CMCP M1

2/6/23, 11:36 AM M1: Introduction: Care of Mother, Child, at-risk or with Problems- NCM 109 (306 hours RLE)-JLMEJILLA
M1: Introduction
High risk pregnancy is one in which the concurrent disorder,

pregnancy-related complication or external factor jeopardize the
health of a woman, the fetus or both.
Nursing care for a woman with pregnancy complication and pre
existing illnesses are the following: close observation of maternal
health and fetal well being, giving of health education of woman
and her family on danger signs to watch during pregnancy and
actions to minimize complication whenever possible.
https://ceu.instructure.com/courses/26429/pages/m1-introduction?module_item_id=1966103 1/1
HIGH RISK MOTHER
AND CHILD
NCM 109
Summary of Primary Cause of Bleeding during Pregnancy
DATE TYPE CAUSE ASSESSMENT CAUTION
FIRST& SECOND Threatened spontaneous Unknown, possibly Vaginal Spotting, perhaps slight cramping Caution women not to
TRIMESTER miscarriage (early under chromosomal or uterine used tampons to halt
16 weeks; late 16-24 abnormalities bleeding as this can lead
weeks to infection
Imminent (inevitable) Unknown reason but Vaginal spotting, cramping, cervical dilation
miscarriage possible poor placental
attachment
Missed Miscarriage Unknown Vaginal Spotting, perhaps slight cramping; no Disseminated

apparent loss of pregnancy intravascular coagulation
is associated with
missed miscarriage
Incomplete Spontaneous Unknown, possibly Vaginal Spotting, cramping cervical dilatation High risk for uterine
miscarriage chromosomal or uterine but incomplete expulsion of uterine content infection and
abnormalities hemorrhage
Complete Spontaneous Unknown, possibly Vaginal Spotting, cramping cervical dilatation

miscarriage chromosomal or uterine but complete expulsion of uterine content
abnormalities
Ectopic (Tubal) Implantation of zygote at Sudden unilateral lower abdominal quadrant May have repeat ectopic
Pregnancy site rather than in uterus pain minimal vaginal bleeding possible signs pregnancy in future is
associated with tubal of hypovolemic shock or hemorrhage tubal scarring is bilateral
contractures
FIRST TRIMESTER BLEEDING
•Spontaneous Miscarriage
–Threatened Miscarriage
–Imminent (Inevitable) Miscarriage
–Missed Miscarriage
–Incomplete Miscarriage
–Complete Miscarriage
•Ectopic Pregnancy
SPONTANEOUS MISCARRIAGE
•any interruption of a pregnancy before the fetus is

viable (more than 20 to 24 weeks gestation or weighs at
least 500 g).
•Early- occurs before wk 16 of pregnancy
•Late- between 16-24 wks
Spontaneous Miscarriage
•Abortion – Medical term of any interruption of a

pregnancy before a fetus is viable
•Elective Abortion
•Planned medical termination of pregnancy
•Miscarriage – interruption occurs spontaneously
•CAUSES:
•Abnormal fetal formation
•Teratogenic factors
•Chromosomal aberration
•Rejection of the embryo through immune response
•Implantation abnormalities
•Inadequate endometrial formation or inappropriate site
of implantation Inadequate implantation inadequate
placental circulation and fetal nutrition
•Causes:
•Corpus luteum fails to produce enough progesterone
•Infection: Rubella, syphilis, poliomyelitis, CMV and
Toxoplasmosis , UTI crosses the placenta fetus fails
to grow placental production of estrogen and
progesterone fails endometrial sloughing
prostaglandins are released uterine contraction and
cervical dilation
•Teratogenic Agents
Assessing Miscarriage and the Usual Management
Type Amount of Uterine Pass-age of Cervi-cal Management
Bleeding Cramping Tissue Dilation
Threa- Slight, Mild No No •Bed rest sedation

tened spotting •Avoid:
Stress
sexual stimulation
 orgasm usually recommended.
Further treatment depends on the woman’s response
to treatment.
Sonogram-check for fetal heart sounds
hCG determination
Avoid strenous activity for 24 to 48 hrs
Emotional support
No coitus for 2 weeks after the bleeding episode

Type Amount of Uterine Pass-age of Tissue Cervi-cal Management
Bleeding Cram- Dilation
ping
Inevitable Moderate Mild to No, loss of pro- Yes Sonogram – if no fetal heart tone,
(imminent) severe ducts of con- empty uterus , non-viable fetus→
ception can-not D&E
be halted
D & E – remove products of
conception, prevent infection
Assess vaginal bleeding post D &

E
Bleeding Cram-ping Tissue Dilation
Incomplete Heavy, profuse Severe Yes Yes, with D & C or suction curettage to prevent
Membrane tissue in hemorrhage and infection
or placenta cervix
is retained
in the uterus
Incomplete Heavy, profuse Severe Yes Yes, with D & C or suction curettage to prevent
Membrane tissue in hemorrhage and infection
or placenta cervix
is retained
in the uterus
Type Amount of Uterine Cram- Pass-age of Cervi-cal Management
Bleeding ping Tissue Dilation
Complete Slight Mild Yes •yes •No further intervention is needed if

Fetus, uterine contractions are adequate to
membranes, prevent hemorrhage and there is no
placenta infection.
•Suction or curettage to ensure no
retained fetal or maternal tissue.
•Bleeding slows down within 2 hours
and ceases within a few days after
passage of products of conception
Type Amount of Uterine Cram- Pass-age of Cervi-cal Management
Bleeding ping Tissue Dilation
Missed With Perhaps No apparent No

( Early Pregnancy slight loss of Sonogram – failure of growth
Failure) cramping pregnancy D&E
- Fetus dies in the If over 14 weeks – induction of labor
utero but is not (misoprostol and oxytocin)
expelled Spontaneous miscarriage within 2
-No increase in weeks (danger of DIC)
fundic height
-No FHT
Type Amount of Uterine Pass-age of Cervical Management
Recurrent Varies Varies Yes Yes, •Varies, depends on type.

(generally usually •Prophylactic cerclage may be done
defined as three if premature cervical dilation is the
or more cause.
consecutive •Tests :
abortions)  parental cytogenetic analysis
lupus anticoagulant and
anticardiolipin antibodies assay.
Type Amou Uterine Pass- Cervi-cal Management
nt of Cram-ping age of Dilation
Bleedi Tissu
ng e
Septic Varies Varies Yes Yes, •Immediate termination of
-abortion complicated usually pregnancy
by infection •Cervical culture and sensitivity
More common among studies
those who self-abort •broad-spectrum antibiotic
Fever, crampy therapy (e.g. ampicillin) is
abdominal pain, uterine started.
tenderness •Treatment for septic shock is
initiated, if necessary.
•Tetanus toxoid/ tetanus Ig
COMPLICATIONS OF MISCARRIAGE
• Assess amount of bleeding

•Hemorrhage
• Rule of thumb: More than one sanitary
pad per hour is excessive
• Monitor vital signs to detect hypovolemic
shock
• Massage the uterine fundus to aid
contraction
• Dilatation and curettage
• Suction curettage
• Transfusion
Fever (>38˚C),
•Infection Abdominal pain / tenderness
Foul vaginal discharge
•Management:
–Perineal care (front to back wiping)
–Not to use tampoons  stasis of
body fluid  increasing risk of
infection
•Isoimmunization – production of antibodies against

Rh-positive blood
•Next pregnancy, these antibodies would attempt to
destroy the red blood cells of the next infant
•Treatment: Rh (D antigen) immune globulin
(RhoGAM) – prevent the buildup of antibodies
Powerlessness or anxiety
Assess feelings and grief over the loss
Surgically Induced Abortion Procedures
•Menstrual Extraction ( Suction Evacuation)

–Simplest type
–Ambulatory Setting
–A narrow polyethylene catheter is introduced vaginally
into the cervix
–Lining of the uterus is then suctioned and removed by
vacuum pressure
•Menstrual Extraction ( Suction Evacuation)

Nursing Interventions:
–Remain on supine position for 15 minutes after the
procedure
–Oral oxytocin
–Watch signs and symptoms of complications
–Vaginal bleeding for a week after the procedure
–Avoid douche, use of tampons, resume coitus after 1
week to avoid introducing infection
• Dilatation and Curettage Used for less than 13 weeks AOG

Ambulatory setting
Paracervical anesthetic block
• Uterus is cleaned with a curette

removing the zygote and trophoblast
cells with the uterine lining
• Dilatation and Curettage

Remains in the hospital for 1 to 4 hours
Oxytocin
Complications:
Perforation
Uterine infection
•Dilatation and Vacuum Extraction

–Used for 12 and 16 weeks
–Cervical dilatation is begun the day before the
procedure:
•Oral misoprostol
•LAminera tent ( seaweed that has been dried and
sterilized)
–Vacuum Extraction
•Dilatation and Vacuum Extraction

–Complications:
•Incompetent cervix
•Infection
•Prostaglandin Induction
–Between 16 to 24 weeks
–Prostaglandin F2-alpha
–Prostaglandin E2 suppository
•Cervical dilatation and uterine cramping
Ectopic Pregnancy
Implantation occurs
outside the uterine cavity
ovary
Cervix
Fallopian tube 95%
•Ampullar portion 80% (distal
third)
•Isthmus 12%
•Interstitial 8%
Ectopic Pregnancy
Predisposing Factors:
Obstruction - tubal scarring
fromPID
Smokes
IUD – slows the transport of the
zygote
History of ectopic pregnancy
Ectopic Pregnancy
•Signs and Symptoms:

–Nausea and vomiting
–Positive pregnancy test
–6 to 12 weeks AOG
•rupture of fallopian tube
•Trophoblast cells break
•Tearing and destruction of the
blood vessels
Ectopic Pregnancy
• Sharp, stabbing pain in the
lower abdominal quadrant
• Scant vaginal spotting
The amount of bleeding evident with
a ruptured ectopic pregnancy does
not reveal the actual amount present
Signs of shock:
Lightheadedness
Rapid pulse
•Complications:
–Peritoneal irritation
•Cullen’s sign – bluish discoloration
of the umbilicus
•Excruciating pain upon movement
of cervix on pelvic exam
• Blood from the peritoneal cavity 
irritates the phrenic nerve 
Shoulder pain
•Tender mass palpated in cul-de-sac
Signs and Symptoms of Hypovolemic Shock
• Decreased central venous pressure

• Increased pulse rate
• Heart is attempting to circulate
decreased blood volume
• Decreased blood is returning to
heart due to reduced blood volume
• Less peripheral resistance because

of decreased blood volume
• Increased respiratory rate
• Increases gas exchange to better

oxygenate decreased red blood cell
volume
• Cold, clammy skin
• Vasoconstriction occurs to maintain

blood volume in central body core
• Inadequate blood is entering kidney

due to decreased blood volume
• Dizziness or decreased level of

consciousness
• Inadequate blood is reaching the

cerebrum
•Diagnosis:
–Ultrasound
•Treatment:
–Before the rupture:
•Methotrexate
–A folic acid antagonist chemotherapeutic
agent
–Attacks and destroys fast growing cells
•Mifepristone
–An abortifacient
–Slough of the tubal implantation
• Treatment
–Ectopic Pregnancy ruptures:
•Emergency case
Ligate the bleeding vessels

