Nursing Process & Pregnancy Complications PDF

OVERVIEW OF THE NURSING PROCESS NURSING PROCESS □systematic, rational method of planning and providing nursing care. □Cyclical, its components follow a logical sequence. □Terminated if goal is achieved. □The cycle may continue with reassessment, or the plan of care maybe modified. GOAL □to ident...

OVERVIEW OF THE NURSING PROCESS NURSING PROCESS □systematic, rational method of planning and providing nursing care. □Cyclical, its components follow a logical sequence. □Terminated if goal is achieved. □The cycle may continue with reassessment, or the plan of care maybe modified. GOAL □to identify a client’s health care status, and actual or potential health problems. □To establish plans to meet the identified needs. □To deliver specific nursing interventions to address those needs. STEPS OF NURSING PROCESS 1. ASSESSMENT (includes subjective and objective data) □ Collect data □ Organize data □ Validate data □ Document data 2. DIAGNOSING (Ineffective airway clearance related to accumulated mucus obstructing airways) □ Analyze data □ Identify health problems, risks and strengths □ Formulate diagnostic assessment 3.PLANNING (restore effective breathing and lung ventilation, develop care plan) □ Prioritize problems/diagnosis □ Formulate goals/desired outcome □ Select nursing interventions □ Write nursing orders 4.IMPLEMENTING (implementation of care plan/nursing intervention) □ Reassess the client □ Determine the nurse’s need for assistance □ Implement the nursing interventions □ Supervise delegated case □ Document nursing activities 5.EVALUATING (evaluation of nursing interventions) □ Collect data related to outcomes □ Compare data with outcomes □ Relate nursing actions to client goals/outcomes □ Draw conclusions about problem status □ Continue , modify, terminate the client’s care plan COMPONENTS OF A NURSING HEALTH HISTORY 1. CHIEF COMPLAINT/REASON FOR VISIT 2. HISTORY OF PRESENT ILLNESS 3. BIOGRAPHIC DATA □ When the symptoms started □ Whether the onset of symptoms was sudden or gradual □ How often the problems occurs □ Character of the complaint □ Activity in which the client was involved when the problem occurred 4. Phenomena or symptoms associated with the chief complaint 5. Factors that aggravate or alleviate the problem 4.PAST HISTORY □ Childhood illness □ Childhood immunizations □ Allergies □ Accidents and injuries □ Hospitalization for serious illnesses □ Medications 5.FAMILY HISTORY OF ILLNESS 6.LIFESTYLE □ Personal habits □ Diet □ Sleep/rest patterns □ ADL □ Instrumental activities of daily living □ Recreation /hobbies 7. SOCIAL DATA □ Family relationships/friendships (clients support system) □ Ethnic affiliation (health customs, beliefs and practices) work □ occupational history (highest level of education) Educational , □ hazards) Occupational history (employment status, absences from 8.PSYCHOLOGIC □ DATA concerns) Economic status (financial □ □ Major Home andstressor neighborhood conditions (safety measures □ Usual at home)coping pattern □ Communication style (verbal expression) 9. PATTERNS OF HEALTH CARE □ All health care resources the client is currently using and has used in the past  PHYSICAL ASSESSMENT 1. Inspection 2. Auscultation 3. Palpation DIAGNOSTIC ASSESSMENT □ Using of laboratory procedures to help diagnose (medical) the disease. Change lecture with positive sign/probable signs of pregnancy/HIGH RISK PREGNANCY Related nursing diagnosis for high risk pregnancy: □ Anxiety □ Fluid volume deficit □ Risk for infection □ Ineffective tissue perfusion  NCM 109-CARE OF MOTHER AND CHILD AT RISK OR WITH PROBLEMS (ACUTE AND CHRONIC) Abnormal Obstetrics  CONTENTS ▣ RISK FACTORS ASSOCIATED WITH PREGNANCY ▣ BLEEDING COMPLICATIONS IN PREGNANCY First Trimester Abortion Ectopic Pregnancy Second Trimester Hydatidiform Mole Incompetent Cervix Third Trimester Abruptio/Ablatio Placenta Placenta Previa ▣ HYPERTENSIVE DISORDERS IN PREGNANCY Gestational Hypertension Chronic Hypertension Pregnancy Induced Hypertension Pre-eclampsia Eclampsia ▣ METABOLIC DISORDER IN PREGNANCY Gestational Diabetes Mellitus ▣ MEDICAL CONDITIONS COMPLICATING PREGNANCY Heart Disease Anemias Infertility  Risk Factors associated with Pregnancy ▣ Maternal age factor ◼ Teenage pregnancy of 16 yrs. and below is considered a high risk pregnancy from both physical and psychosocial standpoint □ Physical ▣ Because of the physical task of adolescence □ Rapid growth during adolescence □ Rapid growth of the fetus ▪ Psychosocial □ Lack of motivation □ Denial □ Ignorance □ Rebellion against authority □ Failure to complete education □ Dependence on others for support □ Failure to establish a stable family life □ High rate of marital failure □ High incidence of repeated out of wedlock pregnancy  Risk Factors associated with Pregnancy ◼ Advanced age of 35 yrs and above is a high risk of pregnancy because of increased incidence of : □ Placenta previa □ Chromosomal abnormalities □ Abruptio / Ablatio placenta □ Hypertension □ Toxemia □ Low birth weight babies ▣ Parity ▣ First pregnancy – is the period of highest risk ▣ Second / Third and Fourth pregnancy – the risk of death for the mother is at its lowest ▣ Fifth pregnancy – marked increase especially when the pregnant mother is over 40 years of age.  DANGER SIGNS OF PREGNANCY 1. VAGINAL BLEEDING = VAGINAL BLEEDING SHOULD BE REPORTED IMMEDIATELY FOR FURTHER EVALUATION 2. PERSISTENT VOMITING ( HYPEREMESIS GRAVIDARUM) = NAUSEA & VOMITING THAT CONTINUES PAST THE 12 WEEK OF PREGNANCY IS EXTENDED VOMITING. IT DEPLETES THE NUTRITIONAL SUPPLY AVAILABLE TO THE FETUS. 3. CHILLS & FEVER = MAY BE EVIDENCE OF INTRAUTERINE INFECTION WHICH IS A SERIOUS COMPLICATION FOR BOTH THE WOMAN & THE BABY. 4. SUDDEN ESCAPE OF FLUID FROM THE VAGINA = MEANS THAT THE MEMBRANES HAVE RUPTURED. BOTH THE MOTHER & THE FETUS ARE THREATENED BECAUSE UTERINE CAVITY IS NO LONGER SEALED AGAINST INFECTION. ** IF FETUS IS SMALL & HIS HEAD DOES NOT FIT INTO THE CERVIX, THE UMBILICAL CORD MAY PROLAPSE WITH THE RUPTURED MEMBRANE , THE HEAD MAY BE COMPRESSED AGAINST THE CORD. ANOTHER DANGEROUS COMPLICATION IS ASCENDING INFECTION.  5.ABDOMINAL OR CHEST PAINS = ABDOMINAL PAINS MAY MEAN TUBAL PREGNANCY THAT HAVE RUPTURED, SEPARATION OF THE PLACENTA, PRETERM LABOR WHILE CHEST PAINS MAY INDICATE PULMONARY EMBOLUS THAT FOLLOWS THROMBOPHLEBITIS. 