BSC – SEM 7 – UNIT 1- OBSTETRICS & GYNECOLOGY NURSING – II
Recognition and Management of problems during Pregnancy
Assessment of High-Risk Pregnancy.
A high-risk pregnancy is one where the health of the mother, fetus, or both is at increased risk due to various maternal, fetal, or environmental factors. Early identification and appropriate management are essential to minimize complications.
I. Definition of High-Risk Pregnancy
A pregnancy is considered high-risk when there is an increased likelihood of adverse outcomes for the mother, fetus, or both due to pre-existing conditions, pregnancy-related complications, or external factors.
Blood Pressure and Sugar Control (Medications, Insulin if Required)
Avoidance of Smoking, Alcohol, and Drugs
B. Specialized Care and Hospitalization
Bed Rest in Certain Conditions (Preeclampsia, Placenta Previa)
Medications:
Tocolytics (To Prevent Preterm Labor)
Corticosteroids (For Fetal Lung Maturity in Preterm Labor)
Antihypertensive Drugs (Labetalol, Methyldopa)
Insulin Therapy (For Gestational Diabetes)
Emergency Interventions:
C-Section in Cases of Fetal Distress, Placental Abruption, Eclampsia
Blood Transfusions for Severe Anemia
C. Psychological Support and Counseling
Mental Health Support (Managing Anxiety, Depression)
Genetic Counseling (For Families with Genetic Disorders)
Birth Planning and Emergency Preparedness
V. Nursing Care Plan for High-Risk Pregnancy
A. Assessment
Monitor vital signs (BP, Temperature, Pulse)
Assess fetal heart rate and movements
Check for edema, weight gain, and signs of preeclampsia
B. Diagnosis
Risk for Fetal Growth Restriction related to maternal hypertension
Risk for Preterm Labor related to uterine abnormalities
Risk for Maternal Complications due to gestational diabetes
C. Planning and Implementation
Provide frequent antenatal monitoring
Educate on warning signs (Bleeding, Severe Headache, Reduced Fetal Movement)
Promote a healthy diet and hydration
Encourage compliance with prescribed medications
D. Evaluation
Improved maternal health and stable fetal growth
Absence of severe complications
Successful pregnancy outcome
Problems/complications of pregnancy.
Hyperemesis Gravidarum:
Hyperemesis gravidarum (HG) is a severe form of nausea and vomiting during pregnancy that can lead to dehydration, weight loss, electrolyte imbalances, and nutritional deficiencies. It is more extreme than typical morning sickness and may require medical intervention.
I. Definition of Hyperemesis Gravidarum
Hyperemesis gravidarum is defined as persistent and excessive vomiting during pregnancy that leads to:
Dehydration
Electrolyte imbalances
Weight loss greater than 5% of pre-pregnancy weight
Nutritional deficiencies
Ketosis (due to prolonged starvation)
It usually begins in the first trimester (before 16 weeks of gestation) but can persist throughout pregnancy in severe cases.
II. Causes and Risk Factors of Hyperemesis Gravidarum
A. Causes (Etiology)
The exact cause of HG is multifactorial and not completely understood, but some possible causes include:
Hormonal Factors
Increased levels of human chorionic gonadotropin (hCG) – The hormone hCG peaks around 10–12 weeks of pregnancy and is believed to trigger severe nausea and vomiting.
Esophageal tears (Mallory-Weiss Syndrome) due to excessive vomiting
Deep vein thrombosis (DVT) due to prolonged immobilization
Fetal Complications:
Low birth weight due to poor maternal nutrition
Preterm birth due to metabolic stress
Small for gestational age (SGA)
Congenital anomalies (if severe nutritional deficiencies occur)
VI. Nursing Management of Hyperemesis Gravidarum
A. Assessment:
Monitor hydration status (skin turgor, mucous membranes).
Monitor urine output (sign of dehydration).
Assess electrolyte levels and replace as needed.
B. Nursing Diagnoses:
Fluid volume deficit related to excessive vomiting.
Imbalanced nutrition: Less than body requirements.
Anxiety related to prolonged illness and hospitalization.
C. Interventions:
Administer IV fluids and electrolytes as prescribed.
Encourage small frequent meals (bland diet).
Educate the patient on avoiding triggers (strong smells, spicy foods).
Provide psychological support (reduce anxiety).
Bleeding in Early Pregnancy: Causes, Diagnosis, and Management
Bleeding in early pregnancy (before 20 weeks of gestation) is a common but potentially serious condition. It can be caused by spontaneous abortion (miscarriage), ectopic pregnancy, or gestational trophoblastic disease (vesicular mole/molar pregnancy). Proper assessment and timely management are crucial to prevent complications.
I. Spontaneous Abortion (Miscarriage)
Definition
Spontaneous abortion is the loss of a pregnancy before 20 weeks of gestation due to natural causes. It occurs in approximately 10-20% of all recognized pregnancies.
Management: IV antibiotics and surgical evacuation of retained products.
Causes of Spontaneous Abortion
Chromosomal abnormalities (50-70%)
Uterine abnormalities (fibroids, septate uterus)
Maternal infections (TORCH infections)
Hormonal imbalances (hypothyroidism, PCOS)
Autoimmune diseases (antiphospholipid syndrome)
Diagnosis
Ultrasound: Confirms viability of pregnancy
Serum β-hCG: Falling levels suggest miscarriage
Complete Blood Count (CBC): Assesses blood loss and infection
Management
Expectant management: If no complications and stable patient
Medical management: Misoprostol to induce uterine contractions
Surgical management: D&C if incomplete abortion or excessive bleeding
Supportive care: Emotional support, blood transfusion if needed
II. Ectopic Pregnancy
Definition
Ectopic pregnancy is the implantation of a fertilized egg outside the uterine cavity, most commonly in the fallopian tube (95%). It is a life-threatening condition due to the risk of rupture and hemorrhage.
Sites of Ectopic Pregnancy
Fallopian Tube (95%)
Ovary
Cervix
Abdomen
Cesarean scar
Risk Factors
Pelvic inflammatory disease (PID)
Previous ectopic pregnancy
History of tubal surgery or ligation
Use of intrauterine contraceptive devices (IUCDs)
Assisted reproductive techniques (IVF)
Symptoms
Classic Triad
Amenorrhea (Missed period)
Abdominal pain (Unilateral, sharp, severe)
Vaginal bleeding (Scanty, dark brown)
Ruptured Ectopic Pregnancy (Emergency Condition)
Severe abdominal pain
Shoulder tip pain (Referred pain from diaphragmatic irritation)
Syncope, dizziness (Shock due to internal bleeding)
Cullen’s sign (Bluish discoloration around umbilicus due to internal bleeding)
Diagnosis
β-hCG Levels
In ectopic pregnancy, β-hCG levels rise slower than normal pregnancy.