Remove or repair the
damaged fallopian tube
HIGH RISK MOTHER
AND CHILD
NCM 109
SECOND Gestational Abnormal Overgrowth of uterus highly Retained
TRIMESTER trophoblastic proliferation of positive human chorionic trophoblast tissue
disease trophoblast cells, gonadotrophin (hCG) test; no fetus may become
(hydatidiform fertilization or present on ultrasound; bleeding malignant
mole) division defect from vagina of old and fresh blood (choriocarcinoma)
accompanied by cyst formation follow for 6 months
to 1 year with hCG
testing
Premature Cervix begins to Painless bleeding leading to Can have cervical
Cervical Dilatation dilate and expulsion of fetus sutures placed to
pregnancy is lost ensure a second
at about 20 weeks; pregnancy
unknown cause
but cervical
trauma from
dilatation and
curettage (D&C)
maybe associated
Second Trimester Bleeding
HYDATIDIFORM MOLE
•Also called Gestational trophoblastic

disease
•The abnormal proliferation and
degeneration of the trophoblastic villi
(ACOG, 2004)
HYDATIDIFORM MOLE
•As the cells degenerate, they

become filled with fluid and appear
as clear fluid-filled, grape-sized
vesicles
HYDATIDIFORM MOLE
•The embryo fails to develop beyond
a primitive start
•Associated with choriocarcinoma, a
rapidly metastasizing malignancy
•Incidence: 1 in every 1, 500
pregnancies
HYDATIDIFORM MOLE
•Risk Factors
•Women with low protein intake
•Women older than 35 years
•Asian heritage
HYDATIDIFORM MOLE
• Pathophysiology
–Trophoblastic villi cells located in the
outer ring of the blastocyst rapidly
increase in size, begin to deteriorate, and
fill with fluid
–The cells become edematous, appearing
as grapelike clusters of vesicles.
–As a result the embryo fails to develop
past the early stages
HYDATIDIFORM MOLE
TYPES
• Complete mole
-all trophoblastic villi swell and become
cystic
-embryo dies early at 1-2 mm in size
-no fetal blood present
-Karyotype normal, 46XX, 46XY
-an “empty ovum” was fertilized
HYDATIDIFORM MOLE
• Partial Mole
-some of the villi will form normally
-syncytiotrophoblast layer of villi is
swollen and misshapen
-a macerated embryo of approximately
9 weeks gestation may be present
-fetal blood may be present
HYDATIDIFORM MOLE
• Partial Mole
-has 69 chromosomes (a triploid formation
in which there are three chromosomes
instead of two for every pair.
– one set supplied by an ovum that apparently
was fertilized by two sperm
– an ovum fertilized by one sperm in which
meiosis or reduction division did not occur
-rarely lead to choriocarcinoma
HYDATIDIFORM MOLE
ASSESSMENT
• Uterus tends to expand faster than
normally
• Absent fetal heart sound
• Positive pregnancy test (hCG produced
by the throphoblast cells)
• Symptoms of PIH before 20 weeks
gestation
HYDATIDIFORM MOLE
•Sonogram shows dense growth

(typically snowflake pattern) but
no fetal growth in the uterus
•Vaginal spotting of dark-brown
blood or as a profuse fresh flow
HYDATIDIFORM MOLE
THERAPEUTIC MANAGEMENT
•Suction curettage to evacuate the
mole
•Baseline pelvic examination, chest X-
ray, serum test for beta subunit of
HCG after mole extraction
HYDATIDIFORM MOLE
•HCG monitoring:
– every 2 weeks until normal
–Every 4 weeks for 6-12 months,
thereafter
•Gradually declining HCG titers

suggest no complication
HYDATIDIFORM MOLE
• Oral contraceptive for 12 months
• If HCG levels are negative after 6

months,:
–free of malignancy
• By 12 months, second pregnancy can

be planned
Premature Cervical Dilatation

• Incompetent Cervix
–Cervix dilates prematurely approximately 20
weeks AOG
–Cannot hold a fetus until term
• Signs and Symptoms:
–Painless dilatation
–Pink stained vaginal discharge
–Increased pelvic pressure
–Discharge of amniotic fluid
–Uterine contractions
Causes:
Increased maternal age
Congenital structural defects
Trauma to the cervix
Repeated D & C
Assessment
Pink-stained vaginal discharge
Increased pelvic pressure followed
by rupture of membranes and
discharge of amniotic fluid
Uterine contractions and birth of
fetus
Occurs at 20 wks of pregnancy
Therapeutic Management
Cervical cerclage
Done at 12-14 weeks
McDonald or Shirodkar
procedure
Sutures can then be removed
at 37 to 38 weeks AOG or left in
place if CS

CERCLAGE
• Surgical procedure used to treat cervical

insufficiency involving the use of a heavy
suture placed at the internal cervical os
• May be done:
– as an outpatient procedure
–during a short 1- to 2-day hospitalization
–as an emergency procedure requiring
hospitalization for approximately 5 days

CERCLAGE
•Usually performed during:
– late first trimester
–early second trimester
•May be removed:
– at approximately 3 7 weeks' gestation
–kept in place with plans for cesarean
delivery

CERCLAGE
•PURPOSE
•Treatment of cervical insufficiency
• to help keep the cervix closed until
term or until the patient goes into
labor
• for patients who have experienced
previous pregnancy losses
CERCLAGE
PROCEDURE
•The patient receives regional anesthesia.
•The health care provider uses a suture or
band to close the cervix using a vaginal
approach.
CERCLAGE
•In a McDonald
cerclage
– sutures placed
horizontally and
vertically high up on
the cervix to pull it
tightly together.
•In Shirodkar's
procedure
–a submucosal band
applied at the level of
the internal cervical os.
CERCLAGE
• POSTPROCEDURE CARE
• Maintain the patient on bed rest as ordered.
• Assess for evidence of uterine contractions and
rupture of membranes.
• Monitor vital signs, especially temperature.
• Assess for signs and symptoms of infection.
THANK YOU!
HIGH RISK MOTHER
AND CHILD
NCM 109
THIRD Placenta Previa Low implantation of placenta Painless at beginning of cervical Don’t allow vaginal
TRIMES possible because of uterine dilatation examination to
TER abnormality minimize placental
trauma
Premature Unknown caused associated Sharp abdominal pain followed by Disseminated
separation of the with hypertension; placenta uterine tenderness vaginal intravascular
placenta (Abruptio separates from uterus before bleeding; signs of maternal coagulation is
Placenta) the birth of the fetus hypovolemic shock, fetal distress associated with
the condition
Preterm Labor Many possible etiologic factors Show (pink-stained vaginal Preterm labor may
such as trauma, substance discharge) accompanied but not be halted if the
abuse, hypertension of uterine contractions becoming cervix is less than 4
pregnancy or cervicitis; regular and effective cm dilated and the
increased chance in multiple membranes are
gestation, maternal illness intact.
Corticosteroids are
administered to aid
fetal lung maturity.
Third Trimester Bleeding
•Placenta Previa
•Premature Separation of the placenta
(Abruptio Placenta)
•Preterm Labor
•Occurs when
placenta implants
near or over the
cervical os rather
than in the uterine
fundus
Total:
internal os is completely
covered by the placenta
when the cervix is fully
dilated
Marginal:
Low lying – implantation placenta extends to
in the lower rather than the internal os;
in the upper portion of it may extend into the
the uterus os during cervical
dilation in labor
Partial:
when the placenta partially
covers the internal os
• Occurs in 1:200
pregnancies after age 35.
• More common in
multigravidas than in
primigravidas
• Vaginal exams are
prohibited because of the
risk of hemorrhage
• RISK FACTORS
-Uterine scarring
(previous uterine surgery)
-Multiple gestation
-History of placenta previa
-Closely-spaced
pregnancies
-Uterine tumors
Increased maternal age

-Endometritis
- Advanced maternal
age (older than age
35)
- smoking
• SIGNS AND SYMPTOMS

–Painless vaginal bleeding
–intermittent or in gushes
– most commonly occurring in the third trimester (30 weeks AOG)
• Lower uterine segment begins to differentiate from upper segment
• Cervix begins to dilate
• Progressively more
severe bleeding as
delivery nears
• Decreasing urinary
output
• Anxiety and fear
• Malpresentation or high
presenting part
• DIAGNOSTIC TESTS
AND LABS
• Abdominal ultrasound
• If hospitalized,
perform a non-stress
test
• Pelvic examination is
contraindicated
• Therapeutic Nursing
Management
-Assess amount and
character of bleeding
-Monitor vital signs
-Monitor urinary output
-Monitor fetal heart rate
and fetal activity
continuously
Avoid digital exams

-Instruct client to avoid
enemas, douching, or sexual
intercourse
-Provide bed rest if previa
occurs prior to 36 weeks
gestation
-Monitor for continued
bleeding and onset of labor
-Administer IVF replacement
• PHARMACOLOGY
Betamethasone:
• For preterm labor prior to
34 weeks gestation
• to promote fetal lung
maturity if delivery seems
unavoidable
Blood transfusion may

be needed for severe
anemia, chronic
abruptio placenta, or
placenta previa
• COMPLICATIONS
-Hemorrhage
-Fetal distress/demise
related to hypoxia in utero
-Intrauterine growth
retardation (IUGR)
-Cesarean delivery
-Preterm birth
• Abruptio placenta is the

premature separation of only
part or of the entire placenta
from the uterine wall
• Usually occurs in the third
trimester
• Occurs in 10% of all deliveries
• Mild to severe abdominal pain
and uterine rigidity
differentiate it from placenta
previa
•Abruption is a medical
emergency :
– risk of maternal
hemorrhage
–fetal death
–10-30% of clients develop
clotting defects (e.g.
disseminated intravascular
coagulation (DIC)
Should be suspected when there

is sudden onset of intense,
localized uterine pain, with or
without vaginal bleeding
• Hospitalization is nearly always
necessary because the placenta
can separate further at any time
• Vaginal birth is usually feasible
• PATHOPHYSIOLOGY
–The spontaneous rupture of
blood vessels at the placental
bed may be caused by a lack of
resiliency or by abnormal
changes in uterine vasculature.
•Normally 5-7 minutes after

birth of the baby, placenta
separates from the
myometrium.
• If 20 minutes had passed
with no signs of separation
the uterus is atonic.
• Treatment depends on severity of

blood loss and on fetal maturity
and status
–Vaginal bleeding is present in 70-
80%
–concealed (retroplacental
hemorrhage)
•Couvelaire uterus – blood infiltrate the
uterine musculature
–Hard, boardlike uterus with no apparent
bleeding
• Clinical symptoms may vary with

degree of separation:
Grade I (mild)
–mild vaginal bleeding
–mild uterine tenderness
–mild uterine tetany
–10-20% of placental surface is
detached
–neither mother or fetus is in
distress
Grade 2 (moderate)
–Uterine tenderness and
tetany, with or without
external bleeding
–Mother not in shock
–Fetal distress present
–About 20-50% of placental
surface is detached
Grade 3 (severe):
–Severe uterine tetany
–woman in shock (although
bleeding may not be obvious)
–fetus is dead
–Woman often has coagulopathy
–More that 50% of placental
surface is detached
• RISK FACTORS
-External uterine trauma
-Drug abuse during pregnancy,
especially cocaine
-Pregnancy-induced
hypertension
-Previous abruption
-Folic acid deficiency
-Smoking
-Cocaine use
-Premature rupture of
membranes
-Maternal hypertension: most
consistently identified risk factor
-Multifetal pregnancies
-Short umbilical cord
• DIAGNOSTIC TESTS AND LABS