6.ABSENCE OF FETAL HEART SOUNDS AFTER THEY HAVE INITIALLY BEEN AUSCULTATED ON THE 4TH & 5TH MONTH ( MAY INDICATE INTRAUTERINE FETAL DEATH - IUFD) 7.SWELLING OF THE FACE & FINGERS = EDEMA 8. FLASHES OF LIGHTS OR DOTS ( SCOTOMA) 9. BLURRING OF VISION 10.SEVERE HEADACHE & DIZZINESS ** MAY MEAN SIGNS OF PREGNANCY INDUCED HYPERTENSION  COMPLICATIONS OF PREGNANCY A. FIRST TRIMESTER BLEEDING: 1. ABORTION -THE EXPULSION OF THE PRODUCTS OF CONCEPTION BEFORE THE AGE OF VIABILITY ( FETUS CAN SURVIVE EXTRAUTERINE LIFE) -FETUS IS LESS THAN 20 WEEKS OR LESS THAN 500 GRAMS CAUSES OF ABORTION: 1. ABNORMAL DEVELOPMENT OF THE ZYGOTE – WHICH WOULD HAVE RESULTED IN SEVERE CONGENITAL ANOMALIES 2. ABNORMALITY IN THE IMPLANTATION PROCESS - IUD 3. TRAUMA – PSYCHOLOGICAL, PHYSICAL 4. HORMONAL IMBALANCE ( LOW PROGESTERONE) 5. INTAKE OF DRUGS – CYTOTEC 6. INFECTIOUS DISEASES – GERMAN MEASLES, PTB, HERPES 7. PRESENCE OF VENEREAL DISEASES 8. ABNORMALITY IN THE REPRODUCTIVE SYSTEM – INCOMPETENT CERVIX 8. SEVERE MALNUTRITION EARLY ABORTION – HAPPENS BEFORE 16 WEEKS LATE ABORTION – HAPPENS BETWEEN 16 – 20 WEEKS  COMPLICATIONS OF PREGNANCY A. FIRST TRIMESTER BLEEDING: 1. ABORTION -THE EXPULSION OF THE PRODUCTS OF CONCEPTION BEFORE THE AGE OF VIABILITY ( FETUS CAN SURVIVE EXTRAUTERINE LIFE) -FETUS IS LESS THAN 20 WEEKS OR LESS THAN 500 GRAMS CAUSES OF ABORTION: 1. ABNORMAL DEVELOPMENT OF THE ZYGOTE – WHICH WOULD HAVE RESULTED IN SEVERE CONGENITAL ANOMALIES 2. ABNORMALITY IN THE IMPLANTATION PROCESS - IUD 3. TRAUMA – PSYCHOLOGICAL, PHYSICAL 4. HORMONAL IMBALANCE ( LOW PROGESTERONE) 5. INTAKE OF DRUGS – CYTOTEC 6. INFECTIOUS DISEASES – GERMAN MEASLES, PTB, HERPES 7. PRESENCE OF VENEREAL DISEASES 8. ABNORMALITY IN THE REPRODUCTIVE SYSTEM – INCOMPETENT CERVIX 8. SEVERE MALNUTRITION EARLY ABORTION – HAPPENS BEFORE 16 WEEKS LATE ABORTION – HAPPENS BETWEEN 16 – 20 WEEKS Type Definition Inevitable Vaginal bleeding or rupture of the membranes before 20 weeks gestation accompanied by advanced dilation of the cervix Incomplete Dilation of cervix and expulsion of some products of conception Complete Closed cervix after expulsion of all products of conception Types of Abortion: SPONTANEOUS = UNINTENDED TERMINATION OF PREGNANCY AT ANY TIME BEFORE THE FETUS HAS ATTAINED VIABILITY. THREATENED – POSSIBLE LOSS OF THE PRODUCTS OF CONCEPTION S/SX: SLIGHT BLEEDING; MILD UTERINE CRAMPING BUT NO CERVICAL DILATATION ON VAGINAL EXAMINATION;NO PASSAGE OF TISSUE ▣ Management: ◼ Bed rest ◼ Save all pads ◼ No coitus up to 2 weeks after bleeding has stopped  INEVITABLE OR IMMINENT ABORTION - is a loss of pregnancy that cannot be prevented. Clinical Manifestations: ▣ Moderate to profuse Bleeding ▣ Moderate to severe uterine cramping ▣ Cervix dilated ▣ Membranes rupture ▣ Management: ◼ Hospitalization ◼ D&C ◼ Oxytocin after D & C ◼ Emotional support TYPES OF INEVITABLE ABORTION: 1) Complete – all products of conception are expelled. Sxs of complete abortion: ▣ Moderate bleeding ▣ Mild uterine cramping ▣ Passage of tissue Management: ▣ Sympathetic understanding & emotional support 2) Incomplete – not all products of conception are expelled from the uterus. Signs and Sxs: ▣ Profuse vaginal bleeding ▣ Severe uterine cramping ▣ Open cervix ▣ Passage of tissue ▣ Other products are retained Treatment and MX: ▣ D and C ▣ Oxytocin after D & C ▣ Emotional support ▣ Missed Abortion ◼ Retention of all products of conception after the death of the fetus in the uterus S/Sx: - No FHT - Signs of pregnancy disappear Management: D&C ▣ Septic Abortion ◼ Abortion complicated by infection S/Sx: - Foul smelling vaginal dischrage - Uterine cramping -Fever Management: - Treat abortion - Antibiotics  HABITUAL OR RECURRENT PREGNANCY LOSS –SPONTANEOUS ABORTION IN THREE OR MORE SUCCESSIVE PREGNANCIES USUALLY DUE TO INCOMPETENT CERVIX. B. Induced Abortion – is an intentional loss of pregnancy through direct stimulation either by chemical or mechanical means. Types of induced abortion: 1) Therapeutic abortion – to preserve the life of the mother 2) Elective abortion Reasons for Induced Abortion: ▣ Therapeutic – to end a pregnancy that is life threatening to the mother ▣ To end a pregnancy of a fetus found to have severe congenital abnormalities that may be incompatible with life ▣ To end an unwanted pregnancy that is a result of rape or incest ▣ To end a pregnancy because of woman’s choice not to have a child yet Prevention of abortion: ▣ Prepregnancy correction of maternal disorders ▣ Immunization against infectious diseases ▣ Proper early antenatal care ▣ Treatment of pregnancy complications ▣ Correction of cervical incompetency 2. ECTOPIC PREGNANCY - ANY PREGNANCY THAT OCCURS OUTSIDE THE UTERINE CAVITY. ---SECOND LEADING CAUSE OF BLEEDING IN EARLY PREGNANCY. TYPES: 1. AMPULAR 4. CERVICAL 2. INTESTINAL 5. ABDOMINA L 3. OVARIAN Predisposing causes: ▣ Salpingitis ▣ Peritubal adhesions ▣ Previous ectopic pregnancy ▣ Previous tubal surgery ▣ Multiple previous abortion ▣ Tumors that distort the tubes ▣ External migration of the ovum ▣ Intrauterine device (IUD) Signs and Sxs: ▣ Vaginal spotting or bleeding ▣ Cul de sac mass ▣ Absence of amniotic sac ▣ Amenorrhea or abnormal menstruation followed by slight uterine bleeding  Signs of tubal rupture: Severe sharp knife like pain in the lower quadrant of the abdomen ▣ Abdominal rigidity ▣ Nausea and vomiting ▣ Low hgb. And hct. ▣ Sharp localized pain in the cervix on internal examination ( wiggling sign) ▣ Signs of hemorrhage: ▣ - Cullen’s sign – bluish discoloration of the umbilicus due to the presence of blood in the peritoneal cavity -Hard or rigid boardlike abdomen. Signs of shock: - Falling BP, rapid pulse - Light headedness - Pallor - Cyanotic nail beds - Cold clammy skin  Diagnostic Aids ▣ Culdocentesis – aspiration of bloody fluid from Cul de sac of Douglas ▣ Ultrasound reveals presence of the gestational sac outside of the uterine cavity Treatment and management: ▣ If not yet ruptured: ◼ Salpingostomy – removal of a conceptus less than 2 cm located at the distal portion of the fallopian tube by performing a linear incision over the ectopic pregnancy. The conceptus will extrude from the incision & removed manually. ◼ Salpingotomy – longitudinal incision is made over the ectopic pregnancy & the conceptus is removed using forceps or gentle suction ◼ Fimbrial evacuation – removal of the conceptus by milking & suctioning of the fallopian tube ▣ If ruptured: - removal of the ruptured tube because the presence of a scar if tube is repaired & left can lead to another tubal pregnancy. Surgical treatment: -Salpingotomy -Salpingectomy – removal of the oviducts ▣ Prevent and treat hemorrhage which is the main danger of ectopic pregnancy. ◼ Blood transfusion ◼ Place patient flat in bed with legs elevated ◼ Monitor Vital signs, I & O, & amount of blood loss ▣ Prevent infection as the woman who lost so much blood is susceptible to infection ▣ Contraception must be started upon discharge from hospital. Ovulation begins as early as 19 days or 3 weeks after resection of ectopic pregnancy. B. SECOND TRIMESTER BLEEDING 1. GESTATIONAL TROPHOBLASTIC DISEASE (HYDATIDIFORM MOLE OR H-MOLE)) - is a mass of abnormal rapidly growing trophoblastic tissue in which avascular vesicles hang in grapelike clusters THAT PRODUCE LARGE AMOUNTS OF HCG.  