Al Rawdah University College

MATERNATY
prepared by: Heba Alsaidi
Content of course :
1) Female reproductive system
2) Female reproductive cycle
3) Conception and fetal development
4) Pregnancy and antenatal care
5) Intrapartum assessment and intervention
6) Normal and complication pureperium
7) Bleeding disorder of pregnancy
8) Complication associated with pregnancy
9) Complication associated with labour

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10) Operative delivery
11) Obstetric emergency

Chapter (1) Female

reproductive system

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Maternity Nursing Is :
It is a delivery of nursing care to women and their
families during pregnancy and parturition and
through the first days of the puerperium
Maternity nursing includes extensive instruction of
mothers in the usual behaviour and needs of a
newborn, in expected patterns of growth and
development of the infant during the first week.
It is concern with all aspects of maternity care and
focused on helping pregnant women and families

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 to meet health needs associated with child
bearing experience
Maternal nurse care:-
1)Avoiding and achieving pregnancies by supported mother to
make informed decision.
2) Maintaining, Monitoring, or Interrupting pregnancy
3) Pregnancy-related problems such as gestational diabetes
mellitus.
4) Support the normal anatomic, physiologic and
psychological adaptation to pregnancy and childbirth.

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5) The care of mothers in labour and delivery, as well as
emotional support in labour and delivery.
6) Ongoing observation for the onset of abnormal signs or
symptoms
Obstetric
It is the surgical specialty, branch of medicine, dealing with the
care of women and their fetus during pregnancy (prenatal
period), childbirth and the postnatal period. Midwifery is the
non-surgical equivalent

Gynaecology
▪ It is the medical practice dealing with the health of the female
reproductive system (uterus, vagina, and ovaries) as well as the

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 male reproductive organs. Literally, outside medicine, it means
"the science of women". It is the counterpart to andrology, which
deals with medical issues specific to the male reproductive system.

Reproductive Anatomy and Physiology

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Anatomy of the Female Reproductive
System
 The female reproductive system consists of external and
internal pelvic structures.
 Other anatomic structures that affect the female reproductive
system include the hypothalamus and pituitary gland of the
endocrine system
External Female Reproductive Organs
Called the vulva. These structures include:

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 ▪ mons pubis, ▪ labia
majora ▪ Minora.
▪ Clitoris.
▪ Structures of the
vestibule
▪ perineum
Mons Pubis
 The mons pubis is the
rounded, fleshy prominence
over the symphysis pubis that
forms the anterior border of
the external reproductive
organs.
 It is covered with varying amounts of pubic hair.
Labia Maiora and Minora
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 The labia majora are two rounded, fleshy folds of tissue that
extend from the mons pubis to the perineum.
 The labia majora protect the more fragile tissues of the external
 The labia minora run parallel to and within the labia majora
genitalia.
 The labia minora extend from the clitoris anteriorly and merge
posteriorly to form the fourchette,
Clitoris
 The clitoris is a small projection at the anterior junction of the
two labia minora.
 This structure is composed of highly sensitive erectile tissue
similar to that of the penis
Vestibule
 The vestibule refers to structures enclosed by the labia minora.
 The urinary meatus, vaginal introitus, and ducts of Skene and
Bartholin glands lie within the vestibule

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 Bartholin glands provide lubrication for the vaginal introitus,
particularly during sexual arousal.
 A small portion of tissue surrounds the opening of the vagina.
Hymnal tissue does not completely cover or occlude the vagina.
 The hymen becomes widened, sometimes by tearing, which may
be accompanied by bleeding.
Hymen
• A small portion of tissue surrounds the opening of the
vagina. Hymnal tissue does not completely cover or
occlude the vagina.
• the hymen becomes widened, sometimes by tearing, which
may be accompanied by bleeding.

Perineum

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 The perineum is the most posterior part of the external
female reproductive organs.
 The perineum extends from the fourchette anteriorly to the
anus posteriorly.
Internal Female Reproductive Organs
The internal reproductive structures are:

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1.The vagina. 2. Uterus. 3. Fallopian tubes. 4. ovaries
These organs are supported and contained within the bony
pelvis

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1. Vagina
 It's a collaps-able tube, 8-10 cm long.
 It presents between the bladder & urethra (anteriorly) & the
rectum (posteriorly).
 It connects the uterus with the perennial opening.

Functions:
It is the female organ of coitus (male—female sexual
union).
Birth canal.
Transports tissue and blood during menses to the outside

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2. Uterus
 It is centrally located in the pelvic cavity between the
bladder (anteriorly) and rectum (posteriorly).
 In unmarried woman, the uterus is pear shaped,
measures approximately 7.5 cm length, 5 cm in width,
and 2.5 cm in thickness.
 The upper part is called the body, the bulging upper
part of the body is called the fundus & the lower part is
called the cervix (neck).
 It is suspended above the bladder and is anterior to the
rectum.
 Its normal position is anteverted (rotated forward over
the bladder) and slightly anteflexed (flexed forward
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Layers of the Uterus.
 The uterus has three layers:
 the perimetrium, the myometrium, and the endometrium
1) Endometrium:
• Is the innermost layer
 It is composed of three layers, and of these, are shed during each menstrual period
and after childbirth in the lochia, the vaginal drainage after
childbirth.
 It is site for implementation , nidation

3) Myometrium:
 It's the thick middle layer.
 The fundus has the thickest part of myometrium.
 It is composed of layers of smooth muscle that extend in three directions—
longitudinal, transverse, and oblique.
3) peritoneum:
 It's the outermost layer.
 It covers all the parts except the lower fourth of the anterior surface & the cervix
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Function of uterus :

1. Nutritional source until the placental develops.

2. Provides a safe environment that protects /fetus
3. Labor.
4. Menstruation.
5. Pregnancy site.
3. Fallopian Tubes

The fallopian tubes, also called oviducts, are 8 to 14 cm long and quite

narrow (2 to 3 mm at their narrowest and 5 to 8 mm at their widest).

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Function:
• Receive the ovulated oocyte

• Provide a site for fertilization

• Attaches to the uterus

• Does not physically attach to the ovary

• Supported by the broad ligament

The fallopian tubes have four divisions

1) The interstitial portion runs into the uterine cavity and lies
within the uterine wall
2) The isthmus is the narrow part adjacent to the uterus.
3) The ampulla is the wider area of the tube lateral to the
isthmus, where fertilization occurs.

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4) The infundibulum is the wide, funnel-shaped terminal end
of the tube.

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4. Ovaries

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4. Ovaries
 Alternately release an egg. When an ovary does ovulate, or release
an egg, it is swept into the lumen of the fallopian tube by the
fimbriae.
 One ovary is located on each side of the uterus, below and behind
the uterine tubes.
 The ovaries are held in the lateral walls of pelvis by two ligaments,
the ovarian and suspensory.
Two functions of the ovaries
 Ovulation: the release of a mature ovum from the ovary at
interval usually monthly.
 Hormones production: steroid sex hormones (oestrogen and
progesterone)
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 Female pelvis
The human pelvis supports the upper body and transmits
its weight to the lower limbs,
Function
 Allows movement of the body, especially walking and
running.
 Helps in child bearing  Protect the pelvic organ.
 Pelvic floor responsible for voluntary control of micturition
and play an important part in sexual intercourse.
 Allows exit to the fetus
The pelvis consists of four pelvic bones :
• two innominate
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• one sacrum • one coccyx.
The innominate bones are each divided into three
regions:
• ilium
• ischium
• pubis.
Divisions
of the
Pelvis:
 True
pelvis----- lies below the pelvic brim or linea terminalis; it is

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 the bony canal through which the fetus must pass. It is divided
into three planes: the inlet, the midpelvis, and the outlet.
 False pelvis----lies above an imaginary line called the
linea terminalis or pelvic brim. Function of the false pelvis
is to support the enlarged uterus

Types of pelvic
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 Gynecoid pelvis: the ideal pelvis for child bearing its rounded
brim
 Android pelvis : It resembles the male pelvis ,its brim is heart
shaped (triangular )
 Anthropoid pelvis: It has along oval brim
 Platypelloid (flat): Has a kidney shape brim

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Muscle layers
The muscles of the pelvic floor are arranged into two
layers, the superficial muscle layer and the deep muscle
layer.
The superficial muscle layer
1. External anal sphincter
2. Transverse perineal
3. Bulbocavernosus
4. The ischiocavernosus
5. The membranous sphincter

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The deep muscle layers (levatores
ani)
1. The pubococcygeus
2. Iliococcygeus
3. The ischiococcygeus

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Male Reproductive System

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▪ The male reproductive tract consists of internal organs
located in the pelvic cavity and external genitalia.
External Male Reproductive Organs
The male has two external organs of reproduction:
the penis and scrotum.
The penis has two functions.
1. As part of the urinary tract, it carries urine from the bladder
to the exterior during urination.
2. As a reproductive organ, the penis deposits semen into the
female vagina during coitus.
Scrotum
 The scrotum is a pouch of thin skin and muscle suspended behind
the penis.
 A wrinkled pouch like fullness of skin, muscle and fascia.
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  It’s divided internally by a septum that each compartment
normally contains one testis, one epididymis and one vas
deferens.
 One of the male gonads (testicle) is contained within each pocket
of the scrotum.
 The scrotum’s main purpose is to keep the testes cooler than the
core body temperature.
 Formation of normal male sperm requires that the testes not be
too warm
Internal Male Reproductive Organs
Testes
 The male gonads, or testes, have two functions: they serve as
endocrine glands, and they produce male gametes, or sperm
also called spermatozoa
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 Androgens (male sex hormones) are the primary endocrine
secretions of the testes.
 Androgens are produced by Leydig cells of the testes. The
primary androgen produced by the testes is testosterone.

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 A feedback loop with the hypothalamus and anterior pituitary
stabilizes testosterone levels. A small amount of testosterone is
converted to estrogen in males and is necessary
 for sperm formation. Spermatogenesis occurs within tiny coiled
tubes, the seminiferous tubules of the testes.
 At ejaculation, approximately 35 to 200 million sperm are deposited
in the vagina.
 This large number is needed for normal fertility, although a single
sperm fertilizes the ovum.
 Only a few sperm ever reach the fallopian tube.
 where an ovum may be available for fertilization. When the first
sperm penetrates the ovum, changes
 Within the ovum prevent other sperm from also fertilizing it

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Accessory Ducts and Glands
 From the seminiferous tubules, sperm pass into the epididymis
within the scrotum for storage and final maturation.
 In the epididymis, sperm develop the ability to be motile,
although secretions within the epididymis inhibit actual motility
until ejaculation occurs.
 The epididymis empties into the vas deferens, where larger
numbers of sperm are stored.
 The vas deferens leads upward into the pelvis and then
downward toward the penis.
 Within the pelvis the vas deferens joins the ejaculatory duct
before connecting to the urethra.
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Three glands—
 The seminal vesicles.
 The prostate.
 The bulbourethral gland—secrete seminal fluids that carry
sperm into the vagina during intercourse

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The seminal fluid has four functions:
1. Nourishing the sperm.
2. Protecting the sperm from the hostile pH (acidic)
environment of the vagina.
3. Enhancing the motility of the sperm.
4. Washing the sperm from the urethra to maximize
the number deposited in the vagina.

Chapter (2) Female

reproductive cycle

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Introduction to menstrual cycle
 Menstrual cycle (also termed a female reproductive cycle) is a periodic
uterine bleeding that begins with the shedding of secretory
endometrium approximately 14 days after ovulation. The purpose of
menstrual cycle is to prepare the uterus for pregnancy.
 Eumenorrhea denotes normal, regular menstruation that the average
duration of bleeding is 5 days (range 3-7 days) with average blood loss
approximately 50 ml (20-80 ml)
 The average length of normal menstrual cycle is 28 days with ± 7 days.
 The individual’s age, physical, environmental and emotional status
influences the regularity of menstrual period.
 The first menstrual cycle is called menarche

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 The first day of the menstrual discharge has been designated as day one
of the cycle.
The regularity of the menstrual cycle is
controlled by the balance of four hormones:
1. Estrogens
2. Progesterone
3. Follicle Stimulating Hormone (FSH)
4.Luteinizing Hormone (LH)
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Menstrual Cycle
A woman’s menstrual cycle is influenced by the ovarian cycle and
endometrial cycle.
Ovarian Cycle: pertains to the maturation of ova and consists of
three phases:
1. Follicular (oestrogen is secreted, FSH falls)
▪ This phase begins in the first day of menstruation and last 12-14 days;
during which graaffian follicle is maturing under influence of LH, and
FSH. The maturing graafian follicle produce estrogen. In endometrial
cycle this phase refers to proliferative phase because a hormone causes
the lining of the uterus to grow, or proliferate.
▪ A large amount of oestrogen is secreted by the follicle during this phase
of the menstrual cycle. This oestrogen does several things:

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 The oestrogen stimulates the endometrial lining of the uterus. It
becomes thicker and enriched.
One follicle begins to ripen and brings an egg to maturity The
estrogen suppresses the further secretion of FSH.
2. Ovulatory Phase (Day 14)
▪ This phase begins when oestrogen levels peak and ends with the

release of egg (refers to ovulation).

▪ The peak level of oestrogen helps stimulate a large and sudden

release of luteinizing hormone (LH). This LH surge occurs 12-36

hours before ovulation, which is accompanied by a transient rise in
body temperature, is a sign that ovulation is about to happen.

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▪ The LH surge causes the follicle to rupture and expel the ripened

egg into the fallopian tube.

▪ After that decrease in oestrogen level and increase in progesterone

level.

3. Luteal or Postovulatory Phase (progesterone increased)

▪ This phase begins after ovulation and lasts approximately 14
days.
▪ After the follicle is ruptured, its walls collapse. It is now
known as the corpus luteum; that begins to secrete large
amounts of progesterone along with low level of oestrogen,
which helps prepare the endometrial lining for implantation.
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▪ If the egg is fertilized, a small amount of the hormone called
human chorionic gonadotrophin (HCG) is released.
▪ HCG can be detected as early as seven days after fertilization, is the
basis for the early pregnancy tests.
HCG keeps the corpus luteum viable, so it can continue pumping
out oestrogen and progesterone, which, in turn, keep the endometrial
lining intact.
By about Week 6 to 8 of gestation, the newly formed placenta
takes over the secretion of progesterone.
▪ If the egg is not fertilized, FSH and LH fall to low level and corpus
luteum regress, decline level of estrogen and progesterone along with
corpus luteum regression will result in menstruation
Endometrial Cycle
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 The endometrial cycle pertains to the changes in the endometrium of

the uterus in responses to the hormonal changes that occur during the
ovarian cycle.This cycle consist of three phases:

1.The proliferative phase:

 Occurs following menstruation and ends with ovulation. During this

phase, the endometrium is preparing for implantation by becoming

thicker and more vascular.

 These changes are in response to the increasing levels of estrogen

produced by the graafian follicle.

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2. The secretory phase:
 Begins after ovulation and ends with the onset of menstruation.
During this phase, the endometrium continues to thicken. The
primary hormone during this phase is progesterone which is secreted
from the corpus luteum.
 If pregnancy occurs, the endometrium continues to develop and
begins to secrete glycogen.
 If pregnancy does not occur and the corpus luteum begins to
degenerate and the endometrial tissue degenerates.

3.The menstrual phase:

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 Occurs in response to hormonal changes and results in the sloughing
off of the endometrial tissue

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 Menstrual Disorder
1. Dysmenorrhea
Painful menstruation that interferes with daily activities. The
possible cause is increased production of endometrial prostaglandin.
Prevalence rates are as high as 90 percent It has two types:
a. Primary Dysmenorrhoea
 Occurs in the absence of organic diseases
 Usually appears after the first 2-3 years of menarche
 Its often improve by age or following pregnancy
 Symptoms may include pain in the back, thighs, and GI upset as
anorexia, nausea and vomiting
b. Secondary Dysmenorrhea
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  Occurs in association with pathological changes
such as endometriosis, pelvic inflammatory disease,
cervical stenosis, uterine or ovarian neoplasm or
uterine polyps
 Presence of IUD may lead to secondary
dysmenorrhea
Treated by:
 Mild analgesia (prostaglandin inhibitors)
 Contraceptives may be used
 Regular exercise
 Emotional support
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2. Premenstrual Syndrome (PMS)
 It’s a combination of severe physical, emotional and psychological
symptoms, such as depression and irritability, occurring just before
menstruation.
 It has a relation with luteal phase and differs from dysmenorrhea in that
it has no relation to ovulation.
 Three most prominent symptoms are irritability, tension, and dysphoria
(unhappiness). Common emotional and non-specific symptoms include
stress, anxiety, difficulty in falling sleep (insomnia), headache, fatigue,
mood swings, increased emotional sensitivity and changes in libido.
 The presence of exclusively physical symptoms associated with the
menstrual cycle, such as bloating, abdominal cramps, constipation,
swelling or tenderness in the breasts, cyclic acne, and joint or muscle
pain is not considered PMS.
Treatment:
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  Progesterone supplement
 Diuretic (Spironolactone)
 Tranquilizers may used
 Low salt diet
3. Amenorrhea
Absence of menstrual flow
It has two types:
a. Primary Amenorrhea
 A girl 16 years and has not menstruated yet.
 Caused by congenital obstruction. Congenital absence of uterus and
absence or imbalance of hormones
b. Secondary Amenorrhea

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  A girl menstruation has begun but stops.
 Physiological conditions as pregnancy, lactation and use of contraceptive
 Pathological condition as hormonal imbalance, poor nutrition, ovarian
lesion and stress.
Treatment: according to the cause.
4. Oligomenorrhea
 The term oligomenorrhea refers to infrequent menstruation (decrease in
time) or in occasional usage very light bleeding (decrease in amount).
 There are several symptoms: less than nine periods in a year, unpredictable
periods, difficulty conceiving and periods that are more than 35 days apart
 Usually, there are environmental factors include: physical illness, emotional
stress, poor nutrition, over exercise, and frequent travel may cause
oligomenorrhea
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 Treatment options for oligomenorrhea will depend upon the cause of the
condition.

5. Menorrhagia
 Menorrhagia is an abnormally heavy or prolonged menstrual period at
regular intervals.
 Causes may be due to abnormal blood clotting, disruption of normal
hormonal regulation of periods or disorders of the endometrial lining of the
uterus.
 Treatment options depend upon the cause of the condition. NSAIDs and
contraceptive pills may relieve the symptoms
6. Metrorragia
 Metrorragia or intermenstrual bleeding refers to any episode of bleeding
that occurs between the expected regular menstrual periods.
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 It’s significant because usually a symptoms of other diseases as cancerous
or benign tumor of uterus, endometriosis and uterine fibroids.
 Mittlestaining, small of bleeding or spotting occurs at the time of
ovulation. Is considered normal (the cause of mittlestaining is unknown).
 Mittelschmerz (ovulation pain) describes the above phenomenon that
characterized by pain in the lower abdominal and pelvic that occurs at
the midcycle
7. Polymenorrhea
 Polymenorrhea occurs when the menstrual cycle is less than 21 days
long. It is sometimes difficult to distinguish polymenorrhea from
metrorragia;
 However, bleeding that occurs at regular intervals less than 21 days apart
is usually polymenorrhea.