-Hemoglobin
-Hematocrit
-Ultrasound of abdomen
-Blood type and crossmatch
-Coagulation profile
-Sonogram (to rule out placenta
previa)
•SIGNS AND SYMPTOMS

-Dark red vaginal bleeding
-Uterine rigidity
-Sudden onset of severe
abdominal pain
-Uterine contractions
-Fetal distress
• Therapeutic Nursing Management

• Assess :
–amount and character of
bleeding
– degree of abdominal rigidity
– degree of abdominal pain
–fetal activity and heart tones
-Measure fundal height if
concealed bleeding is suspected
Monitor for shock (vital signs,

urine output, physical
assessment)
-Keep the woman on the
lateral position
No vaginal nor pelvic exam nor
enema
-Prepare woman for

possible emergency
cesarean delivery
-Administer blood
transfusion as ordered
If Grade 2 or 3 – termination of pregnancy
Cesarean birth-method of choice
If with DIC- IV fibrinogen or cryoprecipitate
Monitor for infection and shock
• COMPLICATIONS
-Severe compromised fetal well
being
-Fetal demise (frequent if
separation is 50% or greater)
-Maternal disseminated
intravascular coagulopathy (DIC)
-Concealed central placental bleed
-Shock
•Labor that occurs after the twentieth week but

th
before the 37 week of gestation.
•Contractions occur more frequent than every 10
minutes, last 30 seconds or longer, and
persistent (4 every 20 minutes)
•Preterm labor may be associated with infection

•Cause is frequently unknown, but the following

conditions are associated with premature labor:
–Cervical incompetence
–Preeclampsia/eclampsia
–Maternal injury
–Infection – UTI and chorioamnionitis ( infection of
the fetal membranes and fluid)
–Multiple births
–Placental disorders
•Assessment:
–Uterine contractions (painful or painless)
–Abdominal cramping ( may be accompanied by
diarrhea)
–Low back pain
–Pelvic pressure or heaviness
–Change in the character and amount of usual
discharge; may be thicker or thinner, bloody, brown
or colorless and may be odorous.
–Rupture of amniotic membranes
• Interventions: Goal: halt labor

- Focus on stopping the labor: identify and treat
infection, restrict activity and ensure hydration.
–Maintain bed rest and a lateral position
–Monitor fetal status
–Administer fluids
–Administer medications as precribed Tocolytics
(nifedipine, indomethacin, magnesium sulfate,
terbutaline sulfate)
Labor that cannot be halted
Membranes ruptured
Cervix > 50% effaced, 3-4 cm dilated
If very immature fetus: CS
NSD: Caution against analgesic agents
Epidural is preferred
•Prevention:
–Minimize or stop smoking: a major factor in preterm labor
and birth.
–Minimize or stop substance abuse/chemical dependency.
–Early and consistent prenatal care
–Appropriate diet/weight gain
–Minimize psychological stressors.
–Minimize/prevent exposure to infections
–Lear to recognize signs and symptoms of preterm labor
•Therapeutic Management
–medical intervention is to attempt to arrest the
premature labor (tocolysis)
–Unless labor is irreversible:
• a condition exists in which the mother or fetus would be
jeopardized
• the membranes have ruptured
–Medications used in the treatment of premature
labor
•Magnesium Sulfate
•Beta adrenergic drugs – Terbutaline and Ritodrine
•Nifedipine (Procardia)
•Indomethacin
–Betamethasone (Celestone)
•fetal lung maturity.
–It is administered IM
–every 12 hrs times 2
–then weekly until 34 weeks gestation
•Nursing Interventions:
–Keep client at rest, side lying position
–Hydrate the patient and maintain with IV or PO fluids.
–Maintain continuous maternal/fetal monitoring
•Maternal/fetal vital signs every 10 minutes; be alert for abrupt
changes.
•Monitor maternal I and O
•Monitor urine for glucose and ketones.
•Watch cardiac and respiratory status carefully
•Evaluate lab test results carefully
•Nursing Interventions:
–Keep client informed of all progress/changes.
–Identify side effects/complications as early as
possible.
–Carry out activities designed to keep client
comfortable.
rupture of fetal membranes with loss of amniotic
fluid during pregnancy before 37 weeks
5-10% of pregnancies
Cause unknown
Associated with chorioamnionitis
•Spontaneous break or tear in the amniotic sac before
onset of regular contractions, resulting in progressive
cervical dilation.
•PROM: rupture 1 or more hours before the onset of
labor
•Preterm PROM: rupture of the membranes before the
onset of labor in a preterm gestation
•The mother is at risk for chorioamnionitis if the latent
period ( time between rupture of membranes and
onset of labor) is longer than 24 hours.
•Signs of Chorioamnionitis:
–Fetal tachycardia
–Maternal fever
–Foul smelling amniotic fluid
–Uterine tenderness
•Complications of chorioamnionitis:
–Sepsis
–Death
•Risks:
–Fetal infection
–Sepsis
–Perinatal mortality
•Increase risks:
– with every hour of ruptured membranes
– every hour of labor
– every vaginal examination
•Pathophysiology: The exact mechanism of premature
rupture of membranes is unclear.
•Causes:
–Unknown
–Accompanied by malpresentation and a contracted pelvis

•Signs and symptoms:
Sudden gush of clear fluid from the vagina
Differentiate from urinary incontinence
–Maternal fever
–Fetal tachycardia
–Foul smelling vaginal discharge (indicate infection)
–TRansvaginal ultrasonography reveals a rupture or tear of
the amniotic sac
•Treatment:
–In term pregnancy:
•Spontaneous labor and vaginal delivery
•Induction of labor
•Cesarean delivery
–Preterm pregnancy less than 34 weeks:
•Hospitalization and observation for signs of infection while
waiting for fetal maturation.
• If clinical status suggests infection: baseline cultures and
sensitivity test.
• If tests confirm infection:
–Induce labor
–IV administration of antibiotic
–Temperature monitoring every 2 hours.
• Culture of gastric aspirate or a swabbing from the neonate’s
ear to determine the need for antibiotic therapy.
THANK YOU!
HIGH RISK MOTHER
AND CHILD
NCM 109
Sofia Magdalena N. Robles, PhDNEd, RN

GESTATIONAL HYPERTENSION
A condition in which vasospasm occurs in both small

and large arteries during pregnancy causing increased
blood pressure.
defined as having a blood pressure higher than 140/90

measured on two separate occasions, more than 6 hours
apart, without the presence of protein in the urine and
diagnosed after 20 weeks of gestation.
Pre eclampsia affects all organs
Vascular spasm – increase cardiac output required by
pregnancy which injures endothelial cells and arteries that
reduce action of prostacyclin , a prostaglandin vasodilator
and excess production of thromboxane – a prostaglandin
vasodilator
Usually during pregnancy blood vessels are resistant to the
effects of pressor substances such as angiotensin and
norepinephrine , so even there is increase blood supply,
blood pressure remains normal
But in gestational hypertension-----reduce

responsiveness to blood pressure changes
appears to be lost because of the
prostalaglandin is released.
Vasoconstriction occurs and BP increases
dramatically.
Heart – is forced to pump against rising of
perepheral resistance-----Reduce blood supply
to organs (kidney, pancreas, liver, brain and
placenta.
Poor Placenta perfusion- reduce fetal

nutrient and blood supply .
Ischemia in pancreas---result in
epigastric
pain and elevated amylase creatinine
ratio.
Spasm in retina – retinal hemorrhage
andeven blindness
Vasospasm in kidney –increase blood flow

resistance---degenerative changes in the glomeruli
because of back pressure----increase permeability
of glomeruli membrane---allowing serum protein
albumin to escapr in urine (proteinuria)
Degenerative change – decreased glomeruli
filtration ---lowered urine output and clearance of
creatinine
Increase kidney tubular reabsorption – retention of
sodium begins- as sodium retains in the fluid –
Edema occurs
Exteme edema – lead to maternal cerebrala nd
pulmonary edema and seizure (Eclampsia)
Arterial spasm – causes bulk of the blood

volume in the maternal circulation to be
pooled in venous circulation -----low
arterial intravascular volume
Thrombocytopenia or a lowered platelet
counts occur----could damage endothelial
cells
Monitor hct –the higher the hct, the higher
is lost.
Normal proteinuria level . normal 24-hour excretion of

urine albumin is less than 30 mg. Usually,
microalbuminuria is defined as greater than 20 μg/min
(or 30 mg/24 h) and less than 200 μg/min (or 300
mg/24 h).
CAUSES OF GESTATIONAL HYPERTENSION
1. Pre-existing hypertension (high blood pressure)
2. Kidney disease.
3. Diabetes.
4. Hypertension with a previous pregnancy.
5. Mother's age younger than 20 or older than 40.
6. Multiple fetuses (twins, triplets) (multiple pregnancy)
7. African-American race.
8. Low socio economic group (poor nutrition)
9.Polyhydramnios (overproduction of amniotic fluid)
SIGNS/symptoms GESTATIONAL HYPERTENSION
 Headache that doesn't go away.