Predisposing factors: cause is unknown ▣ 17 years old below and 35 yrs. Above ▣ Low socioeconomic status ▣ Low protein intake ▣ Previous mole ▣ Higher incidence in Asian women TYPES: 1. COMPLETE MOLE – LACKS AN EMBRYO OR FETUS 2. PARTIAL MOLE – INVOLVES A CHROMOSOMALLY ABNORMAL EMBRYO OR FETUS. - 69 XXX or 69 XXY Gestational trophoblastic disease (hydatidiform mole)  Signs and Sxs: ▣ Rapid increase in uterine size greater than gestational age of the fetus ▣ Marked increase HCG titer; NV:400,000 iu ▣ Excessive nausea and vomiting due to elevated HCG ▣ Brownish vaginal discharge around 4th month containing grapelike vesicles ▣ No FHT is detected after 10 to 12 weeks, no fetal movement after 18-20 weeks ▣ No fetal parts ▣ Bleeding which may vary from spotting to profuse hemorrhage and is usually brownish but may be bright red ▣ No fetal skeleton ▣ Hypertension & other sx of preeclampsia ▣ Symptoms of PIH before 24th week gestation **difference bet.H-mole & pre- eclampsia - before 20 weeks =H mole - after 20 weeks up to 2 weeks post partum = preeclampsia Treatment and management: ▣ D and C or D & E to remove the mole. ( If the woman is more than 40 yrs old, hysterectomy is done since she has a higher chance of developing CHORIOCARCINOMA ▣ Monitor HCG for 1 year ( HCG shld be negative 2-6 weeks after removal of H-mole.) Chest X ray every 3 mos for 6 mos. The lungs are the most common site of metastasis of choriocarcinoma ▣ Chemotherapy ( Methotrexate) if: -HCG titers are increased for 3 consecutive weeks or double at anytime -HCG titers remain elevated 3-4 mos. after delivery ▣ The woman is advised not to get pregnant for 1 year, contraceptive method should NOT be the pills. Pills contain estrogen which promote regrowth of the chorionic villi. ▣ Hysterectomy is the method of tx for women above 40 yrs old because of the higher incidence of malignancies & to clients who have completed childbearing & require sterilization. Prognosis: ▣ Favorable if HCG titers do not recur after evacuation of the mole ▣ Unfavorable if malignancy develops and is untreated  Complications of H- Mole: ▣ Gestational Trophoblastic Tumors – persistent trophoblastic proliferation after H-mole. ** Choriocarcinoma – most severe malignant complication that involve the transformation of chorion into cancer cells that invade & erode blood vessels & uterine muscles. *** Management of all trophoblastic tumors is HYSTERECTOMY **** NURSING MANAGEMENT: 1. MAINTAIN F & E BALANCE. 2. EMPHASIZE THAT PREGNANCY SHOULD BE AVOIDED FOR 1 YEAR ( GREATER CHANCE OF IT RECURRING & MAY EVEN LEAD TO CHORIOCARCINOMA) 3. ADMINISTER BLOOD REPLACEMENT AS ORDERED. 4. PROVIDE EMOTIONAL SUPPORT 2. INCOMPETENT CERVIX OR PREMATURE CERVICAL DILATATION: -PAINLESS CERVICAL EFFACEMENT & DILATATION IN EARLY MIDTRIMESTER RESULTING IN EXPULSION OF PRODUCTS OF CONCEPTION. -MOST COMMON CAUSE OF HABITUAL ABORTION CAUSES: 1. INCREASED MATERNAL AGE 2. CONGENITAL MALDEVELOPMENT OF THE CERVIX – short cervix 3. TRAUMA TO THE CERVIX ( HISTORY OF REPEATED D & C’S; CERVICAL LACERATIONS WITH PREVIOUS PREGNANCIES) Signs and Sxs: ▣ Slight vaginal bleeding ▣ Presence of uterine contractions in midtrimester ▣ Rupture of the bag of waters ▣ Expulsion of the conceptus ▣ Presence of painless cervical dilatation ▣ Relaxed cervical os on pelvic examination MX: 1. CERVICAL CERCLAGE – MEDICAL MANAGEMENT WHEREIN THE PHYSICIAN SUTURES A CERTAIN PART OF THE CERVIX BETWEEN 14 AND 16 WEEKS GESTATION TO PREVENT CERVICAL DILATATION. a. MCDONALD’S – ( temporary) NYLON SUTURES ARE PLACED HORIZONTALLY & VERTICALLY ACROSS THE CERVIX & PULLED TIGHT TO REDUCE THE CERVICAL CANAL TO A FEW MILLIMETERS IN DIAMETER. b. SHIRODKAR – ( permanent) STERILE TAPE IS THREADED IN A PURSE-STRING MANNER UNDER THE SUBMUCUS LAYER OF THE CERVIX & SUTURED IN PLACE TO ACHIEVE A CLOSED CERVIX. ▣ After suturing the cervix: ◼ Place woman on bed rest for 24 hours ◼ Observe for bleeding, uterine contractions, and rupture of BOW ◼ If BOW ruptures – the sutures are removed ◼ If uterine contractions occur, the woman is given ritodrine to stop the contractions ◼ Post-op care: Restrict activities for the next 2 weeks including coitus  Prerequisites of Cervical Cerclage ▣ Cervix not dilated ▣ Intact membranes ▣ No vaginal bleeding & uterine cramping C. THIRD TRIMESTER BLEEDING 1. PLACENTA PREVIA - LOW IMPLANTATION OF THE PLACENTA TYPES: 1. LOW-LYING – IMPLANTATION OF THE PLACENTA IN THE LOWER RATHER THAN IN THE UPPER PORTION OF THE UTERUS  2.MARGINAL – PLACENTA EDGE APPROACHES THAT OF THE CERVICAL OS 3. PARTIAL – IMPLANTATION THAT OCCLUDES A PORTION OF THE CERVICAL OS 4.COMPLETE ( TOTALIS) – PLACENTA THAT TOTALLY OBSTRUCTS THE CERVICAL OS Predisposing factors: ▣ Multiparity ▣ Advanced maternal age – over 35 yo ▣ Multiple pregnancy ▣ Uterine tumor ▣ Cigarette smoking ▣ Scarring from previous previous CS ▣ Decreased vascularity of upper uterine segment Past uterine D&C Signs and Sxs: ▣ Painless, bright red vaginal bleeding during the 3rd trimester ▣ Abdomen soft, non tender ▣ Ultrasound reveals placenta previa NURSING MANAGEMENT: 1. MONITOR VITAL SIGNS & BLEEDING ( WEIGH UNUSED PERINEAL PAD, THEN WEIGH PERINEAL PAD SOAKED IN BLOOD, THEN SUBTRACT. THE DIFFERENCE IS THE WEIGHT OF THE BLOOD LOSS.) 2. PROVIDE STRICT BED REST TO MINIMIZE THE RISK TO FETUS.( CBR without BRP’s ) 3. OBSERVE FOR FURTHER BLEEDING EPISODES.( PREPARE FOR BT) ( Hgb & Hct) 4.AVOID VAGINAL EXAMINATIONS ( NO IE). IF IE IS INDICATED, IT SHOULD BE DONE IN A DOUBLE SET-UP ENVIRONMENT. ( MEANING: the DR is prepared for vaginal exam and for cesarean birth in case the examination precipitates profuse bleeding) WHEREIN THE PATIENT HAS ALREADY SIGNED A CONSENT FORM, PRE-OP MEDS HAVE BEEN GIVEN, ABDOMINAL PREP HAS BEEN DONE SO THAT IF THE PLACENTA IS ACCIDENTALLY DETACHED BECAUSE OF MANIPULATIONS, CS CAN BE DONE IMMEDIATELY. 6. PROVIDE EMOTIONAL SUPPORT DURING THE GRIEVING PROCESS. ** CLASSICAL CESARIAN SECTION UTERUS IS INCISED IN THE VERTICAL SEGMENT) IS DONE IN CASE OF SEVERE BLEEDING.** ▣ Assess fetal lung maturity ▣ Observe for PP hemorrhage ▣ Observe strict aseptic technique Complications of placenta previa: ▣ Hemorrhage ▣ Infection ▣ Prematurity  ** BLEEDING WITH PLACENTA PREVIA OCCURS WHEN THE LOWER UTERINE SEGMENT BEGINS TO DIFFERENTIATE FROM THE UPPER SEGMENT LATE IN PREGNANCY ( APPROXIMATELY WEEK 30 because of uterine contractions ) & THE CERVIX BEGINS TO DILATE. THE BLEEDING PLACES THE MOTHER AT RISK FOR HEMORRHAGE. BECAUSE THE PLACENTA IS LOOSENED, THE FETAL OXYGEN MAY BE COMPROMISED” IMMEDIATE CARE MEASURES: ** TO ENSURE AN ADEQUATE BLOOD SUPPLY TO THE MOTHER & FETUS, PLACE THE WOMAN ON BED REST IN A LEFT SIDE LYING POSITION.