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8. Menopause
 Permanent physiological cessation of menses function. Occurs
when estrogen become so low.
 Menopause typically (but not always) occurs in women between the
age of 45-55 years.
 Menopause may be induced surgically such as hysterectomy
 The age of starting can be influenced by nutrition and genetic
factors.
 Fifty percent of women may report symptoms of heat arising in
chest and spreading to the neck and face due to vasomotor instability
(vasodilatation) and last for 20-30 min.

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 The reproductive system start to atrophy and the women become
prone to diabetes mellitus and osteoporosis.
 Women in this stage of life need for psychological support and
counselling.

Chapter (3)
Fertilization and Fetal Development

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Genes and Chromosomes

 Genes are composed of deoxyribonucleic acid -DNA (heredity

material) which enables them to duplicate themselves (genes)
during cell division and protein.
 Numerous genes are located on each human chromosome, that
each cell contains two sets of genes arranged in a line to form
larger structures called chromosomes.
 During early development, cells begin to take on specific
functions.
 Interrupting the normal gene sequence or stopping it prematurely
Chromosomes
 Chromosome is like a string of beads.

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 Normal human somatic cells contain 46 chromosomes arranged as 23 pairs of
matched chromosomes (one chromosome of each pair is inherited from each
parent).
 There are 22 pairs of autosomes that control of traits in the body and one pair of
sex chromosomes XX (female) or XY (male)..
 Added, missing, and structurally abnormal chromosomes are usually harmful
Cell division
 Cells are reproduced by two different methods: mitosis (cell replicate to
yield two cells with same genetic makeup) and meiosis Mitosis:
 Somatic cells divided by the process of mitosisin which the cell
components including genetic material are distributed equally to the
new formed cells. Each new cell contains the same composition and
genetic potential as the original cell.

Meiosis:
 The process of cell division in the reproductive cells is called
gametogenesis. Gametogenesis takes place by meiosis. Meiosis is a
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 process of reductional division in which the number of chromosomes
per cell is cut in half to form gametes.

Spermatogenesis :
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▪ Is the process of meiosis as it takes place in the testes, the site of sperm production.
▪ Within each testis are seminiferous tubules that contain spermatogonia, which are
stem cells that generate sperm.
▪ A spermatogonium divides by mitosis to form two cells, one of which will remain
in place as a stem cell, while the other differentiates (specializes) to become a
primary spermatocyte that will undergo meiosis

Oogenesis :
▪ Is the process of meiosis for egg cell formation; it begins in the fetal life of the
female.
▪ All of the cells that may undergo meiosis in the woman's lifetime are contained in
her ovaries at birth.
▪ Oogenesis begins in ovaries and is also regulated by hormones

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Conception
 Defined as the union of the couple's sex cells or gametes. The 23
chromosomes of the paternal ,sperm fuses with the 23
chromosomes of the maternal oocyte at fertilization to create a
single cell embryo or zygote containing 46 chromosomes
 This union is the benchmark of the beginning of a pregnancy
 At the moment of fertilization, the baby's genetic make-up is
complete, including its sex. Since the mother can provide only
X chromosomes (she's XX), if a Y sperm fertilizes the egg, the
baby will be a boy (XY); if an X sperm fertilizes the egg, the baby
will be a girl (XX).

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Fertilization

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Placenta
 The placenta is a thick, disc-shaped organ. The placenta has two
components: maternal and fetal
 It is involved in metabolic, transfer, and endocrine functions to
the uterus
 Two umbilical arteries and one umbilical vein transport blood
between the fetus and the fetal side of the placenta.
 Blood is circulated to and from the fetal side of the placenta by
the fetal heart
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Functions of the placenta 1-
Nutrition and respiration:
 The perfusion of the intervillous spaces of the placenta with maternal blood
allows the transfer of nutrients and oxygen from the mother to the fetus
and the transfer of waste products and carbon dioxide back from the fetus
to the maternal blood supply.
2- Excretion
Waste products excreted from the fetus such as urea, uric acid and creatinine
are transferred to the maternal blood by simple diffusion across the placenta.
3- Barrier function:
The foetal blood in the chorionic villi is separated from the maternal blood, in
the intervillous spaces, by the placental barrier.
4- Storage
The placenta metabolises glucose, store it in the form of glycogen
and reconverts it as required. It store iron and fat soluble vitamins.
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5- Endocrine function
 Human chorionic gonadotrophin (hCG): It supports the corpus
luteum in the first 10 weeks of pregnancy to produce oestrogen and
progesterone ,Estrogen, Progesterone
Fetal Membranes
 The two fetal membranes are the amnion (inner membrane) and the chorion (outer
membrane).
 The two membranes are so close they seem to be one membrane (the “bag of waters”)
 If the membranes rupture in labor,
 amnion and chorion usually rupture together, releasing the amniotic fluid within the sac
Amniotic fluid
▪ It is a clear, pale-straw coloured fluid consisting of 99% water, 1% dissolved solid
matter including food substance and waste products

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▪ protects the growing fetus and promotes normal prenatal development. The volume
of amniotic fluid increases during pregnancy and is approximately 700 to 800 mL at
term
▪ An abnormally small quantity of fluid (less than 50% of the amount expected for
gestation or under 400 mL at term) is called oligohydramnios
▪ Hydramnios (also called polyhydramnios) is the opposite situation, in which the
quantity may exceed 2000 mL
▪ Amniocentesis: done to detect sex, state of health and maturity of the fetus.
 Amniotic fluid Functions.:
1) Protects the fetus from direct trauma.
2) Separates the fetus from the fetal membrane.
3) Allows freedom of fetal movement
4) Facilitates symmetric growth and development of the fetus.
5) Protects the fetus from loss of heat and maintains a relatively constant fetal body
temperature.
6) Serves as a source of oral fluid for the fetus (fetus swallow up to 400 ml/day).
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 Umbilical Cord
 It’s the life line that links between the embryo and the placenta, about 50-55 cm long
and 2 cm in diameter and does not contain pain receptors
 Has two umbilical arteries (carry deoxygenated blood) and one umbilical
vein (carry oxygenated blood), that 400 ml of blood flow each minute
 Supported by loose connective tissue containing Wharton’s jelly to prevent kinking of
the cord in the uterus
Fetal Development
 The growth and development of the fetus is typically divided into three
stages:
1. Pre Embryonic Period
 The pre embryonic period is the first 2 weeks after conception
 Around the fourth day after conception, the fertilized ovum, now called a zygote, enters the uterus.
 It is the period of Initiation of Cell Division.
 The zygote divides into 2, then 4, then 8 cells, and so on until the 16-cell stage.

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 The cells become tightly compacted with each division.
 A solid ball of 16 cells, it is called a morula because it resembles a mulberry
 the outer cells of the morula secrete fluid, forming a blastocyst, a sac of cells with an inner cell
mass placed off center within the sac.
 The inner cell mass develops into the fetus.
 Part of the outer layer of cells develops the fetal membranes and the placenta, or the fetal structure
that provides nourishment, removes wastes, and secretes necessary hormones for continuation of
the pregnancy

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 The endometrium, now called the decidua, is in the secretory phase of the
reproductive cycle

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 The endometrial glands are secreting at their maximum, providing rich
fluids to nourish the conceptus before placental circulation is established.
 Implantation or nidation, is a gradual process that occurs between days 6
and 10 after conception.
 During the relatively long process of implantation, embryonic structures
continue to develop
 Normal implantation occurs in the upper uterus, slightly more often on
the posterior wall than the anterior wall.
The embryonic disc develops three layers, called germ layers, .
1) The ectoderm (ecto = outside) gives skin, nails, tooth and nervous
system
2) The endoderm (endo = inner) gives the epithelial inner lining of
GIT, respiratory system,
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endocrine glands and auditory canal
3) The mesoderm (meso = middle)
gives the connective tissue, muscle, blood and vascular system which,
in turn, give rise to Major organ systems of the body
2. Embryonic Stage: 3 to 8 Weeks' Gestation
 Beginnings of all essential structures of the human body are present.
 Most critical stage of physical development
 Organogenesis
 The human embryo now measures just over one inch long and weighs
about 4.5 grams.

3. Fetal Stage: 9 Weeks to Birth

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 Every organ system and external structure present.
Refinement of fetus and organ function occurs
 Fetal Circulation

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 The course of fetal blood circulation is from the fetal heart to the placenta for exchange of oxygen,
nutrients, and waste products and back to the fetus for delivery to fetal tissue

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Fetal circulation circuit:
 The umbilical vein enters the body through the umbilical ring and travels along to the
liver and joins with the portal vein. The blood then moves to the right atrium of the heart.
About half of the blood passes into the liver.
 The other half enters a vessel through ductus venosus which bypasses the liver (the newly
oxygenated blood).
 The ductus venosus travels a short distance and joins the inferior vena cava. There, the
oxygenated blood from the placenta is mixed with the deoxygenated blood from the lower
parts of the body. This mixture continues through the vena cava to the right atrium.
 In the adult heart, blood flows from the right atrium to the right ventricle then through the
pulmonary arteries to the lungs.
 While in the fetus, the lungs are non-functional and the blood largely bypasses them.
 As the blood from the inferior vena cava enters the right atrium, a large
proportion of it, is shunted directly into the left atrium through an opening called
the foramen ovale because of pressure in the right atrium is higher than left
atrium.

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 The more highly oxygenated blood that enters the left atrium through the
foramen ovale is mixed with a small amount of deoxygenated blood returning
from the pulmonary veins (via ductus arteriosus).
 This mixture moves into the left ventricle and is pumped into the aorta.
 Some of it reaches the myocardium through the coronary arteries and some
reaches the brain through the carotid arteries.
 The rest passes into the umbilical arteries, which branch from the internal iliac
arteries and lead to the placenta. There the blood is re-oxygenated

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82
Genetic counseling
 Genetic counseling provides information and support to help People understand the
genetic disorder they are concerned about and the risk for its occurrence in their family,
and make informed decisions about testing and treatment.
 Focus on the Family genetic counseling focuses on the family, not merely on the affected
individual.
 One family member may have a birth defect, but study of the entire family is often needed
for accurate counseling
Important of Genetic Counseling
1) Reassure people who are concerned about their children inheriting
a particular disorder.
2) Allow people who are affected by inherited disorder to make
informed choices about future production.

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 3) Educate people about inherited disorders and the process of
inheritance.
4) Offer support by skilled maternal nursing to people who are
affected genetic disorders.
Indications for Genetic Counseling Referral.
1. Maternal age 35 years of age or older when the infant is born
2. Paternal age 40 years or older
3. Members of a group with an increased incidence of a specific disorder.
4. Carriers of autosomal recessive disorders
5. Women who are carriers of X—linked disorders
6. Couples related by blood (consanguineous relationship).

7. Family history of birth defect or intellectual disability

8. Family history of unexplained stillbirth
9. Women who experience multiple spontaneous abortions
10. Pregnant women exposed to known or suspected teratogens
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11. Other harmful agents either before or during pregnancy
Diagnostic Methods in Genetic Counseling
1. Preconception Screening
2. Family history to identify hereditary patterns of disease or birth defects Examination
of family photographs
3. Chromosomal analysis
4. DNA analysis
5. Prenatal Diagnosis for Fetal Abnormalities
6. Maternal serum tests to screen for abnormalities
7. Maternal serum analytes (i.e., alpha—fetoprotein)
8. Noninvasive Prenatal Screening (NIPS or NIPT)
9. Analysis of cell—free fetal DNA
10. Chorionic villus sampling
11. Amniocentesis 12. Ultrasonography.
13. Percutaneous umbilical blood sampling

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 Chapter (4)
Pregnancy and antenatal care
Terms and definitions used in maternity nursing
 Gestation pregnancy or maternal condition of having a developing
fetus in the body.
 Embryo human conceptus up to the 10th week of gestation (8th
week post conception).
 Fetus human conceptus from 10th week of gestation (8th week Post
conception) until delivery.
 Viability capability of living, usually accepted as 24 weeks, although
survival is rare.

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 Gravida (G) total number of pregnancies of any gestation includes
abortion, ectopic pregnancy, hydatidiform moles(Twins count as
one pregnancy).
 Nulligravida woman who is not now and never has been
pregnant.
 Primigravida woman pregnant for the first time.
 Multigravida woman who has been pregnant more than once.
Abortion loss of intrauterine pregnancy prior reaches
viability (less than 24 week or fetal weight less than 500g.
 Para (P) refers to past pregnancies that have reached viability
(24weeks). (twins count as one )

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 Nullipara woman who has never completed a pregnancy to the
period of viability. The woman may or may not have
experienced an abortion
 Primipara woman who has completed one pregnancy to the
period of viability regardless of the number of infants
delivered and regardless of the infant being live or stillborn.
 Multipara woman who has completed two or more
pregnancies to the stage of viability.
 Grand multiparty is parity of 4 or more.
 Trimesters :
1. First trimester (T1): 0-12 weeks
2. Second trimester (T2): 12-28 weeks
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 3. Third trimester (T3): 28-40 weeks
 Normal pregnancy term (Full term pregnancy): completed 37-42 weeks
 Preterm labor (premature labor): is labor that begins before 37 weeks of
pregnancy.
 Postnatal or postpartum period (Latin for 'after birth'): it is the period beginning
immediately after the birth of a child and extending for about six weeks.
 GTPAL acronym: is a more comprehensive system for notation of obstetrical
history. This system goes further and designates numbers of term infants,
preterm infants, abortions, and living children using the acronym GTPAL as
follows:
G = gravida
T = number of term infants (born after 37 weeks’ gestation – 42wks)
P = number of preterm infants (born between 20 weeks’ gestation and
completed 37 weeks’ gestation)

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 A = number of pregnancies ending before 20 weeks’ gestation, either
spontaneous or induced (abortion)
L = the number of children currently living.

Manifestations of Pregnancy
 Pregnancy may be determined by cessation of menses, enlargement of
the uterus, and a positive result on a pregnancy test. These and the many
other manifestations of pregnancy are classified into three groups:
presumptive, probable, and positive
The signs and symptoms of pregnancy are grouped into three
Classifications:
 Presumptive
Most, but not all, presumptive indications are subjective
Changes experienced and reported by the woman.
 Probable

90
 Probable indications of pregnancy are objective findings that can be
documented by an examiner.
 Positive indications. accepted as positive confirmation of pregnancy
objective.
Presumptive signs and symptoms:
1) Cessation of menses: pregnancy is suspected if more than 10 days
have elapsed since the time of the expected menses onset.
2) Breast changes
a. breasts enlarge and become tender with visible veins.
b. nipples become larger and more pigmented.
c. Colostrums , a thin milky fluid (in the second half of pregnancy).
d. Montgomery glands (secrete a fatty substance that lubricates and
protects the nipple and areola during breastfeeding ) may appear "small
elevations in the a ereolae
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3) Chadwick's sign: a bluish purple discoloration that appears on the
cervix,vagina, and vulva
4) abdominal striae (striae gravidarum) sometime appear on the
breasts, abdomen and thighs because of stretching, rupture and
atrophy of the deep connective tissue of the skin

 Probable signs and symptoms:

1) Enlargement of the abdomen.
2) Changes in shape, size and consistency of the uterus.
 uterus enlarges, elongates and decreases in thickness as pregnancy
progress.
 Hegar's sign, lower uterine segment softens at 6-8 weeks.
3) Changes in cervix:
Goodell's sign: softening of the cervix at 6-8 weeks.
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4) Intermittent contractions of the uterus (Braxton Hick's
contraction):
5) Ballottement: a sinking and rebounding of the fetus in its
surrounding amniotic fluid in response to sudden tap on the
uterus, occurs near mid pregnancy (16-28 weeks)
6) Positive hormonal tests for pregnancy, response of HCG in
maternal blood (4-12weeks) and urine (6-12 weeks).
 Positive signs:

1) Fetal heart sounds by ultra sound (6 weeks) or fetal stethoscope

at 20-24 weeks.
2) Visualization of the fetus by ultrasound at 6 weeks or X-ray at
16 weeks.

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 3) Fetal parts palpated at 24 weeks- Fetal movements are palpable
at 22 weeks and visible are late pregnancy.
Maternal Adaptations to Pregnancy
All changes in a mother‘s body during pregnancy are due to:
The effects of specific hormones.
The growth of the fetus inside the uterus.
These changes enable the mother to support the fetus, prepare her
body for labor, develop her breasts and by down stores of fat to
provide calories for production of breast milk during puerperium
Changes begin soon after fertilization
The uterus:
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 deciduas (name of endometrium after pregnancy) become thicker,
richer and more vascular at the fundus and in the upper body of the
uterus. The deciduas provides a glycogen- rich environment for the
blastocyst until the trophoblastic cells begin to form the placenta.
 Estrogen is responsible for the growth of uterine muscle.
 The uterus changes to a globular shape to anticipate fetal. This causes
pressure on other pelvic organs.
 after 12 weeks, the fundus of the uterus may be palpated abdominally
above the symphysis pubis.
 By 20 weeks gestation, the fundus has reached the umbilicus.
 By 36 weeks, the fundus has reached the xiphoid

The cervix:
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 It acts as an effective barrier against infection.
 Endo-cervical cells secrete mucus under the influence of
progesterone, which becomes thicker and more viscous during
pregnancy.
 A clot of very thick mucus obstructs the cervical canal, which
provides protection from ascending infections called cervical plug.
 Estrogen increases cervical vascularity and if viewed through a
speculum, the cervix looks purple.
 In late pregnancy softening of the cervix occurs in response to
increasing painless contractions.
 Progestron also play a role in cervical softening in readiness for the
onset of labor.

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The vagina:
 Estrogen causes muscle layer hypertrophy and changes the
surrounding connective tissue which allows the vagina to become
more elastic and enabling it to dilate during labor.
 The vagina is more vascular, appearing reddish purple in color.
 The pH of vaginal secretions is 3.5-6 (more acidic) because of
increased production of lactic acid from glycogen in the vaginal
epithelium by lactobacilus acidophilus which prevent infection but
unfortunately, it increase the susceptibility of other infections such
as candida albicans.
 The ovaries:
Ovulation ceases during pregnancy, maturation of new follicles is
suspended.
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 • One corpus luteum functions during early pregnancy (first 8
weeks) producing mainly progesterone.
Notes:
•The placenta blood flow 450-650 ml/min at term.
•The blood flow to the uterus constitutes 2% of cardiac output in
non-pregnant woman and increases to 17% at term of pregnancy
Skin changes
 Increased activity of the melanin- stimulation hormone causes deeper
pigmentation during pregnancy.
 Some develop deeper, patchy coloring on the face which resembles a
mask and is known as chloasma.