Transvaginal Ultrasound (TVS)
No intrauterine gestational sac
Adnexal mass may be present
Culdocentesis
Aspiration of non-clotting blood from the pouch of Douglas suggests rupture.
Management
A. Medical Treatment (for stable cases)
Methotrexate (MTX) – A folic acid antagonist that stops fetal cell growth.
Indications: Unruptured ectopic pregnancy, β-hCG <5000 mIU/mL, sac <3.5 cm.
B. Surgical Treatment (for ruptured cases)
Salpingectomy: Removal of the fallopian tube.
Salpingostomy: Incision to remove ectopic tissue while preserving the tube.
C. Supportive Care
Monitor vital signs, manage hemorrhagic shock.
Rh immunoglobulin (Anti-D) if mother is Rh-negative.
III. Vesicular Mole (Gestational Trophoblastic Disease – GTD)
Definition
Gestational trophoblastic disease (GTD) refers to a group of pregnancy-related tumors arising from abnormal trophoblastic proliferation. The most common form is hydatidiform mole (vesicular mole).
Ultrasound (“Snowstorm appearance”) – No fetus, multiple cystic spaces
Histopathology – Confirms diagnosis after evacuation
Management
A. Medical Management
Evacuation of uterus (Suction Curettage/D&C)
β-hCG monitoring every 1-2 weeks until undetectable for 6 months.
Contraception for at least 1 year to avoid pregnancy before β-hCG normalization.
B. Management of Persistent GTD or Choriocarcinoma
Chemotherapy (Methotrexate or Actinomycin-D) for high-risk cases.
Hysterectomy in women who do not desire future pregnancies.
Medical conditions complicating pregnancy:
Bleeding in Late Pregnancy: Causes, Diagnosis, and Management
Bleeding in late pregnancy (after 20 weeks of gestation) is a serious obstetric emergency that requires immediate evaluation and management. The most common causes include placenta previa, abruptio placentae (placental abruption), and trauma. Timely intervention is crucial to prevent maternal and fetal complications.
I. Placenta Previa
Definition
Placenta previa is a condition where the placenta is abnormally implanted in the lower uterine segment, partially or completely covering the internal cervical os.
Types of Placenta Previa
Complete (Total) Placenta Previa – The placenta completely covers the cervical opening.
Partial Placenta Previa – The placenta partially covers the cervical os.
Marginal Placenta Previa – The placenta reaches the edge of the cervix but does not cover it.
Low-Lying Placenta – The placenta is implanted in the lower uterus but does not reach the cervical os.
Risk Factors
Previous placenta previa
Multiparity (multiple pregnancies)
Previous cesarean section or uterine surgery
Advanced maternal age (>35 years)
Multiple gestations (Twins, Triplets, etc.)
Smoking and cocaine use
Clinical Features
Painless, bright red vaginal bleeding
Bleeding is recurrent and spontaneous
Soft, non-tender uterus
Fetal heart rate is usually normal unless bleeding is severe
Diagnosis
Ultrasound (Transabdominal or Transvaginal)
Confirms placental location.
Transvaginal ultrasound is safe and more accurate in diagnosing placenta previa.
Magnetic Resonance Imaging (MRI) – Used if placenta accreta (abnormal placental adherence) is suspected.
No Vaginal Examination
Digital vaginal examination is contraindicated as it can cause massive bleeding.
Management
A. Conservative Management (If Bleeding is Mild and Fetus is Preterm)
Hospitalization for observation.
Bed rest and avoidance of sexual intercourse.
Corticosteroids (Betamethasone) to enhance fetal lung maturity if <34 weeks gestation.
B. Emergency Management (Severe Bleeding or Term Pregnancy)
Immediate Cesarean Section (C-Section) – The definitive treatment for complete and partial placenta previa.
Blood transfusion if excessive blood loss.
Intravenous fluids (IVF) and oxygen support.
Monitor maternal vital signs and fetal well-being.
II. Abruptio Placentae (Placental Abruption)
Definition
Abruptio placentae is the premature separation of a normally implanted placenta from the uterine wall before delivery, leading to bleeding and fetal distress.
Types of Placental Abruption
Concealed Abruption – Bleeding is trapped behind the placenta, leading to internal hemorrhage.
Revealed Abruption – Bleeding escapes through the vagina, leading to external hemorrhage.
Mixed Abruption – Combination of both concealed and revealed bleeding.
Risk Factors
Hypertension (Chronic or Pregnancy-Induced)
Pre-eclampsia or Eclampsia
Trauma (Abdominal injury, Accidents, Falls, Violence)
Smoking, Cocaine use
Previous history of placental abruption
Premature rupture of membranes (PROM)
Clinical Features
Sudden onset of painful vaginal bleeding (Dark red blood).
Uterine tenderness and contractions.
Rigid, “board-like” abdomen due to uterine hypertonicity.
Fetal distress (abnormal fetal heart rate) due to impaired oxygen supply.
Signs of hypovolemic shock (Pallor, Tachycardia, Hypotension).
Complications
Maternal Hemorrhagic Shock
Disseminated Intravascular Coagulation (DIC)
Fetal Hypoxia and Death
Renal Failure due to Hypovolemia
Diagnosis
Clinical Examination – Based on symptoms and maternal distress.
Ultrasound (Limited Use in Acute Cases) – May show retroplacental hematoma.
Kleihauer-Betke Test – Detects fetal red blood cells in maternal circulation.
Corticosteroids (if <34 weeks) for fetal lung maturity.
B. Severe Cases (Fetal Distress, Maternal Instability, or Heavy Bleeding)
Emergency Cesarean Section (C-Section).
Blood transfusion and management of hypovolemic shock.
Correction of coagulation abnormalities (Fresh frozen plasma, Platelets).
III. Trauma in Pregnancy
Definition
Trauma in pregnancy refers to any physical injury to the mother that may affect fetal and maternal health. Trauma can be minor (falls, blunt trauma) or major (motor vehicle accidents, physical violence, penetrating trauma).
