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Lisa, a 30-year-old woman, is 28 weeks pregnant with her second child. She presents to the prenatal clinic for a routine check-up. During the visit, her blood pressure is recorded at 145/92 mm Hg. She does not report any symptoms such as headaches, visual disturbances, or epigastric pain. A urine dipstick test shows no proteinuria. She has a history of normal blood pressure before pregnancy and during her previous pregnancy.
Based on Lisa's current symptoms and test results, what is the most likely diagnosis?
Lisa likely has gestational hypertension, as indicated by her elevated blood pressure (≥140/90 mm Hg) without proteinuria, occurring after 20 weeks of pregnancy.
Gestational hypertension involves vasospasm in both small and large arteries, which leads to increased vascular resistance. This vasospasm __________________ to various organs, causing hypertension.
reduces blood flow
Without proper management, gestational hypertension can escalate to __________
preeclampsia
Increased blood pressure can lead to______________ of the placenta from the uterus.
premature separation
High blood pressure can necessitate________________ to protect the health of the mother and baby.
early delivery
Condition in which vasospasm occurs in both small and large arteries during pregnancy
Gestational Hypertension
Pregnancy related disease process evidenced by increased blood pressure and proteinuria
Preeclampsia
Predisposing Factors for Eclampsia
Age-primis under 20 y/o & over 40 y/o
Gravida- 5 or more pregnancies
Low socioeconomic background
Multiple pregnancies
Stress
Associated with medical conditions
Hydramnios
Triad Symptoms
PIH
Edema
Proteinurea
Signs and Symptoms of Gestational HPN
BP is 140/90 *cut-off
Systolic pressure elevated 30mmHg
Diastolic pressure elevated 15mmHg
No proteinuria or edema
BP returns to normal after birth
S/S Preeclampsia WITHOUT Severe features
All signs of Gestational HPN
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 extremities or face
S/S Preeclampsia WITH Severe Features
BP 160/110 mmHg
Proteinuria 3+ to 4+ on a random sample and 5 grams on a 24 hour sample
Oliguria (500 ml or less in 24 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 by s/s of preeclampsia are present
Eclampsia
Management for Preeclampsia WITHOUT Severe Features
Antiplatelet Therapy - Low dose of Aspirin
CBR- Left lateral recumbent position
Promote good nutrition - high CHON, COH
Emotional support
Management for Preeclampsia WITH Severe Features
Bed rest
darkened the room
limit visitors
stress free environment
Provide safe environment - side rails
What medications to be given to prevent Eclampsia?
Anti HPN
Apresoline (Hydralazine)
Normodyne (Labetalol)
Nifedipine
Aspirin (low dose -60 mg QID)
MAGNESIUM SULFATE (MgSO4)
CNS Depressant
Vasodilator
Cathartic
What are the indications for Apresoline (Hydrazaline Hydrochloride)?
is an antihypertensive drug indicated for treatment of hypertension by relaxing vascular smooth muscle. *reduce blood pressure
What are the indications for Normodyne (Labetalol)?
used alone or together with other medicines to treat high blood pressure (hypertension).
What are the indications for Nifedipine
primarily used as an antihypertensive and as an anti-anginal medication
as effective as beta-mimetics in decreasing uterine activity
Will only administer Magnesium Sulfate if?
(+) DTR (deep tendon reflex)
RR at least 12 per min
Urine Output at least 100 ml in 6 hours
CALCIUM GLUCONATE
Management for Eclampsia
Turn onto her side
Assess O2 sat
Administer O2
Monitor FHR
Check vaginal Bleeding
Administer MgSO4 or Diazepam (Valium), IV
Delivery – Vaginal (preferred)
Diazepam (Valium) indications
medication that treats anxiety, seizures, muscle spasms or twitches. It works by helping your nervous system calm down.