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 (The heightened pigmentation fades after pregnancy but can recur after
exposure to the sun).
 Many notice a pigmented line running from the pubis to the umbilicus
and sometimes higher, called the linea nigra
 In some women the areas of maximum stretch become thin and stretch
marks, striae gravidarum appear as red stripes during pregnancy

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Changes in the cardiovascular system
 Blood volume increases by 40% to 45% and is due primarily to an
increase in plasma and erythrocyte volume.
 he increased need for oxygen requires the pregnant woman to increase
her iron intake.
 physiological anemia of pregnancy‖ or pseudoanemia.
 The hemodilution effect is most apparent at 32 to 34 weeks. The mean
acceptable hemoglobin level in pregnancy is 11 to 12
 Cardiac output increases, at about 30% to 50% above pre-pregnancy
levels
 With the increased vascular volume & vasodilation (related to
progesterone-induced relaxation of the vascular smooth muscle)
prevents an elevation in blood pressure.
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 supine hypotension syndrome, or vena caval syndrome (faintness related
to bradycardia) if she lies on her back
Changes in the respiratory system
 The tidal volume (amount of air breathed in each minute) increases
30% to 40%. This change is related to the elevated levels of estrogen
and progesterone.
 Estrogen prompts hypertrophy and hyperplasia of the lung tissue.
 Diaphragm is elevated during pregnancy chiefly by enlarged uterus,
but chest circumference increases by 6 cm.
 Maternal oxygen requirements increase in response to increased
metabolic rate.

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 increased respiratory rate and reduced PCO2 probably induced by
progesterone and estrogen effect on respiratory center
Changes in the gastrointestinal system:
 Craving for unnatural substances is termed pica
 Heartburn is common and is associated with gastric reflux due to the
relaxation of cardiac sphincter
 Constipation is a result of sluggish gut motility .
 It can exacerbate hemorrhoids which may exist as a result of the
relaxing effect of progesterone‘s action on the smooth muscle of vein
wall and the pressure exerted by the enlarged uterus on pelvic veins.
 Nausea and vomiting occur mainly during early pregnancy, possibly,
due to raised hCG levels and altered carbohydrate metabolism.
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Changes on urinary system
 urinary urgency, frequency, and nocturia.
 These signs and symptoms disappear during the second trimester and
most of the third trimester.
 Ascending infection (UTI) occurs more frequently in pregnancy due to
relaxation of the smooth muscle of the bladder and urinary sphincter,
changes that allow bacterial ascent into the bladder. Ureters are dilated,
glomarular filtration increased, glycosuria may be evident, proteinuria
doesn‘t occur normally.
 Patients should be encouraged to drink at least 8 to 10 glasses of water
each day and empty their bladders at least every 2 to 3 hours and
immediately after intercourse.
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 These measures help to prevent stasis of urine and the bacterial
contamination that leads to infection
Skeletal changes:
▪ Progesterone and relaxin encourage relaxation of ligaments and
muscles, reaching maximum effect during the last weeks of
pregnancy.
▪ This relaxation allows the pelvis to increase its capacity in
readiness to accommodate the fetal presenting part at the end of
pregnancy and in labor.
▪ Unstable pelvic joints result in the rolling gait sometimes seen in
pregnant women. Alteration in posture and walking due to an
increase in weight which result in back pain.
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Changes in the endocrine system:
 Human placental lactogen (hPL), estrogen and progesterone
produced by the placenta oppose the action of insulin during
pregnancy.
 ACTH, (Adrenocorticotropic hormone), also known as
corticotropin) increase their activity.
 FSH and LH are inhibited by progesterone and estrogen.
 Thyroid gland is moderately enlarged because of hyperplasia of
glandular tissue and increase vascularity leading to increased BMR.
 Adrenal gland secretions (corticosteroid) considerably increased and
may be one of the reasons for glycosuria in pregnancy.

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 Increase secretion of aldosterone promotes retention of water and
increases circulatory volume. The increase in aldosterone may be a
protective response to the increased renal and excretory gland sodium
excretion that occurs due to the effects of progesterone.
Metabolic changes:
 Maternal weight: Continuing weight increase in pregnancy is
considered to be one favorable indicator of maternal adaptation and
fetal growth. Expected increase: 12.0 Kg approximates total.
 Many factors influence weight gain. The degree of maternal edema,
smoking, amount of amniotic fluid, and size of the fetus must all be
taken into account.

106
 Protein metabolism: - At term, fetus and placenta contain 500g of
protein. - Approx. 500g more of protein are added to the uterus,
breasts and maternal blood in the form of hemoglobin and plasma
proteins.Total increase: 1000 grams.
 Carbohydrate metabolism: - Normal pregnancies induce a state of
peripheral resistance to insulin by hPL, estrogen and progesterone.
Duration of pregnancy:
 Average length is 280 days or 40 weeks from the first day of the last
normal menstrual period. - Duration may also be divided into three
equal parts or trimesters of slightly more than 13 weeks or 3 calendar
months each.

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  Estimated date of confinement (EDC) is calculated according to
Nagele rule by adding 7 days to the date of the first day of the last
menstrual period and counting back 3 months.
Antenatal (prenatal) Care
 The prenatal period is a preparatory one, both physically in terms of
fetal growth and maternal adaptation and psychologically in terms of
parenthood.
 Regular prenatal visits ideally begin soon after the first missed
menstrual period, offer opportunities to ensure the health of the
expectant mother and her infant
 Aims of antenatal care
1) Providing a holistic approach to the women’s care to meet her individual needs.

108
2) To support and encourage family's healthy psychological adjustment to
childbearing.
3) To monitor the progress of pregnancy in order to ensure maternal health and
normal fetal development.
4) To ensure that the women reaches the end of her pregnancy and emotionally
prepared for the birth of her baby.
5) To ensure that the women enable to make informed choices about pregnancy and
birth.
6) To support the mother to take informed choice about methods of infant feeding.
Booking visit
 Booking visit means the initial visit that should be done as soon
as pregnancy confirmed because the fetal organs almost
completely by 12 weeks.

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  Observation of physical characteristics is very important in the
booking visit.
 Nursing assessment at booking visit ( history taking ) a) Personal or
demographic information
b) Woman‘s present obstetric history (current pregnancy):
Example: if the woman pregnant only once with twins delivered at the
35th week and the babies survived. The abbreviation that represents this
information is 2-1-2-0-2.(GTPAL) c) Woman‘s menstrual history:
d) Past obstetric history
e) Medical history
Physical Examination and laboratory tests:
I. Screening procedures play an important part in ascertaining normality.

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II. Height of over than160 cm gives an indication of a normal-sized pelvis.
III. Weight: obesity can lead to an increased risk of gestational diabetes and
PIH.
IV. Blood pressure
V. Physical Examination
 Blood tests: “At the initial visit”
Complete blood count values (CBC) Blood
type and Rh factor.
•Antibody screen texoplasmosis, Rh, rubella‘‘ Rubella
titer (if not Known).
Hb electrophoresis, when indicated (to detect for sickle cell, thalassemia).
Hepatitis B virus screen.
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 Follow- up antenatal visits (Subsequent visits):
Schedule: o Conception to 28 weeks—every 4 weeks o
29 to 36 weeks—every 2 weeks o 37 weeks to birth—
weekly. o Each visit includes an individual assessment with
time alone with the health care provider.
o More frequent visits may be required if there are complications.
Abdominal examination:
 Height of fundus above pubic symphsis.

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 Fundus at symphysis pubis- 12 weeks gestation.
 Fundus at umbilicus = 22-2 4weeks gestation.
 Fundus 28 cm from top of symphysis =28 weeks gestation.
 Fundus at lower border of rib cage= 36 weeks gestation.

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 Methods of Abdominal examination:
1. Inspection
The size of the uterus
The shape the uterus
Skin changes
2. Palpation((Leopold’s Maneuvers)
 height of the fundus
 indicate multiple pregnancy or polyhydramnios

Leopold’s Maneuvers
First maneuver (Leopold’s Maneuvers 1)
 Palpate the uterine fundus

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 The breech (buttocks) is softer and more irregular in shape than the
head.
 Moving the breech also moves the fetal trunk.
 The head can be moved without moving the entire fetal trunk, hard and
round, it can be balloted ) between the fingertips of the two hands
because of the free movement of the neck.

115
 Second maneuver (Leopold’s Maneuvers 2)
 Lateral palpation , walking, umbilical maneuvers
 This is used to locate the fetal back in order to determine position
 The fetal back is usually firmer and more regular in form than the
other side of the fetus.
 The hands are placed on either side of the uterus at the level of the
umbilicus
 Gentle pressure is applied with alternate hands in order to detect
which side of the uterus offers the greater resistance.

116
 Third maneuver (Leopold’s Maneuvers 3)
 Pelvic palpation, Pallach's maneuver or grip

117
 Pelvic palpation is used to identify the presentation which that is the
part of the fetus lying in the lower pole of the uterus, over the pelvic
brim.
 The presenting part is engaged or not the presenting part is mobile
(ballotable), or engaging.
 The two-handed technique appears to be the most comfortable for the
woman and gives the most information

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Forth maneuver (Leopold’s Maneuvers 4)
Pawlik's manoeuvre
▪ Determines whether the head is flexed (vertex)or extended
(face).
▪ Where the midwife grasps the lower pole of the uterus
▪ between her fingers and thumb

Engagement
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o Occurred when the widest presenting transverse diameter has passed
through the brim of the pelvis
o In a primigravid woman, the head normally engages at any time from
about 36 weeks.
Lie
o the relationship between the long axis of the fetus and the long axis
of the uterus
o In the majority of cases the lie is longitudinal owing to the ovoid
shape of the uterus; the remainder are oblique transverse.
 Position
 The position is the relationship between the denominator of the
presentation and six points on the pelvic brim
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121
 3. Auscultation
 A Pinard's fetal stethoscope will enable the midwife to hear the
fetal heart directly and determine that it is fetal and not maternal.
 The stethoscope is placed on the mother's abdomen, at right angles
to it over the fetal back.
 The midwife should count the beats per minute, which should be
in the range of 110–160.

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Maternal Nutrition
 Maternal nutrition plays a significant role in fetal well being as well
as in the prevention of high-risk pregnancy.
 A 25% deficit in needed calories and protein can interfere with the
synthesis of DNA.
 As a result during the 1st 2-3 months of pregnancy, a deficit in
nutrients can have teratogenic effect or lead to spontaneous loss.

123
 After 2-3 months, maternal nutritional deficits can restrict fetal
growth, causing a small for gestational age infant or a small brain
growth infant.
 Specific maternal nutritional deficiencies can have deleterious
effects on the fetus.
 Nutritional education during the childbearing period may have
long-term positive effects on the mother, the infant, and the entire
family.
 Minerals that may not be consumed at recommended amounts
during pregnancy are iron and calcium.
 Iron is often added as a supplement and calcium is added for
women with low intake.
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 Vitamin-mineral supplements should be used carefully to prevent
excessive intake and toxicity.
 Increased intake of some nutrients interferes with use of others.
 Pregnant women should drink approximately 8 to 10 cups of fluids
each day.
 They should eat 7 to 9 oz of whole grains, 3 to 3.5 cups of
vegetables, 2 cups of fruits, 3 cups of the dairy group, and 6 to 6.5
oz of protein foods daily.
 Culture can influence diet during pregnancy. Both Asian and
Hispanic dietary practices include the importance of yin and
yang (cold and hot) foods.
 The nurse should know which foods are acceptable at what times
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 Chapter (5)
Intrapartum Assessment and
Interventions
labor
 Labor is described as the process by which the fetus, placenta and
membranes are expelled through the birth canal.
 Normal labor occurs at term and is spontaneous in onset with the fetus
presenting by the vertex.
 The process is completed within 18 hours and no complications arise.

Initiation of labor
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 The exact mechanism that initiates labor is unknown. Theories include
the following:
 Uterine stretch theory: uterus becomes stretched causes a release of
prostaglandins.
 Prostaglandin + oxytocin cause pressure on cervix
stimulate more production of oxytocin).
 There is increased production of prostaglandins by fetal
membranes and uterine decidua as as pregnancy advances
 In later pregnancy, the fetus produces increased levels of cortisone
which inhibit progesterone production from the placenta.
 Placental aging and deterioration triggers the initiation of
contractions.

General terms.
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 Presentation: the part of the fetus deepest in the birth canal.
Presentation may be vertex, face, brow, breech or shoulder
 Attitude: relationship of fetal parts to each other (normal flexion
 Position: Position refers to the location of a fixed reference point
on the fetal presenting part in relation to a specific quadrant of the
maternal pelvis
 Lightening : the setting of the fetus in the lower uterine segment
occurs 2-3 weeks before the onset of labor in the primigravida and
later during labor in the multigravida.
 Lie: a comparison of the long axis of the fetus with the long axis of
the mother. Fetal lie is either, longitudinal, transverse or oblique

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These factors are often called the four Ps:
powers, passage, passenger, and psyche.
 Powers(physiological forces)
1) Uterine Contraction: uterine contractions are the primary force that
moves the fetus through the maternal pelvis.

129
2) Maternal Pushing Efforts : the woman feels an urge to push and
bears down as the fetus distends her vagina and puts pressure on her
rectum
Passage(maternal pelvis)
1) The birth passage consists of the maternal pelvis and soft tissues
2) The bony pelvis is usually more important to the outcome of labor
than the soft tissue because the bones and joints do not readily yield
to the forces of labor.
3) The true pelvis is most important in childbirth

130
131
Passenger(fetus and placenta)
1) The passenger is the fetus, membranes, and placenta
2) Several fetal anatomic and positional variables influence the course
of labor.
3) Fetal Head,the fetus enters the birth canal in the cephalic
presentation =Bones, Sutures, and Fontanels
 Presentation—Fetal body part that is deepest in birth canal and
felt on vaginal exam.
 Cephalic (head)—occiput, sinciput, brow, face, or chin (mentum)

132
131 133
Fetal Head
The bones of the fetal head involved in the birth process are
the two frontal bones on forehead, two parietal bones at the
crown of the head, and one occipital bone at the back of the
head :
1) Sutures: two bone connected to gather.
2) Fontanels: more than one sutures connected to gather.
 The posterior fontanel: has a triangular shape, close at 6 weeks.
 The anterior fontanel: has a diamond shape formed by the
intersection of four sutures close at 18 month.

134
135
Psychosocial (previous experiences, emotional status)
•A woman’s psychological response to labor and birth are influenced
by anxiety, culture, expectations, life experiences, and support.
1) Anxiety
Marked anxiety and fear may decrease a woman’s ability tocope with
pain in labor
2) Culture and Expectations, Birth as an Experience ,support
Successful labor and delivery depend on adequate pelvic
dimensions, adequate fetal dimensions, presentation and adequate
uterine contractions.

136
 True labor and False labor

No. True Labor False Labor

1 Progressive cervical dilation and No progressive cervical dilation and
effacement effacement

2 Occur at regular intervals Occur at irregular intervals

3 Interval between contractions Interval remain the same or increased

decreased

4 Intensity of contraction increase Intensity of remain the same or decrease

5 Located mainly in the back and Located mainly in the groin and
abdomen abdomen
 6 Generally intensified by walking Generally unaffected by walking

7 Contractions not affected by mild Affected by mild sedation

135 sedation
133

Normal Labor
starts when the fetus is mature enough to adjust easily to extrauterine
life term 37-42
Spontaneously , cephalic presentation , without complication.
Natural labor begins when forces favoring continuation of pregnancy
are offset by forces favoring its end.
 Factors that appear to have a role in starting labor.

138
1) Changes in the ratio of maternal estrogen to progesterone, so that
estrogen levels are higher than progesterone levels. Progesterone
promotes smooth muscle relaxation of the uterus during most of
pregnancy.
2) Prostaglandins produced by the decidua and membranes.
3) Increased secretion of natural oxytocin appears to maintain labor once
it has begun.
4) A fetal role in the initiation of labor appears likely
Stages of labor
1) The 1st stage is that of dilation of the cervix. It begins with regular
rhythmic contractions and is complete when the cervix is fully
dilated 10 cm.
139
2) The 2nd stage of labor is the expulsion of the fetus. It begins when
the cervix is fully dilated and is completed when the baby is
completely born.
3) The 3rd stage of labor includes separation and expulsion of placenta
and membranes. It lasts from the birth of the baby until the placenta
and the membranes have been expelled. (about half an hour)
4) The 4th stage lasts from delivery of the placenta until the
postpartum condition of the woman has become stabilized usually
1-2 hour after delivery‖

140
 Mechanism of labor
If the woman‘s pelvis is adequate, size and position of the fetus are
adequate and uterine contractions are regular and of adequate
intensity, the fetus will move through the birth canal.
Decent
Flexion
Internal rotation
Extension
Restitution
External rotation
Delivery of body
141
142
 1. Descent
 Decent of the fetus is a mechanism of labor that accompanied all the
others.
 Accomplished by force of uterine contraction on fetal portion in
fundus during second stage of lab
 Degree of decent described as:-
Floating: presenting part is not engaged in pelvis inlet
Fixed: presenting part enters the pelvis
Engagement: presenting part has passed pelvic inlet
2. Engagement

143
 Engagement occurs when the largest diameter of the fetal
presenting part (normally the head) has passed the pelvic inlet
 Engagement takes place up to two weeks before birth in nulliparas
and at the onset of delivery in multiparas. In many parous women
and in some nulliparas, it does not occur until after labour begins .
3. Flexion
 Fetus meets resistance from soft tissue of the pelvis during decent,
causing flexion so that the chin is close to the chest.
 Head flexion presents the smallest anteroposterior diameter
(suboccipito bragmatic) to the pelvic canal.