Causes of Trauma in Pregnancy
Motor Vehicle Accidents (MVA) – Most common cause.
Falls – Due to center of gravity shift in pregnancy.
Domestic Violence – Increased risk in pregnancy.
Blunt Abdominal Trauma – Can cause uterine rupture, placental abruption, or fetal injury.
Penetrating Trauma (Gunshot, Stabbing) – Can injure maternal and fetal organs.
Effects of Trauma on Pregnancy
Placental Abruption (Commonest Complication of Trauma)
B. Major Trauma (Unstable Mother or Fetal Distress)
Immediate Resuscitation (ABCs, IV Fluids, Oxygen, Blood Transfusion).
Emergency Cesarean Section (if maternal or fetal compromise).
Management of specific injuries (fractures, internal bleeding, organ damage).
Anemia: A Comprehensive Overview
I. Definition of Anemia
Anemia is a condition characterized by a decrease in the number of red blood cells (RBCs) or hemoglobin (Hb) concentration, leading to reduced oxygen-carrying capacity of the blood. In pregnancy, anemia is defined as hemoglobin levels below 11 g/dL in the first and third trimesters and below 10.5 g/dL in the second trimester.
Classification of Anemia Based on Hemoglobin Levels in Pregnancy
Severity
Hemoglobin (g/dL)
Mild
10.0 – 10.9 g/dL
Moderate
7.0 – 9.9 g/dL
Severe
<7.0 g/dL
Very Severe
<4.0 g/dL
II. Types of Anemia in Pregnancy
1. Iron Deficiency Anemia (IDA) (Most Common Type in Pregnancy)
Cause: Deficiency of iron leading to inadequate hemoglobin production.
Risk Factors: Poor diet, increased demand during pregnancy, chronic blood loss (menorrhagia, gastrointestinal bleeding).
Enhancers of Iron Absorption: Vitamin C (citrus fruits, tomatoes).
Inhibitors of Iron Absorption: Tea, coffee, calcium, phytates.
Folate-Rich Foods: Green leafy vegetables, citrus fruits, legumes.
Vitamin B12 Sources: Dairy, eggs, fish, meat.
B. Medical Management
Iron Supplementation:
Oral iron therapy (Ferrous sulfate 100–200 mg/day).
IV iron (for severe anemia or malabsorption).
Folic Acid Supplementation:
400 mcg/day in all pregnancies.
5 mg/day in high-risk cases (previous neural tube defects).
Vitamin B12 Supplementation:
Intramuscular B12 injections for pernicious anemia.
Blood Transfusion:
Indicated in severe anemia (Hb <7 g/dL with symptoms).
VII. Midwifery Nursing Care for Anemia in Pregnancy
A. Assessment
Monitor hemoglobin levels regularly.
Assess dietary habits and educate on iron-rich diet.
Monitor maternal and fetal well-being (fundal height, fetal movements, CTG).
Screen for infections and chronic illnesses.
B. Nursing Diagnoses
Risk for Imbalanced Nutrition related to inadequate dietary intake.
Fatigue related to decreased oxygen-carrying capacity.
Risk for Fetal Growth Restriction related to reduced oxygen supply.
C. Nursing Interventions
Health Education:
Importance of iron and folic acid supplements.
Dietary modifications for iron absorption.
Signs of anemia to watch for.
Medication Administration:
Ensure compliance with iron, folic acid, and B12 supplements.
Monitor for Complications:
Assess for preterm labor, infections, and postpartum hemorrhage.
Psychosocial Support:
Address concerns related to diet, fatigue, and pregnancy outcomes.
Pregnancy-Induced Hypertension (PIH):
I. Definition of Pregnancy-Induced Hypertension (PIH)
Pregnancy-Induced Hypertension (PIH) refers to hypertension (high blood pressure) that develops after 20 weeks of gestation in a previously normotensive woman, without the presence of proteinuria or organ dysfunction. PIH is a significant cause of maternal and fetal morbidity and mortality.
Classification of Hypertensive Disorders in Pregnancy
Type
Definition
Gestational Hypertension (PIH)
BP ≥140/90 mmHg after 20 weeks of pregnancy, no proteinuria.
Preeclampsia
BP ≥140/90 mmHg + Proteinuria (≥300 mg/24 hours) or organ dysfunction.
Severe Preeclampsia
BP ≥160/110 mmHg + severe symptoms.
Eclampsia
Preeclampsia + Seizures.
Chronic Hypertension
BP ≥140/90 mmHg before pregnancy or diagnosed before 20 weeks.
Chronic Hypertension with Superimposed Preeclampsia
Worsening BP with new-onset proteinuria.
II. Risk Factors for PIH
A. Maternal Factors
First pregnancy (Primigravida)
Advanced maternal age (>35 years)
Obesity (BMI >30 kg/m²)
Chronic hypertension or kidney disease
Diabetes mellitus
Family history of preeclampsia or PIH
History of PIH in previous pregnancies
B. Pregnancy-Related Factors
Multiple pregnancies (Twins, Triplets)
Molar pregnancy (Hydatidiform mole)
Placental abnormalities
C. Lifestyle and Environmental Factors
Smoking, alcohol, and drug use
Poor nutrition and low calcium intake
Stress and sedentary lifestyle
III. Pathophysiology of PIH
Abnormal Placental Development – Incomplete trophoblastic invasion of the spiral arteries leads to reduced blood flow to the placenta.
Endothelial Dysfunction – Release of antiangiogenic factors causes vascular constriction and hypertension.
Increased Systemic Vascular Resistance – Leads to high blood pressure and organ damage.
A. Mild PIH (BP 140-159/90-109 mmHg, No Organ Damage)
Home monitoring of BP.
Bed rest and reduced salt intake.
Antenatal visits every 1-2 weeks.
Calcium and low-dose aspirin (For prevention in high-risk women).
B. Severe PIH (BP ≥160/110 mmHg or End-Organ Damage)
Hospitalization – Continuous BP and fetal monitoring.
Antihypertensive Medications:
Labetalol (First-line) – Lowers BP safely.
Methyldopa – Safe for long-term use.
Nifedipine – Calcium channel blocker for acute BP control.
Magnesium Sulfate (MgSO₄) – Prevents seizures in severe preeclampsia/eclampsia.
Delivery of the Baby:
Indicated at 37 weeks for stable cases.
Emergency C-section if fetal distress or maternal complications.