 Edema (swelling)
 Sudden weight gain.
 Vision changes, such as blurred or double vision.
 Nausea or vomiting.
 Pain in the upper right side of your belly, or pain around your
stomach.
 Making small amounts of urine.
SYMPTOMS OF GESTATIONAL HYPERTENSION
HYPERTENSION TYPE SYMPTOMS
Blood pressure is 140/90 mmHg or

GESTATIONAL HYPERTENSION systolic pressure elevated 30 mmHg
or diastolic pressure elevated 15
mmHg above prepregnancy level; no
protein-uria or edema; blood pressure
returns to normal after birth.
Blood pressure is 140/90 mmHg or systolic

pressure elevated 30 mmHg or diastolic
PREECLAMPSIA WITHOUT SEVERE pressure elevated elevated 15 mmHg
FEATURES above prepregnancy level; proteinuria of 1+
to 2+ on a random sample; weight gain
over 2 lb/week in second trimester and 1
lb/week in third trimester; mild edema in
upper extrememities or face.
Blood pressure is 160/110 mmHg; proteinuria

3+ to 4+ on a random sample and 5 g on a 24-
hour sample; oliguria (500 mL or less in 24
PREECLAMPSIA WITH SEVERE FEATURES hours or altered renal function tests; elevated
serum creatinine more than 1.2 mg/dl);
cerebral or visual disturbances (headache,
blurred vision); pulmonary or cardiac
involvement; extensive peripheral edema;
hepatic dysfunction; thrombocytopenia;
epigastric pain.
Either seizure or coma accompanied

ECLAMPSIA by signs and symptoms of
preeclampsia are present.
PRE ECLAMPSIA
Is a pregnancy related disease process evidenced by

increased blood pressure and proteinuria,
Toxemia of pregnancy – older term
Pre-eclampsia is a condition that affects some pregnant women
usually during the second half of pregnancy (from around 20
weeks) or immediately after delivery of their baby. Women
with pre-eclampsia have high blood pressure, fluid retention
(edema) and protein in the urine (proteinuria).
Nursing Intervention for PRE ECLAMPSIA without severe
features
1. Monitor antiplatelet therapy – due to increase

tendency of platelets to cluster along arterial walls,
such as low dose aspirin , it will prevent or delay
pre eclampsia
2. Promote bed rest
3. Promote good nutrition
4. Promote emotional support
Nursing Intervention for PRE ECLAMPSIA with severe
features
1. Support bed rest
2. Monitor maternal well being (BP q 4, lab, daily
weighing
3. monitor fetal well being
4. Support a nutritious intake
5. Administer medication to prevent eclampsia
(hypotensive drugs: apresoline or hydralazine,
betalol, nifidifine and
Magseium So4-drug of choice for eclampsia
Ca gluconate – Antidote for magnesium toxicity
ECLAMPSIA
It is the most severe classification of pregnancy-related hypertensive

disorders. A woman has passed into this stage when cerebral edema is so
acute a grand mal (tonic-clonic) seizure or coma has occurred. With
eclampsia, the maternal mortality can be as high as 20% from causes such as
cerebral hemorrhage, circulatory collapse, or renal failure.
(Gongora & Wenger, 2015)
The fetal prognosis with eclampsia is also poor because of
hypoxia, possibly caused by the seizure, with consequent fetal
acidosis.
If premature separation of the placenta from extreme
vasospasm occurs, the fetal prognosis becomes even graver. If
a fetus must be born before term, all the risks of immaturity will
be faced.
DRUGS USED IN PREECLAMPSIA
DRUG INDICATION DOSAGE COMMENTS
Infuse loading dose slowly over 15-30

minutes.
Always administer as a piggyback

Loading dose 4-6 infusion.
Magnesium Muscle relaxant; g
prevents seizures Assess respiratory rate, urine output,
sulfate Maintenance
deep tendon reflexes, and clonus evry
hour.
dose 1-2 g/hr IV
Urine output should be over 30 ml/hr and
respiratory rate over 12 breaths/min.
Serum magnesium level should remain
below 7.5 mEq/l.
Observe for central nervous system

(CNS) depression and hypotonia in infant
at birth and calcium deficit in the mother.
Hydralazine Antihypertensive
(Apresoline) 5-10 mg IV Administer slowly to avoid sudden fall in
(peripheral vasolidator);
used to decrease blood pressure.
hypertension
Maintain diastolic pressure over 90
mmHg to ensure adequate placental
filling.
Diazepam (Valium) Administer slowly. Dose may be

Halt seizures 5-10 mg IV separated q 5-10 minutes
(up to 30 mg/hr).
Calcium gluconate Antidote for magnesium Have prepared at bedside as the antidote
intoxication 1 g IV (10 ml of a 10% when administering magnesium sulfate.
solution)
Administer at 5 ml/min.
HELLP SYNDROME
HELLP syndrome – is a variation of the gestational hypertensive
process named for the common symptoms that occur:
• Hemolysis leads to anemia

• Elevated liver enzymes lead to epigastric pain
• Low platelets lead to abnormal bleeding/clotting (Pourrat, Coudroy,
& Pierre, 2015)
The syndrome occurs 4% to 12% of patients who have elevated blood

pressure during pregnancy. It is a serious syndrome because it results in
a maternal morality rate as high as 24% and an infant mortality rate as
high as 35%.
HELLP SYNDROME
HELLP syndrome is a complication of pregnancy

characterized by hemolysis, elevated liver enzymes, and a
low platelet count. It usually begins during the last three
months of pregnancy or shortly after
The cause of HELLP syndrome is unknown, but there are

certain factors that may increase your risk of developing it.
Preeclampsia is the greatest risk factor. This condition is
marked by high blood pressure, and it typically occurs
during the last trimester of pregnancy.
HELLP SYNDROME
Pregnant women developing HELLP syndrome

have reported experiencing one or more of
these symptoms:
Headache.
Nausea/vomiting/indigestion with pain after eating.
Abdominal or chest tenderness and upper right
upper side pain (from liver distention)
Shoulder pain or pain when breathing deeply.
Bleeding.
Changes in vision.
CAUSES of HELLP SYNDROME
Unknown but there are certain factors that may increase your risk of
developing it.
Preeclampsia is the greatest risk factor. This condition is marked by high
blood pressure, and it typically occurs during the last trimester of
pregnancy.
HELLP SYNDROME
Though the cause of HELLP is not yet fully
understood, it can lead to lung and heart
failure, permanent liver and kidney damage, internal
bleeding, stroke, and other serious complications in
the mother.
Other serious complications for the fetus include
intrauterine growth restriction and respiratory
distress syndrome.
MULTIPLE PREGNANCY
MULTIPLE PREGNANCY- is considered a

complication of pregnancy because a woman’s body
must adjust the effects of more than one fetus. The
incidence of multiple births has increased
dramatically because of the use of in vitro
fertilization, but still only occurs in 2% to 3% of all
births (Bush & Pernoll, 2012).
MULTIPLE PREGNANCY
MULTIPLE PREGNANCY- usually referred to as

multiple gestation, is one in which more than one
fetus develops simultaneously in the mother's womb.
MULTIPLE PREGNANCY
The frequency of multiple births in the United States has been steadily
increasing with advances in reproductive technologies. It is estimated that
pregnancies resulting from assisted technologies have a 25–30 percent
incidence of twins and a 5 percent incidence of triplets. The frequency of
naturally occurring twins is approximately one in 80 births; however the
frequency of multiple births in the United States for 2002 was as follows:
twins, one in 32
triplets, one in 583
quadruplets, one in 9,267
quintuplets and up, one in 58,286
Read more: http://www.healthofchildren.com/M/Multiple-Pregnancy.html#ixzz6C7pAnh30

MULTIPLE PREGNANCY
two types of twin pregnancy:

1. fraternal
2. identical
 Read more: http://www.healthofchildren.com/M/Multiple-Pregnancy.html#ixzz6C7qUk03A
MULTIPLE PREGNANCY
Fraternal twins develop from two separate ova released at the same
time and fertilized by two separate sperm.
Fraternal twins are referred to as dizygotic twins, meaning that two
unions of two gametes or male/female sex cells occurred to produce
two separate embryos.
Characteristics:
each has its own placenta and amniotic sac.
may be the same or different sex,
occur twice as frequently as identical twins,
and have a mortality rate of 11.5 percent.
Read more: http://www.healthofchildren.com/M/Multiple-Pregnancy.html#ixzz6C7qUk03A

MULTIPLE PREGNANCY
Identical twins will have the same DNA, genetic material

(genotype), but it may be expressed differently (phenotype).
Three ways identical twins can exist in the uterus:
1. dichorionic-diamniotic twins;
2. monochorionic-diamniotic twins;
3. monochorionic-monoamniotic twins.
MULTIPLE PREGNANCY
dichorionic-diamniotic twins -- division of the

fertilized egg occurs within 72 hours past fertilization, before
the inner cell mass has developed.
About 30 percent of identical twins have this classification, and
each twin has its own chorion, amnion, and placenta.
Mortality is 9%
MULTIPLE PREGNANCY
2. monochorionic-diamniotic twins, division occurs in the

range of four to eight days after fertilization, and the inner cell mass divides
in two.
placenta has one chorion and two amnions, so each twin has its own
amniotic sac.
Approximately 68 percent of identical twins are in this classification, and
they have a mortality rate of 25 percent.
MULTIPLE PREGNANCY
3. monochorionic-monoamniotic twins
contained in the same amniotic sac.
The division of the fertilized egg .
in this case occurs nine to 13 days past fertilization or near the time
of implantation in the uterus.
Since they share an amniotic sac, they have an increased risk of
their umbilical cords becoming entangled or knotted.
Only 2 percent of identical twins are in this classification, and they have a mortality
rate of greater than 50 percent.
MULTIPLE PREGNANCY
If a complete separation does not take place

during the division process, the result is
Siamese (or conjoined) twins.
Conjoined twins also known as Siamese twins are identical twinsjoined in utero. An
extremely rare phenomenon, the occurrence is estimated to range from 1 in 49,000 births to
1 in 189,000 births, with a somewhat higher incidence in Southwest Asia and Africa.
Read more: http://www.healthofchildren.com/M/Multiple-Pregnancy.html#ixzz6C7vhQE2S

MULTIPLE PREGNANCY
Only 2 percent of identical twins are in this

classification, and they have a mortality rate
of greater than 50 percent.
If a complete separation does not take place

during the division process, the result is
Siamese (or conjoined) twins.
Read more: http://www.healthofchildren.com/M/Multiple-Pregnancy.html#ixzz6C7vhQE2S
POLYHYDRAMNIOS
Polyhydramnios is a medical condition describing an

excess of amniotic fluid in the amniotic sac. It is seen in
about 1% of pregnancies. It is typically diagnosed when
the amniotic fluid index (AFI) is greater than 24 cm.
Usually, the aminiotic fluid volume at term is 500 to 1,000 ml.

Polyhydramnios occurs when there is excess fluid of more than
2,000 ml or an aminiotic fluid index above 24 cm
(Weigand, Beamon, Chescheir, et al., 2016).
POLYHYDRAMNIOS
Women with polyhydramnios may experience:
 premature contractions,
longer labor,
difficulties breathing, and
other problems during delivery.
The condition can also cause complications for
the fetus, including anatomical problems,
malposition, and, in severe cases, death.
Common Causes of POLYHYDRAMNIOS
• gestational diabetes,
• fetal anomalies with disturbed fetal
swallowing of amniotic fluid,
• fetal infections and other, rarer causes.
The diagnosis is obtained by ultrasound.