144
4. Internal rotation
 As the head decent to the ischial spine, it gradually turns anteriorly
to accommodating to the birth canal that the fetal occiput becomes
anterior to the symphysis pubis (OA). Less commonly, the head
may turn posteriorly so that the occiput is directed toward the
mother’s sacrum (OP).
5. Extension
 The fetal head extend to passes beneath the mother’s symphysis pubis.
6. External rotation
 When head is born with the occiput directed anteriorly, the
shoulders must rotate internally to align with AP diameter of the
pelvis.
145
 After the head is born, it’s spontaneously returns to the same side
as in utero to realigns with the shoulders and back through process
called restitution.
 7. Expulsion
Expulsion of the fetal shoulders at first and follows with fetal body

1) First Stage
▪ It begins with the onset of true labor contractions and ends
with complete dilation (10 cm) and effacement (100%) of the
cervix.
▪ The first stage of labor is the longest for both nulliparous and
parous women.
146
 ▪ Three phases within the first stage are latent, active, and
transition.
Latent Phase.
• Defined as 0 to 3 cm dilated.
• Longer nullipara than for the multipara.
• contractions Last 30—40 sec.
• The interval between contractions shortens until contractions are
about 5 minutes apart.
Active Phase.
 When the rate of cervical change accelerates.
 cervix 4—7 cm dilated

147
 Contraction every 2—5 minutes
 contractions Last 40—60 sec, and moderate to strong intensity

Transition phase:
 The cervix dilates from 8 to 10 cm
 Contraction:. Strong, every 11/2—2 min, last 60—90 se
 Strong contractions combined with fetal descent may cause the woman
to have an urge to push and bear down during contractions.
 Other sensations that a woman may feel during transition include rectal
pressure, an increased urge to bear down, an increase in bloody show,
and spontaneous rupture of the membranes (if they have not already
ruptured).
Nursing Assessment
148
1) Collection of History and Baseline Data:
Pregnancy History (identifies problems that may affect this birth) .Past and
present history , Labor status.
2) Contractions ( mild, moderate, severe , frequency , strength ,duration,
/10mintue ).
Mild contractions,
the uterus can be easily indented with the fingertips.
 The contractions feel similar to the tip of the nose.
Moderate contractions:
the uterus is firm and is indented with more difficulty.
 The contractions feel similar to the chin.
Firm contractions:

149
The uterus feels rigid or board—like and cannot be readily indented.
The contractions feel similar to the forehead
3) Labor Progress
The frequency of vaginal examinations depends on the woman’s
parity, status of her membranes, and overall speed of her labor
Vaginal examination are limited to avoid the introduction of
microorganisms from the perineal area into the uterus.
Purpose
1. To determine whether membranes have ruptured.
2. To determine cervical effacement and dilation.
3. To determine fetal presentation, position, and station
150
 Indications for vaginal exam
a) diagnosis of labor, dilation of the cervix
b) Identification of presentation.
c) To determine whether the head is engaged in case of doubt.
d) Assess ruptured M or to rupture them artificially.
e) To exclude cord prolapsed after rupture of membranes.
f) To assess progress or delay in labor.
g) To apply a fetal scalp electrode
4) Membrane status
Spontaneous rupture of the membranes (SROM)
Amniotomy (artificial rupture of the membranes orAROM).
151
 The time of rupture, FHR, color, odor, and quantity of the amniotic
fluid are noted and charted.
• Greenish, meconium-stained fluid may be seen in response to
transient fetal hypoxia, post term gestation, or placental in
sufliciency.
• Fluid with a foul or strong odor, cloudy appearance, or yellow
color suggests Chorioamnionitis (inflammation of the amniotic sac,
usually caused by bacterial and viral infections.
5) Fetal Evaluation
To determine whether the fetus
seems to be healthy and tolerating labor well.
Average rate at term is110—160bpm.
152
intermittent auscultation (CTG) or EFM.
FHR assessments are recommended before and after procedures
Healthy women with uncomplicated labour Pinards/Doppler
recommended
▪ every 15mins 1st stage
▪ every 5mins 2nd stage
Continuous EFM is recommended if:
Baseline < 110 or >160bpm;
Decelerations or intrapartum risk factors develop
The CTG the documentation of the pattern should include:
 –woman’s name, date and time
 –estimated gestational age,
153
 –clinical indications for performing the FHR pattern, –maternal
pulse rate.

154
6) Physical Examination
General appearance Vital
signs:
Abdomen.
Deep tendon reflexes (DTRs)
Midstream urine specimen: Assess protein Negative or trace of
protein an and glucose levels with a dipstick.
Laboratory tests, CBC, Blood type and Rh factor

Nursing Interventions in the first stage:

1) Monitor progress of labor, vital signs, contractions and fetal heart
sounds every15 minutes
155
2) Assist with controlled breathing as contractions occur
3) Discourage the woman from bearing down until cervical
dilatation is complete
4) Encourage the women to rest between contractions to conserve
energy
5) Provide concise and brief explanations because woman is irritable
6) Remind the woman that labor is nearing its end
7) Prepare the woman for movement to the delivery room

156
2) Second Stage
 The second stage (expulsion) begins with complete (10cm)
dilation and full (100%) effacement of the cervix and ends with
the birth of the baby.
 Duration of second stage labor also varies
Nulliparous: 2.8 hours. / Multipara: 1.1 to 1.3 hours
 Contractions may diminish slightly or even pause briefly May
be slightly less intense than during transition phase of first stage.

157
 As the fetus descends, pressure of the presenting part on the
rectum and the pelvic floor causes an involuntary pushing
response in the mother.
 The maternal urge to push does not always occur the moment
the woman is fully dilated.
Nursing Interventionsin the second stage:
1) Monitor FHR, contractions and blood pressure every 5
minutes
2) Encourage pushing, only with contractions using abdominal
muscles

158
3) If the partner or support person is present, have him to
support woman and see birth if desired
4) Change positions frequently to increase comfort and promote
fetal descent.
5) Evaluate bladder fullness, and encourage voiding or
catheterize as needed.
6) Evaluate effectiveness of anesthesia as indicated; notify if
alterations in dosing are needed to facilitate progression while
maintaining pain control
7) Prepare the infant resuscitation area; notify pediatric personnel, if
appropriate, per facility policy.

159
8) Notify necessary obstetric personnel and primary practitioner to
prepare for delivery.
9) If delivery room is to be used, transfer the primigravida to the
delivery room when the fetal head is crowning.
10) Position the woman for delivery using a large cushion for her head,
back, and shoulders.
11) Elevate the head of the bed.
12) When the vulvovaginal ring encircles the head, an episiotomy may
be performed to prevent tearing of the perineum

160
11) Episiotomy is a surgical incision of the perineum that is
performed to enlarge the vaginal orifice during the second stage
of labor.
12) Nuchal cord intervention—if loops of umbilical cord are found
around the neonate's neck, they are loosened and slipped over
the head. If the cord cannot be slipped over the head, it is
clamped with two clamps and a cut is made between the two
clamps.
13) the woman is instructed to give a gentle push to assist with
delivery of the neonate's body.

161
14) If color and tone are adequate and accompanied by a vigorous
cry, basic neonatal care can be delayed to support family
bonding. ( SkinTo Skin 90 minutes).
Many medication preparations exist to treat postpartum
hemorrhage:
 Methergine I.M .5mg max if not contraindication.
 Prostaglandin F2 Alpha Hemabate ( protocol).
 Dinoprostone (Prostin E2) 20 mg per rectum (PR).
 Misoprostol (Cytotec) 200 to 400 for a maximum dose of 1,000 mcg
PR, increase I.V. fluids (normal saline solution of choice) and may
need to add a second I.V. ( be aware of side effect , shivering).

162
3) Third Stage
▪ The third (placental) stage begins with the birth of the baby and ends
with the expulsion of the placenta
▪ This stage is the shortest, with an average length of 6 minutes.
▪ No difference in duration exists between nulliparas and parous
women.
▪ When the infant is born, the uterine cavity becomes much smaller.
▪ The reduced size decreases the size of the placenta site, causing it to
separate from the uterine wall)
The following four signs suggest placenta separation:
1) The uterus has a spherical shape.
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2) The uterus rises upward in the abdomen as the placenta
descends into the vagina and pushes the fundus upward.
3) The cord descends further from the vagina.
4) A gush of blood appears as blood trapped behind the
placenta is released
• The uterus must contract firmly and remain contracted after the
placenta is expelled to compress open vessels at the
implantation site.( figure of 8, living ligature.)
• Inadequate uterine contraction after birth may result in
hemorrhage.

164
• Pain during the third stage of labor results from uterine
contractions and brief stretching of the cervix as the placenta passes
through it
• Evaluate volume of vaginal bleeding as stable or unstable per the
patient's vital signs and uterine response

165
166
 Nursing Interventions in the third stage:
 Immediately after initiating Oxytocin (IM according to protocol).
 Gently massage uterine fundus periodically to promote firmness.
 Uterine massage is done with two hands, one anchored at the
lower uterine segment above the symphysis pubis and the other
hand gently massages the fundus. Look the causes of post partum
4Ts
Excessive uterine activity
reduces placental blood
flow by prolonged
167
 compression of the vessels
that supply the intervillous
spaces
4) Fourth Stage
 Considered to be the stage of recovery period but in the same time it
is a critical period for the mother and the newborn
 It lasts from the delivery of the placenta through the first 1 to 4 hours
after birth.
 Immediately after birth, the firmly contracted uterus can be palpated
through the abdominal wall as a firm, rounded, at or below the level
of the umbilicus.
168
 A full bladder or blood clot in the uterus interferes with uterine
contraction, increasing blood loss
 Localized discomfort from birth trauma such as lacerations, an
episiotomy.
 Ice packs on the perineum limit this edema and hematoma formation.
 The vaginal drainage after childbirth is called lochia.
 The three stages are lochia rubra, lochia serosa, and lochia alba, After
pains: breast feeding – normal
 The fourth stage of labor is an ideal time for bonding of the new family
because the interest of both the parents and the newborn is high.
Nursing Interventions in the fourth stage:
169
1. Monitor BP, pulse, and respirations every 15 minutes for 1 hour,
then q4hrs.
2. Uterine fundal tone, height, and position.
3. The uterus should be firm around the level of the umbilicus, at the
midline.
4. If deviated to the side (usually the right side), it is indicative of a full
bladder; have the mother empty her bladder and the uterus should
return to midline
5. Amount of vaginal bleeding (lochia) at each interval of assessment.
6. Perineum for edema, discoloration, bleeding, odor, or hematoma
formation.
7. Episiotomy for approximation, drainage, or bleeding.

170
8. Provide oral fluids and a snack or meal as tolerated if vital signs are
stable and bleeding is controlled.
9. Encourage drink and food before assisting the woman out of bed.
NB: A good method to remember how to check and care the
postpartum changes is the use of seven B:
1. Brain (Emotional response)
2. Bleeding (Lochia)
3. Breast
4. Bottom (Episiotomy)
5. Bladder
6. Bowel
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7. Body
A good method to remember how to evaluate the episiotomy is
the use of the acronym REEDA:
 R- Redness.
 E - Edema.
 E -Ecchymosis (purplish patch of blood flow).
 D - Discharge.
 A -Approximation, or the closeness of the skin edges

Immediate care of mother

 Massage the uterus and expel the clot.

172
 Give Ergometrine (Methergine) to control of bleeding to facilitate
delivery of the placenta and to prevent bleeding after childbirth.
 The vulva is swabbed and a sterile pad placed in position
 Buttocks should be dry and any wet sheet is removed, the sterile towel
is laid over the lower abdomen and thighs and cover with warm
blanket.
 Check the maternal pulse and blood pressure
 Take body temperature – subnormal due to loss of body heat due to
reactions of prolonged labour.
 Encourage the woman to pass urine.

173
 Immediate care of newborn
 Clear airway by aspirating the mucous from the infant’s mouth and
pharynx with suction catheter.
 Dry the infant well immediately after birth that a wet small
newborn loss up to 200 calories/kg/minute in the delivery room
through evaporation, convection and radiation.
 Caring of umbilical cord that the cord is tied off approximately 2.5
cm from the abdominal wall by plastic clamp. Count the number
of vessels that less than three is associated with renal and cardiac
anomalies.

174
 Caring of the infant’s eyes that prophylactic treatment (2 drops of
silver nitrate solution is placed in conjunctival sac) against
ophthalmia neonatorum (gonorrheal conjunctivitis
 Administer 1 mg of vitamin K in the delivery room to prevent
hemorrhagic disease in the early neonatal period. Infant at delivery
does not manufacture vitamin K because has no intestinal flora.
 Check infant’s weight, height and circumferences of head and
chest.
 Apply ID band to infant’s arm including mother’s name, hospital
number, infant’s sex and time and date of birth.

175
 Record your observations during labor: Method of delivery,
anesthesia and sedative if used, blood loss and perineum
statuslaceration, episiotomy.
 Evaluate infant’s condition by Apgar scoring at one and five
minutes, Be ready to rescue the infant if required, after birth by
using the nextApgar chart:

176
 177
173
 Chapter (6) The Normal
Puerperium
The puerperium
 Is the period beginning after delivery and ending when the
woman's body has returned closely as possible to its
prepregnant state.
 The period lasts approximately 6 weeks
The characteristics of the puerperium:

178
 The generative organs return almost to their pre - pregnancy
state.
 The lactation is initiated and established.
 The mother recovers from the physical and emotional stress
from the delivery
Physiologic changes during puerperium
Involution of uterus
 Uterine changes (Involution): uterus returns to pre-gravid status
 The fundus is usually midline and about at the level of the
umbilicus after delivery.

179
 The level of the fundus descends about 1cm each day until the 10th
day, it has descent into the pelvic cavity and can no longer be
palpated immediately at or below umbilical.
 Uterus is reduced at uniform rate 1.5 – 2.5 cm every day, finger
– breadth each day
 One week, it’s palpable at the level of SP.
 By 10 days uterus is not palpable.

180
Subinvolution :
181
  An arrest of involution , the process by which the puerperal
uterus is normally restored to its original proportions
 Failure to descend one finger breadth per day
Causes:
 Retention of placental fragments, pelvic infection
 Anesthesia , prolonged labour, grand multipara
 Lochia
Lochia: discharge from the uterus during puerperium. Amount is
varies with each woman. Odor is heavy and unpleasant that
described as musty or earthy but not offensive. A foul odor may
182
 suggest endometrial infection. The lochia undergo sequential
change as involution progresses as the next:
Lochia Rubra: red in color last 1-4 days consists of blood, chorion,
decidua, amniotic fluid, lanugo, vernix caseosa and meconium.
Lochia Serosa: purple color, lasts 5-9 days contains less blood and more
serum as well as leukocytes & organisms.
Lochia Alba: white, creamish pale discharge lasts 9-12 days (blood ↓
andWBC ↑).
 Post Partum Assessment
BUBBLE-HE
183
  Beast
 Uterus
 Bladder
 Bowel
 Lochia
 Episiotomy (REEDA) rednnes edema ecchymosis
drainage, discharge approximation
 Leg
 Emotion.
Management of the Puerperium
At admission to the post natal ward
184
 The mother and baby are usually transferred to the post natal ward within
an hour or 2 after delivery.
 The midwife/nurse should welcome the mother and help her to settle in
the ward.
 She will observe her general condition, palpate the uterus to note whether
it is contracted or not and observe the lochia.
 Promote sleep and rest and keep a quiet comfortable atmosphere without
disturbance. Strong analgesic may be needed and it is given without
hesitation.
 Ambulation encourage the mother feeling of wellbeing from this early
activity and this reduces the incidence of thrombi embolic disorders.
 A good balanced diet should be taken. Protein foods are important
particularly if she is breast feeding.

185
 Excess fruit should be avoided as substances from this will pass to the baby
in the milk & may cause diarrhea. The daily fluid intake should be from
2.5-3 liters.
Postnatal care (daily care)
Care of the mother
 Clean perineum & apply sterile pad

 Allow her to rest and to be comfortable position

 Record vital sign 4 times daily for the 1st & 2nd day then twice
daily.

186
 Promote regular exercises as promote drainage of lochia and

prevent hypostatic pneumonia

 Check for any abnormal bleeding.

 Initiate discharge planning for the mother.

Care for the baby
 Give baby bath at birth and daily

 Change napkin whenever wet or soiled; have the mother to do it.

187
 Take temperature twice daily or & hourly if necessary Check cord

for bleeding and signs of infection.

 Place the baby laterally with the head slightly lower than the rest of the
body to help drains any remaining amniotic fluid or mucous from the
stomach or nasopharynx.
 Provide worm environment (24-27c).

 Initiate discharge planning that the fetus is kept beside her mother.

 Gives the mother instructions about bathing, cord care, breast feeding
and recognizing abnormal sign.
188
 Post partum complications
1) Puerperal Infection “Puerperal Sepsis”
It's any clinical infection of the genital canal that occurs within
10 days after abortion or delivery excluding the first day.
2) Endometritis
Uterus usually larger than expected for postpartum day.
Lochia may be profuse, bloody and foul smelling.
Chills, fever, anorexia and general malaise.
3) Thrombophelibitis:
It is an inflammation of a venous wall with clot formation
4) Subinvolution of the Uterus
189
5) Postpartum Psychological Complications Postpartum
blues. Postpartum Depression, Postpartum Psychosis,
Postpartum hemorrhage
 Postpartum hemorrhage is a major cause of maternal death
and morbidity Traditionally, postpartum hemorrhage.
 Was defined as blood loss greater than 500 mL for a
vaginal birth and greater than 1000 mL for a cesarean
birth.
Types:
1) Early postpartum hemorrhage.

190
  Hemorrhage in the first 24 hours after childbirth 2) Late
postpartum hemorrhage.
 Hemorrhage after 24 hours or up to 6 to 12 weeks after
birth
Cause: 4 Ts
1) Tone: 70%
2) Trauma 20%: Lacerations, hematomas
inversion, rupture.
3) Tissue 10% : Retained tissue, invasive placenta
4) Thrombin1%: Coagulopathies
Uterine Atony
191
The relaxed muscles allow rapid bleeding from the
endometrial artery.
Predispasing Factors.
Over distention of the uterus
multiple gestation, a large infant, or hydramnios.
prolonged labor; contractions that were excessively
vigorous,
Resulting in precipitous labor; and labor that was induced or
Augmented with oxytocin.
Clinical Manifestations:
A uterine fundus that is difficult to locate
192
A soft or “boggy” feel when the fundus is located
A uterus that becomes firm as it is massaged but loses its
tone when massage is stopped.
A fundus that is located above the expected level
Excessive lochia, especially if it is bright red.
Excessive clots expelled, either with or without uterine
massage
Management:
1) uterine massage and pharmacologic measures
Early administration of oxytocin IM is recommended for
all births.
193
 Intravenous (IV) infusion of dilute oxytocin (not IV
push)
Massage the fundus until it is firm and to express clots
Pushing on a uterus that is not contracted could invert
the uterus and cause massive hemorrhage and rapid
shock
Empty bladder catheterize.
 Methylergonovine (Methergine) is a common second drug of
choice when oxytocin is not effective.
Misoprostol (Cytotec), a synthetic (PGEI) given
 orally or sublingually also may be used to control bleeding.
194
Hemabate; Prostin/15M]) PGFZOL; carboprost IM.
2) Bimanual compression of the uterus.
 one hand is inserted into the vagina and the other
compresses the uterus through the abdominal wall.
 A balloon may be inserted into the uterus to apply
pressure against the uterine surface to stop bleeding.

195
3) Uterine packing also may be used.
4) A laparotomy.
5) Ligation of the uterine or hypogastric artery or
embolization (occlusion) of pelvic arteries

196
 may be required if other measures are not
effective .
6) Hysterectomy is a last resort to save the life of
a woman with uncontrollable postpartum
hemorrhage
Trauma:
Vaginal, cervical, or perineal lacerations &hematomas.
Management.
1. Surgical repair is often necessary.
2. Visualizing lacerations of the vagina or cervix may
under genral anesthsisa.
197
 3. Large hematomas may require incision, evacuation of
the clots, and location and ligation of the bleeding
vessel.
Tissue
Retained Placenta defined as the failure of the placenta
to deliver within 30 minutes after birth.
Invasive placenta
Placenta accreta adheres to the myometrium.
placenta increta invades the myometrium.
placenta percreta penetrates the myometrium to or
beyond the serosa.
198
 The usual treatment for invasive placenta is hysterectomy
Managements remove manually or under GA.