VIII. Nursing Care for PIH in Midwifery
A. Assessment
Monitor BP at each antenatal visit.
Check urine protein levels regularly.
Assess for warning signs (headache, vision changes, epigastric pain).
Monitor fetal heart rate and movements.
B. Nursing Diagnoses
Risk for Impaired Gas Exchange related to hypertension.
Risk for Decreased Cardiac Output related to increased vascular resistance.
Risk for Fetal Growth Restriction related to reduced placental perfusion.
C. Nursing Interventions
Health Education:
Teach mothers to recognize danger signs of PIH.
Encourage low-sodium, high-protein diet.
Promote bed rest in the left lateral position to improve placental blood flow.
Monitoring:
Check BP, urine protein, fetal movements daily in severe cases.
Observe for seizure activity (Eclampsia precautions).
Emergency Preparedness:
Keep Magnesium Sulfate and Antihypertensive medications readily available.
Be prepared for immediate delivery if maternal or fetal conditions worsen.
Gestational Diabetes Mellitus (GDM):
I. Definition of Gestational Diabetes Mellitus (GDM)
Gestational Diabetes Mellitus (GDM) is defined as glucose intolerance that develops during pregnancy, typically diagnosed after 24 weeks of gestation, and resolves postpartum. It increases the risk of complications for both the mother and the fetus.
II. Classification of Diabetes in Pregnancy
Type
Definition
Pre-Gestational Diabetes (PGDM)
Diabetes diagnosed before pregnancy (Type 1 or Type 2 Diabetes).
Gestational Diabetes Mellitus (GDM)
Diabetes first diagnosed during pregnancy and usually resolves postpartum.
III. Risk Factors for GDM
A. Maternal Risk Factors
Obesity (BMI >30 kg/m²)
Advanced maternal age (>35 years)
Family history of diabetes
Previous history of GDM in earlier pregnancies
Polycystic Ovary Syndrome (PCOS)
Previous history of macrosomia (baby >4 kg at birth)
Hypertension or pre-eclampsia
B. Lifestyle and Environmental Factors
Sedentary lifestyle
Unhealthy diet (high carbohydrate and fat intake)
Excessive weight gain during pregnancy
IV. Pathophysiology of GDM
Increased Insulin Resistance – Due to pregnancy hormones (human placental lactogen, progesterone, cortisol) that impair insulin function.
Reduced Insulin Production – Pancreatic β-cells cannot compensate for increased demand.
Hyperglycemia (High Blood Sugar Levels) – Leads to fetal overgrowth, complications, and increased risk of maternal metabolic disorders.
V. Clinical Features of GDM
A. Maternal Symptoms (Usually Asymptomatic)
Excessive thirst (Polydipsia)
Frequent urination (Polyuria)
Increased hunger (Polyphagia)
Fatigue and weakness
Recurrent urinary tract or vaginal infections
B. Fetal and Neonatal Effects
Macrosomia (Large baby >4 kg at birth)
Polyhydramnios (Excess amniotic fluid)
Fetal hypoxia leading to stillbirth
Neonatal hypoglycemia (low blood sugar after birth)
Respiratory distress syndrome (RDS)
VI. Diagnosis of GDM
A. Screening Tests (Performed at 24–28 Weeks of Pregnancy)
Oral Glucose Challenge Test (OGCT) (Non-Fasting Test)
50g Glucose Load → Check blood sugar after 1 hour.
If ≥140 mg/dL → Proceed to OGTT.
B. Confirmatory Test: Oral Glucose Tolerance Test (OGTT) (Fasting Test)
Fasting blood sugar (FBS) ≥ 92 mg/dL
1-hour post-glucose ≥ 180 mg/dL
2-hour post-glucose ≥ 153 mg/dL (Diagnosis: GDM if any one value is abnormal).
C. HbA1c (Glycosylated Hemoglobin) Test
Used in early pregnancy to identify undiagnosed Type 2 diabetes.
HbA1c ≥ 6.5% suggests pre-existing diabetes rather than GDM.
VII. Complications of GDM
A. Maternal Complications
Increased risk of Type 2 Diabetes Mellitus (T2DM) postpartum
Preeclampsia and Hypertension
Polyhydramnios leading to preterm labor
Increased risk of cesarean section (due to macrosomia)
Postpartum hemorrhage (due to large baby causing uterine atony)
Insulin Requirement: Increases as pregnancy progresses.
Oral Hypoglycemic Agents (Used in Select Cases)
Metformin – Used when insulin is not feasible.
Glibenclamide – Less preferred due to the risk of neonatal hypoglycemia.
C. Delivery Plan
Induction of Labor at 38–40 Weeks
If blood sugar is well-controlled and there are no complications.
Cesarean Section (C-Section) Indications
Estimated fetal weight >4.5 kg (Macrosomia).
Fetal distress or maternal complications.
IX. Postpartum Management of GDM
Blood Sugar Monitoring: Fasting and 2-hour postprandial glucose checks for 6 weeks.
75g OGTT at 6 weeks postpartum – To check for persistent diabetes.
Counseling on diet, weight control, and lifestyle modifications to reduce Type 2 Diabetes risk.
X. Midwifery Nursing Care for GDM
A. Assessment
Monitor blood sugar levels regularly.
Assess fetal growth using ultrasound and fundal height measurement.
Monitor maternal blood pressure (risk of preeclampsia).
Check for polyhydramnios and fetal movements.
B. Nursing Diagnoses
Risk for Imbalanced Nutrition related to glucose metabolism disorders.
Risk for Fetal Growth Disturbance related to uncontrolled blood sugar.
Risk for Maternal and Neonatal Complications related to GDM.
C. Nursing Interventions
Health Education:
Teach the mother about healthy diet and exercise.
Explain the importance of blood sugar monitoring.
Educate on the symptoms of hypoglycemia and hyperglycemia.
Medication Administration:
Ensure proper insulin administration techniques.
Educate on timing of meals with insulin therapy.
Fetal Monitoring:
Conduct regular ultrasound and fetal non-stress tests (NST).
Advise on kick count monitoring (to assess fetal well-being).
Postpartum Follow-Up:
Encourage OGTT at 6 weeks postpartum.
Counsel on long-term diabetes prevention strategies.