POLYHYDRAMNIOS
Treatment may include:
.
Drainage of excess amniotic fluid from uterus
Amniocentesis - the sampling of amniotic fluid using a hollow needle
inserted into the uterus, to screen for developmental abnormalities in a fetus.
Indomethacin (Indocin) Medication----may prescribe

orally to help reduce fetal urine production and
amniotic fluid volume.
POLYHYDRAMNIOS
Treatment may include:

Indomethacin is an appropriate first-line tocolytic for the
pregnant patient in early preterm labor (< 30 wk) or
preterm labor associated with polyhydramnios.
The fetal renal effects of indomethacin may be

beneficial to reduce polyhydramnios.
POLYHYDRAMNIOS
.
POLYHYDRAMNIOS
.
OLIGOHYDRAMNIOS
Oligohydramnios refers to a pregnancy with less than

the average amount of aminiotic fluid (Kumar, 2012).
Because part of the volume of aminiotic fluid is

formed by the addition of fetal urine, this reduced
amount of fluid is usually caused by a bladder or
renal disorder in the fetus that is interfering with
voiding.
OLIGOHYDRAMNIOS
Low amniotic fluid (oligohydramnios) is a condition in

which the amniotic fluid measures lower than expected
for a baby's gestational age.
No treatment has been proved effective long term. But

short-term improvement of amniotic fluid is possible and
might be done in certain circumstances.
OLIGOHYDRAMNIOS
Oligohydramnios refers to amniotic fluid volume that is less

than
expected for gestational age. It is typically diagnosed
by ultrasound examination and may be described qualitatively
(eg,
normal, reduced) or quantitatively (eg, amniotic fluid index

[AFI] ≤5)
AFI between 8-18 is considered normal..

OLIGOHYDRAMNIOS
During pregnancy, amniotic fluid provides a cushion that

protects the baby from injury and allows room for growth,
movement and development.
Amniotic fluid also keeps the umbilical cord from being

compressed between the baby and the uterine wall.
In addition, the amount of amniotic fluid reflects the

baby's urine output — a measure of a baby's well-being.
Causes of OLIGOHYDRAMNIOS
Bag of water is breaking

The placenta peeling away from the inner wall of the uterus —
either partially or completely — before delivery (placental
abruption)
Certain health conditions in the mother, such as chronic high
blood pressure
Use of certain medications, such as angiotensin-converting
enzyme (ACE) inhibitors
Certain health conditions in the baby, such as restricted growth
or a genetic disorder
Treatment for OLIGOHYDRAMNIOS
36 to 37 weeks pregnant ------- the safest treatment might be
delivery.
less than 36 weeks pregnant-------monitoring your pregnancy with
fetal ultrasounds.
might recommend drinking more fluids — especially if you're
dehydrated.
If you have low amniotic fluid during labor, - amnioinfusion , a

procedure in which fluid is placed in the amniotic sac , done during
labor if there are fetal heart rate abnormalities.
Amnioinfusion is done by introducing saline into the amniotic sac
through a catheter placed in the cervix during labor.
Causes of OLIGOHYDRAMNIOS
 Bag of water is breaking

 The placenta peeling away from the inner wall of the uterus —
either partially or completely — before delivery (placental
abruption)
 Certain health conditions in the mother, such as chronic high
blood pressure
 Use of certain medications, such as angiotensin-converting
enzyme (ACE) inhibitors
 Certain health conditions in the baby, such as restricted
growth or a genetic disorder
Isoimmunization (Rh Incompatibility)
Isoimmunization is a condition where a mother

with Rh-negative blood is pregnant with a baby that
has Rh-positive blood. This can cause a problem if the
baby's blood enters the mother's blood flow. The Rh-
positive blood from the baby will make the mother's body
create antibodies.
Rh incompatibility, also known as Rh disease, is a condition

that occurs when a woman with Rh-negative blood type is
exposed to Rh-positive blood cells, leading to the development
of Rh antibodies. ...
Rh incompatibility can also occur when an Rh-negative
female receives an Rh-positive blood transfusion.
How is placenta affected by Rh Incompatibility
During pregnancy, red blood cells from the unborn baby can
cross into the mother's blood through the placenta.
If the mother is Rh-negative, her immune system treats Rh-
positive fetal cells as if they were a foreign substance.
The mother's body makes antibodies against the fetal blood
cells.
ISOIMMUNIZATION
Rh Incompatibility in Pregnancy. Rh
incompatibility occurs when a pregnant
woman whose blood type is Rh-negative is
exposed to Rh-positive blood from her fetus,
leading to the mother's development of
Rh antibodies. ... This causes the
fetus to become anemic, which can
lead to hemolytic disease of the newborn.
ISOIMMUNIZATION
Coombs' Test. - used to detect antibodies that act against

the surface of your red blood cells. The presence of these
antibodies indicates a condition known as hemolytic anemia,
in which your blood does not contain enough red blood
cells because they are destroyed prematurely.
Coombs test – A positive result means the blood has

antibodies that fight against RBC. This can caused by a
blood transfusion of incompatible blood or baby with
with RH positive blood and may result to heymolytic
disease of a Newborn (HDN)
A condition in which vasospasm occurs in both small

and large arteries during pregnancy causing increased
blood pressure.
defined as having a blood pressure higher than 140/90

measured on two separate occasions, more than 6 hours
apart, without the presence of protein in the urine and
diagnosed after 20 weeks of gestation.
ISOIMMUNIZATION
WHAT IS THE TREATMENT FOR RH
INCOMPATIBILITY
Rh incompatibility is treated with a

medicine called Rh immune
globulin. Treatment for a baby who has
hemolytic anemia will vary based on the
severity of the condition.
HIGH RISK MOTHER
AND CHILD
NCM 109
Sofia Magdalena N. Robles, PhDNEd, RN

2/6/23, 11:42 AM Lesson 3: Pre-existing or Newly Acquired Disease: Care of Mother, Child, at-risk or with Problems- NCM 109 (306 hours RLE)-JL…
Lesson 3: Pre-existing or Newly

Acquired Disease
When a woman enters pregnancy with a chronic condition or a newly acquired

disease, both she and the fetus can be at risk for complications because either the
pregnancy can complicate the disease or the disease can complicate the pregnancy.
This lesson about Pre-existing or Newly Acquired Disease on a pregnant mother

gives an idea that risks for the child may include miscarriage, growth restriction,
growth acceleration and birth defects.
https://ceu.instructure.com/courses/26429/pages/lesson-3-pre-existing-or-newly-acquired-disease?module_item_id=1966126 1/2
2/6/23, 11:42 AM Lesson 3.1 Preexisting or Newly Acquired Illness(Pregnant Mother with Asthma & Diabetes Mellitus): Care of Mother, Child, at-risk…
Lesson 3.1 Preexisting or Newly

Acquired Illness(Pregnant Mother with
Asthma & Diabetes Mellitus)
Respiratory diseases range from mild (common cold) to

severe (pneumonia) to chronic (tuberculosis). Any respiratory
condition can worsen in pregnancy because the rising uterus
compresses the diaphragm, reducing the size of the thoracic
cavity and available lung space.
Any respiratory disorder can pose serious hazards to the

fetus if allowed to progress to the point where the mothers
oxygen-carbon dioxide exchange is altered or the mother or
fetus can not receive enough oxygen.
Diseases of the endocrine system are relatively

common. An endocrine system
disease usually involves the secretion of too much or

not enough of a hormone. When too much hormone is
secreted, the condition
is called hypersecretion. When not enough hormone

is secreted, the condition is called hyposecretion. The most common endocrine
disease is diabetes (https://medlineplus.gov/diabetes.html) . There are many others.
They are usually treated by controlling how much hormone your body makes.
Hormone supplements can help if the problem is too little of a hormone.
https://ceu.instructure.com/courses/26429/pages/lesson-3-dot-1-preexisting-or-newly-acquired-illness-pregnant-mother-with-asthma-and-diabetes-mell… 1/2
2/6/23, 11:42 AM Lesson 3.1 Preexisting or Newly Acquired Illness(Pregnant Mother with Asthma & Diabetes Mellitus): Care of Mother, Child, at-risk…
To further understand the concept of these illnesses please click below:
NCM 109 High RIsk- ASTHMA-1.pptx (https://ceu.instructure.com/courses/26429/files/8834164?

wrap=1) (https://ceu.instructure.com/courses/26429/files/8834164/download?download_frd=1)
NCM 109 High Risk- DIABETES MELLITUS.pptx

(https://ceu.instructure.com/courses/26429/files/8834063?wrap=1)
(https://ceu.instructure.com/courses/26429/files/8834063/download?
download_frd=1)
https://ceu.instructure.com/courses/26429/pages/lesson-3-dot-1-preexisting-or-newly-acquired-illness-pregnant-mother-with-asthma-and-diabetes-mell… 2/2
Pre Existing or
Newly Acquired
Illness
PRESENTATION TITLE LINE
RESPIRATORY DISORDER
ASTHMA
Symptoms are often triggered by an irritant
It is a disorder marked by airflow
(e.g. an inhaled allergen such as pollen or
Icon obstruction, airway hyperactivity Icon smoke)
and airway inflammation. It
complicates about 1% of With inhalation of the allergen, there is an
pregnancies and associated with immediate release of bioactive mediators such
increased risk of perinatal as histamine and leukotrienes from an
complications. IgE/immunoglobulin interactions which results
Icon Icon
in constriction of the bronchial smooth muscle
marked mucosal inflammation and swelling an
the production of thick bronchial secretion.
ASTHMA
These processes caused a The inhaled corticosteroids Beclomethazone
Icon marked reduction in the size of Icon (Beclovent), Vancenase) and Budesonide
the lumen of air passages. This (Pulmicort, Rhinocort) are commonly used by
causes difficulty pulling in air, on women with persistent asthma and are the best
exhalation that has so much choice for pregnant women and those who
difficulty releasing air that makes
might become pregnant.
a high-pitched whistling sound
Icon (bronchial wheezing) from air Icon
.
being pushed past the bronchial
narrowing.
Image or icon Image or icon
Image or icon Image or icon

Nursing
Diagnosis Image or icon Image or icon Image or icon
and
Related
Interventions
Family Icon
Teaching
Icon
Icon
Icon
Family Icon
Teaching
Icon
Icon
Icon
HAVE A NICE DAY!

