ginger (500-1000 mg  Weigh client for weight loss  Uncertain diagnosis daily)  Offer kidney basin  Intractable vomiting  Pyrldoxine (B6; 25mg  Assess the collor, amount, characteristics of the vomitus  Persistent ketone or q8 hrs)  I&O: expect decrease in urine output in severe HG electrolyte  Doxylamine/pyridoxine  TSB for fever abnormalities after (Diclegis 10mg/10mg; volume repletion 2 tabs qHS)  Weight loss of >10% of pre-pregnancy Class B weight  Ondansetron  Metoclopramide  Diphenhydramine Class C  Promethazine 23 BULAWAN, CIVILES, DONALVO, GAGARRA, OBEJERO, ROMARATE, SANTOS BSN 2D  COMPLICATIONS Maternal Fetal Hypokalemia Growth restriction Hyponatremia and central Wernicke’s encephalopathy pontine myelinosis is associated with 40% fetal death Wernickie’s encephalopathy Vitamin B6/B12 deficiency Malnutrition Mallory-Weiss esophageal tears Venous thromboembolism Psychological morbidity NURSING DIAGNOSIS OF HYPEREMESIS GRAVIDARUM  Actual Potential Fluid Volume Deficit r/t  Imbalance Nutrition; less than Body Requirements r/t  Fatigue r/t  Ineffective Coping r/t  Anxiety r/t REFERENCES I. Notes from: Maam Operario’s Discussion II. Ma’am Domanais’ Quipper PPT 24 BULAWAN, CIVILES, DONALVO, GAGARRA, OBEJERO, ROMARATE, SANTOS BSN 2D  BLEEDING COMPLICATIONS DURING Imminent Abortion PREGNANCY  Aka impending abortion characterized by bleeding and colicky pains OUTLINE  The cervix is usually effaced and expanded o An effaced cervix is accompanied by dilatation I. Abortion Complete Abortion II. Ectopic Pregnancy III. Hydatidiform Mole  Occurs when all of the IV. Placenta Previa products of a pregnancy have V. Abruptio Placenta been removed VI. Placenta Previa and Abruptio Placenta  Minimal bleeding Differences  Cervical dilatation VII. Preterm Labor  Passage of all POC  Closed cervical OS ABORTION  Rx: Observation Fig. 3 Complete  Termination of pregnancy before the age of viability ( 12 weeks – expulsion by oxytocin infusion  Mild cases - broad spectrum antibiotics are started and  General measures uterus is evacuated o Excessive bleeding is controlled by administering  Severe cases – maintenance of perfusion and ventilation methergin 0.2 mg  IV infusion and CVP line is inserted o Blood loss is corrected by IV fluid therapy and blood  Blood transfusion transfusion  Oxygen given by nasal catheter Inevitable Abortion  Antibiotics commenced after taking a high vaginal swab  Ampicillin, Gentamycin and Metronidazole/third  Immediate evacuation of pregnancy generation cephalosporin life cefotaxime or cefurozime o If pregnancy is less than 12 weeks – suction with metronidazole or clindamycin evacuation o Pregnancy greater than 12 weeks – oxytocin  Evacuation of uterus after infection is controlled transfusion MANAGEMENT OF OTHER TYPES OF ABORTION  Shock-resuscitation with IV fluids and blood transfusion  Prophylactic antibodies and anti-D  Hospitalization  Oxytocin administration (incomplete abortion) Threatened Abortion o To contract the uterus to expel conception products left inside  Conservative with bed rest and reassurance till bleeding  Completion curettage stops  Prophylactic antibiotic  Tocolytic medication (Isoxilan HCL: Duvadilan)  Analgesics  Treat underlying factors  Fluid/blood replacement  No sexual activity  Emotional support  Sex can trigger uterine contraction, leading to bleeding 27 BULAWAN, CIVILES, DONALVO, GAGARRA, OBEJERO, ROMARATE, SANTOS BSN 2D  NURSING CARE  Counseling about the procedures and alternatives  Provide nonjudgmental care  Allow the client to express her feelings  Preparation for the procedures: o Surgery - D&C or hysterotomy (rarely used) o Medications:  “Morning-after pill”- RU 482  Oxytocin  Prostaglandins -ProstinE2  Misoprostol (Cytotec)  Post- procedure care  Administer RhoGAM if the client is Rh-negative  Discharge instructions NURSING MANAGEMENT Fig. 9 Sites of Ectopic Pregnancy (a)  For spontaneous abortion – provide bed rest, sexual abstinence, no straining on defecation  Allow expression of feelings: listen  Pt education: available forms of contraception, community resources  Counseling  Pelvic exam lab studies. RhoGAM, STD screening NURSING DIAGNOSIS  Alteration in comfort; pain  Anticipatory Grieving  Risk for Fluid Volume Deficit ECTOPIC PREGNANCY Fig. 10 Sites of Ectopic Pregnancy (b)  Implantation: outside the uterus, should be at endometrium o Ampulla – where fertilization usually occurs  The most common site is within the fallopian tube, hence the term ”tubal pregnancy” Fig. 11 Sites of Ectopic Pregnancy (c) SIGNS AND SYMPTOMS OF ECTOPIC PREGNANCY Fig. 8 Ectopic Pregnancy There are symptoms that will help in deducing the ectopic FACTORS CAUSING ECTOPIC PREGNANCY pregnancy. Although it is also not necessary that all these pregnancy symptoms will be seen.  Advanced maternal age  Pelvic Inflammatory Disease (PID)  Breast pain  Previous ectopic pregnancy  Delayed menstruation  Tubal/uterine surgery  Nausea and vomiting  Intrauterine Device (IUD)  Spotting their genital tract  In vitro fertilization  Pain during intercouse  Lack of appetite  Basal temperature rises  Symptoms of bleeding 28 BULAWAN, CIVILES, DONALVO, GAGARRA, OBEJERO, ROMARATE, SANTOS BSN 2D  Bleeding into the uterine cavity  Anti Shock Treatment  Sharp one sided abdominal pain o IV line made patent, crystalloid is started  Syncope or fainting o Blood sample for HB, blood grouping and cross o Decreased tissue perfusion; less oxygen supply matching, BT, CT  Referred shoulder pain (ruptured EP) o Folley’s catheterization done o Shoulder pain which occurs, as the fetus draws o Colloids for volume replacement blood for its growth, hampers the functions of  Laparotomy diaphgram. o Principle is ‘Quick in and Quick Out’  Lower abdominal pain o Rapid exploration of abdominal cavity is done o increases over a period of time, accompanied by o Salpingectomy is the definitive surgery (sent for lower back pain. HP study)  Vaginal bleeding o Blood transfusion to be given o different from normal can be be heavier or lighter o Autotransfusion only when donated blood not and the blood is dark color. available  Abdominal tenderess  Low HcG hormone  Weakness and pale skin, followed by fainting (because of bleeding)  Low blood pressure when the bleeding is heavy DIAGNOSTIC EXAMINATIONS OF ECTOPIC PREGNANCY  Transvaginal ultrasound o Best ultrasound for early pregnancy  Physical examination: cephalocaudal  Pregnancy test  HcG  Pelvic examinations: I.E Fig. 13 Photo of Tubal Pregnancy A SIGNS OF A RUPTURED ECTOPIC PREGNANCY  Sudden, severe abdominal or pelvic pain  Dizziness or fainting  Pain in the shoulders (due to leakage of blood into abdomen affecting the diaphragm)  Pain in the lower back Fig. 14 Photo of Tubal Pregnancy B Fig. 12 Ruptured Tubal Ectopic Pregnancy MANAGEMENT OF ECTOPIC PREGNANCY Principle: Resuscitation and Laparotomy/Laparoscopy Fig. 15 Photo of Ovarian Pregnancy  Methotrexate NURSING INTERVENTIONS o stops cell growth and dissolve existing cells  Prepare patient for surgery o drug of choice  Institute measures to control bleeding/treat shock if  Salphingostomy via laparoscope hemorrhage serve and continue to monitor o it is a procedure in which the contents of the postoperatively fallopian tube are removed by making an opening  May be given methotrexate instead of surgery  Laparoscopic salphingectomy o is the surgical removal of one (unilateral) or both  Allow patient to