5 Ps
Power
Passenger
Passageway
Position of the mother
Psychological make up of the mother
Anna, a 26-year-old first-time mother, is admitted to the labor and delivery unit at 39 weeks of gestation. She has been in labor for the past 12 hours. Upon initial assessment, her contractions are mild and irregular, and her cervical dilation has been stagnant at 4 cm for the past 3 hours. Despite efforts to encourage labor progression through walking and position changes, there has been no significant change. Anna expresses increasing fatigue and anxiety about her prolonged labor.
Based on Anna’s presentation, what is the most likely diagnosis?
Anna is likely experiencing dystocia due to inefficient uterine contractions, characterized by inadequate strength and frequency of contractions leading to prolonged labor and lack of cervical dilation.
Dystocia occurs when uterine contractions are __________, infrequent, or uncoordinated to effectively dilate the cervix and push the baby through the birth canal. This can be due to various factors, including uterine muscle fatigue, maternal exhaustion, or inadequate hormonal signaling.
too weak
Ineffective contractions result in ______________, increasing the risk of maternal and fetal complications due to prolonged pressure and reduced oxygenation.
prolonged labor
Prolonged labor can lead to ___________________-, impacting the mother's ability to cope with labor.
severe fatigue and dehydration
Ineffective contractions and prolonged labor can compromise __________________ leading to _______________.
fetal oxygenation
distress
Prolonged labor increases the risk of maternal and neonatal ____________ due to prolonged rupture of membranes or frequent vaginal examinations.
infections
if inefficient or ineffective, there will be __________ = resulting to complications to labor and delivery
no cervical dilatation
Ineffective Uterine Force (Causes)
Injudicious use of analgesia (pain reliever)
Fetal malposition
Overdistention of the uterus
Grand multiparity
Excessive cervical rigidity
Maternal age
What happens when the client (mother) is overdose on analgesia or pain reliever?
may cause problem to the uterine contraction
continuous delivery or multiple pregnancies (grand multiparity) may lead to?
losing the elasticity/stimulation of the uterus to contract
Dystosia
Dysfunctional Labor
Sluggishness = ?
no progress in uterine contraction
Hypotonic Contraction
Uterine contractions are too weak
Too short, irregular or infrequent
No progressive cervical dilatation & effacement occurs
Presenting part failed to descend
Management for Hypotonic Contraction
Assessment
Vaginal exam
X-ray pelvimetry
Administration of oxytocin
Amniotomy
Cesarean section
to determine ineffective or inefficient uterine force?
Monitor uterine contraction
Check duration - from the start of uterine contraction to end
check the frequency - start of contraction to start of another contraction
Interval - end of one contraction to start of next contraction
Vaginal exam - check the progress of cervical dilatation and effacement
Cervical dilation in terms of cm
Xray - para malaman kung mali ba pwesto o maliit ba sipit-sipitan (di gaano ginagawa)
Nursing action for stimulating uterine contraction
hahawakan abdomen, massage, nipple ippinch
Pag di tumalab, administer oxytocin - check of the contraindication of oxytocin
Amniotomy
artificial or intentional rupture of amniotic sac
When amniotic sac is ruptured, what will happen to the prostaglandin?
prostaglandin increases leading to stimulating uterine contraction
premature rupture; amniotic fluid gushing tends to let?
cord slip
If Amniotomy and administering oxytocin did not work?
cesarean section
Complication of Hypotonic Contraction
exhaustion - irregular breathing technique
DHN
Intrapartum infection - prolong rupture of membrane; opening of amniotic sac is the portal entry for infection
Amnio hook
used to rupture the amniotic sac
Hypertonic Contractions
Relaxations are inadequate/mild
Common seen in a latent phase
More painful than the usual
Hypotonic VS Hypertonic Uterine Dysfunction
Hypertonic - do not induce labor
Hypotonic - prolong progress of labor due to weak uterine contraction, need to induce labor
Management for Hypertonic Uterine Function
Rests & sedation (morphine)
IVF
Oxytocin is Contra Indicated
Cesarean Section
Complication of Hypertonic Uterine Function
Fetal distress - too much uterine contraction, depletes oxygenation to the fetus
Intrapartal infection
Emily, a 29-year-old second-time mother, is admitted to the labor and delivery unit at 38 weeks of gestation. She has been in active labor for 10 hours. Upon examination, it is noted that her contractions are irregular and asymmetrical, meaning they vary in intensity and do not follow a consistent pattern. Despite these contractions, her cervical dilation has been slow, currently at 5 cm with minimal progression over the past 4 hours. Emily reports significant discomfort and frustration due to the lack of progress.