Thrombin1%: Coagulopathies
 PPH may be the result of coagulation failure
 It can occur following severe pre-eclampsia, APH, massive PPH,
amniotic fluid embolus, intrauterine death or sepsis.
Managements
 Evaluation should include coagulation status and replacing
appropriate blood components.

199
 Fresh blood is usually the best treatment, as this will contain
platelets and the coagulation factors V and VII
Postpartum Psychological Complications
 A women’s psychological state is affected during the postpartum period by
hormonal changes, lack of sleep, and stress of integrating a new person within
the woman’s life and within the family unit.
 A majority of women will experience postpartum blues that occur during the
first few postpartum weeks, last for a few days and require no medical
intervention.
 A small percentage of women, 6.5% to 12.9%, will experience major mood
disorders that have a profound effect on their ability to care for themselves
and/or their infants
 Two major mood disorders are postpartum depression and postpartum
psychosis. The primary role of the perinatal nurse is assessing for early signs of

200
 potential mood disorders and reporting these findings to the woman’s health
care provider for further evaluation and treatment.
Postpartum Depression
 Postpartum depression (PPD) is a mood disorder characterized by severe
depression
 A major difference between postpartum blues and PPD is that PPD is disabling;
the woman is unable to safely care for herself and/or her baby. Women who
receive proper treatment will recover from PPD
Postpartum Psychosis
 Postpartum psychosis (PPP) is a variant of bipolar disorder and is the most serious form of
postpartum mood disorders. This is a rare postpartum mood disorder that occurs in 1 to 2
women per 1,000 births
 Onset of symptoms can be as early as the third postpartum day. Women with PPP require
immediate hospitalization and evaluation, as they are at risk for injuring themselves or their
infants.
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Risk Factors
 Women with known bipolar disorder
 Family history of bipolar disorder
Assessment Findings
 Delusions, paranoia, hallucinations, mood swings, extreme agitation and confused thinking
 Strange beliefs, such as that she or her infant must die and disorganized behavior
Medical/Psychiatric Management
 Psychiatric evaluation and may be hospitalized/ Antidepressant and antipsychotic/
Psychotherapy
Nursing Actions
 Review the prenatal record for risk factors.
 Educate women who are at risk and their support system of early signs of PPP such as mood
swings, hallucinations, and strange beliefs, and instruct them to contact the health care
provider if symptoms are present.
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 Chapter (7)
Bleeding Disorders
Bleeding in Pregnancy
 Any bleeding during pregnancy is abnormal. When bleeding occurs
early in pregnancy, the most common causes are abortion, ectopic
pregnancy and vesicular mole.
 When hemorrhage occurs late in pregnancy, the most common causes
are placenta previa and abruption placenta.
Bleeding In Early Pregnancy

203
 Vaginal bleeding occurs in 16% of all pregnant women during the 1st
trimester. 15-20% of recognized pregnancies miscarry, with 80
percent of these losses occurring in the first trimester).
 The most common bleeding during the first half of pregnancy (before
the 20th week) are abortion, ectopic pregnancy and vesicular mole.
 Abortion can be defined as the death or expulsion of the fetus
either spontaneously or by induction, before the 20th week of
pregnancy, and weight less than 500g.

 Abortus: Fetus lost before 20 weeks of gestation, less than

17.5 oz. (500 g), or less than 9.8 inches (25 cm) in size.
 Types of abortion
204
1. Spontaneous abortions ―Miscarriage: occur
without planning.
2. Induced abortions: are performed deliberately for
medical (therapeutic) or social (elective) reasons.
The most common cause of spontaneous abortion
1) Severe congenital abnormalities that are often
incompatible with life, monosomy X (45,X) or autosomal
trisomy
2) Another chromosomal abnormality i anembryonic.a
“blighted ovum.

205
3) Maternal infections such as syphilis, listeriosis,
toxoplasmosis, brucellosis, rubella, cytomegalic virus.
4) maternal endocrine disorders such as hypothyroidism,
diabetes, and decreased progesterone
5) Other causes are related to inherited thrombophilias
(factor V Leiden).
6) Anatomic defects of the uterus, uterine septum, or
cervical incompetence may contribute to pregnancy loss at
any gestational age.
7) Heavy alcohol consumption and heavy smoking.
Spontaneous abortion is divided into seven subgroups:

206
1. Threatened Abortion: Any intrauterine bleeding before
20 weeks of gestation, without dilation of the cervix or
expulsion of any POC (products of conception). Small to
moderate amount of bleeding with a closed cervix.
2. Inevitable Abortion: No expulsion of products, but
bleeding and dilation of the cervix such that a pregnancy is
unlikely. Moderate to large amount of bleeding with
uterine cramping with pain and cervical dilation.
3. Complete Abortion: passage of all products of
conception after which bleeding stops. Cervical os is
closed, uterus is small and no tenderness. No other
symptoms appear
207
4. Incomplete Abortion: partial passage of products of
conception. Continued, heavy bleeding with discharge of
pieces of tissue, severe uterine cramping and open cervical
os. The uterus is smaller than expected.
5. Missed Abortion: Death of the embryo or fetus before
20 weeks of gestation with complete retention of the
product of conception (POC) ; these often proceed to a
complete abortion within 1 to 3 weeks but occasionally
they are retained much longer. No symptoms of abortion,
but symptoms of pregnancy regress. Condition may persist
for many years as slight irregular bleeding.

208
6. Recurrent (Habitual) Abortion: Is defined as three or
more successive spontaneous abortions.
Primary: no previous successful pregnancies.
Secondary: repetitive losses after live birth.

7. Septic Abortion: infected conceptus with a soft tender

uterus, odorous discharge, persistent bleeding, fever and
pain. It can progress to septic shock.

209
210
Assessment: -- Signs and Symptoms:

 Vaginal bleeding: the earliest sign of an impending

abortion (blood stained discharge, brown spotting or a
bright red loss) which may be variable in amount.
 Pain and cramping: usually felt in a central position, low
in the abdomen, intermittent and accompanied by
backache. Decreased symptoms of pregnancy
Dilation of the cervix: present when abortion becomes
inevitable.
Interventions: (Spontaneous Abortion )

211
The goal of interventions is to prevent damage to the mother and
to save the pregnancy.
Threatened Abortion:
- Bed rest with close observation of all vaginal
discharge.
- Emotional support.
- Measures to promote relaxation in a quiet
comfortable environment.
- Poor outcome predicted by: falling of hCG,
progressive bleeding and cramping.
212
Inevitable and Incomplete Abortion:
IV. hydration - Dilation and curettage (D & C) or suction
curettage.
Observe 4-6 hours after procedure.
Rh negative clients should receive Rh immune globulin.
Always check pathology to rule out mole. Analgesics
and emotional support are provided
Complete Abortion:
Rh negative clients should receive Rh immune globulin.
Submit POC (Product of Conceptus) to pathology.
Missed Abortion:
dilation and evacuation Septic Abortion:

213
 Culture and sensitivity.
Antibiotic therapy.
Induced abortion
 Therapeutic Abortion :Is the termination of pregnancy before the
time of fetal viability for the purpose of safeguarding the health of the
mother. Religious and legal considerations are always respected.
 Indications:
1. When continuation of the pregnancy may threaten the life of the
woman or seriously impair her health.
2. When continuation of the pregnancy is likely to result in the birth of a
child with serious physical deformities or mental retardation.
Counseling before Elective Abortion:
214
Reasons for the abortion should be identified and discussed.
Discussion of possible resolutions of these reasons.
Discussion of alternatives of abortion.

Ectopic Pregnancy
 is an implantation of a fertilized ovum in an area outside the
uterine cavity.
 Although implantation can occur in the abdomen or cervix, 97%
of ectopic pregnancies occur in the fallopian tube.
 Ectopic pregnancy has been called “a disaster of reproduction”
 Ectopic pregnancy remains a significant cause of maternal death
from hemorrhage.
215
 Tubal damage caused by an ectopic pregnancy reduces the
woman’s chances of subsequent pregnancies

216
Risk factors of Ectopic Pregnancy:

217
  Maternal age of 35-44 years.
 Previous ectopic pregnancy.
 Previous pelvic or abdominal surgery.
 Pelvic Inflammatory Disease (PID) Several induced
abortions.
 after having a tubal ligation or while an IUD is in place.
 Endometriosis
Clinical Manifestations
Early Signs and Symptoms:
1) Menstrual irregularities (irregular vaginal bleeding)
2) Symptoms of early pregnancy.
218
3) Dull pain on the affected side.
Signs and Symptoms of Tubal rupture:
1) Pain: sudden, severe and unilateral, generalized and radiated to the
shoulder and neck due to phrenic nerve stimulation.
2) Vaginal bleeding, about 25% of cases without vaginal bleeding.
3) Nausea, vomiting, fainting (signs of internal blood loss).
4) Signs of shock.
5) Normal or low temperature: Fever is important in distinguishing
Ruptured tubal pregnancy from Salpingitis.
6) Tenderness over abdomen upon palpation. 7) Pelvic mass posterior or
lateral to uterus.
8) Cervical pain during vaginal examination
Diagnosis:
219
 The combined use of transvaginal ultrasound examination and
determination of beta-hCG
 An abnormal pregnancy is suspected if beta-hCG is present but at
lower levels than expected.
 If a gestational sac cannot be visualized when beta-hCG is present, a
diagnosis of ectopic pregnancy may be made with great accuracy.
 Visualization of an intrauterine pregnancy, however, does not
absolutely rule out an ectopic pregnancy. (she can has both can)
Therapeutic Management
 Management of tubal pregnancy depends on whether the tube is intact or ruptured.
1) If the tube is unruptured
1. Medical management by methotrexate
220
  The goal of medical management is to preserve the tube and improve the
chance of future fertility.
 Methotrexate, a chemotherapeutic agent, is a folic acid antagonist that
inhibits cell replication
 It is approximately 90% effective in treating ectopic tubal pregnancy.
Successful medical management is associated:
 With small ectopic size.
 low initial serum beta-hCG levels.
 absent fetal cardiac activity.
 It may be given in a single dose or multiple dose protocol
 The single dose protocol calls for 50 mg/m2 of body surface area
2. Surgical management
 a linear salpingostomy: removal of the ectopic pregnancy from the tube in
an effort to salvage the tube.
221
Salvaging the tube is particularly important to women concerned about future
fertility
 salpingectomy—removal of the tube
2) Rupture of the fallopian
 The goal of therapeutic management is to control the bleeding & prevent
hypovolemic shock.
 Ruptured ectopic pregnancy is a major emergency.
 When the woman’s cardiovascular status is stable, salpingectomy with
ligation of bleeding vessels may be required.
Nursing Interventions:
1) To Reduce Pain: -Administer prescribed analgesics as needed.
2) To Prevent/Treat Shock: - Monitor vital signs, assess indications
of impending shock. - Start I.V. fluids/blood as prescribed.
222
 Provide constant monitoring, noting any changes in the woman‘s
condition. - Inspect for vaginal bleeding. - Prepare the woman for
surgery. - Postoperative care as any patient who had any
abdominal Laparatomy.
3) To Establish Fluid Volume: - Monitor vital sighs. - IV.
fluids/blood. - Intake and output.
4) To cope with anxiety: - Listen to the woman‘s account of what
has happened. -Ask the woman to explain her understanding of
future childbearing potential, correct misinformation and
reinforce positive aspects..

223
Gestational Trophoblastic Disease
 Hydatidiform (Vesicular ) Mole It is a developmental
anomaly of the placenta and trophoblast in which the
fertilized ovum deteriorates and the chorionic villi convert
into a mass of clear grape-like vesicles.
 It is one of the most common lesions anteceding
choriocarcinoma, a malignant tumor of the trophoblast with
a tendency toward rapid and widespread metastasis.

224
Molar pregnancies are categorized into partial and complete moles
1) Complete mole
 Occur when the ovum is fertilized by a sperm that duplicates its own
chromosomes and
 the maternal chromosomes in the ovum are inactivated.
2) Partial mole
The maternal contribution is usually present, but the paternal
contribution is doubled, and therefore the karyotype is triploid
(69,XXY or 69,XYY).

225
 Clinical Manifestations
 Painless bleeding: the most common sign and vary from spotting to
profuse, continuous or intermittent red or brownish bloody discharge in
second trimester (about the 12th week of gestation) may pass villi
 Higher levels of beta-hCG than expected for gestation.
 A uterus that is larger than expected for gestational age
 There may also be more vomiting than would be expected
(hyperemesis) due to excessive hCG from trophoblast (hCG titer is
markedly increased beyond the 60th day of gestation).
 Increase in blood pressure along with protein in the urine (signs of
preeclampsia but earlier than 20 weeks gestation).
 Absent fetal heart tone and fetal parts (except in partial mole) on
ultrasound or X-ray.
226
 Anxiety and tremors due to thyroid dysfunction resulting from high
hCG’s level.

Diagnosis
 Measurement of beta-hCG levels detects the abnormally high
levels of the hormone before treatment.
 Pattern showing the vesicles, ultrasound examination.
 A partial mole that includes some fetal tissue and membranes
 Acomplete mole that is composed only of enlarged villi but
contains no fetal tissue or membranes

227
 Management
1. Suction curettage has low complications rate with uterine
size < 16 weeks. Excessive uterine enlargement may
predispose to pulmonary complications, preeclampsia and
fluid overload.
2. Primary Hysterectomy: - Patients who have completed
childbearing and desire sterilization are good candidates.
Reduce malignant sequelae from 20% to 5%.
3. Prophylactic chemotherapy: - May reduce malignant
sequelae in high-risk patient. - Not routinely recommended
in cases of uncomplicated mole.
228
4. Blood transfusion: to correct anemia and to replace blood
loss.
5. Follow-up is critical to detect changes suggestive of
trophoblastic malignancy

Nursing Considerations
 Bleeding is a possible complication with a molar pregnancy follow
up vaginal bleeding.
 But emotional care of the woman is also essential. As abortion,
psychological support.
 Advice the woman for the one year follow-up care.
 Counsel the woman to avoid attempting pregnancy for 1 year to
allow hCG to be monitored carefully.
229
 Preoperative and postoperative care:

1. Replace blood as prescribed.

2. Prepare the woman for surgery, suction curettage or
hysterectomy.
3. Administer antimetabolite drugs as prescribed.
4. Observe for complications e.g. hemorrhage or rupture uterus. -
Bleeding in late pregnancy
 Bleeding in late pregnancy (Antepartum Hemorrhagic) during
2nd half of pregnancy occurs in 3% to 4% of woman.
 After 20 weeks of pregnancy, the two major causes of
hemorrhage are the disorders of the placenta called:
230
 1) Placenta previa .
2) Placental abruption.
3) Placental abruption may be further complicated by
disseminated intravascular coagulation(DIC)

Placenta Previa
 Is an implantation of the placenta in the lower uterine
segment, partially or completely covering the internal cervical
os.
 Classification: Traditionally categorized in to 3 types:

1) Complete, total or central previa: internal os entirely covered.

It is associated with the greatest amount of blood loss.
231
2) Partial placenta previa: internal os partially covered.
3) Marginal placenta previa(low-lying Implantation ) placenta
reaches edge of the internal os.

232
233
Etiology:
Placenta previa may be associated with conditions that cause
scarring of the uterus such as:
 a prior cesarean section
 multiparity, or increased maternal age.
 Large placental mass as seen in multiple gestations.
 Smoking, cocaine use.
Prior history of placenta previa
Closely spaced pregnancies
 Maternal age greater than 35 years

234
 Clinical Manifestations
 The classic sign of placenta previa is the sudden onset of
painless uterine bleeding in the last half of pregnancy.
 Bleeding results from tearing of the placental villi from
the uterine wall as the lower uterine as begins to dilate
near term.
 Bleeding is painless because it does not occur in a closed
cavity and does not cause pressure on adjacent tissue.
 It may be scanty or profuse, and it may cease
spontaneously, only to recur later

235
 Diagnostic Evaluation
 Using ultrasonic scanning will confirm the existence of
placenta previa and its degree.
 The color of the blood is bright red, denoting fresh bleeding
from placenta previa until proven otherwise.
 Definitive diagnosis by direct palpation of placenta is not
recommended.
 Vaginal Examination should not be attempted unless, double
setup procedure, prepared for cesarean delivery in the
operating room. If greater than 3 cm dilated and no placenta
covering os, then perform amniotomy (by the physician).

236
Management

 No Digital examination, or no manual vaginal examinations

should be performed can cause additional placental separation
or tear the placenta itself, causing severe hemorrhage and
extreme risk to the fetus.
 Managements based on the condition of the expectant mother
and the fetus.
 Also depend on the amount of hemorrhage, and electronic fetal
monitoring is initiated to evaluate the fetus.
 Fetal gestational age is a third consideration.

237
Management
1) Conservative managements
 If the mother’s cardiovascular status is stable and the fetus is
immature and has a reassuring status.
 Delaying birth may increase birth weight & maturity.
 Administration of corticosteroids to the mother speeds
maturation of the fetal lungs, (protocol).
 Home care only under ideal circumstances as location near
hospital, ability to maintain bed rest and 24-hour transportation
available.

238
2) Active management:
 Sever vaginal bleeding will necessitate immediate delivery by
caesarean section (fetus ≥ 36 weeks).
 This should take place in a unit with facilities for special area of
the new born especially if the baby will be preterm.
 Post-delivery, if uterine bleeding can’t be controlled with
oxytocics drugs, ligation of the internal iliac arteries or even
hysterectomy may be necessary.
Nursing Intervention:

239
 Promote bed rest and avoid vaginal or rectal examinations to
prevent premature delivery
 Regular assessment of blood loss, uterine contractility, pain, FHR
and vital signs
 Maintain adequate fluid balance (Intravenous fluids) and blood
transfusion for emergency
 Nursing assessments focus on determining whether she experiences
bleeding episodes or signs of preterm labor which includes:
1) Periodic electronic fetal monitoring (EFM).
2) Delivery may be scheduled if the fetus is older than 36 weeks of
gestation and the lungs are mature
3) Immediate delivery may be necessary regardless of fetal
immaturity if bleeding is excessive.
240
4) If cesarean birth is necessary, nurses should prepare the
expectant mother for surgery.
5) One or more IV line starts, administration of preoperative
antibiotics, anesthesia, Foley catheter insertion.
6) Neonatology or a team from the neonatal intensive care are
usually notified.

Abruptio Placentae
 Premature separation of the normally implanted placenta.
Separation occurs in the area of deciduas basalis, most often in
the third trimester, but can happen any time after 20 weeks.

241
 The severity of the complication depends on the amount of
bleeding and the size of the hematoma.
 If bleeding continues, the hematoma expands
 and obliterates inter villous spaces. Fetal vessels are disrupted
as placental separation occurs, resulting in fetal and maternal
bleeding.
The major dangers for the woman 1)
Hemorrhage. 2) Consequent
hypovolemic shock 3) Clotting
abnormalities, DIC.
The major dangers for the fetus:
242
1) Asphyxia.
2) Excessive blood loss.
3) Prematurity.