Pre Existing or
Newly Acquired
Illness
ENDOCRINE DISORDER
Diseases of the endocrine system are relatively common.
An endocrine system disease usually involves the secretion of
too much or not enough of a hormone. When too much hormone
is secreted, the condition is called hypersecretion. When not
enough hormone is secreted, the condition is called
hyposecretion. The most common endocrine disease
is diabetes. There are many others. They are usually treated by
controlling how much hormone your body makes. Hormone
supplements can help if the problem is too little of a hormone.
Icon
DIABETES DURING
PREGNANCY
DIABETES MELLITUS Placental insulinase may cause increased

breakdown of degradation of insulin. This
Glomerular filtration of glucose is increased resistance to or destruction of insulin is
Icon (the glomerular excretion threshold is Icon helpful in a normal pregnancy because it
lowered), causing slight glycosuria. prevents the blood glucose from falling to
dangerous limits, despite the increased
The rate of insulin secretion is increased, Insulin secretion that occurs. It causes
Icon Icon difficulty for a diabetic pregnant woman in
and the fasting blood sugar is lowered. All that she must increase her insulin dosage
women appear to develop insulin resistance Beginning at about week 24 of pregnancy
as pregnancy progresses to prevent hyperglycemia.
A Woman with
Gestational Diabetes
Image
A Woman with
It is unknown whether gestational diabetes results from
inadequate insulin response to carbohydrate or from
excessive resistance to insulin: a combination of both
may occur. Risk factors for gestational diabetes
include: Image
 Obesity
Age over 25 years
History of large babies
History of unexplained fetal or perinatal loss
History of congenital anomalies in previous
pregnancies
Family history of diabetes ( one close relative or two
distant one)
Member of a population with high risk for diabetes
Classification Icon
of Diabetes
Mellitus Icon
Icon
Icon
Classification Icon
of Diabetes
Mellitus Icon
Icon
Icon
Classification
of Diabetes
Mellitus
Classification
of Diabetes Image or icon Image or icon
Mellitus
Assessment of
Image
Assessment of
Image
Oral Glucose Challenge
Test Values for Pregnancy
Image
Monitoring a
Woman with Image or icon
Diabetes
glycosylated hemoglobin
Opthalmic examination
urine culture
Nursing
Diagnosis
and Related
Interventions Image or icon
Ima
Education
Regarding
Nutrition
During Image or icon
Pregnancy
Ima
A PLEASANT DAY
AHEAD OF YOU!
2/6/23, 11:50 AM Lesson 3.2 Pre Existing Disease (Pregnant Mother with Anemia & Cardio Vascular Disease): Care of Mother, Child, at-risk or with …
Lesson 3.2 Pre Existing Disease

(Pregnant Mother with Anemia & Cardio
Vascular Disease)
Anemia in Pregnancy
Anemia in Pregnancy
During pregnancy, a woman may develop a slight expansion in the blood volume than the normal
RBC count as the body prepares for catering to the growing fetus inside the mother’s womb. It is
called pseudoanemia of early pregnancy- which is part of the normal changes in the woman’s body.
True anemia, however, occurs as a complication of pregnancy.
According to Anderson & Anderson (1990), it can be classified as pathologic or physiologic. It can be
considered as pathologic if it is because of a disorder in the production of erythrocytes or is there is
excessive loss of erythrocytes due to bleeding or destructions. Meanwhile, it can be a physiologic
type of anemia in pregnancy if the decline in production is due to hemodilution or when the plasma
volume expands more than the RBC volume.
TYPES of Anemia
1. Iron deficiency anemia - most common one, which can be simply described as a condition which
is presented with a decrease in hemoglobin and oxygen transport. Its etiology may vary but maybe
sometimes due to an anemic state, heavy menstrual periods, and poor nutritional intake prior to
pregnancy. It can be suspected when the hemoglobin level is below 11 mg/dl. Furthermore, it is
characterized by a small-sized RBC and a reduced hemoglobin level than the average cell count.
The mean corpuscular volume and the mean corpuscular hemoglobin are both observed to be low in
this type of anemia. Thus, it is associated with low birth weight and premature delivery.
https://ceu.instructure.com/courses/26429/pages/lesson-3-dot-2-pre-existing-disease-pregnant-mother-with-anemia-and-cardio-vascular-disease?mod… 1/5
2. Megaloblastic anemia or folic acid deficiency is defined as a disorder in the RBC production in
which the red cells fail to divide and become enlarged. Folic acid is very important in the synthesis of
nucleic acid which is also required for the production of red blood cells. During pregnancy, a woman
needed more folic acid than ever before. He MCV is, however, elevated compared to Iron deficiency
anemia. Its complications may correspond to adverse defects in fetal development and also for early
abortion and abruption placenta.
3. Sickle cell anemia. It is caused primarily of the Hemoglobin S causing other red blood cells to
sickle or follows a crescent shape. Thus, it is considered as an autosomal recessive disorder. It does
not influence the pregnancy itself but a woman with a sickle disease, pregnancy is considered the
complication. The threat is directed to the growth and well being of the fetus since this disease
usually results in clumping (due to increased tension to the cells) which in return causes some veno-
occlusive crisis. The blockage in blood vessels especially to the placental circulation could lead to
fetal compromise and worse to death.
Nursing considerations in general for pregnant clients with anemia include:
Assessment of nutritional intake and status

Assess for fatigue, pallor, sore tongue, anorexia, nausea and vomiting, stomatitis, some signs of
infection, and severe pain (due to veno- occlusive crisis
Observe and monitor hematologic laboratory results
Encourage the client to eat foods high in iron and folic acids like green leafy vegetables, fish,
meat, poultry, eggs, and legumes.
Teach how to prepare food in order to minimize the loss of iron and folic acid (steaming with small
amount of water)
Encourage to take foods high in Vitamin C (https://rnspeak.com/vitamin-c-drug-study/) for iron
absorption
Emphasize diet high in fiber and fluids to avoid constipation (a side effect of iron intake)
Emphasize also good hygiene to avoid urinary tract infection
Also instruct the client to avoid people with infection, as they may be prone to acquire the
infection, too.
Teach the client to watch out for signs of preterm labor
Observe and monitor the fetal well being
Allow the client to rest as much as possible and provide emotional support
For further readings you may click the link provided:
Anemia in Pregnancy (https://www.youtube.com/watch?v=PYr6TE9JACE)
Women with heart disease – the leading cause of death during pregnancy – should be closely cared
for by a specialized team during pregnancy, according to a new report from the American Heart
Association.
Women with preexisting cardiovascular conditions, such as chronic high blood pressure, heart
disease and high cholesterol, would benefit from careful monitoring and counseling, from
preconception until post-childbirth, the scientific statement says. Doctors may choose to prescribe
regular exercise, medications or other strategies.
"Cardiovascular diseases are the leading cause of pregnancy-related death and are increasing,
possibly because women are having babies at older ages and are more likely to have preexisting
heart disease or heart disease risk factors," Dr. Laxmi Mehta, chair of the group that wrote the
statement, said in a news release. Mehta is a professor of medicine and director of preventive
cardiology and women's cardiovascular health at The Ohio State University Wexner Medical Center
in Columbus, Ohio.
"For each of these cardiac conditions, pregnancy can impact treatment as there are limitations in
medication management and invasive procedures given the potential fetal risks."
Between 1987 and 2015, pregnancy-related deaths rose from 7.2 to 17.2 deaths per 100,000 live
births in the United States, according to the statement published Monday in the American Heart
Association's journal Circulation. It highlights several potential dangers for women with heart issues
that could be helped with the correct treatment.
For example, pregnant women with the high blood pressure disorder called preeclampsia have a
71% greater risk of dying from heart disease or stroke over their lifetime. The statement reports that
several studies have linked regular exercise during pregnancy to preeclampsia prevention.
Other conditions may require pharmaceutical intervention. Pregnant women with valvular heart
disease, which increases the risk of a clot-caused ischemic stroke, could benefit from medications
after the first trimester to reduce clotting, the statement says.
Heart rhythm disorders could be treated with medication or surgery if they are severe enough. Data
show these disorders are on the rise, potentially because women are having babies later in life.
Older mothers should take extra precautions, the statement says. Advanced maternal age – defined
as 35 or older – is associated with a higher risk of premature birth, chronic hypertension,
preeclampsia and gestational diabetes.
The statement recommends women with the preexisting cardiovascular disease be cared for by a
cardio-obstetrics team that includes an obstetrician, cardiologist, anesthesiologist, maternal-fetal
medicine specialist, and nurses.
While medications may help some patients, all expectant mothers should recognize the importance
of healthy habits, Mehta said.
"The role of a healthy lifestyle during pregnancy – whether or not a woman has a cardiovascular
condition – cannot be emphasized enough," she said. "Healthy diet, moderate exercise including
walking, smoking cessation and other healthy behaviors are important tools for a healthy pregnancy
for both mother and child." (retrieved from: https://www.heart.org/en/news/2020/05/04/pregnant-

women-with-heart-disease-need-specialized-care
(https://www.heart.org/en/news/2020/05/04/pregnant-women-with-heart-disease-need-specialized-care) )
To understand further please study the PowerPointpresentation Pregnant Mother with Cardio
Problem.pptx (https://ceu.instructure.com/courses/26429/files/8833902?wrap=1)
(https://ceu.instructure.com/courses/26429/files/8833902/download?download_frd=1)
PREGNANT MOTHER WITH
CARDIOVASCULAR
PROBLEM
Dr. Sofia Magdalena N. Robles