Based on Emily’s presentation, what is the most likely diagnosis?
Emily is likely experiencing dystocia due to asymmetrical uterine contractions, characterized by irregular, uneven contractions that are insufficient to effectively dilate the cervix
_______________________ are those that vary in intensity, frequency, and duration, causing ineffective labor. This can result from uterine muscle fatigue, misalignment of the baby, or hormonal imbalances.
Asymmetrical contractions
Asymmetrical contractions fail to produce consistent pressure on the cervix, leading to slow or stalled cervical dilation, ______________, and increased maternal and fetal stress.
prolonged labor
Prolonged labor with ineffective contractions can lead to severe _____________, increasing the risk of complications during delivery.
fatigue
Prolonged labor increases the likelihood of maternal and neonatal __________, especially if the membranes have ruptured.
infections
Sarah, a 32-year-old woman, is in labor at 40 weeks of gestation with her first child. She has been experiencing strong contractions for the past 8 hours. However, her labor is not progressing as expected. During her vaginal examination, the nurse notes that Sarah's cervix is only 3 cm dilated and there is no significant descent of the fetus. Sarah reports a sensation of contractions moving upward rather than downward, which is accompanied by severe back pain. The fetal heart rate is within normal limits, but Sarah is becoming increasingly anxious and exhausted.
Based on Sarah’s symptoms, what is the most likely diagnosis?
Sarah is likely experiencing dystocia due to reverse peristalsis, where contractions are not effectively moving in the downward direction necessary for labor progression.
Reverse peristalsis refers to contractions that move upward instead of downward. This atypical contraction pattern can___________________________ into the birth canal, leading to ineffective cervical dilation and stalled labor.
prevent the fetus from descending
Jessica, a 25-year-old woman, is 35 weeks pregnant with her second child. She comes to the prenatal clinic reporting a dull, low backache that has been persistent for the past few hours. She also mentions experiencing some vaginal spotting and increased vaginal discharge. Jessica describes a feeling of pelvic pressure and abdominal tightening, along with menstrual-like cramping. She has noticed increasing uterine contractions that are becoming more regular and uncomfortable.
Based on Jessica's symptoms, what is the most likely diagnosis?
Jessica is likely experiencing premature labor, indicated by her symptoms of a low backache, vaginal spotting, pelvic pressure, abdominal tightening, menstrual-like cramping, increased vaginal discharge, and regular uterine contractions before the end of the 37th week of gestation.
Premature labor occurs when regular uterine contractions result in the opening of the cervix before _______________. The exact cause can vary, including infection, inflammation, placental abruption, or stress. This process involves the activation of biochemical pathways that lead to uterine contractions and cervical changes, ultimately causing labor to begin earlier than expected.
37 weeks of gestation
Premature labor can impact the mother by increasing the risk of complications such as ____________________, and it can significantly affect the baby by leading to premature birth, which carries risks related to immature organ systems.
infection or hemorrhage
Potential Complications for the Baby (premature birth)
Respiratory Distress Syndrome (RDS): Due to underdeveloped lungs.
Intraventricular Hemorrhage (IVH): Bleeding in the brain due to fragile blood vessels.
Necrotizing Enterocolitis (NEC): A serious intestinal disease affecting preterm infants.
What medication should be administered to Jessica (premature birth case)
Administer medications such as tocolytics to help slow or stop contractions, corticosteroids to accelerate fetal lung maturity, and antibiotics if infection is suspected.