Cardiac Disease in Pregnancy:
I. Definition of Cardiac Disease in Pregnancy
Cardiac disease in pregnancy refers to any pre-existing or newly diagnosed heart condition that complicates pregnancy and poses risks to maternal and fetal health. It is a leading cause of maternal morbidity and mortality, requiring multidisciplinary care involving obstetricians, cardiologists, and midwives.
II. Classification of Cardiac Disease in Pregnancy
A. Congenital Heart Diseases (CHD) (Present at Birth)
Atrial Septal Defect (ASD)
Ventricular Septal Defect (VSD)
Patent Ductus Arteriosus (PDA)
Tetralogy of Fallot (TOF)
Coarctation of the Aorta
B. Acquired Heart Diseases (Develop Later in Life)
Rheumatic Heart Disease (RHD) – Common in developing countries.
Mitral Valve Stenosis (Most common in pregnancy due to RHD)
Aortic Valve Stenosis
Mitral or Aortic Regurgitation
Ischemic Heart Disease (IHD) / Coronary Artery Disease (CAD) – Rare but increasing due to lifestyle changes.
Peripartum Cardiomyopathy (PPCM) – Heart failure in the last month of pregnancy or postpartum.
C. Functional Classification (New York Heart Association – NYHA)
Class
Symptoms
Pregnancy Risk
Class I
No symptoms with normal activity.
Low risk.
Class II
Mild symptoms with ordinary activity.
Moderate risk.
Class III
Marked limitation in activity.
High risk.
Class IV
Symptoms at rest.
Very high risk, pregnancy contraindicated.
III. Risk Factors for Cardiac Disease in Pregnancy
Pre-existing heart disease (Congenital or Acquired)
History of Rheumatic Fever
Hypertension or Pre-eclampsia
Diabetes Mellitus
Obesity (BMI >30 kg/m²)
Family history of cardiac disease
Anemia or thyroid disorders (which increase cardiac workload)
Smoking, alcohol, or drug abuse
IV. Pathophysiology of Cardiac Disease in Pregnancy
During pregnancy, the cardiovascular system undergoes major changes to support maternal and fetal needs:
Risk for Impaired Gas Exchange related to pulmonary congestion.
Decreased Cardiac Output related to increased cardiac workload.
Risk for Fetal Growth Restriction related to maternal cardiac insufficiency.
C. Nursing Interventions
Educate the mother on activity modification and diet.
Ensure compliance with medications and follow-up visits.
Provide emotional support to reduce anxiety.
Assist in planning for a safe delivery in a tertiary care center.
Pulmonary Disease in Pregnancy:
I. Definition of Pulmonary Disease in Pregnancy
Pulmonary diseases refer to respiratory conditions that affect lung function during pregnancy. Pregnancy-induced physiological changes in the respiratory system can worsen pre-existing pulmonary diseases or contribute to new-onset respiratory complications. These conditions pose risks to both the mother and fetus, requiring careful management.
II. Classification of Pulmonary Diseases in Pregnancy
A. Pre-Existing Pulmonary Conditions (Chronic Diseases)
Asthma (Most Common Pulmonary Disease in Pregnancy)
Chronic Obstructive Pulmonary Disease (COPD)
Pulmonary Tuberculosis (TB)
Cystic Fibrosis (CF)
Pulmonary Hypertension
B. Pregnancy-Related or Acute Pulmonary Diseases
Pulmonary Embolism (PE) – Most Common Cause of Sudden Maternal Death
Acute Respiratory Distress Syndrome (ARDS)
Pneumonia (Bacterial or Viral, including COVID-19 pneumonia)
Aspiration Pneumonitis (Mendelson’s Syndrome in Labor and Anesthesia)
III. Risk Factors for Pulmonary Disease in Pregnancy
History of asthma or other lung diseases
Smoking or exposure to secondhand smoke
Obesity (BMI >30 kg/m²)
Environmental pollutants and occupational exposure
Viral or bacterial infections (Influenza, Tuberculosis, COVID-19)
Antibiotics (Amoxicillin-Clavulanic Acid, Azithromycin – Safe in pregnancy).
Oxygen therapy if SpO₂ <95%.
Hydration and chest physiotherapy to mobilize secretions.
E. Acute Respiratory Distress Syndrome (ARDS) Management
Mechanical Ventilation (In Severe Cases).
ICU Admission for Respiratory Support.
VIII. Delivery Plan for Women with Pulmonary Disease
Condition
Preferred Mode of Delivery
Mild Asthma, Well-Controlled TB
Vaginal Delivery (Preferred)
Severe Pulmonary Hypertension, Uncontrolled Pulmonary Embolism
Cesarean Section (High-Risk Cases)
Intrapartum Management:
Oxygen therapy to maintain maternal SpO₂ >95%.
Continuous fetal heart rate monitoring.
Avoid opioids (Respiratory depressants).
IX. Postpartum Management of Pulmonary Disease
Monitor for post-delivery respiratory complications (Pulmonary Embolism risk remains high).
Encourage early mobilization to prevent blood clots.
Postpartum contraception counseling (Avoid estrogen-based pills in PE history).
X. Midwifery Nursing Care for Pulmonary Disease in Pregnancy
A. Assessment
Monitor respiratory rate, oxygen saturation, and heart rate.
Assess for worsening dyspnea, wheezing, or chest pain.
Check fetal well-being (NST, Doppler studies).
B. Nursing Diagnoses
Ineffective Airway Clearance related to bronchospasm.
Impaired Gas Exchange related to pulmonary congestion.
Risk for Fetal Growth Restriction related to maternal hypoxia.
C. Nursing Interventions
Educate the mother about inhaler techniques and medication adherence.
Encourage breathing exercises and positional adjustments.
Ensure oxygen therapy if saturation drops below 95%.
Encourage infection prevention (Handwashing, Flu and COVID-19 vaccination).
Thyrotoxicosis in Pregnancy:
I. Definition of Thyrotoxicosis in Pregnancy
Thyrotoxicosis refers to an excess of thyroid hormones (T3 and T4) in the bloodstream, leading to hypermetabolic symptoms. In pregnancy, thyrotoxicosis can be caused by Graves’ disease (most common cause), gestational transient thyrotoxicosis (GTT), toxic multinodular goiter, or thyroiditis. Uncontrolled thyrotoxicosis poses significant risks to both the mother and fetus.
II. Classification of Thyrotoxicosis in Pregnancy
A. Causes of Thyrotoxicosis
Cause
Mechanism
Pregnancy Relevance
Graves’ Disease (Autoimmune)
Thyroid-stimulating antibodies cause excessive hormone production.