** 2. ABRUPTIO PLACENTA - ABRUPT SEPARATION OF AN OTHERWISE NORMALLY IMPLANTED PLACENTA AFTER 20 WEEKS AOG. TYPES: 1. MARGINAL ( OVERT) SEPARATION BEGINS AT THE EDGES OF THE PLACENTA ALLOWING BLOOD TO ESCAPE FROM THE UTERUS. BLEEDING IS EXTERNAL. 2. CENTRAL ( COVERT) PLACENTA SEPARATES AT THE CENTER RESULTING IN BLOOD BEING TRAPPED BEHIND THE PLACENTA. BLEEDING THEN IS INTERNAL AND NOT OBVIOUS. CAUSES: 1. MATERNAL HYPERTENSION ( CHRONIC OR PREGNACY INDUCED) 2. ADVANCED MATERNAL AGE 3.GRAND MULTIPARITY – MORE THAN 5 PREGNANCIES 4. TRAUMA TO THE UTERUS 5.SUDDEN RELEASE OF AMNIOTIC FLUID THAT CAUSE SUDDEN DECOMPRESSION OF TE UTERUS. 6. SHORT UMBILICAL CORD 7.CIGARETTE SMOKING & COCAINE ABUSE 8. PROM S/SX: 1.SHARP PAIN IN THE FUNDAL AREA AS THE PLACENTA SEPARATES 2.PAINFUL DARK RED VAGINAL BLEEDING IN COVERT TYPE 3.PAINFUL BRIGHT RED VAGINAL BLEEDING IN OVERT TYPE 4.HARD, RIGID, FIRM,BOARD-LIKE ABDOMEN CAUSED BY OF BLOOD BEHIND THE PLACENTA WITH FETAL PARTS HARD TO PALPATE. 5.ABNORMAL TENDERNESS DUE TO DISTENTION OF THE UTERUS WITH BLOOD. 6.SIGNS OF SHOCK & FETAL DISTRESS AS THE PLACENTA SEPARATES. PREMATURE SEPARATION OF THE PLACENTA  CLASSIFICATION ACCORDING TO PLACENTAL SEPARATION: 1. GRADE 0 = NO SYMPTOMS OF PLACENTAL SEPARATION, DIAGNOSED AFTER DELIVERY WHEN PLACENTA IS EXAMINED & FOUNDTO HAVE DARK, ADHERENT CLOT ON THE SURFACE. 2. GRADE 1 = SOME EXTERNAL BLEEDING, NO FETAL DISTRESS, NO SHOCK, SLIGHT PLACENTAL SEPARATION  3.GRADE 2 = EXTERNAL BLEEDING, MODERATE PLACENTAL SEPARATION, UTERINE TENDERNESS, FETAL DISTRESS 4.GRADE 3 = INTERNAL & EXTERNAL BLEEDING, MATERNAL SHOCK, FETAL DEATH, DIC MX: 1.WHEN PLACENTA ABRUPTIO IS SUSPECTED OR DIAGNOSED, HOSPITALIZATION IS A MUST. 2.BEDREST OR SIDE LYING POSITION FOR OPTIMUM PLACENTAL PERFUSION. 3.MONITOR VITAL SIGNS, FHT, AMOUNT OF BLOOD LOSS – GIVE MASK O2 IF FETAL DISTRESS IS PRESENT. 4. DELIVERY: ** VAGINAL DELIVERY – IF THERE IS NO SIGN OF FETAL DISTRESS, BLEEDING IS MINIMAL & VITAL SIGNS ARE STABLE. ** CESARIAN DELIVERY – IF BLEEDING IS SEVERE, FETAL DISTRESS IS PRESENT & FETUS CANNOT BE DELIVERED IMMEDIATELY WITH VAGINAL METHOD. COMPLICATIONS: 1. COUVELAIRE UTERUS OR UTERINE APOPLEXY – INFILTRATION OF BLOOD INTO THE UTERINE MUSCULATURE RESULTING IN THE UTERUS BECOMING HARD & COPPER COLORED. 2. HEMORRHAGE & SHOCK – TREATED BY BLOOD TRANSFUSION 3. DIC – MANAGED BY FIBRINOGEN & CRYOPRECIPITATE ▣ Disorder of blood clotting □ Fibrinogen levels fall below effective limits ( Hypofibrinogenemia) ▣ Symptoms □ Bruising or bleeding □ massive hemorrhage initiates coagulation process causing massive numbers of clots in peripheral vessels (may result in tissue damage from multiple thrombi), which in turn stimulate fibrinolytic activity, resulting in decreased platelet and fibrinogen levels □ signs and symptoms of local generalized bleeding (increased vaginal blood flow, oozing IV site, ecchymosis, hematuria, etc) ❑ monitor PT, PTT, and Hct, protect from injury; no IM injections  3. Disseminated Intravascular Coagulation (DIC) ▣ Result from an imbalance between clot formation systems and clot breakdown systems that results in hemorrhage. This problem begins with the excessive triggering of coagulation mechanisms, most commonly encountered in abruptio placenta, PIH, amniotic fluid embolism. This overstimulation of the coagulation system leads to rapid formation of massive numbers of clots. In turn, the fibrinolytic system is overactivated & clots are broken down. As a result, clotting factors are used up & generalized hemorrhage occurs leading to shock & death. ▣ Tx: ◼ Replacement of clotting factors _ Cryoprecipitate or fresh frozen plasma or platelet transfusion  HYDRAMNIOS / POLYHYDRAMNIOS - CHARACTERIZED BY EXCESSIVE AMOUNT OF AMNIOTIC FLUID, MORE THAN 2000 ML. - NORMAL AMOUNT OF AMNIOTIC FLUID AT TERM IS 500 TO 1200 ML CAUSES: 1. MULTIPLE PREGNANCY = ONE FETUS USURPS THE GREATER PART OF THE CIRCULATION RESULTING IN CARDIOMEGALY, WHICH IN TURN RESULTS IN INCREASED URINE OUTPUT. 2. FETAL ABNORMALITIES: a. ESOPHAGEAL ATRESIA – FETAL SWALLOWING OF AMNIOTIC FLUID IS ONE OF THE MECHANISMS THAT REGULATE THE AMOUNT OF AMNIOTIC FLUID. IN ATRESIA, THE FETUS CANNOT SWALLOW  b. SPINA BIFIDA – INCREASED TRANSUDATION OF AMNIOTIC FLUID FROM THE EXPOSED MENINGES. S/SX: 1. EXCESSIVE UTERINE SIZE, OUT OF PROPORTION TO AOG WITH DIFFICULTY PALPATING FETAL PARTS & FINDING FHT – PRIMARY CLINICAL FINDINGS 2. SHORTNESS OF BREATH CAUSED BY PRESSURE OF THE OVERLY DISTENDED UTERUS AGAINST THE DIAPHRAGM. 3. BACK PAIN, VARICOSITIES, CONSTIPATION, FREQUENCY OF URINATION & HEMORRHOIDS DIAGNOSTIC AIDS: 4. ULTRASOUND 5. RADIOGRAPHY COMPLICATIONS: 1. PREMATURE LABOR & DELIVERY 2. ABRUPTIO PLACENTA 3. POSTPARTUM HEMORRHAGE DUE TO OVERDISTENTION 4. CORD PROLAPSE MX: 1. MILD TO MODERATE DEGREES USUALLY DOES NOT REQUIRE TREATMENT. 2. HOSPITALIZATION IF SX INCLUDES DYSPNEA, ABDOMINAL PAIN, DIFFICULT AMBULATION. 3. AMNIOCENTESIS – REMOVAL OF AMNIOTIC FLUID TO RELIEVE MATERNAL DISTRESS 4. INDOMETHACIN THERAPY – A DRUG THAT DECREASES FETAL URINE FORMATION. SE: POTENTIAL PREMATURE CLOSURE OF THE DUCTUS ARTERIOSUS. 5. HEALTH INSTRUCTIONS FOR RELIEF OF SYMPTOMS: 6. PLACE IN SEMI-FOWLERS POSITION TO ASSIST IN BREATHING 7. EMPTY BLADDER FREQUENTLY  3.INCREASE FLUID INTAKE & HIGH FIBER DIET TO PREVENT CONSTIPATION 4.REST FREQUENTLY ON LEFT LATERAL POSITION TO PREVENT FATIGUE & BACK PAIN. 5.WATCH CLOSELY FOR HEMORRHAGE AFTER DELIVERY.  