CENTRO ESCOLAR UNIVERSITY: FOR INTERNAL CIRCULATION ONLY 2019 February 6, 2023 2
THANK YOU FOR
LISTENING!
Dr. Sofia Magdalena N. Robles
NURSING CARE OF A
PREGNANT FAMILY WITH
SPECIAL NEEDS
JOYLYN L. MEJILLA, MAN, RN
FACULTY
NCM 109
LEARNING OUTCOME
1. Identify the characteristics and the
risks of pregnancy for a pregnant
woman who has special needs
2. Formulate nursing care plan
related to pregnancy for a woman
with special needs
THE PREGNANT ADOLESCENT
REASONS FOR HIGH NUMBER OF
TEENAGE PREGNANCIES
Earlier age of menarche in girls
Rates of sexual activity among
teenagers
Lack of knowledge about ( or failure
to use) contraceptives or abstinence
Desire by young girls to have a baby
DEVELOPMENTAL TASKS
To establish a sense of self-worth or a
value system
To emancipate from parents
To adjust a new body image
To choose a vocation
PRENATAL ASSESSMENT
HIGH RISK PATIENTS BECAUSE OF THE FF:
1. Iron deficiency anemia
2. Premature labor
3. Low birth weights infants
4. Cephalopelvic disproportion
5. Hemorrhoids
6. Conflicting development crises
7. Intimate partner violence
Early and consistent prenatal care is essential to
their health and health of their baby
A primary nursing or case management
approach is effective
Factors contributing to the lack of
prenatal care include:
1. Denial she is pregnant
2. Lack of knowledge of the importance of
prenatal care
3. Dependence on others for transportation
Factors contributing to the lack of
prenatal care include:
4. Feeling awkward in a prenatal
setting
5. Fear of first pelvic examination
6. Difficulty relating to authority figures
HEALTH HISTORY
Take a detailed health history and
best done without a parent present
Be alert to the possibility of
pregnancy when an adolescent
describes symptoms that are vague
and hard to define “ weight gain and
feeling tired all the time”
HEALTH HISTORY
Be certain for press for the
responses needed to allow you to
assess them safely
Ask for the reason for delayed
first prenatal visit
HEALTH HISTORY
Ask the parent separately if there are any
concerns he or she wishes to discuss
If the baby’s father attends prenatal care
- help him to feel welcome
- allow him to offer support in the current
pregnancy
- be sure he receives compassionate
education on preventing further pregnancies until
he is more mature
HEALTH HISTORY
Teach adolescent common
pregnancy symptoms and
reassure her they are part of a
normal pregnancy
HEALTH HISTORY
 Listen for signs of “nest-building”
behavior
Role- playing or simulation may be an
effective technique to help them tell
their parents about the
pregnancy
FAMILY PROFILE
Ask the girl where she is living, the source
of her income, and whom she would call if
she suddenly became ill
Ask about home life may reveal
dysfunctional family or an incest
relationship as the cause of the
pregnancy
Know local and state laws on this topic
and make necessary report
FAMILY PROFILE
Help in making arrangements for the next
few months of her pregnancy and for a
child care afterward
Ask the girl if planning to continue with
school
Get a detailed day history to learn more
about her as a whole person ( nutritional
practices, sleep, daily activities, use of
drugs or alcohol or friends who can
support her throughout this experience
PHYSICAL EXAMINATION
Make the health examination both a
learning experience and relieves anxiety
who tend to be very concerned about body
appearance
Obtain a baseline pressure at the first
prenatal visit
Use doppler technique to obtain FHT and
assess fundal height
.
PHYSICAL EXAMINATION
Check the urine sample for specific
gravity ( water has 1.000 and urine
has 1.003 to 1.030)
Teach adolescent that a healthy
weight gain is important for fetal
growth and this weight can be lost
afterward.
PREGNANCY EDUCATION
They need a great deal of health teaching
during pregnancy
Adolescents may respond to health
teaching that is directed to their own
health more than to that of a fetus
They need instructions about possible
discomforts and changes associated with
pregnancy and measures
Focus on hemorrhoids, striae
gravidarum and chloasma
Suggest cover makeup and offering
reassurance the pigmentation will
fade after pregnancy
NUTRITION
 Lack of nutritional stores is serous
because it can result to preterm births and
low-birth-weight newborns
The girl should have an intake that both
allows for growth of the fetus and her
own growing body
Protein, iron, folic and vitamins A, C and
D are necessary
NUTRITION
They may need to gain more weight than
a mature woman to supply adequate
pregnancy nutrients
Overweight and obese adolescents
should not actively restrict nutrients
during pregnancy , their body maybe
deficient in proteins and vitamins
NUTRITION
Talk to the person who does the
cooking in the family
Need to advice to abandon a food
fad like drinking soda switch to
noncaffeinated soft drinks
Teach how to “ brown bag or buy
nutritious cafeteria lunch
NUTRITION
Need to construct a quick healthy
breakfast and midmorning snacks
such as fruits that also supply
vitamins
Remind to take their vitamin and
iron supplement
ACTIVITY AND REST
Assess participation in sports and
determine which ones such as diving,
gymnastics, or touch football, may need
to discontinued during pregnancy
Suggest an alternative activities such as
joining a drama or language clubs
Planning for enough rest times during
pregnancy without compromising social
relationships
PHYSIOLOGICAL CHANGES
They need substantial education
on the physiological changes that
will occur during pregnancy
They need to know a great deal
more about her body and her
ability to monitor her health
CHILDBIRTH PREPARATION
Peer companionship is a strong
need
Suggest to join a class of other
adolescents in preparation for
childbirth
BIRTH DECISIONS
Pelvic measurements should be
taken early and carefully because
CPD is real because of the girls’
incomplete pelvic growth
Information on cesarean birth must
be scheduled is shared with the girl
and her parents
PLANS FOR THE BABY
Be certain they know all the options
available to them when the baby is
born ( keeping the baby, placing the
baby in a temporary foster home,
adoption)
Encourage to breastfeed
COMPLICATIONS OF PREGNANCY
1. IRON DEFICIENCY ANEMIA
Because their low intake cannot balance
the amount of iron lost with menstrual
flows
Chronic fatigue, pale mucous
membranes, and a hgb level less than
11 g/dl , associated with pica
Must take iron and folic acid supplement
1. IRON DEFICIENCY ANEMIA
Review iron rich foods she needs to eat
daily
Reticulocyte account may be scheduled
after 2 weeks of taking supplemental iron
Taking a stool swab and assessing for
black tinge of an iron supplement or
reassessing her serum iron level
2. Preterm labor
Their uterus is not fully grown
Review the signs of labor by the third
month of pregnancy
Stress labor contractions usually begin as
only a sweeping contractions no more
intense than menstrual cramps
Any vaginal bleeding must be reported
COMPLICATIONS OF LABOR, BORTH,
AND THE POSTPARTUM PERIOD
1. Cephalo Pelvic Disproportion

Suggested by lack of engagement at
the beginning of labor, prolonged first
stage of labor and poor fetal decent
Be certain an adolescent has a
support person with her in labor
COMPLICATIONS OF LABOR, BIRTH,
2. POSTPARTUM HEMORRHAGE
Because a girl’s uterus is not fully
developed, it becomes overdistended by
pregnancy , not likely to contract as
readily, bleeding will occur
May have more frequent and deeper
perineal and cervical lacerations because
of the size of the baby
COMPLICATIONS OF LABOR, BIRTH AND
THE POSTPARTUM PERIOD
3. INABILITY TO ADAPT POSTPARTALLY

Immediate postpartum period
almost an unreal time
Urge her to talk about labor and birth
Prevent postpartum depression
COMPLICATIONS OF LABOR, BIRTH, AND
4. LACK OF KNOWLEDGE ABOUT INFANT
CARE
Spend time with the girl, observing
how she handles her infant
Demonstrate bathing and changing
the baby
Model good parenting behaviors
COMPLICATIONS OF LABOR, BIRTH, AND
4. LACK OF KNOWLEDGE ABOUT
INFANT CARE
Education about the importance of
breastfeeding
Select a feeding method that is
satisfying to them and safe for the
baby
THE PREGNANT WOMAN OVER AGE 40
YEARS
 Developmental task and Pregnancy
Advance maternal age is the label for pregnant

women 35 years and older at delivery
 the developmental challenge is to expand their
awareness or develop GENERATIVITY
This is the moving away form themselves and
becoming involved with the world or community
They will feel ambivalent during the pregnancy
YEARS
Developmental task and
Pregnancy
Help her balance her life and manage two life
phases
They may also be dealing with the issues of
older adults
It may also create extra strain on her finances
and time and it creates “sandwich generation “
Important worries include having enough energy,
arranging for child care , and financial and space
strains
YEARS
PRENATAL ASSESSEMENT : HEALTH
HISTORY
Ask woman to document their symptoms of
pregnancy, how they feel about the pregnancy ,
and how it fits into their lifestyle
Ask if she has been taking any medication or
herbal remedies
YEARS
PRENATAL ASSESSEMENT :FAMILY
PROFILE
Plans to become pregnant immediately
She finds herself making many adjustments at
once ( new life partner, house or apartment and
community and also to a pregnancy )
Identify woman’s source of income
Extra emotional support is needed
YEARS
PRENATAL ASSESSEMENT :DAY
HISTORY
Ask about the type of work or home responsibilities
Estimate the amount of walking or back strain those
entail
Ask about recent diet or exercise programs
 saunas and hot tubs for longer than 10 minutes at
a time is contraindicated because of possible
hyperthermia and teratogenic effects of extreme
heat
Identify personal habits such as cigarette smoking
and alcohol consumption
YEARS
PRENATAL ASSESSEMENT :PHYSICAL
EXAMINATION
She needs a thorough physical examination to
establish her general health specifically
circulatory disturbances
Check for varicosities
Obtain urine specimen and test it for specific
gravity. Glucose, and protein
Assess breast for any abnormalities
Assess carefully for fundal height and fetal
movement at prenatal visits
YEARS
PRENATAL ASSESSEMENT:CHROMOSOMAL
ASSESSMENT
Genetic screening to detect if an open spinal
cord or chromosomal defect could be present
in the fetus
Ultrasound to examine for nuchal
translucency and analysis of maternal serum
levels of alpha-fetoprotein ( MSAFP),
pregnancy associated plasma protein A
( PAPP-A) and free beta human human
chorionic gonadotrophin ( done at 11-13
weeks)
YEARS
PRENATAL ASSESSEMENT:
CHROMOSOMAL ASSESSMENT
Blood test, circulating free DNA testing as early
as 10 weeks
Chorionic villi sampling and amniocentesis , they
asses actual karyotype of the fetus to give a
definite answer
At 15 and 20 weeks MSAFP is repeated to
identify of the fetus is at risk for open neural tube
defects
YEARS
PREGNANCY EDUCATION: NUTRITION
Give tips on how to obtain the same nutrition
whether she prepares her meals at home or eats
them at an office or community function
Substitute a caffeine-free soft drink in place of
an alcoholic beverages
Substitutes milk or juice or decaffeinated
coffee for regular coffee
Increase calcium like puddings or yogurt or
calcium supplements
YEARS
PREGNANCY EDUCATION:PRENATAL
CLASSES
She is interested in joining a childbirth
preparation or prenatal exercise
Offer interventions on how to avoid
complications such as varicosities
Breathing exercises in preparation for labor
How to integrate pregnancy with a full-time work
position and supplying discussion time on how
she is reacting to this dramatic life changes
YEARS
 COMPLICATIONS OF PREGNANCY
1. Gestational hypertension
 Take adequate supply of protein and
obtain adequate rest each day
1. Preterm or post term birth
2. Cesarean birth
• Because the circulatory system may not be as

competent as when she was younger
• Her body tissues may not be as elastic as they were
once
YEARS
COMPLICATIONS OF LABOR, BIRTH AND
Failure to progress in labor
- labor may be prolonged because cervical
dilatation does not seem to occur spontaneously
- graphing labor is a good method
- may need CS
- encourage women to verbalize how she is
feeling and allow for reassurance and prompt
intervention
YEARS
COMPLICATIONS OF LABOR, BIRTH
2. Difficulty accepting the event