Most common cause of persistent hyperthyroidism in pregnancy.
Gestational Transient Thyrotoxicosis (GTT)
High hCG stimulates thyroid function in early pregnancy.
Usually resolves spontaneously by the second trimester.
Toxic Multinodular Goiter
Autonomously functioning thyroid nodules produce excess hormones.
Can persist postpartum, requiring treatment.
Subacute Thyroiditis
Inflammation leads to transient hormone release.
Self-limiting; often post-viral.
Struma Ovarii (Rare)
Ovarian tumor secretes thyroid hormones.
May require surgery.
III. Risk Factors for Thyrotoxicosis in Pregnancy
Personal or family history of thyroid disease (Graves’ Disease, Goiter).
Autoimmune diseases (Type 1 Diabetes, Lupus).
Multiple pregnancies (Higher hCG levels increase risk of GTT).
Molar pregnancy (Very high hCG stimulates thyroid).
Excessive iodine intake or thyroid hormone supplementation.
IV. Pathophysiology of Thyrotoxicosis in Pregnancy
Normal Pregnancy and Thyroid Function
Thyroid hormone production increases by 30-50% due to higher metabolic demands.
Human Chorionic Gonadotropin (hCG) mimics TSH, mildly stimulating the thyroid.
Estrogen increases Thyroxine-Binding Globulin (TBG), increasing total T4 levels.
Pathophysiology of Hyperthyroidism (Graves’ Disease)
Thyroid storm risk during labor – ICU support may be needed.
IX. Postpartum Management
Monitor for Postpartum Thyroiditis (Up to 6 months postpartum).
Neonatal Thyroid Screening (TSH, Free T4) in newborns of hyperthyroid mothers.
Contraception Counseling: Avoid estrogen-containing contraceptives in women with cardiac complications.
X. Midwifery Nursing Care for Thyrotoxicosis in Pregnancy
A. Assessment
Monitor maternal heart rate, blood pressure, and fetal heart rate.
Assess for signs of worsening hyperthyroidism (Weight loss, tremors, palpitations).
Monitor for thyroid storm (Fever, tachycardia, confusion, cardiac failure).
B. Nursing Diagnoses
Risk for Imbalanced Nutrition related to increased metabolism.
Risk for Fetal Growth Restriction related to maternal thyrotoxicosis.
Risk for Postpartum Hemorrhage related to hyperthyroidism.
C. Nursing Interventions
Educate on medication compliance (PTU/MMI adjustments).
Encourage rest, hydration, and stress reduction.
Monitor fetal growth and neonatal thyroid function postpartum.
Sexually Transmitted Diseases (STDs) in Pregnancy:
I. Definition of Sexually Transmitted Diseases (STDs) in Pregnancy
Sexually Transmitted Diseases (STDs), also called Sexually Transmitted Infections (STIs), are infections spread through sexual contact (vaginal, anal, or oral sex). STDs in pregnancy pose serious risks to both the mother and fetus, leading to preterm labor, congenital infections, stillbirth, and neonatal complications.
II. Classification of STDs in Pregnancy
A. Bacterial STDs
STD
Causative Organism
Effects in Pregnancy
Chlamydia
Chlamydia trachomatis
Preterm labor, neonatal conjunctivitis, pneumonia
Gonorrhea
Neisseria gonorrhoeae
Preterm labor, neonatal conjunctivitis, sepsis
Syphilis
Treponema pallidum
Congenital syphilis, stillbirth, miscarriage
Bacterial Vaginosis (BV)
Gardnerella vaginalis
Preterm birth, postpartum infections
B. Viral STDs
STD
Causative Organism
Effects in Pregnancy
Human Immunodeficiency Virus (HIV)
HIV virus
Vertical transmission, fetal immunodeficiency
Herpes Simplex Virus (HSV-2)
Herpes simplex virus
Neonatal herpes, stillbirth, encephalitis
Human Papillomavirus (HPV)
HPV virus
Genital warts, risk of respiratory papillomatosis in newborn
Hepatitis B (HBV)
Hepatitis B virus
Chronic hepatitis in newborn, neonatal liver failure
C. Parasitic and Protozoal STDs
STD
Causative Organism
Effects in Pregnancy
Trichomoniasis
Trichomonas vaginalis
Preterm labor, low birth weight
III. Risk Factors for STDs in Pregnancy
Multiple sexual partners
Unprotected sex (without condoms)
History of previous STDs
Low socioeconomic status (Limited healthcare access)
Substance abuse (Increased risky behavior)
HIV infection (Higher risk of co-infections)
IV. Pathophysiology of STDs in Pregnancy
Bacterial STDs – Bacteria infect the genital tract, causing inflammation and complications like preterm labor and neonatal infections.
Viral STDs – Viruses spread through the bloodstream or contact with infected genital secretions, leading to fetal transmission during pregnancy or birth.
Protozoal STDs – Trichomonas vaginalis causes vaginal inflammation, increasing the risk of preterm birth.
V. Clinical Features of STDs in Pregnancy
A. Maternal Symptoms
Vaginal discharge (Foul-smelling, yellow-green, frothy, or purulent in gonorrhea, trichomoniasis).
Painful urination (Dysuria – Common in chlamydia, gonorrhea, herpes).
Genital ulcers or sores (Painful in herpes, painless in syphilis).
Lower abdominal pain (Pelvic Inflammatory Disease in untreated bacterial infections).
Acyclovir 400 mg TID (Start at 36 weeks to prevent neonatal herpes)
Hepatitis B
Tenofovir (Prevents fetal transmission)
HPV (Genital Warts)
No treatment needed in pregnancy unless symptomatic
C. Protozoal STDs Treatment
STD
First-Line Treatment
Trichomoniasis
Metronidazole 2g single dose
VIII. Delivery Plan for Pregnant Women with STDs
Condition
Mode of Delivery
HIV (Undetectable Viral Load)
Vaginal delivery
HIV (High Viral Load >1000 copies/mL)
Cesarean section at 38 weeks
Active Genital Herpes
Cesarean section to prevent neonatal herpes
Syphilis, Chlamydia, Gonorrhea
Vaginal delivery with antibiotic prophylaxis
Hepatitis B Positive Mother
Vaginal delivery + HBV Vaccine & HBIG for baby
IX. Postpartum Management
Neonatal prophylaxis (HBV Vaccine + HBIG for Hepatitis B).