express feelings about loss of pregnancy (bilateral) fallopian tubes and concern about future pregnancies 29 BULAWAN, CIVILES, DONALVO, GAGARRA, OBEJERO, ROMARATE, SANTOS BSN 2D  NURSING CARE  Assess the appearance and the amount of vaginal bleeding  Monitor vital signs  Assess the woman’s emotional status and coping abilities  Evaluate the couple’s informational needs  Provide post-operative care NURSING DIAGNOSIS Fig. 21 Complete Mole  Alteration in comfort: pain r/t  Ineffective Tissue Perfusion r/t Additional Notes:  Anticipatory grieving r/t  Do not discard the specimen because the vesicles  Decreased Cardiac Output r/t should be measured, shown to the watchers, or  Fluid Volume Deficit r/t will undergo biopsy HYDATIDIFORM MOLE (H-MOLE; MOLAR PREGNANCY) CLINICOPATHOLOGICAL FEATURES OF HYDATIDIFORM MOLE  Is growing mass of tissue inside your womb (uterus) that will not develop into a baby Molar  Is a pregnancy/conceptus in which the placenta contains Pathological Pregnancy Clinical Factors grapelike vesicles (small sacs) that are usually visible Features Type with the naked eye Vaginal bleeding  It results from an abdominal meiotic division of a zygote Large for dates from 2 sperm cells and 1 egg cell Diploid (45, XX; uterine sizes Normal Conception rarely 46, XY) Bilateral theca lutein Absent fetus/embryo cysts Complete  2 sets of genes Diffuse swelling of Medical Mole  1 paternal + 1 maternal villi complications  Normal fetus Diffuse trophoblastic hCG often >100,000 hyperplasia mlU/mL 15 to 20% postmolar GTN* Pre-D&C diagnosis Triploid (69, XXY, usually incomplete Fig. 16 Normal Conception 69, XXY; 69 XXX) or missed abortion Partial Mole Abnormal Medical Partial Mole fetus/embryo  3 sets of genes complications rare Focal swelling of villi hCG rarely >100,000  1 egg cell + 2 sperm cells Focal trophoblastic mlUmL  Abnormal first meiotic division hyperplasia < 5% postmolar GTN  Non-viable fetus *GTN – Gestational Trophoblastic Neoplasia Fig. 17 & 18 Partial Mole Complete Mole  Empty egg + normal sperm  2 sets of paternal genes; no maternal genes  Embryo dies at very early age  No embryonic tissues  No fetus Fig. 19 & 20 Complete Mole Fig. 22 Spectrum of Gestational Trophoblastic Neoplasia 30 BULAWAN, CIVILES, DONALVO, GAGARRA, OBEJERO, ROMARATE, SANTOS BSN 2D  SIGNS AND SYMPTOMS OF H-MOLE Duration of Frequency Percentage Follow-up  Vaginal bleeding 0-1 month 7 21.8%  Uterine enlargement is bigger than usual pregnancy 2-5 month 13 40.6%  Increase HcG 6 months – 1 yr 3 9.3%  Hyperemesis gravidarum >1 yr 2 6.2%  No FHT/fetal movement Loss to follow-up 3 9.3%  Ask the mother if she every felt any movement; always check for FHT Additional Notes: DIAGNOSTIC TESTS  Time required obtaining normal BhCG values  hCG test in uring and blood following evacuation was 69+6 days. 28 (87.5%)  USD used contraception after receiving their treatment for the molar pregnancies. Barrier method using male condom was the most common contraceptive method used in 46.8% (15/32) of cases. NURSING CARE  Post D&C: monitor for VS q15 mins for 2 hours Fig. 23 Diagnostic Test Results  Assess for vaginal bleeding  Keep uterus contracted: massage, ice pack COMPLICATIONS OF HYDATIDIFORM MOLE  Administer Oxytocin post-surgical evacuation of mole  Pulmonary Complications  Administer Antibiotics - prevents infection o ARDS  Assessment for shock and infection o Trophoblast embolization  Hydration: IVF  Hemorrhage, uterine perforation  I&O  Thyroid storm  Perineal care  PIH  Administer Methotrexate  Symptomatic theca lutein cysts HEALTH TEACHINGS  Malignant sequelae  Counseling with the client and partner must be done TREATMENT  Instruct the client about the hCG monitoring schedule