OLIGOHYDRAMNIOS - AMNIOTIC FLUID LESS THAN 500 ML CAUSES: 1. FETAL RENAL ANOMALIES THAT RESULTS IN ANURIA 2. PREMATURE RUPTURE OF MEMBRANES MX: 1. OBSERVE NEWBORN FOR COMPLICATIONS THROUGHOUT THE REMAINDER OF PREGNANCY. a. CLUBFOOT b. AMPUTATION c. ABORTION d. STILLBIRTH e. FETAL GROWTH RETARDATION  f. ABRUPTIO PLACENTA 2. DURING LABOR & DELIVERY a. CORD COMPRESSION b.FETAL HYPOXIA AS A RESULT OF CORD COMPRESSION c. PROLONGED LABOR  PSEUDOCYESIS ▣ Or spurious pregnancy occurs in women nearing menopause & in women who have intense desire to become pregnant. These women develop the belief that they are pregnant when in fact they are not. The women often experiences all the subjective symptoms of pregnancy: fatigue, amenorrhea, tingling sensations & fullness of the breast, nausea & vomiting. Some of these women repost feeling fetal movements which are actually movement of air in the intestines or muscular contractions of the abdominal wall. ▣ Management: ◼ Explain pregnancy test result, clarify misconceptions & false beliefs ◼ Provide referrals when necessary, psychologic counselling ◼ Provide emotional support & understanding  Hyperemesis Excessive nausea & vomiting that persists beyond ▣ Gravidarum 12 weeks gestation & which leads to complications like dehydration, weight loss, starvation & fluid & electrolyte imbalance. ▣ Etiology: Unknown SSx: 1. Excessive nausea & vomiting not relieved by ordinary remedies persisting beyond 12 weeks 2. Signs of dehydration: thirst, dry skin, increased pulse rate, weight loss, concentrated & scanty urine. Management: MX: D10NSS 3000 ML IN 24 HOURS IS THE PRIORITY OF TREATMENT > REST > ANTI-EMETIC – ( EX. PLASIL) HYPERTENSIVE DISORDERS IN PREGNANCY: GESTATIONAL HYPERTENSION: - HYPERTENSION THAT DEVELOPS DURING PREGNANCY OR DURING THE FIRST 24 HOURS AFTER DELIVERY WHICH IS NOT ACCOMPANIED BY EDEMA, PROTEINURIA & CONVULSIONS & DISAPPEARS WITHIN 10 DAYS AFTER DELIVERY. CHRONIC HYPERTENSION: -THE PRESENCE OF HYPERTENSION BEFORE PREGNANCY OR HYPERTENSION THAT DEVELOP BEFORE 20 WEEKS GESTATION IN THE ABSENCE OF H-MOLE & PERSIST BEYOND THE POSTPARTUM PERIOD. PREGNANCY INDUCED HYPERTENSION (TOXEMIA): - HYPERTENSION THAT DEVELOPS WEEK THE 20THAFTER OF GESTATION TO A PREVIOUSLY NORMOTENSIVE WOMAN. RISK FACTORS: 1. SAID TO BE A DISEASE OF PRIMIPARAS – HIGHER INCIDENCE IN PRIMIPARAS BELOW 17 & ABOVE 35 YEARS. 2. LOW SOCIO ECONOMIC STATUS ( LOW PROTEIN INTAKE ) 3. HISTORY OF CHRONIC HYPERTENSION ON THE MOTHER, H-MOLE, DIABETES MELLITUS,MULTIPLE PREGNANCY, POLYHYDRAMNIOS, RENAL DISEASE, HEART DISEASE 4. HEREDITARY – hx of preeclampsia in mothers or sisters 5. H-mole CAUSES: 1. UNKNOWN 2. PROTEIN DEFICIENCY THEORY 3. UTERINE ISCHEMIA 4. ARTERIAL VASOSPASM TRIAD SX: I HYPERTENSION 2. EDEMA ( INCRESE IN WEIGHT) 3. PROTEINURIA = 2nd leading cause of maternal death = chief causes of maternal death due to PIH: - cerebral hemorrhage - cardiac failure with pulmonary edema - rena, hepatic or resp. failure - obstetric hemorrhage assoc. with abruptio placenta  VASOSPASM – due to damAge to the VASCULAR endothelium KIDNEY EFFECTS EFFECTS INTERSTITIAL EFFECTS VASOCONSTRICTIO DECREASED DIFFUSION OF N GLOMERULI FLUID FROM BLOOD FILTRATION RATE & STREAM INTO INCREASED INTERSTITIAL PERMEABILITY OF TISSUE GLOMERULI POOR MEMBRANES Inc BLOOD EDEM ORGAN UREA NITROGEN, URIC A PERFUSION ACID, CREATININE INCREASED DECREASED URINE BP & OUTPUT PROTEINURIA Warning Signs: ◼ Rapid weight gain, 4-5 lbs in a single week ◼ Sudden swelling ◼ Swelling of face & hands ◼ Swelling of ankles or feet that does not go away after 12 hours rest ◼ A rise in BP ◼ Protein in the urine ◼ Severe headaches ◼ Blurry vision ◼ Seeing spots in the eyes ◼ Severe pain over the stomach, under the ribs ◼ Decrease in the amount of urine SIGNS & SYMPTOMS: S & SX MILD PREECLAMPSIA SEVERE PREECLAMPSI A BLOOD PRESSURE 140/90; Systolic 160/110 elevation of 30 mm/Hg Diastolic elevation of 15 mm/Hg Proteinuria +1 to +2 +3 to +4 in clean 300 mg/ L24 hour catch urine or 5 g/24 urine collection hour urine collection Edema Digital edema ( +1 Pitting edema (+3 +2) Dependent +4) Generalized edema edema Weight Gain 3 lb/week More rapid weight gain Urinary Output Not less than 500 Less than 500 ml/24 hours ml/24 hours; oliguria Headache Occasional headache Severe headache Reflexes Normal to +1 +2 Hyperreflexia,+3 +4 Epigastric Pain Absent Right upper (liver quadrant pain involvement) (aura to convulsion) EDEMA: (+1) – PHYSIOLOGIC TYPE IN PREGNANCY, THERE IS SLIGHT EDEMA IN THE LOWER EXTREMITIES ( DUE TO PRESSURE & POSTURE) (+2) – MARKED EDEMA OF LOWER EXREMITIES (PATHOLOGIC) (+3) – EDEMA FOUND ON THE FACE & FINGERS. (+4) – GENERALIZED EDEMA ( ANASARCA) SEIZURE PRECAUTIONS: 1. SIDE RAILS UP 2.PAD THE SIDE RAILS 3. PUT BED AT LOWEST POSITION. 4. ROOM SHOULD BE DIM, QUIET,& AWAY FROM AREAS OF ACTIVITY. ( AVOID BRIGHT LIGHTS SUCH AS FLASHLIGHTS) 5. RESTRICT VISITORS TO ALLOW PATIENT TO REST. 6. HAVE EMERGENCY EQUIPMENT AVAILBLE: - SUCTION APPARATUS, MAGNESIUM SULFATE, CALCIUM GLUCONATE, O2 MEDICATIONS: 1. HYDRALAZINE – ( APRESOLINE ) -ANTIHYPERTENSIVE ( PERIPHERAL VASODILATOR) USED TO DECREASE Hpn Dosage – 5-10 mg/IV - administer slowly to avoid sudden fall in BP -Maintain diastolic pressure at 90 mm/Hg to ensure adequate placental 2.MAGNESIUM SULFATE ( MgSO4) - DRUG OF CHOICE TO TREAT & PREVENT CONVULSIONS, also a muscle relaxant -Loading dose is 4-6g. Maintenance dose is 1-2g/h IV - Infuse loading dose slowly over 15- 30 min. - Always administer as a piggyback infusion - Serum Mg level should remain below 7.5 mEq/L ACTIONS OF MgSO4: a. PREVENT CONVULSION b. REDUCE BLOOD PRESSURE CHECK THE FOLLOWING FIRST BEFORE ADMINISTERING MgSO4: 1. DEEP TENDON REFLEX PRESENT - +2 ( NORMAL) 2. RR SHOULD BE AT LEAST 12 BPM 3. URINE OUTPUT SHOULD BE AT LEAST 30 ML/HR ▣ Diazepam ( Valium) ◼ Halt seizures ◼ 5-10 mg/IV ◼ Administer slowly ◼ Dose may be repeated every 5-10 mins ( up to 30 mg/hr) ◼ Observe for respiratory depression or hypotension in mother & respiratory depression & hypotonia in infant at birth. ** IF MgSO4 TOXICITY DEVELOPS AS SHOWN BY RR DEPRESSION TO LESS THAN 12 BPM & DISAPPEARANCE OF THE DTR, GIVE THE ANTIDOTE CALCIUM GLUCONATE & NOTIFY PHYSICIAN. - 1g/IV ( 10 ml of a 10% sol) -have prepared at bedside when administering MgSO4 ** IF MgSO4 IS GIVEN POSTPARTUM, MONITOR FOR UTERINE ATONY AS IT CAN CAUSE UTERINE RELAXATION. SIGNS & SYMPTOMS OF ECLAMPSIA 1. ALL THE SIGNS & SYMPTOMS OF PREECLAMPSIA 2. CONVULSION FOLLOWED BY COMA IS THE MAIN DIFFERENCE OF ECLAMPSIA & PREECLAMPSIA 3. OLIGURIA  HELLP Syndrome ▣ Serious complication of pregnancy induced hypertension & the client develops multiple organ damage. ▣ Usually develops before delivery but may occur postpartum as well. ▣ HELLP syndrome consists of the following problems: ◼ Hemolysis – red blood cells break down ◼ Elevated liver enzymes – damage to liver cells cause changes in liver function lab tests ◼ Low platelets – cells found in the blood that are needed to help clot the blood to control bleeding ◼ Anemia – breakdown of RBC’s may cause anemia ◼ DIC – may lead to severe bleeding ◼ Placenta abruptio – may also occur MANAGEMENT: A. AMBULATORY MX 1. HOME MANAGEMENT IS ALLOWED ONLY IF: a. BP IS 140/90 O BELOW b. THERE IS NO PROTEINURIA c.THERE IS NO FETAL GROWTH RETARDATION d.THE PATIENT IS NOT A YOUNG PRIMIPARA. 2.BED REST – THE WOMAN SHOULD BE IN BED REST FOR MOST PART OF THE DAY & FREE FROM PHYSICAL & EMOTIONAL  3.THE WOMAN SHOULD CONSULT THE CLINIC AS OFTEN AS NECESSARY. 4.DIET SHOULD BE HIGH IN PROTEIN & CARBOHYDRATES WITH MODERATE SODIUM RESTRICTION. 5.HOSPITALIZATION IS NECESSARY IF CONDITION WORSENS. 