Causes
 Maternal use of cocaine, which causes vasoconstriction in
the endometrial arteries.
 Maternal hypertension.
 Maternal cigarette smoking.
 Multigravida status.

243
  Short umbilical cord, abdominal trauma, Premature
rupture of the membranes.
 History of previous premature separation of the
placenta.
Cases of placental abruption are divided into two main types:

1) Hemorrhage is concealed.
The bleeding occurs behind the placenta but the margins remain
intact, causing formation of a hematoma 2) Hemorrhage is
apparent revealed.
blood flows out through the vagina.
Amniotic fluid often has a classic “port wine” color
244
Bleeding, which may be evident vaginally or concealed behind the
placenta
Uterine tenderness that may be localized at the site of the abruption.
Uterine irritability with frequent low-intensity contractions and poor
relaxation b/t contractions
Apparent bleeding does not always correspond
to the actual amount of blood lost, and signs of
shock (tachycardia, hypotension, pale color, and
cold, clammy skin) may be present when little or
no external bleeding occurs

245
 Clinical Manifestations
Bleeding, which may be evident vaginally or concealed behind the
placenta
Uterine tenderness that may be localized at the site of the abruption.
Uterine irritability with frequent low-intensity contractions and poor
relaxation between contractions
Abdominal or low back pain that may be described as aching or dull.
High uterine resting tone identified with use of an intrauterine pressure
catheter
“Board-like” abdomen—the abdomen feels firm to touch because of the
blood that can be concealed.
Port wine” colored amniotic fluid

246
Non reassuring FHR patterns or fetal death
Signs of hypovolemic shock

247
248
Complications: “Accompany with degree of sepration
 Hypovolemic shock: may causing pituitary necrosis (Sheehan
Syndrome) and renal failure.
 Fetal hypoxia or anoxia with possible fetal death.
 Consumptive Coagulopathy due to hypofibrinogenemia leading to
DIC(Disseminated Intravascular Coagulation)
 Couvelair uterus: bleeding into the myometrium resulting in
board-like rigidity of the uterus.
 Hepatitis post blood or fibrinogen transfusion
Therapeutic Management
 Hospitalized and evaluated at once.

249
 evaluation focuses on the cardiovascular status of the expectant
mother and the condition of the fetus.
If the condition is mild and the fetus is under 34
weeks and shows no signs of distress, conservative
management may be initiated this includes:
1) Bed rest .
2) Administration of tocolytic medications to reduce uterine
activity
3) Steroids to accelerate fetal lung maturity.
If signs of fetal compromise exist or if the mother
exhibits signs of excessive bleeding, either obvious
or concealed managements:
250
 1) Immediate delivery of the fetus is necessary
2) Intensive monitoring fetal and mother, of both the woman and
the fetus is essential because rapid deterioration of either can
occur.
3) Blood products for replacement should be available.
4) two large-bore IV lines should be started for replacement of
fluid and blood.
Nursing Interventions:
 Placental abruption is frightening for a woman .
 She experiences severe pain and is aware of the danger to herself
and to the fetus.
251
 She should be carefully assessed for signs of concealed
hemorrhage.
 If immediate cesarean delivery is necessary, health care team
hastily prepares her for surgery.
 Excessive bleeding and fetal hypoxia are always major concerns
with placental abruption.
 nurses are responsible for continuous monitoring of both the
mother and the fetus so that problems can be detected early
before the condition of the woman or the fetus deteriorates.

252
 253
246
Disseminated Intravascular Coagulation(DIC)

 Is a life-threatening defect in coagulation that may occur

with several complications of pregnancy such as placental
abruption or hypertension
 At the same time anticoagulation is occurring,
inappropriate coagulation also is taking place in the
microcirculation.
 The results of DIC are excessive bleeding and the
formation of tiny clots in tiny blood vessels, blocking blood
flow to organs and causing ischemia
254
 Some factor initiates clotting mechanisms
inappropriately
 The first result is consumption of plasma factors, including
platelets, fibrinogen, prothrombin, factor V, and
factorVIII.
 When these plasma factors are consumed, the circulating
blood then becomes deficient in clotting factors and is
unable to clot.
 Fibrin degradation products accumulate and further
interfere with coagulation.

255
Therapeutics managements
 The priority in treatment of DIC is to correct the cause.
 In the case of a missed abortion, delivery of the fetus and the placenta
ends the production of thromboplastin, which is fueling the process.
 Blood replacement products such as whole
 blood, packed red blood cells (RBCs), and cryoprecipitate are
administered, as needed, to maintain the circulating volume and to
transport oxygen to body cells.
 Laboratory studies help establish a diagnosis. Levels of fibrinogen and
platelets usually are decreased, PT and PART II The Family Before

256
 Birth activated PTT (aPTT) may be prolonged, and levels of fibrin
degradation products, the most sensitive measurement

Nursing intervention
 the nurse should observe for bleeding from unexpected sites
including IV insertion and venipuncture sites for laboratory work.
 No bleeds or spontaneous bruising may be early indicators of DIC.
 An additional IV line should be started to prepare
 for additional crystalloids, colloids, or blood products that may
need to be administered
 the nurse should apply oxygen at 10 liters per minute by face mask
because of the blood loss.
 Monitoring of frequent vital signs closely.
257
  An accurate record of intake and output should be obtained.
 Weighing of all blood-soaked materials to obtain an accurate
output.

Chapter (8)
complication associated with
pregnancy
Subjects:
Hyperemesis Gravidarum
Hypertensive Disorders of Pregnancy
preeclampsia
258
 eclampsia
Diabetes Mellitus
 Heart disease
Anemia
Hyperemesis Gravidarum
 Is exaggerated nausea and vomiting during pregnancy, persisting in
the 1st trimester.
 About 70-85% of all women experience a mild form of nausea in
early pregnancy called morning sickness usually disappear by about
12th week, however vomiting persist causing serious dehydration
and starvation

259
  Such a condition is called hyperemesis gravidarum which means
"excessive vomiting of pregnancy".
 Causes:

Hormonal changes of pregnancy: increase hCG hormone level.

Emotional factors, insecurity, anxiety.
▪ Risk Factors:
 increased placental mass associated with multiple gestation  a
history of hyperemesis gravidarum in a previous pregnancy
 history of motion sickness or migraine headaches.
 women who are pregnant with a female child

Clinical manifestations:

260
  Begin with morning sickness and become increasingly
severe.
 Frequent vomiting when mention, sight or smell food.
 Pregnant C/O Loss of weight, Dehydration,
Tachycardia. Scanty concentrated urine.
 Jaundice caused by liver damage.
 Blindness caused by retinal hemorrhage. Convulsions.
Death.
Nursing interventions:
 Maintaining fluid and Electrolyte Balance
 If vomiting is severe, the woman is hospitalized and oral intake is
restricted for 24-48 hours.

261
 I.V. fluids are administered. Oral liquid intake is resumed slowly,
usually high in carbohydrate of the type preferred by the woman.
Vitamin B complex to combat nausea.
 Sedative and antiemetic as prescribed.
 Improve Nutritional Status: Offer small and frequent meals, high in
carbohydrates.
 Avoid strong food odors. Avoid greasy foods.
 Give vitamin supplementation as prescribed
Hypertensive Disorders of Pregnancy
hypertension is defined as a systolic blood pressure of 140 mm Hg or
greater or a diastolic blood pressure of 90 mm Hg or greater.
Hypertensive disorders are classified into four
categories:
262
1) Chronic hypertension:
 Hypertension that is present befor pregnancy, diagnosed before 20
weeks of gestation, or continuing beyond 12 weeks postpartum.
 Chronic hypertension with superimposed preeclampsia
2) Gestational hypertension= Pregnancy induced
hypertension (PIH)
 Onset of hypertension after20 weeks of pregnancy without
proteinuria.
 A woman develops an elevated blood pressure (140/90
mmHg) but has no proteinuria or edema.
 Systolic blood pressure greater than 30 mmHg and diastolic
blood pressure greater than 15 mmHg above pregnancy values.
 No edema, no proteinuria and blood pressure returns to
normal after birth.
263
 if gestational hypertension persists after 12 weeks postpartum,
chronic hypertension is diagnosed..
3) Preeclampsia
 a systemic disease with hypertension accompanied by
proteinuria after the 20th week of gestation;
 Syndrome of pregnancy-induced hypertension manifested
by hypertension, proteinuria, edema and frequently other
organ system disturbances.
 Preeclampsia may be mild or severe
mild preeclampsia” be replaced with ‘preeclampsia
without severe feature
 proteinuria 300 mg/24 hours or higher
 a woman has proteinuria (1+ or 2+ on a reagent test strip
on a random sample).
264
 occurs in previously normotensive women and resolves
after
delivery.

Severe preeclampsa :If one or more of the

following criteria are present:
1. Blood pressure of equal or more than 160 mm Hg
systolic or equal or more 110 mm Hg diastolic or
higher on two occa— sions at least 6 hrs. apart
while the patient is on bed rest
4. Oliguria of <500 mL in 24 hrs.
5. elevated serum creatinine (more than 1.2 mg/dL)
6. Cerebral or visual disturbances (blurred vision).
7. Pulmonary edema or cyanosis.
8. Impaired liver function as indicated

265
9. Epigastric or right upper quadrant pain. severe
persistent right upper quadrant or epigastric pain
unresponsive to medication and not accounted for by
alternative diagnoses, or both.
10. Thrombocytopenia.
11. Renal insufficiency
4) Eclampsia:
 This is the most severe classification of PIH.
 A woman has passed into this stage when cerebral edema is so
acute that seizure or coma occurs.
 Seizures may occur during antepartum, intrapartum, or post
partum period.
 maternal mortality is high from cause such as cerebral
hemorrhage, circulatory collapse or renal failure.
 The fetal prognosis in eclampsia is poor because of hypoxia and
consequent fetal acidosis.
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 The manifestations are the same of sever preeclampsia
accompanied by seizure
Examination:
Hypertension.
Marked oedema (may be dependent or generalized).
Hyper-reflexic.
Proteinuria on urinalysis:
a positive urine dipstick for protein needs to be confirmed
with a 24 hour urine sample.
Pathophysiology of preeclampsia

267
268
Pathophysiology
 In normotensive pregnancies, the spiral arteries of the uterus are remodeled by invasion of
endovascular trophoblast cells, which allows them to widen to accommodate a 10fold
increase in blood flow.
 In a preeclamptic woman, this remodeling is incomplete and the spiral arteries remain thick
walled, resulting in suboptimal placental perfusion
 Preeclampsia is a result of generalized vasoconstriction and vasospasm resulting in a
multiple system organ failure disease in pregancy.
 Begins in early pregnancy during placenta formation and implantation.
1. abnormal development in the maternal spiral arteries leading to decreased perfusion
and oxygenation.
2. a dysregulation of maternal immune response to fetal and placental antigens
leading to inflammatory changes which to Alter vasoconstriction/vasodilation ratio.
 Vasospasm decreases the diameter of blood vessels, which results in endothelial cell
damage.
 Vasoconstriction also results in impeded blood flow and elevated blood pressure.

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 As a result, circulation to all body organs, including the kidneys, liver, brain, and
placenta, is decreased

 Reduce placenta perfusion increases the risk of abruption

placenta, DIC and IUGR
Management

Therapeutic Management of Preeclampsia

 The only cure for preeclampsia is delivery of the baby and placenta.
 Delivery is indicated in the woman with preeclampsia without severe
features at 37 weeks of gestation.
 If the fetus is less than 34 weeks of gestation, steroids to accelerate fetal
lung maturity may be given and an attempt made to delay birth for 48
hours.

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 However, if the maternal or fetal condition deteriorates, the infant
should be delivered, regardless of gestational age or administration of
steroids.
 Vaginal birth is the preferred delivery method, reserving cesarean
section for the usual obstetric implications
 Home Care. Management in the home may be possible for select women
without severe features and without evidence of worsening fetal or
maternal status, which includes:
 Activity Restrictions
 Blood Pressure. family should be taught Weight.
 Urinalysis.
 Fetal Assessment , (“kick counts”).

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 Diet, ample protein and calories, a regular diet without salt or fluid
restriction.
Management of Severe Preeclampsia
 Requires inpatient hospitalization
 Goals of management are to improve placental blood flow and fetal oxygenation
and prevent seizures and other maternal complications, this is includes:

1) Bed Rest and Fetal Monitoring 2) Antihypertensive

Medications recommended to slowly reduce the woman’s
blood pressure.
Antihypertensive Medications

272
First line because of their efficacy and preservation of uteroplacental
blood flow
 Labetalol:

Has less maternal tachycardia and fewer adverse effects.

Contraindicated in patients with asthma, heart disease, or CHF;
associated with hypoglycemia an small for gestational age infants.
 Hydralazine (Apresoline)

Higher doses are associated with maternal hypotension, headaches, and

fetal distress.
 Nifedipine:

May be associated with reflex tachycardia and headaches;

because of mechanism of action.a synergistic effect with

273
 magnesium sulfate may result in hypotension and neuromuscular
blockade.
 Anticanvulsant Medications.

 Magnesium sulfate is the drug most often used to prevent

seizures.
 Phenytoin (Dilantin) and diazepam (Valium) are not
recommended as first-line agents because of their decreased
efficacy compared with magnesium.
Magnesium sulfate (Action)
1) Decreases acetylcholine released by motor nerve impulses,
thereby blocking neuromuscular transmission.
2) Depresses central nervous system irritability and relaxes smooth
muscle.
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3) decreasing frequency and intensity of uterine contractions.
4) Slows cardiac conduction.
5) Produces flushing, hypotension, and vasodilation.
Indications
 Prevention and control of seizures in severe preeclampsia.
 prevention of uterine contractions in preterm labor, and neuro
protection of preterm fetus.
Dosage and Route
 A common intravenous (IV) administration protocol for
preeclampsia includes a loading dose and a continuous infusion using
a controlled infusion pump 4 g I.V. load then 1-2 g/ hour.
 •Keep serum magnesium 4-8 mg/dl.
 •IM doses more painful.
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  •10 g load IM, then 5 g IM every 4 hours.
Magnesium Sulfate Toxicity:
 Loss of patellar reflex.
 Respiratory depression, respiratory rate is less than 12
breath/min.
 Defective cardiac conduction.
 Treatment of toxicity: antedote: Calcium Gluconate 10% (1 g
I.V. over 3 min)..
Nursing Implications
1) Monitor blood pressure closely during administration.
2) Assess the woman for respiratory rate above 12 breaths per minute.
3) urinary output greater than 30 mL/hr before administering magnesium.
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4) Place resuscitation equipment (suction and oxygen) in the room.
5) Ensure calcium gluconate, which acts as an antidote to magnesium, is readily
available

Complications
Maternal:
1) Eclampsia:
2) tonicclonic seizures, probably caused by cerebrovascular
vasospasm;
maternal/fetal hypoxia Cerebrovascular
haemorrhage:
3) HELLP’ syndrome:
4) Disseminated intravascular coagulation:

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 5) simultaneous bleeding and clotting in the circulation.
Renal failure.
Pulmonary oedema.
 Neonatal:
1) Intra-uterine growth restriction (IUGR), particularly if
preeclampsia occurs B36 weeks‘ gestation; due to ischaemic
placenta.
2) Pre-term delivery.
3) Placental abruption
HELLP syndrome
 A life-threatening occurrence that complicates 10% of pregnancies.

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 1/2 of the women affected by HELLP also have severe preeclampsia,
although hypertension may be absent.
 As in preeclampsia, HELLP syndrome may occur during the
postpartum
 HELLP syndrome :
H haemolysis;
EL elevated liver enzymes;
LP low platelets.
 Hemolysis is believed to occur as a result of the fragmentation and
distortion of erythrocytes during passage through small damaged
blood vessels
 The prominent symptom of HELLP syndrome is pain in the right
upper quadrant, the lower right chest, or the mid epigastric area.
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 This tenderness may result from liver distention.
 A sudden increase in intra abdominal pressure, including that caused
by a seizure, could lead to rupture of a subcapsular hematoma,
resulting in internal bleeding and hypovolemic shock.
 Hepatic rupture can lead to fetal and maternal mortality
Managements
1. Magnesium sulfate to control seizures and hydralazine or labetalol
to control blood pressure.
2. Fluid replacement.
3. Cervical ripening with labor induction may be performed if the
gestation is at least 34 weeks.

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4. Delivery may be delayed if the gestation is less than 34 weeks and
the woman’s condition is stable, to allow for steroid administration
to stimulate fetal lung maturation.
Diabetes Mellitus
 Diabetes is an endocrine disorder characterized by high blood levels of glucose
in the urine. A person has high blood sugar, either because the body does not
produce enough insulin, or because cells do not respond to the insulin that is
produced.
 This high blood sugar produces these symptoms :polyuria, polydipsia and
polyphagia
 Pregnancy imposes an additional physiological stress on a diabetic woman. So
if a mother was already diabetic before pregnancy, her insulin needs will be
increased.
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 Gestational diabetes mellitus (GDM):
 is a condition in which women without previously diagnosed
diabetes exhibit high blood glucose levels during pregnancy) may
develop during pregnancy.
 development of impaired glucose tolerance during pregnancy that
normalizes after pregnancy; .
 Pregnancy is an insulin-resistant state. Placental hormones (HPL,
Placental insulinase have antiinsulin effect result in increasing the
incidence of ketoacidosis.
Risk factors:
1) previous history of gestational diabetes
2) fetus4 kg & more
3) previous unexplained stillbirth
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4) family history of diabetes;
5) high body mass index;
6) presence of polyhydramnios
7) persistent glycosuria
Assessment and Diagnosis:
Should attend (visit) antenatal clinic every two weeks until 20 weeks gestation and
then weekly until term.

1) Glucose Challenging Test: No fasting or dietary

restrictions
The woman ingests 50g oral glucose solution, blood glucose
concentration checked 1 hour later (Less than 140 mg/dl is
normal). If greater than 140 mg/dl perform oral glucose
tolerance test.
2) Oral Glucose Tolerance Test (OGTT) The woman instructs to ingest good
carbohydrate diet 3 days before the test.

283
Fast for 10 hours prior to do fasting test and then ingest 100 g oral glucose solution.
Perform blood level tests at fasting, 1, 2 and 3 hours after drinking solution. Upper
limits for normal glucose levels are respectively 95, 180, 155 and 140 mg/dl.
Gestational diabetes is diagnosed if two or more abnormal values are
occurring. If one abnormal value occurs, repeat OGTT in one month later.

complications:
Maternal Effects:
1) Hypoglycemia: usually occurs in the first half of
pregnancy and needs to adjust insulin dose based on
caloric intake and hyperglycemia tends to occur in
second half of pregnancy.
2) Urinary tract, other infections and anemia
3) Hypertension: diabetic women are at higher risk for
hypertensive disorders of pregnancy.