Newborn eye prophylaxis (Erythromycin eye drops for gonorrhea/chlamydia).
Neonatal HIV testing and ART prophylaxis if mother is HIV positive.
Maternal contraception counseling to prevent future STDs.
X. Midwifery Nursing Care for STDs in Pregnancy
A. Assessment
Monitor for vaginal discharge, genital lesions, fever.
Assess for fetal growth restriction (IUGR, low birth weight).
Screen high-risk patients for STDs.
B. Nursing Diagnoses
Risk for Infection Transmission related to untreated STDs.
Risk for Fetal Growth Restriction related to maternal infection.
Knowledge Deficit related to prevention and safe sexual practices.
C. Nursing Interventions
Educate about safe sex practices and partner treatment.
Ensure compliance with prescribed medications.
Support emotional well-being and reduce stigma.
Provide postpartum follow-up for neonatal screening.
Human Immunodeficiency Virus (HIV) in Pregnancy:
I. Definition of HIV in Pregnancy
Human Immunodeficiency Virus (HIV) is a retrovirus that attacks the immune system, specifically CD4 T cells, leading to progressive immune deficiency. When untreated, it progresses to Acquired Immunodeficiency Syndrome (AIDS). HIV in pregnancy is of critical concern as it can be transmitted from mother to child during pregnancy, labor, delivery, or breastfeeding.
II. Classification of HIV in Pregnancy
A. Based on Disease Progression (WHO Staging)
Stage
Clinical Features
Stage 1 (Asymptomatic HIV)
No symptoms, normal CD4 count.
Stage 2 (Mild HIV Symptoms)
Minor skin infections, weight loss <10%.
Stage 3 (Advanced HIV)
Chronic diarrhea, weight loss >10%, oral candidiasis, anemia.
Stage 4 (AIDS)
Severe opportunistic infections, tuberculosis, malignancies.
Long-term contraception (Injectable, IUD, Implant) to prevent unintended pregnancy.
Avoid estrogen-based contraceptives with certain ART drugs (Efavirenz interacts with oral pills).
X. Midwifery Nursing Care for HIV in Pregnancy
A. Assessment
Monitor maternal weight, CD4 count, and viral load.
Assess for opportunistic infections (TB, candidiasis, pneumonia).
Screen for anemia, malnutrition, and co-infections (Hepatitis B, Syphilis).
B. Nursing Diagnoses
Risk for Infection related to immunosuppression.
Risk for Fetal Growth Restriction related to maternal HIV.
Knowledge Deficit related to HIV transmission prevention.
C. Nursing Interventions
Ensure ART adherence (Explain benefits to mother and baby).
Provide psychological support (Reduce stigma, encourage disclosure to partner).
Educate on safe sex practices to prevent reinfection.
Encourage exclusive breastfeeding only if the mother is on ART.
Monitor newborn for HIV and ensure prophylactic treatment.
Rh Incompatibility in Pregnancy:
I. Definition of Rh Incompatibility
Rh incompatibility occurs when an Rh-negative mother carries an Rh-positive fetus, leading to maternal immune sensitization against fetal red blood cells. If untreated, it can result in hemolytic disease of the fetus and newborn (HDFN), causing severe anemia, jaundice, hydrops fetalis, and stillbirth.
II. Classification of Rh Incompatibility
A. Based on Maternal and Fetal Blood Group
Maternal Blood Type
Fetal Blood Type
Risk of Rh Incompatibility
Rh-negative
Rh-positive
High Risk
Rh-negative
Rh-negative
No Risk
Rh-positive
Any fetal Rh type
No Risk
B. Based on Sensitization Status
Type
Description
Primary Sensitization
First exposure to Rh-positive RBCs → Mild antibody response
B. Management of Sensitized Pregnancies (If Indirect Coombs Test is Positive)
Fetal Condition
Management
Mild Cases (No Anemia)
Monitor with serial ultrasounds and Doppler studies
Moderate Anemia
Intrauterine Transfusion (IUT) via umbilical vein
Severe Hydrops Fetalis
Early delivery (Usually before 37 weeks)
C. Postnatal Management for Affected Newborns
Neonatal Condition
Treatment
Neonatal Jaundice
Phototherapy (First-Line Treatment)
Severe Jaundice / Anemia
Exchange transfusion (Replaces infant’s blood)
Severe Anemia (Low Hemoglobin)
Packed RBC transfusion
VIII. Delivery Plan for Rh-Incompatible Pregnancies
Condition
Mode of Delivery
No fetal anemia
Vaginal delivery (Preferred)
Fetal distress or hydrops fetalis
Early induction or Cesarean Section
IX. Postpartum Management of Rh-Negative Mothers
Administer RhoGAM within 72 hours postpartum if the newborn is Rh-positive.
Monitor newborn for jaundice, anemia, and kernicterus.
Counsel mother on risks for future pregnancies and importance of RhIg prophylaxis.
X. Midwifery Nursing Care for Rh Incompatibility
A. Assessment
Check maternal Rh status in the first trimester.
Monitor for signs of fetal anemia (Ultrasound, Doppler MCA).
Screen for maternal antibodies (Indirect Coombs Test).
B. Nursing Diagnoses
Risk for Fetal Hemolysis related to Rh incompatibility.
Knowledge Deficit related to Rh sensitization and prevention.
Risk for Neonatal Hyperbilirubinemia related to maternal-fetal blood incompatibility.
C. Nursing Interventions
Educate mothers about RhIg prophylaxis and the importance of follow-up tests.
Monitor for sensitization events (Vaginal bleeding, trauma, procedures).
Ensure timely administration of anti-D immunoglobulin.
Support emotional well-being in cases of fetal complications.
Infections in pregnancy
Infections in Pregnancy:
Infections during pregnancy pose significant risks to both the mother and fetus. They can be bacterial, viral, protozoal, fungal, or urinary tract infections (UTIs). Some infections are mild, while others can cause preterm labor, fetal abnormalities, stillbirth, or severe maternal illness. Early diagnosis and proper management are crucial to ensuring a safe pregnancy and delivery.
I. Urinary Tract Infection (UTI) in Pregnancy
Definition
A urinary tract infection (UTI) is a bacterial infection of any part of the urinary system, including the bladder (cystitis), urethra (urethritis), or kidneys (pyelonephritis). Pregnant women are more susceptible due to hormonal changes, urinary stasis, and increased bladder pressure from the growing uterus.