6.PROVIDE DETAILED INSTRUCTIONS ABOUT WARNING SIGNS: a. EPIGASTRIC PAIN –AURA TO CONVULSION b. VISUAL DISTURBANCES c. SEVERE CONTINUOUS HEADACHE  d. NAUSEA & VOMITING B. HOSPITAL MANAGEMENT: 1. BP GOES ABOVE 140/90 mm Hg 2.BED REST IS ONE OF THE MOST IMPORTANT PRINCIPLES OF CARE. a. REST IN LEFT LATERAL POSITION TO PROMOTE BLOOD SUPPLY TO THE PLACENTA & THE FETUS.  STAGES OF CONVULSION: 1. STAGE OF INVASION – FACIAL TWITCHING, ROLLING OF THE EYES TO ONE SIDE, STARING FIXEDLY IN SPACE. 2. TONIC PHASE – BODY BECOMES RIGID, AS ALL MUSCLES GO INTO VIOLENT SPASMS OR CONTRACTIONS, EYES PROTRUDE, HANDS ARE CLENCHED, WOMAN STOPS BREATHING FOR 15-20 SECONDS. 3. CLONIC PHASE – JAWS & EYELIDS CLOSE & OPEN VIOLENTLY, FOAMING OF THE MOUTH, FACE BECOMES CONGESTED & PURPLE,MUSCLES OF THE BODY CONTRACT & RELAX ALTERNATELY. THE CONTRACTIONS ARE SO VIOLENT THAT THE WOMAN MAY THROW HERSELF OUT OF BED. LASTS FOR ABOUT A FEW MINUTES. 4. POST ICTAL PHASE –WOMAN IS SEMICOMATOSE, NO MORE VIOLENT MUSCULAR CONTRACTIONS. THE PATIENT WILL NOT REMEMBER THE CONVULSION & THE EVENTS IMMEDIATELY BEFORE & AFTER.  RESPONSIBILITIES DURING A CONVULSION 1. ALWAYS MONITOR PATIENT FOR IMPENDING SIGNS OF CONVULSION: EPIGASTRIC PAIN, SEVERE HEADACHE, NAUSEA & VOMITING. 2 THE MAIN RESPONSIBILITIES OF A NURSE DURING A CONVULSION ARE: MAINTENANCE PF PATENT AIRWAY & PROTECTION OF PATIENT FROM INJURY. 3.TURN PATIENT TO HER SIDE TO ALLOW DRAINAGE OF SALIVA & PREVENT ASPIRATION.  5.DO NOT RESTRICT MOVEMENT DURING A CONVULSION AS THIS COULD RESULT IN FRACTURES. 6.WATCH FOR SIGNS OF ABRUPTIO PLACENTA: VAGINAL BLEEDING, ABDOMINAL PAIN, DECREASED FETAL ACTIVITY. 7. TAKE VITAL SIGNS & FHT AFTER A CONVULSION. 8.DO NOT GIVE ANYTHING BY MOUTH UNLESS THE WOMAN IS FULLY AWAKE AFTER A CONVULSION ** THE ONLY KNOWN CURE OF PIH IS DELIVERY OF THE BABY. ** AS SOON AS THE BABY IS STABLE, THE BABY IS DELIVERED. ** THE PREFERRED METHOD OF DELIVERY IS VAGINAL. ** IF LABOR INDUCTION IS UNSUCCESSFUL & FETAL DISTRESS IS SO SEVERE THAT THE FETUS NEED TO BE DELIVERED, CESARIAN SECTION IS PERFORMED. POSTPARTUM CARE: 1. THE DANGER OF CONVULSION EXISTS UNTIL 24 HOURS AFTER DELIVERY. MgSO4 THERAPY IS CONTINUED UNTIL THE IMMEDIATE 24 HOUR POSTPARTUM. 2. ERGOT PRODUCTS ARE CONTRAINDICATED BECAUSE THEY ARE HYPERTENSIVES. 3. TWO YEARS SHOULD ELAPSE BEFORE ANOTHER PREGNANCY IS ATTEMPTED TO DECREASE THE LIKELIHOOD THAT PIH WILL RECUR ON THE SUBSEQUENT PREGNANCY. SSx of HELLP syndrome: ▣ Right sided upper abdominal pain around the stomach ( epigastric area) ▣ Nausea & vomiting ▣ Headache ▣ Increased BP ▣ Protein in the urine ▣ edema How is HELLP diagnosed? ▣ BP measurement ▣ RBC count ( hemolysis) ▣ Bilirubin level – substance produced by the breakdown of RBC ▣ Liver function tests ( ALT & AST) ▣ Platelet count ( thrombocytopenia ) ▣ Urine tests for protein Treatment: ▣ Bedrest ▣ Blood transfusion ▣ MgSO4 ( as anti convulsant) ▣ Antihypertensive medications ▣ Lab testing of liver, urine & blood ( for changes that may signal worsening of HELLP syndrome ▣ Corticosteroids – to help in the maturity of fetal lungs ▣ Delivery ( if HELLP syndrome worsens & endangers the well being of the mother or fetus)  Multiple Pregnancy ⦿ When 2 ( twin), 3 (triplet), 4 (quadruplet) or even 5 ( quintuplet) fetuses develop in the uterus at the same time ⦿ Associated with more risks than a singleton pregnancy ⦿ TYPES: ⦿ MONOZYGOTIC or IDENTICAL TWIN › Develop from one ovum & one sperm cell that undergo rapid cell division after fertilization that resulted in two or more individuals. Since they come from only one sperm and one ovum, these individuals possess the same genetic traits and are always of the same sex. ⦿ If twinning occurred within 72 hours after fertilization, there will be: › 2 amnions ( diamnionic) › 2 chorions ( dichorionic) › 2 embryos ⦿ If twinning occurred between the 4th & 8th day after fertilization, there will be : › 2 amnions › 1 chorion ( monochorionic) › 2 embryos ⦿ If twinning occurred after 8 days, there will be : › 1 amnion ( monoamnionic) › 1 chorion › 2 embryos ⦿ If twinning occurred after the embryonic disc is formed, CONJOINED TWINS will develop. Conjoined twins are classified according to the part of the body where they are attached. › Anterior – Thoracopagus › Posterior – pyopagus › Cephalic – craniopagus › Caudal – Ischiopagus ⦿ DIZYGOTIC TWINS or FRATERNAL TWINS › Develop from 2 or more ova and sperm cells that were fertilized at the same time. They have the same genetic traits, may or may not be of the same sex and always have 2 chorions & 2 amnions. ** More females than males because female zygote has a higher tendency to divide into twins ** Female zygotes have higher rate of survival than male zygotes ⦿ Predisposing factors of Dizygotic Twinning › Race – highest in black women › Heredity – more common in women with familial history of twinning › Age & parity – increased incidence in high parity & advanced maternal age › Higher incidence in women taking fertility drugs that promote ovulation & release of several ova at the same time › Higher incidence within the first months after stopping oral contraceptives because of the sudden & greater amount of pituitary gonadotropin released at this time › In vitro fertilization – stimulation of formation of numerous follicles, harvesting them in the ovary & fertilizing them in vitro. All zygotes that were fertilized are returned to the uterus to grow & develop ⦿ Complications of Multiple Fetuses: › Abortion › Death of one fetus › Perinatal mortality › Preterm labor – as the number of fetuses increases, the duration of pregnancy decreases › Low birth weight › Congenital malformations › Hydramnios › Maternal hypertension › Placenta previa & Abruptio placenta › Intrauterine growth retardation › Cord entanglement, prolapse & compression › Maternal anemia ⦿ S/Sx › 1. Uterus large for gestational age › 2. Auscultation of two or more fetal heart tone › 3. Hx of twins in the family › Palpation of three or more large fetal parts › Ultrasound reveals two or more gestational sac  Management: ⦿ Clinic Visit: ⦿ First Trimester – every month ⦿ Second Trimester – every 2 weeks ⦿ Third Trimester – every week ⦿ Nutrition – additional 300 kcal to the normal pregnancy requirement ⦿ 6 small meals rather than 3 large meals to decrease discomfort of a large uterus compressing a full stomach  Labor and Delivery: ⦿ The cord is cut right after delivery of the first infant ⦿ Presentation of second infant is ascertained after birth of first twin either by ultrasound or Leopold’s or both ⦿ The normal interval of delivery of the first twin and second twin is (30 minutes) ⦿ If the second twin cannot be delivered vaginally because of abnormal position, CS is done. ⦿ Cesarean delivery – delivery of choice if the twins or one of them cannot be delivered normally or if complications arise that necessitate immediate delivery. ⦿ Post partum period – watch out for Hemorrhage due to overdistention of the uterus.  