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4) Polyhydramnios: May occur in 10-20% of diabetic
pregnancies probably result of fetal polyuria
resulting from fetal glucosuria.
5) Retinopathy and postpartum hemorrhage.
Fetal Effects:
1) There is an increased risk of spontaneous abortion,
stillbirth and fetal abnormality
2) Macrosomia: usually defined as infants greater than
4500g. High incidence of birth trauma.
3) Perinatal mortality is 2 or 3 times higher for diabetic
mother
4) The main four neonatal effects are: hypoglycemia,
hypocalcemia, hyperbillirubinemia and respiratory
distress.
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Management :
 Dietary Regulation Need

 Recommended diet is high protein ,normal caloris

,low carbohydrate
 Intake distributed among meals and 2 snakes Mother should
not gain more than 1.3-1.6 kg / month.
 Insulin Therapy:

 Insulin dosage is based on blood and urine glucose levels.

Oral hypoglycemic are not used because they are
fetotoxic and don’t provide adequate control.
 Adjust insulin according to pregnancy progress
 They need to know the symptoms of hypoglycemia and
hyperglycemia and appropriate emergency management
of each.

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 Heart disease
 Every pregnancy places extra demands on the cardiovascular
system especially on the heart.
 Blood volume and cardiac output are increased 40-50% and the
rate is accelerated.
 The normal heart is well able to compensate for the added work
but the damaged or diseased one may not.
Signs of Cardiac Decompensation:
1) Increasing fatigue and breathlessness with usual exertion.
2) Episodes of murmurs, palpitation and tachycardia.
3) Hemoptysis. Progressive generalized edema.

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 Incidence:
0.5%-2% of pregnant woman.
4.5% these with rheumatic heart disease.
3% of these with congenital heart disease.
Classification:
Woman with heart disease are classified into 4 groups
according to the level of activity tolerated without
symptoms. Medical and nursing care is adjusted
accordingly.
1) Class INo limitation of physical activity, no symptoms of cardiac
insufficiency or anginal pain with ordinary physical activity.

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2) Class IISlight limitation of physical activity, comfortable at rest,
excessive fatigue, palpitation, dyspnea or anginal pain with heavy physical
activity.
3) Class IIIMarked limitation of physical activity, comfortable at rest,
excessive fatigue, palpitation, dyspnea or anginal pain with less than
ordinary physical activity.
4) ClassIV Inability to perform any physical activity without discomfort,
cardiac insufficiency signs possible at rest, discomfort increased with
physical activity.
Patients classified as I and II generally do well during pregnancy, but those classified as III or
IV have a significantly increased risk of morbidity and mortality with pregnancy .
Effects of Heart Disease on Pregnancy:
Prematurity.
 Placental insufficiency,
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 IUGR ( Intrauterine growth restriction ) Intrauterine
fetal death.

Assessment:
 History.
 Cardiac status of women should be evaluated very early in pregnancy if
not before {chest X-ray, ECG}.
 Cardiac status and functional capacity are monitored carefully throughout
pregnancy.
 Monitor for signs of cardiac decompensation {cyanosis, dyspnea,
tachycardia, edema, hemoptysis, and cough…}.
Interventions:
The woman`s vital signs and fetal heart tones are monitor.
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 The woman may receive oxygen during the course of
labor. Regional anesthesia may be used to reduce pain.
To avoid having the mother push, forceps delivery may be
used.
Infection must be avoided.
A well balanced diet, high in protein, iron, vitamins and
minerals to prevent anemia
Cesarean delivery is avoided because of (grater blood loss,
risk of infection, risk of thromboemboism ).
Second stage of labor is shortened to reduce stress on the
mother`s heart as much as possible
Class 1 and Class 2
Rest is most important; 10 hours sleep per night
and rest throughout the day. stress is to be avoided.
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 Hospitalization prior to delivery is usual for women
Class 3 and Class 4
therapeutic abortion may be indicated, sterilization
surgery may be recommended for those who
attempt pregnancy of the 4th class,
absolute bed rest, hospitalization During labor and
delivery
Anemia of pregnancy
 Hb value below the lower limits of normal not explained by the state of
hydration.
 Anemia during pregnancy 11 or 10.5 g/dl . Anemia is defined as a reduction
in the total circulating red blood cell mass. 20-60% of prenatal patients will be
found to be anemic at sometimes during pregnancy.

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 Types of Anemia
1) Acquired: as iron- deficiency anemia, anemia caused by acute blood loss,
megaloblastic anemia, acquired hemolytic anemia, aplastic or hypoplastic
anemia.
2) Hereditary: as thalassemia, sickle- cell anemia and hereditary hemolytic
anemia.

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 Iron Deficiency Anemia

 It's a hypochromic microcytic anaemia that occurs when

iron stores are inadequate to support normal
erythropoiesis. The major reason for poor iron stores are
thought to be menstrual loss.
 It is the most common nutritional anaemia, accounts for
75% of all anemias diagnosed during pregnancy.
 Pregnancy places large demands on iron balance and can’t
be met with usual diet. In absence of iron
supplementation, iron deficiency develops.
Clinical manifestation

Tissue hypoxia: fatigue, lightheadness , weakness , pallor and

exertional dyspnea.
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palpitation and tachycardia (hyperdynamic circulation).
 An underlying disease: - Chronic infection. - Chronic liver
disease. - Chronic renal disease. - Multiple pregnancies.
Note: In obstetric patients anemia is discovered because
CBC is obtained as part of laboratory evaluation at the initial
prenatal visit or at repeat screening at 28-32 weeks.
Severe anemia is associated with: Congestive heart failure.
Multi-organ failure. Tissue hypoxia.
 Pica: the ingestion of various substances that have no dietary value is a
striking manifestation of iron deficiency. { Pagophagia (ice), geophagia (clay)
and amyophagia ( starch) } are common examples of pica..
Treatment :

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 Preventable by routine use of iron supplementation.
 Correct the underlying cause
Neonatal effects:
preterm delivery low birth weight infants and stillbirth.
The outcome is related to the gestational age when
maternal iron deficiency is diagnosed.
The fetus stores enough iron to meet requirements for
3-6 months after birth.
Megaloblastic Anemia :Is the second most common
nutritional anemia seen during pregnancy
Folate deficiency is the cause but a deficiency in vitamin
B12 must be considered
Folate: Folic acid, a water-soluble vitamin is widely
available in diet. Folate is absorbed in the proximal
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 jejunum. Pancreatic conjugates reduce folate to
monoglutamate before its absorption.

Vitamin B12: available in the diet bond to animal

proteins. Its absorption requires HCL and pepsin to free the
cobalamin molecule from protein. Most of the vitamin B12
is stored in the liver and most people have a 2-3 years store
available.
Nursing Interventions

1) Improve Nutritional Status:

 Provide a well- balanced diet high in iron.
 Administer iron supplementation if prescribed.

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 With iron supplementation, increase intake of foods high in fiber and
fluids to prevent constipation. Increase intake of foods high in vitamin
c to enhance iron absorption.
 For folic acid deficiency anemia, provide folic acid supplement and
diet high in animal protein and green leafy vegetables.
 In severe anemia, IM iron or transfusion of packed RBCs may be
necessary.
2) Improve Fetal Nutrition and Oxygenation:
 Improve maternal nutrition by provide diet with vitamin and mineral
supplementation.
 Oxygenation to fetus can be improved by:
 Improving maternal Hb level.
 Avoidance of maternal infection, which increases BMR and oxygen
consumption

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 Chapter (9) complication of
pregnancy and labor
1- Premature Rupture of Membranes
(PROM)
 Is the spontaneous rupture of fetal membranes one hour or more
before the onset of labor.
 •Incidence: 10% of all pregnancies. Risk factors:
 Polyhydaminos
 Cerculage
 Amniocentesis
 Placental abruption.
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 Infection
 More common in twins gestation.
 Seldom associated with
Examination:
 Visualize pool of fluid in vaginal fornix Leakage of fluid
through cervix.
 pH of amniotic fluid is 7.1 to 7.3,Normal vaginal pH is
4.5 to 6,Nitrazine paper turns blue at pH > 6.5
Cervical dilation is assessed.
 Observe for prolapsed fetal part or umbilical cord.
 Collection of fluid for lung maturity Ultrasound is a final
confirmatory step in some cases.
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  Establish gestational age and fetal maturity Rule out
infection& fetal distress.
 continuous fetal heart tone monitoring
Management and interventions:
Term patients:
 Immediate induction is suggested. Preterm patients:
 Survival rate after 26 weeks is close to 50%.
 If less than 34 weeks, efforts are directed toward maintaining pregnancy.
 Tocolytic therapy (terbutaline)
 Antibiotics therapy
 Nurse monitors vital signs
 emotional support are provided
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 prepares the mother for delivery, cesarean birth, a preterm neonate and
potential loss of the fetus
Complications:
 Preterm delivery.
 Maternal or fetal infections:
–Chorioamniositis
–endometrits clinically persisting after delivery.
 Fetal distress
–Umbilical prolapsed more common in cases of
PROM.
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 Increase rate of stillbirths
Preterm Premature Rupture of Membranes
 Preterm premature rupture of membranes (PPROM) is defined
asrupture of membranes before 37 completed weeks' gestation
with or without the onset of spontaneous labor..

303
Risk factors :
1) Infection (amnionitis; group B beta-hemolytic Streptococcus)
2) Previous history of PROM or PTB
3) Hydramnios (polyhydramnios/oligohydramnios)
4) Incompetent cervix
5) Increased intrauterine volume (multiple gestation, fibroids,
polyhydramnios)
6) Abruptio placentae
7) Cigarette smoking
8) Fetal anomalies
9) Coitus (intercourse)
10) Vaginal colonization with group B beta-hemolytic Streptococcus
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Diagnostic Evaluation
Same as PROM.
 Ultrasound to assess amniotic fluid volume.
 Watch for vaginal leakage of blue fluid to assess for ruptured
membranes.
Management
 For PPROM, tocolytics, corticosteroids (to decrease the severity
of RDS in the premature neonate), and prophylactic antibiotics
are used.
 Management is influenced by gestational age.
Initial management:

305
-Confirm rupture of membranes.
-Determine if bacterial infection is present at time of
rupture by vaginal/cervical cultures.
-Document age of gestation.
-Determine fetal lung maturity by amniocentesis or
vaginal culture.
Active management:
-Tocolytic therapy.
-Antibiotic therapy.
-Corticosteroid administration.
-Amnioinfusion.
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Conservative management
 Bed rest.
 Vital signs per your facility's policy and patient condition.
 Monitor fetal well-being daily or more frequently as dictated
by your facility's policy and patient condition.
Complications
1) Maternal
 Increased risk of intrauterine infection
 Postpartum endometritis
 Placental abruption
2) Fetal infection Neonatal RDS, infection, death

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 2- Preterm labor
Is defined as rhythmic uterine contractions that produce cervical
changes prior to completion of 37 weeks gestation.
•Incidence: 7% to 10% of infants are born prematurely.
•Responsible for 75% of prenatal mortality and about 50% of
neurological deficits.
Etiology:
 Upper and lower extremes of age.
 Lower socioeconomical status. Smoking and drug abuse.
 Prolonged periods of standing.
 Fatigue and long hours at work.
 Reproductive history:
308
 Previous preterm delivery.
 Incompetent cervix.
 Spontaneous or induced abortion.
 Uterine anomalies e.g. leiomyomata.
 Multiple gestations.
 Premature rupture of membranes (most common cause).
 Infection.
Assessment:
 Cervical dilation.
 Membranes: ruptured or not.
 Presences of sever preeclampsia and hemorrhage.
 Ultrasonography: to determine fetal gestational age, condition and
weight
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 Management and intervention:
 • Signs and symptom reinforced:
 •Increased or change in vaginal discharge.
 •Uterine contractions.
 •Vaginal bleeding or leaking fluid.
 •Bed rest and hydration: increase uterine blood flow.
 •Continuous monitoring.
 •Tocolytics:
 Now most frequently used agents are magnesium sulfate and
beta mimetic agents → acts on β2 receptors on myometrium.
 - Maternal transport: tocolytic therapy may improve outcomes
by delaying delivery enough to facilitate transport.
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:labor IF not stopped if one or more of the following are present
"exclusion criteria for tocolytic therapy":
1) Advanced cervical dilation, usually > 6 cm.
2) PROM.
3) Abruption.
4) Fetal distresses or death.
5) Major fetal anomalies incompatible with life.
6) PIH with HELLP syndrome.
7) Fetal maturation therapy: glucocorticord therapy

311
3- Postdate (post term pregnancy or
prolonged pregnancy)
 Duration of pregnancy: 280 days or 40 weeks from the first day of
the LMP or 266 days from ovulation, based on 28 day cycle.
 Post term: pregnancy lasting more than 2 weeks beyond the
expected date of delivery ―after day 294, 42 completed weeks or
more“
 The exact cause of postterm pregnancy is unknown. However, a
possible cause may be related to a deficiency of placental estrogen
and the continued secretion of progesterone.
 •Low levels of estrogen may result in a decrease in prostaglandin &
reduced formation of myometrial oxytocin receptors.

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Complication
Maternal problems:
1. Emotional stress.
2. Potential for delivery trauma.
3. Hemorrhage, infection, and labor abnormalities.
Fetal prooblem :
1. Oligohydramnios associated with cord compression, acute fetal
hypoxia
2. Macrosomia birth trauma, obstructive labor, shoulder dystocia.
3. Meconium aspiration due to thick meconium as a result of
oligohydramnios.
4. Intraprtum fetal distress.
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5. Dysmaturity:
6. asphyxia, meconium aspiration syndrome, hypoglycemia,
polycythemia, respiratory distress, and dysmaturity syndrome
Management :
 Weekly vaginal examination, plan induction when cervix is
favorable.
 •Antepartum fetal heart monitoring, non stress test, ultrasound
scans.
 •Induction of labor, prostaglandins or oxytocin, forceps- or
vacuum-assisted birth and cesarean birth
 IF Fetal distress , emergency cesarean section sometimes
required.
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 4- Multiple Gestation
▪ Multiple gestation or multifetal pregnancy results when
two or more fetuses are present in the uterus at the same
time.
▪ Multiple gestation is not a complication of pregnancy;
rather, it is a condition that presents an increased risk of
morbidity and mortality for the mother and neonates.
Types of twinning
1. Dizygotic (fraternal)occurs when two separate ova
arefertilized (ie, two separate eggs and two sperm

315
2. Monozygotic (identical)occurs when one ovum divides
earlyin gestation and two embryos develop (ie, one egg and one
sperm
Clinical Manifestations
 Usually, the uterus is large for gestational age
 Auscultation of two distinct and separate fetal hearts may
occur with a Doppler late in the first trimester or with a
fetoscope after 20 weeks' gestation.
 Ultrasound is the best screening test at present; used for
95% to 100% of cases.
 High initial quantitative -hCG levels in infertility care are
typically the earliest indications of multiple gestation.
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ultrasound should be used to confirm the diagnosis in the
presence of elevated -hCG levels
Complications
1) Cardiopulmonary(Pulmonary edema,Complications from
tocolysis, Preeclampsia, )
2) Obstetric( PTL or birth,Cervical effacement and dilatation,
Increased incidence of cesarean delivery, Increased use of
tocolysis, Antepartum hemorrhage,Abruptio placentae, Uterine
rupture,Postpartum hemorrhage,Infections, Gestational
diabetes,Polyhydramnios; oligohydramnios common with twins)
3) Spontaneous abortion
4) . IUGR

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 5) Umbilical cord problems, such as entwinement, cord prolapse, or
vasa previa
6) Structural abnormalities, such as congenital heart defects,
intestinal tract anomalies, neural tube defects
7) Twin-to-twin transfusion syndrome
Management and Nursing Interventions
 Nutrition counseling
 Fetal evaluation encourage follow-up to evaluate growth and
development
 Evaluate the woman for signs and symptoms of obstetrical
complications

318
▪ PTL prevention explain that hospitalization may be necessary
for signs and symptoms of PTL.
 Encourage bed rest and hydration.
 Institute fetal monitoring and assist with tocolytic therapy,if ordered
 Explain to the woman that mode for delivery depends on the
presentation of the twins, maternal and fetal status, and gestational
age. Cesarean delivery
5- Polyhydramnios
 Polyhydramnios or hydramnios is an excessive amount of amniotic
fluid in the amniotic sac.

319
 At 36 weeks gestation, approximately 1 L of fluid is present. The
amount of amniotic fluid normally decreases after this time. The
amount of amniotic fluid present is controlled in part by fetal
urination and swallowing.
Etiology
 The etiology is usually unclear.
 Normal amniotic fluid volume at term is 500 to 1,000 mL.
 The volume in polyhydramnios exceeds 2,000 mL between 32
and 36 weeks.
 Anomalies causing impaired fetal swallowing or excessive
micturition may contribute to the condition.