o hCG test monitoring is done to ensure that there Hydatidiform mole treatment consists of two phases is no H-mole left  The first is immediate evacuation of the mole,  If still +, another D&C will be done  The second is subsequent evaluation for persistent  Monitoring will last until negative hCG (a year or more) trophoblastic proliferation or malignant change  Avoid conception while on hCG monitoring as baby in  Computed tomography or magnetic resonance imaging to pregnancy with H-mole will be compromised evaluate the liver or brain is not performed routinely  Teach about contraception while on hCG monitoring  Only when the client tests negative for hCG will she be Suction Dilation and Curettage allowed to get pregnancy again o Ensures safety of mother and baby  To remove benign hydatidiform moles  Comply with hcg monitoring strictly  When the diagnosis of hydatidifrom mole is established,  Instruct to take Methotrexate as ordered as home the molar pregnancy should be evacuated medications while on hCG monitoring  An oxytocic agent should be infused intravenously after the start of evacuation and continued for several hours to PLACENTA PREVIA enhance uterine contractility MANAGEMENT OF H-MOLE  Implantation of the placenta at the lower uterine segment (d/t  Suction evacuation less vascularized uterus on top) o Commonly used  Implantaion happens before the  Dilatation and Curettage baby  Hysterectomy o Removal of uterus (especially if bleeding is so severe)  Methotrexate o Use to stop the rapid growth of H-mole Fig. 24 Placenta Previa 31 BULAWAN, CIVILES, DONALVO, GAGARRA, OBEJERO, ROMARATE, SANTOS BSN 2D  Fig. 25 Placental Placements Placenta Previa Marginalis \ Fig. 29 Differences between the type  Covers the edge/margin of the cervical opening and location of placenta previa (a)  Does not occlude the internal os Fig. 26 Placenta Previa Marginalis Placenta Previa Partialis  Partially covers the internal os Fig. 30 Differences between the type and location of placenta previa (b) RISK FACTORS OF PLACENTA PREVIA  Advance maternal age  beyond 35 yrs old  Scared Vascularized Uterus  Multiparity o Wear and tear principle; loss of strength of abdominal cavity, specifically the uterus; less vascularity in the uterine cavity  Placental Abnormality  Previous uterine surgery Fig. 27 Placenta Previa Partialis o Can lead to less vascularity in the uterine cavity  Breech and Transverse position Placenta Previa Totalis o Drags the placenta to the lower region  Totally covers the internal os  Endometrial Abnormality  Post CS/Surgery  Infection of Endometrium  Large Placenta SIGS AND SYMPTOMS OF PLACENTA PREVIA  Painless bright red bleeding (Hallmark Symptom)  Recurrent and heavier as pregnancy progress  No uterine contraction Fig. 28 Placenta Previa Totalis 32 BULAWAN, CIVILES, DONALVO, GAGARRA, OBEJERO, ROMARATE, SANTOS BSN 2D  MANAGEMENT OF PLACENTA PREVIA MARGINALIS PARTIALIS TOTALIS  Bed rest  Steroids  No sexual  Tocolytic contact  Delivery: CS  No sexual  Avoid stress or NSVD contact  Report if  Bed rest bleeding PLACENTA PREVIA CARE Fig. 32 Abruptio Placenta (b) PREVIA Painless bright red bleeding Replace blood loss Evident in lower segment Vitals indicate shock Inspect FHR Avoid vaginal exams Fig. 33 Normal Placenta vs Abruptio Placenta NURSING CARE  Bed rest without BRP; provide bed pan  Hook client to EFM  Strictly no Internal Exam  Shock Block Position of the bed  Monitor for uterine contraction  Monitor for FHT: fetal distress  Monitor for dilation effacement  Monitor for vaginal bleeding  Watch out for RBOW  Start IVF  Incorporate Duvadilan as sidedrip to the IVF  Check cardiac rate before starting Duvadilan drip as it may increase heart rate