Premature Labor: ▣ Is labor that occurs between 20 weeks to 37 weeks gestation characterized by regular uterine contraction that lasts more than 30 seconds & result in cervical dilatation & effacement. It is the greatest cause of neonatal mortality & morbidity. Causes: ▣ PROM – most often associated with infection ▣ Infection of amniotic fluid – ▣ Retained IUD ▣ Fetal death ▣ History of premature labor & abortion ▣ Overdistention of the uterus – caused by multiple pregnancy, hydramnios ▣ Abnormal placentation ▣ Uterine abnormalities ▣ Incompetent cervix ▣ Serious maternal conditions SSx: ▣ Dx is made when there is regular uterine contractions occuring 5-8 minutes apart accompanied by: ◼ Progressive cervical changes ◼ Cervical dilatation of more than 2 cm ◼ Cervical effacement of 80% or more ◼ Duration of at least 30 secs ◼ 10 mins apart ▣ Menstrual like cramping ▣ Watery or bloody vaginal discharge ▣ Low back pain MX: 1. Prevention – regular prenatal check up 2. If fetus is less than 32-34 weeks, and still premature to be delivered, labor must be arrested: 1. Bedrest LL to promote blood flow to the placenta 2. Hydration – IV fluids 3. Tocolytics – medications to stop uterine contractions ( relaxes smooth muscles) 1. Ritodrine Hcl 2. Terbutaline –( check pulse rate because it can cause tachycardia) 3. Prostaglandin inhibitors ( Indomethacin) Drugs to hasten fetal lung maturity: - GLUCOCORTICOID therapy if labor can be delayed for 48 hours – administration of BETAMETHASONE accelerate fetal lung maturity & prevents respiratory distress & hyaline membrane disease ( most common problem of the premature neonate). - MEDICAL CONDITIONS COMPLICATING PREGNANCY  HEART DISEASE CLASSIFICATION: 1. CLASS I = NO LIMITATION,UNCOMP ROMISED = ASYMPTOMATIC, NO DISCOMFORT WITH ORDINARY PHYSICAL ACTIVITY. 2.CLASS II =SLIGHT LIMITATION, SLIGHTLY COMPROMISED, ORDINARY ACTIVITY CAUSES 3.CLASS III = MARKED LIMITATIONLESS THAN ORDINARY ACTIVITY CAUSE EXCESSIVE FATIGUE; PALPITATIONS, CHEST PAIN & DYSPNEA. 4.CLASS IV =SEVERE LIMITATION; PATIENT EXPERIENCES SYMPTOMS ATEVEN REST; UNABLE TO AN PERFORM PHYSICAL WITHOUY ACTIVITY DISCOMFORT. T SIGNS & SYMPTOMS: 1. DIFFICULTY OF BREATHING – DYSPNEA, ORTHOPNEA, NOCTURNAL DYSPNEA 2. HEMOPTYSIS 3. SYNCOPE WITH EXERTION 4. CHESTPAIN 5. CYANOSIS 7. CLUBBING OF FINGERS 8. NECK VEIN DISTENTION 9. SYSTOLIC & DIASTOLIC MURMURS NURSE ALERT: ** REMEMBER A PREGNANT WOMAN WITH HEART DISEASE SHOULD AVOID INFECTION, EXCESSIVE WEIGHT GAIN, EDEMA & ANEMIA BECAUSE THESE CONDITIONS INCREASE THE WORKLOAD OF THE HEART. MX: A. PRENATAL CARE: 1. PROMOTION OF REST ( CLASS I & CLASS II) *8 HOURS OF SLEEP DURING THE NIGHT & HAVE FREQUENT REST PERIODS DURING THE DAY. *LIGHT WORK IS ALLOWED BUT NO HEAVY WORK, NO STAIR CLIMBING, NO EXHAUSTION. 2. DIET *HIGH IN IRON,  3.AVOID HIGH ALTITUDES, SMOKING AREAS, UNPRESSURIZED PLANES & OVERCROWDED AREAS. CIGARETTE SMOKING & ALCOHOLIC BEVERAGES ARE STRICTLY PROHIBITED. 4.PREVENTION OF INFECTION *AVOID PERSONS WITH ACTIVE INFECTIONS (COLDS, COUGH). * EARLY TREATMENT OF INFECTIONS 5.PROVIDE INSTRUCTIONS ON DANGER SIGNS OF HEART FAILURE: *COUGH WITH CRACKLES IS USUALLY THE FIRST SIGN OF AN IMPENDING HEART FAILURE.  * INCREASING DYSPNEA, TACHYCARDIA, RALES, EDEMA MEDICATIONS: >IRON SUPPLEMENTATION TO PREVENT ANEMIA >DIGITALIS TO STRENGTHEN MYOCARDIAL CONTRACTION AND SLOW DOWN HEART RATE >NITROGLYCERINE TO RELIEVE CHEST PAIN >ANTIBIOTICS TO PREVENT AND TREAT INFECTION INTRAPARTAL CARE 1. EARLY HOSPITALIZATION- WOMAN IS HOSPITALIZED BEFORE LABOR BEGINS TO PROMOTE REST, FOR CLOSER SUPERVISION AND PREVENT INFECTION 2. WOMAN IN LABOR IS IN SEMI-FOWLER’S POSITION OR LEFT LATERAL RECUMBENT POSITION. NO LITHOMY POSITION. 3.ITAL SIGNS- VITAL SIGNS ARE MONITORED CONTINUOUSLY. TACHYCARDIA AND RESPIRATORY RATE MORE THAN 24 ARE SIGNS OF IMPENDING CARDIAC DECOMPENSATION. DURING THE FIRST STAGE, MONITOR VITAL SIGNS EVERY 15 MINUTES AND MORE 4.EPIDURAL ANESTHESIA- IS INSTITUTED FOR PAINLESS AND PUSHLESS DELIVERY. FORCEPS IS USED TO SHORTEN THE SECOND STAGE. PUSHING IS CONTRAINDICATED 5. WOMEN WITH HEART DISEASE ARE POOR CANDIDATE FOR CS DUE TO INCREASED RISK FOR HEMORRHAGE, *INFECTION AND THROMBOEMBOLISM POSTPARTUM CARE 1. THE MOST DANGEROUS PERIOD IS THE IMMEDIATE POSTPARTUM BECAUSE OF THE SUDDEN INCREASE IN CIRCULATORY BLOOD VOLUME. 2. MONITOR VITAL SIGNS. 3.PROMOTE REST- RESTRICT VISITORS TO ALLOW PATIENT TO REST, THE WOMAN STAYS IN THE HOSPITAL LONGER, UNTIL CARDIAC STATUS HAS STABILIZED. 4.EARLY BUT GRADUAL AMBULATION TO PREVENT THROMBOPHLEBITIS. 5. MEDICATIONS *ANTIBIOTICS *STOOL SOFTENERS TO PREVENT STRAINING AT STOOL CAUSED BY CONSTIPATION. SEDATIVES MAY BE ORDERED TO PROMOTE REST. 6. BREASTFEEDING IS ALLOWED IF THERE ARE NO SIGNS OF CARDIAC DECOMPENSATION DURING PREGNANCY,  The Anemias of Pregnancy ▣ Hemoglobin level of less than 11g/dl in the first and third trimester and less than 10.5g/dl in the second trimester.  Iron DeficiencyAnemia ▣ Most common type of anemia during pregnancy. Most women enter pregnancy without enough iron reserve so that deficiency develops particularly on the 2nd and 3rd trimester when iron requirements increases. Predisposing Factors: ▣ Poor diet and poor nutrition ▣ Heavy menses ▣ Pregnancies at close intervals, successive pregnancies ▣ Unwise reducing programs ▣ **Nurse Alert** “ The newborn of the severely anemic mother IS NOT AFFECTED by iron deficiency anemia. This is because the amount of iron transported to the fetus of an anemic mother is almost the same as the amount transported to the fetus of a mother without anemia” Signs and Symptoms ▣ Easy fatigability ▣ Sensitivity to cold ▣ Proneness to infection ▣ Dizziness ▣ Laboratory findings will reveal low hgb  Effects of Anemia to Pregnancy ▣ Decreased resistance to infection ▣ Associated with prematurity & low birth weight infants ▣ Predispose to heavy bleeding during labor & puerperium ▣ May increase digestive discomfort of pregnancy  Management: 1. Oral iron supplementation – 200 mg of elemental iron daily in the form of: ◼ Ferrous Sulfate – the most absorbable form of iron ◼ Ferrous Fumarate ◼ Ferrous Gluconate □ Inform the mother about the possible side effects. Tarry stool, constipation, GI discomfort □ Never take with milk but with citrus juice □ If given in liquid form, use straw to prevent staining the teeth. Tell patient to rinse mouth. □ If iron is to be given parenterally, give IM by Z tract technique to prevent