Premature Birth
Before the end of 37th week of gestation
Dull and low backache
Vaginal spotting
Pelvic pressure or abdominal tightening
Menstrual like cramping
Increased vaginal discharge
Increasing uterine contractions
Why should we monitor fetal heart sound and uterine contraction?
because of possibility of premature birth
Sympathomimetic drugs for pregnant woman
it has an effect to stop or calm the uterine contraction (tocolytic agent)
When will you administer steroid or betamethasone for glucocorticoid?
below 34 weeks
Betamethasone indication
prevents respiratory distress syndrome and will be injected to the mother in order to develop the lungs substance of lungs
Cut the cord immediately to prevent?
cyanosis
Amanda, a 27-year-old woman, is admitted to the labor and delivery unit at 39 weeks of gestation with her third child. Upon arrival, she reports intense and frequent contractions that started suddenly about two hours ago. Her contractions are now every two minutes and very strong. She feels an urgent need to push and is experiencing significant pressure and pain. During the initial assessment, the nurse notes that Amanda's cervix is fully dilated, and the baby's head is crowning. Amanda has a history of fast labors with her previous pregnancies.
Based on Amanda’s symptoms, what is the most likely diagnosis?
Amanda is likely experiencing precipitate labor, characterized by extremely rapid labor and delivery, typically lasting less than three hours from the onset of contractions to delivery.
Precipitate labor occurs when uterine contractions are unusually strong and frequent, causing the cervix to ______________and the baby to descend quickly through the birth canal.
dilate rapidly
The rapid progression can result in insufficient time for the cervix and perineum to stretch, leading to ______________________.
potential trauma
Precipitate Dilatation and Precipitate Labor differences
Dilatation - occur at a rate of 5 cm or more in 1 hour in a primipara and 10 cm or more in multipara. usually it took time for cervix to dilate
Labor - labor that last less than 3 hours
Causes of Precipitate Labor
Multiparity
Oxytocin administration (overdose)
Amniotomy
Maternal Effects of Precipitate Labor and Delivery
extensive laceration - due to pressure exerted in the vaginal canal
abruptio placenta - pressure exerted and the mechanism itself is very fast to have placental separation
Hemorrhage or shock
Fetal effects of Precipitate Labor and Delivery
fetal asphyxia - a lack of blood flow or gas exchange to or from the fetus in the period immediately before, during, or after the birth process.
Subdural hemorrhage - bleeding in the area between the brain and the skull
this is all due to sudden release of pressure
Uterine Rupture
occurs when the uterus undergoes more strain that it is capable of sustaining (rare)
Samantha, a 34-year-old woman, is in labor with her second child at 40 weeks of gestation. She has a history of a previous cesarean section. During her current labor, Samantha reports sudden, severe abdominal pain that is constant and not associated with contractions. She feels a sense of something tearing inside her abdomen. The fetal heart rate monitor shows a sudden drop in the baby's heart rate, and there is a loss of uterine tone. Samantha also begins to exhibit signs of shock, including a rapid pulse, low blood pressure, and pallor.
Based on Samantha’s symptoms, what is the most likely diagnosis?
Samantha is likely experiencing a uterine rupture, indicated by her sudden severe abdominal pain, signs of shock, and fetal distress.
Uterine rupture occurs when the muscular wall of the uterus tears during pregnancy or labor, leading to the fetus, placenta, and other contents potentially spilling into the abdominal cavity. This can result from previous uterine surgery (such as a cesarean section), excessive uterine contractions, trauma, or overdistention of the uterus. Uterine rupture compromises maternal and fetal circulation, leading to life-threatening ____________ and ___________.
hemorrhage and fetal distress.
Severe blood loss can lead to________________ and require blood transfusions.
hypovolemic shock
Surgical removal of the uterus may be necessary to _____________________ and save Samantha's life. (Hysterectomy)
control bleeding
Compromised oxygen supply due to____________________________ can lead to brain injury or death.
disruption of placental blood flow
Causes of Uterine Rupture
previous scar from cesarean section - vaginal birth after cesarian section (hysterectomy)
obstructed labor
unwise use of oxytocin
multiple gestation - overdistension of uterus
faulty presentation
prolonged labor
Complete rupture
The uterine wall is fully torn through, creating a direct connection between the uterine cavity and the peritoneal cavity.