-Review plans for child care and
postpartum rest
-Help women learn how to balance their
lives
-Help making child care arrangement
YEARS
COMPLICATIONS OF LABOR, BIRTH
3. Postpartum hemorrhage
- The uterus may not contract as readily
- More prone to perineal-anal tears because her
perineum is less supple, check for amount of
lochial flow or potential perineal bleeding
- Respect for need for independence
THE PREGNANT WOMAN WHO IS PHYSICALLY
OR COGNITIVELY CHALLENGED
Developmental task and Pregnancy
 Women with conditions such as vision, hearing, cognitive,
neurologic , or orthopedic challenges
 Begin with preconception care so medicines they are taking can
be evaluated, careful planning for safe pregnancy can be started
 General areas of care that are important
1. Transportation
2. Pregnancy counselling
3. Support person
4. Health
5. Work
6. Recreations
7. Self-esteem
Rights
Hospital cannot deny care to a person with
disability
She has full rights to her child, so the baby can
not be taken from her at birth without her full
consent
She cannot be forced to terminate a pregnancy
or undergo sterilization unless that is her
informed decision
MODIFICATIONS FOR PREGNANCY
1. Safety measures to explore
2. Emergency contacts
3. Transportation
4. Mobility
5. Elimination
6. Autonomic responses
 PRENATAL CARE MODIFICATIONS TO MEET
SPECIFIC NEEDS
 PE may be modified depending on individual

circumstances for women with disabilities
 Clear instruction is needed for pelvic examination
 Secure a ramp so the wheelchair can be elevated to the
level of the obstetric examining table
 Dorsal recumbent position may be required for pelvic
examination for woman with a spinal cord injury or
cerebral palsy
 If sexually abused, talk and work through this experience
before pelvic examination
 PRENATAL CARE MODIFICATIONS TO MEET
SPECIFIC NEEDS
Resist petting guide dogs of visually challenged

women
For visually challenged women , use demonstration
aids that allow woman to feel or touch instead
Always alert a visually challenged women when you
are going to tough her
For women with hearing impairment, stand by the
head of the table where they can see your lips and
repeat instructions or questions as necessary
 Modify health teaching to meet each woman’s specific
needs
 For a woman who is cognitively challenged , instructions
about pregnancy may need to be given her care provider
 For visually challenged woman, offer the pamphlets to
the support person to read these to the pregnant woman
 Those using assistive technology ( visually challenged
woman) provide material in a audio file
 Nutritional counseling needs to center on foods that can
be prepared without cooking or only microwave warmed
 Activity and rest : Walking around her home or apartment is
suggested
 Childbirth preparation is still valuable
 Practice breathing exercises to control pain in labor
 Emphasized on not smoking or drinking alcohol during
pregnancy
 If they depend on lip reading , be certain she is deciphering new
words such as amniotic, gestation, or edema.
 Show printed words when presenting new pregnancy terms
 Be certain to talk to the woman with hearing challenged , NOT to
the interpreter
 Activity and rest : Walking around her home or apartment is
suggested
 Childbirth preparation is still valuable
 Practice breathing exercises to control pain in labor
 Emphasized on not smoking or drinking alcohol during
pregnancy
 If they depend on lip reading , be certain she is deciphering new
words such as amniotic, gestation, or edema.
 Show printed words when presenting new pregnancy terms
 Be certain to talk to the woman with hearing challenged , NOT to
the interpreter
 MODIFICATIONS FOR LABOR AND BIRTH : FEW
ADAPTATIONS
 1. For woman with spinal cord injury: palpate her
abdomen periodically for tightening or the presence of
contractions so she is aware of beginning labor
 2. Women with spasticity or spinal cord injury: may need
Cesarean birth or forceps birth
 3. Birth from a Sims or dorsal recumbent position is
usually best
 4. visually challenged may need to time the length of
contractions by counting their length rather then timing
them by watch
MODIFICATIONS FOR LABOR AND
BIRTH : FEW ADAPTATIONS
5. Hearing challenged: directly face the client
when giving information; keep her hands
unencumbered by equipment; hand the infant to
her a soon as possible after birth
6. be certain to identify the usual sounds of
birthing rooms for the visually challenged
woman
MODIFICATIONS FOR POST
PARTUM CARE
Whether a woman needs additional support to
be successful at breastfeeding
Return appointment for follow-up care
Whether she desires contraceptive information
and what would be best for her individual
circumstances
MODIFICATIONS FOR PLANNING
CHILD CARE
 Allow ample time during the first days after birth for
mother-child interaction
 For visually challenged : may need extra time to
understand the transition from being pregnant to having
a baby; want to reassure herself that her baby can see
 For spinal cord disability may be interested in inspecting
her baby’s back
 For hearing challenged: point out other features such as
pretty eyes or long to help with bonding if their baby can
hear ( couple who are hearing challenged may not be
pleased )
CHILD CARE
 Breastfeeding has special advantages for women who
are physically or cognitively challenged
 Will need referral for home care follow-up and the use of
home health aide to ensure safe child care
 Encourage what baby equipment will be best for them
 If a woman has difficulty with mobility , ask how she
anticipates carrying her infant
 Urge a visually challenged woman to remember to make
eye contact with newborns ; encourage her to turn the
light after dinner to help develop the vision of her infant
CHILD CARE
 For hearing impaired : help her plan to bring the infant’s
crib or bassinet close to her so she can feel the vibration
of the baby’s stirring and waking
 If the baby can hear, urge her to talk to her infant as she
gives care so the baby is introduced to sounds and
words , will develop speech pattern
 For cognitively challenged : investigate whether a
newborn will receive safe care before hospital discharge
; know if the woman has a responsible friend or partner
to help her with child care
A WOMAN WHO IS SUBSTANCE
DEPENDENT
Definition
 Substance Abuse: inability to meet major role
obligations, an increase in legal problems or risk-taking
behavior, or exposure to hazardous situations because
of an addicting substances
 Substance dependent:
1. when he or she has withdrawal symptoms following
discontinuation of the substance ,
2. with -abandonment of important activities ,
3. spending increased time in activities related to the substance
use
4. substance for a longer time than planned
5. continued use despite worsening problems because of substance
use
DEPENDENT
Definition
Illicit substances tend to be of small molecular

weight , they cross the placenta , can lead to
fetal effects, fetal abnormalities, or preterm birth
The risk for hepatitis B or HIV infection
increases
The risk for STI poses threat to the fetus
DEPENDENT
COCAINE
 Extremely harmful during pregnancy because of extreme
vasoconstriction , severely compromised placental
circulation leading to premature separation of the
placenta, preterm labor and fetal death
 Infants can suffer immediate effects of intracranial
hemorrhage and an abstinence syndrome of
tremulousness, irritability, an muscle rigidity.
 Learning and social interactions defects as long term
effects
DEPENDENT
AMPHETAMINES
Women develop blackened and infected teeth
Newborn show jitteriness and poor feeding at
birth and growth may be restricted
DEPENDENT
MARIJUANA AND HASHISH
They produce tachycardia and a sense
of well-being
Associated with loss of short-term memory and
increased incidence of respiratory infections in
adults
Woman maybe advised not to breastfeed
because of reduced milk production and the risk
to the newborn from excretion of the substance
in breast milk
DEPENDENT
PHENCYCLIDINE
It creates a sense of euphoria and causes
irritation and possibly long-term hallucination
Tends to leave the maternal circulation and
concentrate in fetal cells it may particularly
injurious to a fetus
DEPENDENT
NARCOTIC AGONISTS
 Pregnancy complications related to use include
gestational hypertension , phlebitis , subacute bacterial
endocarditis and hepatitis B and HIV infection
 Heroin dependency in the pregnant women can result to
fetal opiate dependence and severe abstinence
symptoms , tend to be SGA, increased incidence of fetal
distress and meconium aspiration
 Baby will demonstrate the same abstinence symptoms
after birth
 Fetal liver may mature faster than usual , better able to
cope with bilirubin at birth
 Fetal lung tissue also appears to mature more rapidly
DEPENDENT
INHALANTS
Refers to sniffing or huffing of aerosol
substances
They contain freon as a propellant which can
lead to severe respiratory and cardiac
irregularities
Have similar effect to alcohol dependency
Respiratory depression can cause limitation of
fetal oxygen supply to a serious level
DEPENDENT
ALCOHOL
 It is detrimental to fetal growth as illicit substances
 Fetal alcohol spectrum disorder , a syndrome with
recognizable facial features , possible cognitive
challenges and memory deficits occur
 Women are advised not to drink alcohol during
pregnancy
 Discuss alcohol ingestion with late adolescents,
mention about binge drinking ( 5 or more alcohol
drinks on one occasion ) is not safe during
pregnancy
Have a nice day!
JOYLN L. MEJILLA, RN, MAN
FEBRUAURY 9,2020

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2/6/23, 11:36 AM M1: Introduction: Care of Mother, Child, at-risk or with Problems- NCM 109 (306 hours RLE)-JLMEJILLA

High risk pregnancy is one in which the concurrent disorder,

Missed Miscarriage Unknown Vaginal Spotting, perhaps slight cramping; no Disseminated

Complete Spontaneous Unknown, possibly Vaginal Spotting, cramping cervical dilatation

•any interruption of a pregnancy before the fetus is

•Abortion – Medical term of any interruption of a

Threa- Slight, Mild No No •Bed rest sedation

Avoid strenous activity for 24 to 48 hrs

No coitus for 2 weeks after the bleeding episode

Assess vaginal bleeding post D &

Complete Slight Mild Yes •yes •No further intervention is needed if

Missed With Perhaps No apparent No

Recurrent Varies Varies Yes Yes, •Varies, depends on type.

• Assess amount of bleeding

•Isoimmunization – production of antibodies against

•Menstrual Extraction ( Suction Evacuation)

•Menstrual Extraction ( Suction Evacuation)

• Dilatation and Curettage Used for less than 13 weeks AOG

• Uterus is cleaned with a curette

• Dilatation and Curettage

•Dilatation and Vacuum Extraction

•Dilatation and Vacuum Extraction

•Signs and Symptoms:

• Decreased central venous pressure

• Less peripheral resistance because

• Increases gas exchange to better

• Cold, clammy skin

• Vasoconstriction occurs to maintain

• Inadequate blood is entering kidney

• Dizziness or decreased level of

• Inadequate blood is reaching the

Ligate the bleeding vessels

•Also called Gestational trophoblastic

•As the cells degenerate, they

•Sonogram shows dense growth

•Gradually declining HCG titers

• If HCG levels are negative after 6

• By 12 months, second pregnancy can

Premature Cervical Dilatation

Premature Cervical Dilatation

Premature Cervical Dilatation

• Surgical procedure used to treat cervical

Premature Cervical Dilatation

Premature Cervical Dilatation

Increased maternal age

• SIGNS AND SYMPTOMS

Avoid digital exams

Blood transfusion may

• Abruptio placenta is the

Should be suspected when there

•Normally 5-7 minutes after

• Treatment depends on severity of

• Clinical symptoms may vary with

• DIAGNOSTIC TESTS AND LABS

•SIGNS AND SYMPTOMS

• Therapeutic Nursing Management

Monitor for shock (vital signs,

-Prepare woman for