tissue staining. Do not massage after injection. ▣ Oral iron should be continued until 3 months after anemia has been corrected. ▣ Increase intake of iron rich foods: lean meat, liver, dark green leafy vegetables. Good food sources of iron include the following: ◼ Meats – beef, pork, lamb, liver,& other organ meats ◼ Poultry – chicken, duck, turkey, liver ( especially dark meat) ◼ Fish – shellfish, including clams, mussels, oysters, sardines and anchovies ◼ Leafy greens of the cabbage family such as broccoli ◼ Legumes such as lima beans & green peas; dry beans & peas ◼ Yeast-leavened whole wheat bread & rolls ◼ Iron enriched, white bread, pasta, rice & cereals  Folic Acid DeficiencyAnemia ▣ Folic acid is necessary for the normal formation and nutrition of red blood cells. Deficiency in folic acid leads to the formation of large and immature blood cells that have shorter life span than normal red blood cells. Women who have folic acid deficiency during pregnancy are more at risk of giving birth to babies with neural tube defects. Effects on Pregnancy: ◼ ABORTION, Abruptio placenta, Neural defect in fetus Predisposing Factors: ◼ 1. Long term use of oral contraceptives ◼ 2. Poor nutrition ◼ 3. Multiple pregnancies ◼ 4. Successive pregnancies S/SX ◼ 1. Nausea ◼ 2. Vomiting ◼ 3. Anorexia – lack of appetite  Management: ▣ Folic acid supplementation of 1 mg/day accompanied oral iron. RDA for all women – 0.4mg/day ▣ Vit supplements containing 400 micrograms of folic acid are now recommended for all women of chilbearing age and during pregnancy. These supplements are needed because natural food sources of folate are poorly absorbed and much of the vitamin is destroyed in cooking. Food sources of folate include the ff: ▣ Leafy dark green vegetables, dried beans & peas, nuts, citrus fruits & juices & most berries, fortified breakfast cereals, enriched grain products Hemolytic Disease: ISOIMMUNIZATION / RH INCOMPATIBILITY -OCCURS WHEN AN RH-NEGATIVE MOTHER IS CARRYING AN RH-POSITIVE FETUS. -FOR SUCH A SITUATION TO OCCUR, THE FATHER OF THE CHILD MUST EITHER BE A HOMOZYGOUS ( DD) OR HETEROZYGOUS ( Dd) RH POSITIVE. -IF THE FATHER OF THE CHILD IS HOMOZYGOUS (DD), 100% OF THE COUPLE’S CHILDREN WILL BE RH (+).  -PEOPLE WHO HAVE RH (+) BLOOD HAVE A PROTEIN FACTOR ( D ANTIGEN) THAT RH (-) PEOPLE DO NOT. -WHEN AN RH(+) FETUS BEGINS TO GROW INSIDE AN RH (-) MOTHER, IT IS THOUGH HER BODY IS BEING INVADED BY FOREIGN AGENT, OR ANTIGEN. -THEORETICALLY, THERE IS NO CONNECTION BETWEEN FETAL BLOOD & MATERNAL BLOOD DURING PREGNANCY BUT BUT SOMETIMES ACCIDENTAL BREAKS IN THE PLACENTAL VILLI RESULTS IN FETAL BLOOD ENTERING THE MATERNAL BLOODSTREAM. (also AMNIOCENTESIS , PUBS). -ONLY A FEW ANTIBODIES ARE FORMED THIS WAY SO THAT IT DOES NOT AFFECT THE FIRST INFANT. -DURING PLACENTAL SEPARATION AND DELIVERY, A GREAT AMOUNT OF MATERNAL & FETAL BLOOD ARE MIXED, CAUSING THE MOTHER TO PRODUCE LARGE AMOUNTS OF ANTIBODIES DURING THE FIRST 72 HOURS AFTER PLACENTAL DELIVERY.  - IF THE FETUS IN SUBSEQUENT PREGNANCIES IS RH (+), THE ANTIBODIES ALREADY PRESENT IN THE BLOODSTREAM WILL CROSS THE PLACENTA ATTACK & DESTROY THE FETAL RED BLOOD CELLS ( HEMOLYSIS). THE FETUS BECOMES SO DEFICIENT IN RBC’S THAT SUFFICIENT O2 TRANSPORT TO BODY CELLS CANNOT BE MAINTAINED. THIS CONDITION IS TERMED “ HEMOLYTIC DISEASE OF THE NEWBORN” OR ERYTHROBLASTOSIS FETALIS. DX: 1.INDIRECT COOMB’S TEST – TEST TO CHECK FOR THE PRESENCE OF ANTIBODIES IN MATERNAL SERUM. 2.DIRECT COOMB’S TEST –TEST TO CHECK THE PRESENCE OF ANTIBODIES IN FETAL CORD BLOOD.  Prevention:  ▣ Administration of Rh ( anti D) globulin (Rhogam) at 28 weeks gestation and within the first 72 hours after delivery to a woman who: ◼ Have delivered Rh positive fetus ◼ Have had untypeable pregnancies such as ectopic pregnancies, stillbirth & abortion ◼ Have received ABO compatible Rh positive blood ◼ Have had invasive diagnostic procedure such as amniocentesis, PUBS ( cordocentesis) MX of HEMOLYTIC DISEASE: 1. SUSPENSION OF BREASTFEEDING DURING THE FIRST 24 HOURS TO PREVENT PREGNANEDIOL (BREAKDOWN PRODUCT OF PROGESTERONE EXCRETED IN BREASTMILK) FROM INTERFERING WITH THE CONJUGATION OF INDIRECT BILIRUBIN TO DIRECT BILIRUBIN. 2. PHOTOTHERAPY – DESTRUCTION OF RBC’S RESULTS IN THE FORMATION OF INDIRECT BILIRUBIN. INDIRECT BILIRUBIN MUST FIRST BE CONVERTED TO DIRECT BILIRUBIN BY THE LIVER CELLS BEFORE IT CAN BE EXCRETED IN THE BODY. THE LIVER IS IMMATURE AT BIRTH SO BILIRUBIN FORMED DURING HEMOLYSIS OF RBC. a. USES BILI OR FLUORESCENT LIGHTS POSITIONED 12 – 30 INCHES ABOVE THE INFANT. NURSING CARE DURING PHOTOTHERAPY: 1. COVER EYES WITH DRESSING 2. COVER GENITALS TO PREVENT PRIAPISM. 3. EXPECT THE STOOL TO BE LOOSE & BRIGHT GREEN FROM EXCESSIVE BILIRUBIN EXCRETION & THE SKIN TO BE DARK  4.PROVIDE GOOD SKIN CARE BECAUSE STOOL CAN BE IRRITATING TO THE SKIN. 5.EXPECT THE URINE TO BE DARK COLORED BECAUSE OF UROBILINOGEN FORMATION. 6.ASSESS FOR DEHYDRATION ( I & O ; SKIN TURGOR). FLUID LOSS THROUGH INSENSIBLE WATER LOSS MAY OCCUR BECAUSE OF THE HEAT FROM THE FLUORESCENT LIGHT ABOVE THE INFANT. 7.OFFER GLUCOSE WATER EVERY 3 HOURS TO PREVENT DEHYDRATION. 8. MAINTAIN BODY TEMP BETWEEN 36C & EXCHANGE TRANSFUSION: 1. INTRAUTERINE TRANSFUSION: -DONE BY INJECTING RBC’S DIRECTLY INTO A VESSEL IN THE FETAL CORD OR DEPOSITING THEM IN THE FETAL ABDOMEN USING AMNIOCENTESIS TECHNIQUE. -BLOOD USED FOR TRANSFUSION IS EITHER THE FETUS’ OWN TYPE OR GROUP O NEGATVE IF THE FETAL BLOOD TYPE IS UNKNOWN. -FROM 75 TO 150 ML OF WASHED RBC’S WILL BE USED, DEPENDING ON THE AGE  -INTRAUTERINE TRANSFUSION IS NOT WITHOUT RISK. A CORD VESSEL MAY BE LACERATED BY THE NEEDLE. BUT FOR A FETUS WHO IS SEVERELY AFFECTED BY ISOIMMUNIZATION, HOWEVER, SUCH A RISK IS NO GREATER THAN LEAVING THE FETUS UNTREATED. -MOTHER RECEIVES AN RhIG INJECTION( RhoGAM) AFTER THE TRANSFUSION TO HELP REDUCE ISOIMMUNIZATION FROM THE AMNIOCENTESIS. -AS SOON AS FETAL MATURITY IS REACHED ( L:S RATIO 2:1), DELIVERY WILL NOTE: ADMINISTER RhoGAM TO ALL Rh (-) MOTHERS DURING PREGNANCY ( AT 28 WEEKS GESTATION) AND WITHIN 72 HOURS OF DELIVERY OR ABORTION OF AN Rh (+) FETUS **  - AFTER BIRTH, THE INFANT MAY REQUIRE AN EXCHANGE TRANSFUSION TO REMOVE HEMOLYZED BLOOD CELLS & REPLACE THEM WITH HEALTHY ONES. Notify your healthcare provider if your baby has any of the following s/s after returning home: > Fever > Jaundice > Poor appetite or poor weight gain >Excessive crying that does not stop when the baby is held. Signs in the newborn: ▣ Paleness ▣ Jaundice that begins within 24 hours after delivery ( pathologic jaundice) ▣ Unexplained bruising or blood spots under the skin ▣ Tissue swelling ( edema) ▣ Seizures ▣ Lack of normal movement ▣ Poor reflex response