Obstetrics nursing

Bleeding disorder in pregnancy 

- anytime 
Bleeding - age of gestation
1st - abortion, ectopic pregnancy 
2nd - abortion, incompetent cervix, h mole
3rd - placenta previa abruption placenta 

Abortion - Before the period of Viability - 20th weeks

Causes -

faulty fertilization 
Maternal undernutrition
Trauma 
Infection 
Medical problem - hypertension, gravida cardia 

Types
1. Spontaneous - non intentional 

Threaten - TOCOLYTIC 
cervix dilation -  closed 
bag of water - intact (+)
 UC/Bleeding - mild 
TISSUES  - intact (+)
MANAGEMENT -complete bed rest , monitor the pad , save the pad or monitoring, no IE , External
fetal monitoring , no sex , drug : TOCOLYTIC, sedation 
Imminent,
Open 
Ruptured (-)
Moderate to strong
Inact  (+)

Complete ( depends of the timing of the consultation of the mother ) in her house 
Open 
Ruptured
Mild
Negative 

The following day 

Closed 
Negative 
Negative to mild 
Gone, negative 
Check up ( physical, pelvic exam 

Incomplete ( placenta inside pa)  uterine relaxation 

Open 
Ruptured
Mild to negative
Positive
Dilation and curettage, perineal care , antibiotics, analgesic, antiinflammatory. 
Example in house several days later : septic abortion 
Missed abortion 
IUFD intrauterine death (4 to 6 weeks without fetal causing bleeding: to know the fetal is
dead : no fetal movement . 
Closed 
Intact 
Negative
 Intact no sign of fetal life ( no movement, and heart rate) 
Septic - develops infection 
Closed 
Ruptured ( Brownish, foul smelling, vaginal discharge)
 Moderate to strong
Positive
Dilation and curettage 
Habitual / recurrent , naturally caused , miscarriage 

Cause : 3 or more consecutive spontaneous abortion ,  

1st cause incompetence cervix  - premature cervical dilatation 
Mouth of uterus ( cervix). Carry the amniotic fluid and the baby during the pregnancy, it
should be closed when pregnancy
Relax cervix - spotting (bleed ) - painless because of absence of uterine contractions in 2nd
trimester 
Cervix - Continues to open - increase of bag of water and ruptured
Happen less than 5 mons - IC abortion 
happen <9 PL
Suturing technique - cerclage 
McDonald suture 28 th week of pregnancy  - removed the suture -  s/s true labor , 37
week , 32 week Basta may true labor 
Shirodkar (permanent suture) pwede pa din mapreggy 
To prevent - kegel exercise ( muscle control )

G spot 
Vaginal 
Clitoris 

Management: for abortion 

Blood transfusion 

OXITOXIC DRUGS - increases uterine contractions cause vasoconstriction on the blood vessels on the mother
, not safe 

TOCOLYTIC - smooth muscle relaxant , safe 

1.  Syntocino - O - IV incorporation 
2. Duvadilan- T *
3. Pitocin- o
4. Dactulyn - t 
5. Yutolat -t
6. Methergine - o , IM after the placenta is out , effect sustained uterine  contractions . 
7. Oxytocin - o , 1 min after the baby is out , effect . Rhythmic 
8. Bricanyl - t , terbutaline 
9. MgS04 magnesium sulfate - t , eclampsia , abruptio placenta ( boarlike matigas , continues uterine
contractions) 

2. Induced intentional -

therapeutic abortion - legal  , to save life of mother , example:  ectopic pregnancy, gravido cardia (3 and
4 class) 
non therapeutic abortion - criminal , get rid of unwanted pregnancy , example : rape victim. 
No. 1 abortionist

Hilot 
Midwifes
Doctor
Nurses - prescribing medication : cytotec- oral 

Parity - no. Viable pregnancy delivered regardless of outcome 

Abortion - 

Causes of bleeding
1.Abortion -  20 th week 
Clinical age of viability - 
Surfactant - function - decreases surface tension in alveilo And lubricate. 
FETAL LUNG MATURITY - 2 IS TO 1 RATIO, LS RATIO
Lecithin and sphingomycin

Rds lack of oxygen 

 fetal distress inside uterus 

FLM
LS RATIO.- aminiotic fluid  via amniocentesis- aspiration of fluid 

2nd trimester bleeding 

RH compatibility
Rh incompatibility occurs when the mother's blood type is Rh negative and her fetus' blood type is Rh positive.
Antibodies from an Rh negative mother may enter the blood stream of her unborn Rh positive infant

- rhesus - 

Mother - RH negative
Baby - RH positive 

Fetal blood - placenta 

Mother blood - uterus 

1st time pregnant

Compatible (-)(-)

Coomb's test - to know if the mother produce antibody or not . 