Incomplete rupture
The uterine wall is partially torn but does not create a complete opening into the abdominal cavity. The rupture may be contained within the uterine muscle or the peritoneum, with no extrusion of fetal parts into the abdominal cavity.
S/S of Uterine Rupture
sudden severe pain during a strong labor contraction - leading to severe blood loss
may report a “tearing sensation”
Management for Uterine rupture
fluid replacement & blood transfusion to correct blood loss
laparotomy - to determine the extent of damage to repair
advise not to conceive again (when repaired)
hysterectomy; ligation (if not repaired)
Inversion of uterus
the uterus is turned inside out
Linda, a 28-year-old woman, has just delivered her third child vaginally. The delivery was uncomplicated, and the baby is healthy. However, shortly after the placenta is delivered, Linda suddenly experiences severe lower abdominal pain and a feeling of intense pressure. The nurse observes a significant drop in Linda’s blood pressure and an increase in her heart rate. Upon examination, it is discovered that the uterus is not palpable in the abdomen and there is a mass protruding from the vaginal canal. Linda is pale and diaphoretic, exhibiting signs of shock.
Based on Linda’s symptoms, what is the most likely diagnosis?
Linda is likely experiencing a uterine inversion, where the uterus turns inside out, often following the delivery of the placenta.
Severe blood loss can lead to?
hypovolemic shock
Inversion of the Uterus (Causes)
strong fundal pressure - can cause rupture
attempts to deliver the placenta before sign of placental separation appear
Partial/Incomplete
fundus lie within the uterine cavity
without extension beyond the external cervical os
Total/Complete
Collapse of the entire uterus through the cervix into the vagina.
S/S of Inversion of the Uterus
sudden gush of blood from the vagina
fundus is not palpable
sudden rise of the abdomen
bleeding
uterine tenderness
lightning of umbilical cord
Management for Inversion of the Uterus
MVS
IVF
oxygen administration
anesthesia administer
CPR (p.r.n.)
Laparotomy
Hysterectomy
administer IV fluid to correct blood loss
oxygen administration
position patient in a trendelenburg when experiencing shock
Amniotic Fluid Embolism
Occurs when a large amount of amniotic fluid gains access to the central maternal circulations
Jessica, a 29-year-old woman, is in labor at 38 weeks of gestation with her first child. The labor progresses normally until shortly after her membranes rupture spontaneously. Within minutes, Jessica experiences sudden shortness of breath, chest pain, and a sense of impending doom. She quickly becomes hypotensive and cyanotic. The fetal heart rate monitor shows signs of fetal distress. Jessica’s condition rapidly deteriorates, and she becomes unresponsive.
Based on Jessica’s symptoms, what is the most likely diagnosis?
Jessica is likely experiencing an amniotic fluid embolism (AFE), characterized by sudden cardiovascular collapse, respiratory distress, and fetal distress.
Amniotic Fluid Embolism Predisposing Factors
High parity
Advanced maternal age
Abruptio Placenta
Intrauterine fetal death
Oxytocin augmentation
S/S of Amniotic Fluid Embolism (Cardinal Symptoms)
dyspnea, tachypnea, &cyanosis
hemorrhage
shock- blood loss
coma
S/S of Amniotic Fluid Embolism (Premonitory Symptoms)
shaking chills &diaphoresis
increasing restlessness & anxiety
chest pain
coughing with frothy pink sputum
Prolapse of the Umbilical Cord
A loop of the umbilical cord slips down in front of the presenting part
Normal delivery, baby comes first before umbilical cord, this case cord came first ( for oxygenation having the 1 vein and 2arteries)
When vulva protrudes, the umbilical cord will _______________, the veins arteries will shrink, oxygenation will be affected
dry out
Note
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