320
 Maternal disease as DM, renal disease.
Multiple pregnancies.
Fetal abnormalities that affect the swallowing mechanism.
Clinical manifestations:
 Excessive uterine enlargement, fundal height increases out of
proportion to gestational age.
 Difficulty in breathing.
 Difficult to hear FHR and to palpate the fetus.
 Difficult finding a comfortable sleeping position.
 Pain in abdomen, back and thighs due to increased pressure.
 Difficult ambulating.
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 Varicosities.
 Nausea and vomiting
Complications
1) Dysfunctional labor with increased risk for
cesarean delivery
2) Postpartum hemorrhage 3) fluid embolus is
possible.
4) Acute fetal hypoxia secondary
5) Potential for delivery of a preterm neonate
Management:
 Hospitalization, if the mother is dyspnic or in pain.
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  Transabdominal or vaginal amniocentesis with the aid of
sonography and careful monitoring of vital signs. Remove the
fluid slowly to avoid abruptio placenta.
 Offer support by explaining procedures.
 Encourage the woman to rest on her left side in semirecumbent
position to increase blood flow to uterus and fetus and to relief
symptoms.
 Watch carefully for signs of abruption placenta , abnormal
presentation and post partum hemorrhage.
6- Oligohydramnios
 Oligohydramnios is the marked decrease of amniotic fluid in the amniotic
sac of less than 0.5 L between 32 and 36 weeks' gestation.
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 Etiology
 Frequently related to fetal problems, such as obstruction in the urinary
tract, renal agenesis, and IUGR (Any condition that prevents the
formation of urine or the entry of urine into the amniotic sac usually
results in oligohydramnios.)
 Associated with premature rupture of membranes (PROM) and severe
preeclampsia where there is a significant decrease in fetal vascular volume
causing decreased urine output
 Frequently seen in
1) postdate pregnancies
2) Placental insufficiency
3) Premature separation of placenta from the uterus
4) Twin-to-twin transfusion

324
Clinical Manifestations
 Prominent fetal parts on palpation of the abdomin
 Small-for-date uterine size
 Nonreassuring variable decelerations or repetitive late decelerations
on fetal tracing
Diagnostic Evaluation
1) Ultrasound evaluation of the AFIamniotic fluid of less than 5 cm
total in all four vertical plane quadrants of the uterus is
associated with lower perinatal mortality. AFI between 5 and 8
cm is considered borderline with treatment being provider
driven.
2) FH less than AOG.
325
Management
 Frequent evaluation of fetal status
 Ultrasound is also done to further evaluate fetal renal
Amnioinfusion (the installation of fluid into the amniotic
cavity to replace normal volumes of amniotic fluid) Delivery
may be indicated for conditions, such as IUGR or fetal
compromise.
Complications
1) PTL
2) Umbilical cord compression
3) Passage of meconium
4) Fetal/neonatal death
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7- Prolonged pregnancy
Or post term pregnancy which continuo for over than 42 weeks
Factor increasing risk:
1. Older primigravida
2. Poor obstetric history
3. Pre- eclampsia
4. Diabetes mellitus
5. Previous large baby
Complication:
1. Fetal skull ossify so moulding will decrease

327
2. Placenta insufficiency
3. Intrauterine death
4. Fetal distress
5. Meconium aspiration
6. Delivery trauma
7. Psychological, increase anxiety
Management:
1. If no complication conservative management
2. Assess maternal and fetal well being
3. Induced labour at term

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8-Induction of labor
Is the initiation of labour by artificial means, for medical

reasons Indication:
1. Prolonged pregnancy
2. Pre- eclampsia
3. Diminish fetal well being
4. The older primigravida
5. Poor obstetric history
6. Premature rupture of membranes
7. Previous large baby
8. Diabetes mellitus
9. Unstable lie
10. Placenta abruption
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11. Intra uterine death
Contraindication:
1. Unreliable EDD
2. Malpresentation 3. Cephalopelvic disproportion
Methods of induction:
1. Prostaglandin
2. Intravenous oxytocin
3. Artificial rupture of membrane
4. Observation to mother and fetous

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9-Accelerated labour
 Differ than induction by her labour started spontaneously, the
process aim to increase the efficiency of uterine contractions
when progress in labour is slow

Method used:
 The same as in induction

10-Prolonged labour
If labour exceeds 24 hours.
Causes in first stage:
1. Insufficient uterine contraction
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2. Pelvic abnormalities
3. Large fetus
4. Psychological
Management
1. Identify the cause
2. Syntocinon for increasing uterine action
3. If no progress terminate by CS
4. Assess mother condition for exhausted
5. Fetal heart monitoring
Causes in second stage:
1. Hypotonic contractions
2. Ineffective maternal effort

332
3. A rigid perineum
4. Reduced pelvic outlet
5. Large baby Complication:
1. Edema and laceration
2. Uterine prolapse
3. UTI
4. Fetous head compression and hypoxia
11-Obstructed labour
When there is no advance of the presenting part despite strong uterine
contractions.
Causes:
333
1. Cephalopelvic disproportion
2. Fetal abnormalities
3. Malpresentations
4. pelvic tumors
Signs of obstructed labour:
1. No engagement despite of good contraction
2. The cervix dilated slowly
3. Dehydration
4. Rapid pulse
5. Poor urinary out put
6. Signs of fetal distress 7. Retraction ring is seen
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Management:
Caesarian section is performed if not response to
instrumental

Chapter (10)
operative labor
Caesarean Section
 The delivery of a viable fetus through an incision in the abdominal
wall and uterus
 The primary goal of caesarean delivery is the preservation of the life
and well-being of both mother and fetus
335
Types of Cesarean Section

1. Elective C/ S , Non-Elective C/S

2. Primary C/S (first performed), Repeated C/ S

3. LSCS : The uterine incision in the lower segment

4. USCS : The uterine incision in the upper segment

usually through a transperitoneal route rarely

through extraperitoneal route.
336
 Indications for C/S

Maternal Indications:
1) Antepartum hemorrhage (placenta praevia, severe
abruptio-placentae), Contracted pelvis(CPD) 2)
Pelvic tumors obstructing labor.
3) Pelvic fracture.

337
4) Previous successful vaginal surgery for stress
incontinence or urinary fistula.

5) Invasive carcinoma of the cervix..

6) Severe maternal hypertension.

7) Previous Cesarean Sections or other uterine scar

threatening uterine rupture

8) Cerebral aneurysm or arterio-venous malformations.

Indications for C/S. Cont.
338
Fetal indications:

1) Fetal distress ( with or without dystocia)

2) Certain cases of malpresentation ( face, brow,

compound presentation, persistent OP, transvese lie

as no place for internal version with single living
fetus and C/S for breech presentation is increasing
3) Multiple pregnancy

339
4) Fetal anomalies (with associated dystocia or due to

worsening conditions in utero).

5) Macrosomia and extreme prematurity are examples

of fetal indications for CS. Maternal genital Herpes

infection and thrombocytopenia are also fetal
indication for CS due to risk of fetal infection and
hemorrhage.

Contraindications of Cesarean Section:

340
There are no absolute contraindications , yet C/S is better

avoided in cases of fetal demise, major anomalies

incompatible with life and in some maternal diseases as
cardiac diseases and coagulopathy

Timing of elective C/S

 For maternal interest no choice

 For fetal interest consider maturity & fetal condition

341
  Usually at 38 wks

Before Emergency C/S

Explain to the woman & husband & obtain consent
Inform anesthetist, OR staff, pediatrician
100% oxygen mask in case of fetal distress
Sodium citrate 20 ml , metoclopramide 10 mg IV
Transfer to the theatre, IV fluid , take blood for Hb, x-match
2 units of blood
Preferable to use spinal or epidural anaethesia
Catheterize the bladder
Tilt the mother 15 º by using wedge
342
Pneumatic inflatable boots or Ted stockings
Prophylactic Antibiotics to decrease incidence of infection
Inform pediatrician if the mother had opiates in the last 4
hrs.
Halothane should not be used uterine relaxation &
bleeding
Heparin as thromboprophylaxis
Parts cleansed with antiseptic solution
Left lateral position- reduce aortocaval compression , reduce
risk of supine hypotension
General anesthesia or Regional anesthesia
Regional - Spinal or Epidural
343
 Preoperative Preparation
• Preoperative visit by the anesthesiologist is important to assess
the patient's anesthesia status.
• For elective procedure should be kept fasting for at least 8
hours.
• Plans to decrease potential morbidity associated with
aspiration of gastric contents should be carried out in
nonelective procedure including administration of oral antacid
(Magnesium Citrate within 1h of start of anesthesia).

344
Preoperative Preparation
• A large intravenous line is begun prior to the
anesthetic administration and an infusion of crystalloid
solution started.
• A recent Hb and Hct is checked and blood type and
screen is done.
• Blood should be available in high risk patients .
• Urinary bladder should be empty, either by a catheter
or allowing the woman to empty her bladder
immediately before operation.
345
Preparation of the abdominal and perineal area
include shaving just prior to surgery, 5-min scrubbing
with a suitable detergent and covered with a sterile
draping
• The operating team should comply with all phases of
universal precautions to avoid exposure to infectious
agents.
• Anesthesia is usually divided into two categories:
general endotracheal technique and regional anesthesia
which usually entail either spinal or epidural blocks.

346
Post operative care of C/ S
 Close monitoring for 1st 6-8 hrs
 Parenteral fluids
 Blood transfusion if needed
 Analgesics and sedatives
 Oral fluids
 Early ambulation and deep breathing exercises Light
solid diet .
 Discharged –day following suture removal/if transverse or
subcuticular-5th/6th day
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 Postoperative care hints
1. The incision should be covered with a compression
dressing and should be checked when the vital signs
are measured for signs of hemorrhage through the
bandage.
2. Assess for the development of hematomas, seromas,
or wound infections. Areas of redness and palpable
masses or extraordinary tenderness or.Signs of
cellulitis require cultures and antibiotic therapy.
3. Assess for postoperative complications as any major
surgeries
348
4. Patients are encouraged to ambulate on the first
postoperative day and are made to turn, cough, and
deep-breathe immediately after surgery.
5. The diet is progressed from clear liquids on the
evening of the operative day if surgery was in the
morning, usually beginning about 8 to 12 hours
after surgery.
6. Adequate pain medication is an essential component
of postoperative management
Postnatal care
 V/S & blood loss must be monitored

349
 Uterine fundus palpated, massaged

 Effective parentral analgesics

 Deep breathing & coughing encouraged

 Early mobilization

 Fluid therapy & diet

 Assess bladder & bowel function

 Wound care

 Lab investigations

 Breast care and baby care

 Prophylaxis for thrombembolism

350
 Complications
A. Intraoperative

1) Bleeding & the need for blood transfusion

2) Hysterectomy
3) Complications of anaesthesia
4) Damage to the bladder, ureter, colon , retained placental
tissue
5) Fetal injury
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Complications
B. Postoperative

1) Gaseous distension
2) Paralytic ileus
3) Wound dehiscence & infection
4) Infectins UTI, pulmonary
5) DVT & pulmonary embolism
6) Death
7) Vesico uterine fistula
Mode of delivery in next pregnancy
352
Criteria for VBAC:

 Pt must agree to the procedure

 A low transverse uterine incision

 Non recurrent cause of the previous CS

 No macrosomia, malposition, multiple gestation,

breech

Mode of delivery in next pregnancy Cont.

353
 Contraindication for VBAC:

 Previous classical CS

 2 or more previous CS

 Previous other uterine surgery

 Hx of scar rupture

 Placentaprevia or transverse lie

Episiotomy
 Episiotomy is an incision made in the perineum to enlarge the
vaginal outlet.
354
  Because sutures used to repair episiotomy are of absorbable
material, they don’t need to be removed and no dressing is
applied. the purposes:
1) Prevent tearing of the perineum
2) Facilitate repair of laceration and to promote healing.
3) Minimize prolonged and severe stretching of the muscles
supporting the bladder or rectum which may later lead to stress
incontinence or vaginal prolapsed.
4) Shorten the second stage.
5) Enlarges the vagina in case manipulation is needed to deliver an
infant
355
Types of Episiotomies: The type of episiotomy is designated by site and
direction of the incision.
1. Median: Is the one most commonly applied procedure
 It is effective, easily repaired and generally the least painful.
 Incision is made in the middle of the perineum and directed toward the
rectum.
 Is believed to heal with few complications, more comfortable for the
woman.
 If a long and large incision is needed during delivery, it may necessitate
incision into anal sphincter (considered a limitation for this method).
2. Mediolateral: Incision is made laterally in the perineum.

356
 This method avoids the anal sphincter if enlargement is needed.
 The blood loss is greater, the repair is more difficult (considered a
limitation for this method)
Management and Nursing Interventions:
 The episiotomy site is inspected every 15 minutes during the first hour after delivery, then
once daily. Healing should be completely reached in several weeks.
 The site is assessed of tenderness, redness, swelling and evidence of hematoma
 Patient teaching about reasons for episiotomy, signs of infection and hygienic measures.
 Reduction of pain and discomfort by apply ice packs after procedure to reduce edema
 Warm Sitz baths after 24hr and dry heat help increase circulation to the area and promote
healing.
 Use local analgesic sprays or oral analgesic to promote comfort.

357
OperativeVaginal Delivery / Forceps–Assistant
Delivery
 Obstetric forceps are made from two double-curved, spoon- like
articulated blades. Forceps are designed for rotating or extracting the
fetal head
Indication for forceps delivery:
Fetal conditions
 Fetal distress, cord prolapsed, abruptio placenta and excess pressure
on the fetal head from arrested descent.
Maternal conditions

358
 Eclampsia, heart disease, maternal hemorrhage, maternal exhaustion
and failure of progress in the second stage because of poor uterine
contractions.
Prerequisites for Application of Forceps:
 Cervix must be completely dilated.
 Fetal head must be engaged, preferably deeply engaged.
 Vertex or face presentation (Accurate diagnosis of position and station).
 Pelvis should be adequate with no disproportion.
 Membranes should be ruptured.
 Some form of anesthesia should be used.
 Rectum and bladder should be empty to avoid laceration and fistula formation.
Types of forceps delivery
359
 Low Forceps: forceps are
applied after the head has
reached the perineal floor. This
will be an easy forceps delivery.
 Mid Forceps: the vertex is at
ischial spines. Any forceps
delivery requiring rotation
regardless of the station.
 High Forceps: forceps are
applied before engagement has
taken place (above ischial

360
spine). Most hospitals have policies against high forceps application.
Replaced by cesarean delivery.

361
Vacuum-Assistant Delivery
 Vacuum extraction is accomplished by use of a specialized vacuum
extractor, which has a cap like
suction device that can be applied to
the fetal head to facilitate extraction
Indications
 Dysfunctional labor, fetal distress,
PIH and abruptio placenta.
 When forceps are to be avoided.
 Maternal cardiopulmonary disease
362
 Malposition; occipito lateral and occipito posterior positions

Chapter (11)
obstetric emergency

363
 Prolapsed Umbilical Cord
 Umbilical cord prolapse occurs when a loop of the
umbilical cord slips down below the presenting part of the
fetus.. It may slip down immediately with the fluid gush or
long after the membranes rupture

364
 Causes:
1) Rupture of membranes when the presenting
part is not engaged in the pelvis
2) More common in shoulder and foot
presentation.
3) Prematurely: small fetus allows more space
around presenting part.
4) Polyhydramnios: causes greater amount of
fluid that cause greater force when membranes

365
 rupture 5) Contracted pelvis 6) Placenta
previa.
Clinical Manifestations:
Cord may be seen protruding from vagina, or can be
palpated in the vaginal canal or cervix.
Signs of fetal distress: the cord is compressed between
the presenting part and bony pelvis.
If cord is exposed to cold room air, there may be reflex
constriction of umbilical vessels.
Fetal heart rate pattern may be irregular with periodic fetal
bradycardia.
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Management:
the priority is to relieve pressure on the cord to improve
umbilical blood flow until delivery.
FHR is assessed continuously,
Place the women in recovery or knee-chest position or
Trendelenburg position.
 Administer oxygen to the women.
Place sterile gloved hand in vagina and push the fetal head up
ward to relief compression of the cord.
Prepare of immediate vaginal delivery if cervix is dilated.
Prepare of immediate cesarean delivery if cervix is not
deleted.
367
In home situation, cover-protruding cord with clean wet
dressing. Elevate the woman's hips and transports to
hospital immediately.

368
 Rupture of the uterus
 Uterine rupture is a spontaneous or traumatic rupture of the
uterus.
 May precede labor’s onset
 May be Complete rupture, incomplete, dehiscence.
369
Clinical manifestation:
1) Complete rupture:
 Sudden sharp abdominal pain during contractions.
 Abdominal tenderness. – Cessation of contractions.
 Bleeding into abdominal cavity and sometimes into vagina.

370
 Fetus easily palpated, fetal heart tones cease.
 Signs of shock.
2) Incomplete rupture:
 Develops over a period of few hours.
 Abdominal pain during contractions.
 Contractions continue, but cervix fails to dilate.
 Vaginal bleeding may be present.
 Tachycardia, pale skin.
 Loss of heart tones.
Causes:
 Weak caesarian section scar
 Trauma during operative manipulation per vagina

371
  The unwise use of oxytocin
 Prolonged or obstructed labor
 Excessive manual pressure applied to the fundus
during delivery
 Congenital uterine anomaly.
 Prolonged or obstructed labor.
 Forced delivery of fetus with abnormalities.
Internal or external version Managements :
Initial management is to stabilize the woman and the fetus
for a cesarean birth.

372
Emergency laparotomy is performed with complete
rupture, usually the uterus is removed and attempts
are made to save the baby.
Administer IV fluids and blood as directed.
Administer oxygen to the woman.
Prepare the woman for emergency surgery.
Monitor maternal & fetal vital signs until surgery
begins.
Uterus may be repaired if rupture is not extensive, if
extensive hysterectomy is necessary.

373
 Amniotic Fluid Embolism
 Is the accidental infusion of amniotic fluid in to the
mother's blood stream under pressure from the
contracting uterus.
 Amniotic fluid containing fetal vernix, lanugo,
meconium, and mucus enters maternal blood through
defect's in to the placental attachment.
 These particles become emboli in the mother’s general
circulation causing:
 Acute respiratory, circulatory collapse, hemorrhage and
corpulmonale as they block the vessels of her lungs.
374
 These particles stimulate abnormal coagulating, initiating
DIC.
 Amniotic fluid embolism is rare and usually fatal
(mortality rate is as high as 80% for mothers &
approximately 50% of neonates)
Clinical manifestations
 Sudden dyspnea and chest pain.
 cyanosis.
 tachycardia.
 Pulmonary edema.
 Prolonged shock due to:
375
 1. Anaphylaxis, which cause vascular collapse.
2. Uterine bleeding with development of hypofibrinogenemia.

Management and nursing intervention:

Emergency measures are instituted immediately including,
cardiopulmonary resuscitation (CPR).
Improving tissue perfusion and cardiopulmonary function.
Administer O2 as soon as possible, when situation is recognized.
Provide assisted ventilation.
Maintaining fluid volume and correction of DIC.
Administer fresh whole blood and fibrinogen.
Administer IV fluids and plasma.

376
Provide continuous monitoring of maternal and fetal status.
Delivery of fetus.
Since fetus is in great danger, cesarean approach is used.
Care for the neonate and provide family members with comfort and
information about the status of mother and infant.

Uterine Inversion
 Uterine inversion (uterus is turned inside out) is a rare
but potentially life-threatening complication. causes:
Most common cause is excessive pulling on the umbilical
cord in an attempt to hasten the third stage of delivery.

377
vigorous fundal pressure, uterine atony, and abnormally
adherent placental tissue.
Clinical Manifestations:
 When complete inversion occurs, a large, red, globular
mass (that may contain the still-attached placenta)
protrudes 20 to 30 cm outside the vaginal introitus.
 A partial or incomplete inversion is not visible; instead, a
smooth mass is palpated through the dilated cervix.
 Maternal symptoms include pain, hemorrhage, and
shock
Management
378
 Involves manual replacement of the fundus (under
general anesthesia) by the physician, followed by
oxytocin to facilitate uterine contractions and antibiotic
therapy to prevent infection.
 Prevention (by not pulling strongly on the cord until the
placenta has fully separated) is the safest and most
effective therapy.
Vasa Praevia
 It's an obstetric complication defined as fetal
vessels crossing or running in close proximity to
the inner cervical os.
379
 These vessels course within the membranes
(unsupported by the umbilical cord or placental
tissue) and are at risk of rupture when the
supporting membranes rupture
 Normally, the umbilical cord inserts into the middle of the
placenta as it develops.
 Vasa previa is present when fetal vessels traverse the fetal
membranes over the internal cervical os.
 Abnormally: In velamentous cord insertion, the umbilical
cord inserts into the fetal membranes (choriamniotic

380
 membranes), then travels within the membranes to the
placenta (between the amnion and the chorion).
 The exposed vessels are not protected by Wharton's jelly and
hence are vulnerable to rupture. Rupture is especially likely if
the vessels are near the cervix, in which case they may
rupture in early labor, likely resulting in a stillbirth
Diagnosis
 This is rarely confirmed before delivery but may
be suspected by Doppler that reveals a vessel
crossing the membranes over the internal cervical
os.
381
 The diagnosis is usually confirmed after delivery
on examination of the placenta and fetal
membranes.
Treatment
 Treatment immediately with an emergency cesarean
delivery is usually indicated

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