She will not produce - negative test - no production of antibodies 
Types 
Indirect - maternal blood
Direct - fetal blood
RHOGAM ( not permanent) -  when : result is negative, this will prevent antibody production. Within 72
hours. Makes baby safe 

Isoimmunization 
 -  (Sometimes called Rh sensitization, hemolytic disease of the fetus, Rh incompatibility) What is
isoimmunization? A condition that happens when a pregnant woman's blood protein is incompatible with the
baby's, causing her immune system to react and destroy the baby's blood cells.
Antibody produced - permanent

2nd time 
Baby (-) 
Baby(+) problem because the antibody wil enter the placenta . Amniotic fluid become yellow because high
level of bilirubin ( come from destroyed fetal RBC's) 

Goal care - 

Prevent isoimmunization 

IUEBT intrauterine exchange blood transfusion 

BLOOD : -O universal donor (O)
Jaundice at birth ( pathologic )- phototherapy , regular turning - promote oxidation, prevent dehydration 
Jaundice 2 weeks above ( physiologic)

ECTOPIC PREGNANCY 

Outside the uterus 

Extra uterine pregnancy
Causes

1. Pelvic inflammatory disease

sphingitis - inflammation of fallopian tube 
2. USED of IUD - 

 Between 10-12 week - expected to ruptures

Sign of ruptured ectopic pregnancy 
Earliest sign : 
Kohr's - unilateral pain radiating
Cullen's - bluish
S/d shock 

Differential diagnosis

Abdominal Ultrasound
Terminate before the other organ ruptured

Sign 

Pregnancy -
aminorrhea 
Pain - 

 4 sites of 

1. Tubal - most common .  management: exploratory laparotomy  > ectomy  (2 sites ; ampula and
interstitial ( most dangerous, easily ruptured) 
2. Ovarian 
 3. Abdominal  - most dangerous , Expolap > 
4. Cervical - rare , friable easily bleeds - management: drugs - methotrexate 

HMOLE 

- GESTATIONAL trophoblast disease

HM, or molar pregnancy, results from abnormal fertilization of the oocyte (egg). It results in an abnormal
fetus. The placenta grows normally with little or no growth of the fetal tissue. The placental tissue forms a
mass in the uterus

Egg sperm 
Zygote 
Cleavage - splits into two ( twins identical ) 
Blastomere - 16 ( morula, mulberry like 
Blastocyst ( thromboplast( finger like structure - attached .Outside 
Inside ( chorionic villa 50 k to 400 k 
Possible causes 
Protein deficiency 
Low socio economic status 
Faulty fertilization - one egg , two sperm 

4 Classical sign of h mole 

Uterus is bigger than date 

HCG is abnormally high  - 
Absence of fetal sign heart rate , no movement 
Passage of vesicles  can confirm HMOLE - when to expect the vesicles ruptures - 16 th -20th weeks of
pregnancy - brownish and foul smelling and contain vesicles. 

Management: dilation and suction curettage . Ovum forceps. 

Avoid pregnancy at least 1 year to avoid HMOLE , ecg thither .
 Choriocarcinoma - cancer develops 

Snow storm structure - vesicles ( fluids ) 

3rd trimester bleeding

1.  Placenta Previa -
Problem - Location of implantation, lower  
LUS - Lower uterine segment . 
Prevent baby to 
Painless- no uterine contractions because she is not on labor 
Uterus - soft
Pian - absent 
Color of blood - bright red
Type of bleedng - overt , obvious bleeding 
Engagement  the head is  not engage (-

2. abruptio placenta -
Timing of placental separation , sudden / premature  , early,  abrupt 
Predisposing Factor : high parity ( common in multipara) 
Short umbilical cord 
Double cord coil 
PIH ( pregnancy induced hypertension
Trauma 
 Uterin contractions
Boardlike  or rigid 
Pain present 
Color of blood - dark red bleeding
Type of bleeding - either covert( conceal) o overt  : why ? Type of placenta separation 
duncan and schultz ( more painful bleeding )  
Couvelaire uterus (also known as uteroplacental apoplexy) is a life-threatening condition in which
loosening of the placenta (abruptio placentae) causes bleeding that penetrates into the uterine
myometrium forcing its way into the peritoneal cavity. This condition makes the uterus very tense
and rigid.
Engagement - either engage or not 
Most dangerous 
Always to emergency CS

Management
Bedrest
Auto therapy 
No IE
EXTERNAL fetal monitoring
Abruptio placenta:  magnesium sulfate
Method of delivery: prepare for emergency Cesarian section 

PIH PREGNANCY INDUCED HYPERTENSION

classic sign 

Edema 
Proteinuria
Hypertension 

Pre disposing factor 

Age - below 18 or above 35

History of hypertension
Primigravida
Protein deficiency
Low socio economic status 

Different types 

1. Gestational hypertension -
Onset of hypertension - 20th week & above
S/s - 150/9 above 

1. Pre eclampsia
Same 
PIH
2. Eclampsia
Same 
PIH
3. Chronic hypertension 
< Before 20th week 
PIH 

Effects of hypertension

Vasoconstriction
1 . Increases workload (pumping) on  heart >Increases BP > HPN
2. DECREASES renal blood flow >renal hypoxia> Glomerular damage > ok increases Glomerular permeability>
proteinuria>edema
3. Hepatic hypoxia> hepatic inflammation> increase production of liver enzymes> cause epigastric pain 
4. Cerebral hypoxia> result to possible headache ( excruciating (sobrang sakit), unrelenting ( Di nawawala)
pounding headache> vision disturbance , hyper reflexia
5. Decrease placental perfusion> affect the growth of the baby > IUGR intrauterine growth retardation/
restrictions> SGA > Fetal distress abruptio placenta 

Management:

Protenuria . Primigravida. Goal of care - promote safety during pregnancy. 

I ldima . 
Hypertension . Hydralazine apresoline . 

Magsulfate - decreases Neuro muscular irritability. CNS depressant. Loading dose - 6 to 10 grams 
Maintenance dose 1grm

✓Check for sign of hypermagnesemia

1. Reflexis - hypo ( hyporeflexia o areflexia (no reflexis) 
2.RR below 12 min 
3. Urine output below 30 ml /hr 

Mild preeclampsia
Bp- 140 /90 to 160/110
Protenuria 1 to +2
Edema - mild to moderate 

Severe 
160/110 >
+3 +4
Severe generalized face 

Eclamptic 
same 
Same 
Same 

Monitoring

Monitor BP
Weight for edema
Possible ultrasound ( can affect baby IUGI
FHR
Kick count ( MORE THAN 15 fetal distress

Gravido cardia
Pregnant woman with heart disease

Types 

1.  Rheumatic heart disease 

Type . 
Mitral valve stenosis. Rubells infection ( 1st trimester) - organogenesis 
RHD due to Rheumatic fever - streptococcus ( go to mitral valve -
Increase 30 , 50%blood volume 

CLASS 1 

Classification : ASYMPTOMATIC 
SS VERY MIN 
DAMAGE IN MV NONE 
 ACTIVITY SS APPEAR NONE
LIMITATIONS NONE
DELIVERY NSVD
CLASS 2

SYM
MIN
HEAVY 
SLIGHT 
NORMAL DELIVERY TO FORCEP 

CLASS 3 

SYMP 
MOD
LIGHT 
MARKED 
FORCEP TO THERAPEUTIC ABORTION 

CLASS 4 

SYMP 
SEVERE 
S/S AT REST 
TOTAL COMPLETE LIMITATIONS 
FORCEP TO THERAPEUTIC ABORTION 

Drug: digoxin - increase cardiac output by increasing the force of heart contractions but decreases rate of
heart contractions 
. Do not give when the blood pressure is less than 160 

Gestational Diabetes mellitus

Hormone : Human placental lactogen - blocks the action of insulin during pregnancy.
24 th week of pregnancy - 6 mons . The placenta  Increases the production of Hpl 
High level of HPL 
rbc ( glucose) . G attracts water
Insulin produce by the beta cells and help  pushes RBC 
Hyperglycemia. 
Polyuria
Polydipsia ( excessive thirst
Polyphagia ( hungry )
Other source of energy 
Protein . Muscle converted to amino acids - muscle wasting
Fats. Liver, ketones leads to acidosis . Poorly control of blood glucose level, produces
ketones ,> brain >DKA > coma
Good glycemic control . 
Ketones can cross to the placenta > baby ( down syndrome . Trisomy 21. Neurologic
impairment 
Atrract water - aminiotic fluid - polyhydramnios 
LGA .
Glucose can cross o placenta - increase the production of fetal insulin . Macrosomia. 
Baby blood glucose . Normal 40 -60 
40 breastmilk 
35 mg - IV glouse s
Screening
Glucose CT. Screening test . No npo. 50 grams glucose solution . 1 blood extraction only .
Result  < 145 mg/dl
  OGTT . CONFIRMATORY TEST. W / npo post midnight . 100 grams glucose solution . 4
times blood extraction.  Increases intake 2-3 days before the test . Result:  FBS < 90 mg/dl .
Post 1hr < 180 mg/dl. Post 2hrs <155 mg/dl . Post 3 hrs<145 mg/dl

Management. 

1. Diet and exercise

2. Insulin 
Types 
Regular  fast but short 
Onset 30 mins- 1 hr
Peak  4hr
Duration 5-8 hr 
Intermediate  slow but longer 
2 hrs
6-8 
12 

Complications. Prolonged hypoglycemia

1. Topic. Asepsis. Site ( abdomen, thighs), dosaging. 

1. Diabetic exchange diet 

Type 1 IDDM INSULIN DEPENDENT DM . Insulin > diet & exercise ...  

type 2 MDDM NON INSULIN DM . Diet & exercise> OHA ORAL hypoglycemic  > insulin
type 3 Gestational DM . Diet & insulin > insulin