Causes
Escherichia coli (E. coli) (Most common)
Klebsiella pneumoniae
Group B Streptococcus (GBS)
Proteus mirabilis
Symptoms
Burning sensation during urination (dysuria)
Frequent urination (polyuria)
Cloudy, foul-smelling urine
Lower abdominal pain
Fever and chills (if the infection spreads to the kidneys)
Complications
Preterm labor and preterm premature rupture of membranes (PPROM)
Pyelonephritis (Kidney infection, which can lead to sepsis)
Low birth weight baby
Increased risk of postpartum infections
Diagnosis
Urine Culture and Sensitivity Test to identify bacteria
Urinalysis (Leukocytes, nitrites, and bacteria in urine confirm UTI)
Management
Antibiotics (Safe in Pregnancy) – Amoxicillin, Cephalexin, Nitrofurantoin (Avoid Trimethoprim in the first trimester)
Increased fluid intake to flush out bacteria
Frequent urination to prevent bacterial multiplication
Proper perineal hygiene to prevent reinfection
II. Bacterial Infections in Pregnancy
1. Group B Streptococcus (GBS) Infection
Streptococcus agalactiae is a bacteria that colonizes the genital tract.
Asymptomatic in the mother but can cause severe neonatal sepsis, pneumonia, and meningitis.
Screening at 35-37 weeks pregnancy with vaginal-rectal swab.
Treatment: Intrapartum IV Penicillin or Ampicillin to prevent neonatal infection.
2. Bacterial Vaginosis (BV)
Caused by an imbalance of vaginal bacteria (Gardnerella vaginalis overgrowth).
Symptoms include thin, grayish-white vaginal discharge with a fishy odor.
Associated with preterm birth and postpartum infections.
Treatment: Metronidazole (Safe in Pregnancy).
3. Listeriosis
Listeria monocytogenes is a bacteria found in contaminated unpasteurized dairy, deli meats, and raw vegetables.
Causes fever, flu-like symptoms, and miscarriage or stillbirth.
Treatment: IV Ampicillin or Penicillin.
Pregnant women should avoid raw or unpasteurized foods.
III. Viral Infections in Pregnancy
1. Cytomegalovirus (CMV)
A common viral infection transmitted through body fluids.
Leading cause of congenital infections, causing microcephaly, hearing loss, and developmental delays in newborns.
Diagnosis: CMV IgG and IgM serology, PCR from amniotic fluid.
No specific treatment; hand hygiene and avoiding infected fluids help prevent transmission.
2. Herpes Simplex Virus (HSV)
Genital herpes (HSV-2) is transmitted sexually and can cause neonatal herpes, leading to neurological damage or death.
Treatment: Spiramycin to reduce fetal transmission.
3. Trichomoniasis
Trichomonas vaginalis is a sexually transmitted protozoal infection.
Symptoms: Greenish frothy vaginal discharge, itching, and pain during urination.
Treatment: Metronidazole (Safe in Pregnancy).
V. Fungal Infections in Pregnancy
1. Candidiasis (Vaginal Yeast Infection)
Caused by Candida albicans, due to hormonal changes in pregnancy.
Symptoms: Thick white cottage cheese-like vaginal discharge, itching, burning.
Treatment: Clotrimazole or Miconazole vaginal cream (Avoid oral fluconazole in pregnancy).
2. Systemic Fungal Infections (Rare but Severe)
Cryptococcus, Aspergillosis can cause pneumonia or meningitis in immunocompromised pregnant women.
Management: Amphotericin B for severe cases.
VI. Midwifery Nursing Care for Infections in Pregnancy
Assessment
Routine screening for infections in antenatal care (HIV, Syphilis, HBV, GBS).
Assess for fever, vaginal discharge, urinary symptoms, or fetal growth restriction.
Monitor fetal well-being (Non-stress test, ultrasound for infections like CMV).
Nursing Diagnoses
Risk for Infection Transmission to fetus.
Risk for Preterm Labor related to infection.
Knowledge Deficit related to prevention of infections.
Nursing Interventions
Education on hygiene and infection prevention (Handwashing, Safe sex practices).
Ensure compliance with prescribed antibiotics and antivirals.
Advise avoidance of high-risk foods (Unpasteurized dairy, raw meats, cat litter).
Monitor fetal heart rate and growth in maternal infections.
Provide emotional support for women diagnosed with HIV or other chronic infections.
Appendicitis in Pregnancy:
I. Definition of Appendicitis in Pregnancy
Appendicitis is an inflammation of the appendix, which can lead to rupture, peritonitis, and sepsis if untreated. It is the most common non-obstetric surgical emergency during pregnancy, occurring in 1 in 1000 pregnancies. Delayed diagnosis increases the risk of complications, making timely surgical intervention essential.
II. Causes of Appendicitis in Pregnancy
Obstruction of the appendix by fecaliths (hardened stool), lymphoid hyperplasia, parasites, or tumors.
Increased intra-abdominal pressure due to the growing uterus, which can compress the appendix and lead to poor drainage.
Hormonal changes affecting gastrointestinal motility, increasing the risk of appendiceal blockage.
Infections causing secondary bacterial invasion of the appendix, leading to inflammation and pus formation.
III. Pathophysiology of Appendicitis in Pregnancy
Obstruction of the appendix → Mucus accumulation → Bacterial overgrowth (E. coli, Bacteroides).
Increased pressure leads to ischemia (loss of blood supply).
IX. Midwifery Nursing Care for Appendicitis in Pregnancy
A. Assessment
Monitor pain intensity and location.
Observe for fever, tachycardia, or signs of sepsis.
Assess fetal well-being using fetal heart rate (FHR) monitoring.
Check for preterm labor symptoms (contractions, cervical changes).
B. Nursing Diagnoses
Acute Pain related to appendiceal inflammation.
Risk for Infection related to surgical procedure or perforation.
Risk for Preterm Labor related to peritoneal irritation.
Anxiety related to fetal health concerns.
C. Nursing Interventions
Provide pain relief and emotional support.
Educate the patient about the need for surgical intervention.
Ensure fetal monitoring before and after surgery.
Administer prescribed IV fluids, antibiotics, and pain relievers.
Encourage early ambulation post-surgery to prevent complications.
Monitor for signs of preterm labor and educate on warning signs (abdominal tightening, vaginal bleeding, fluid leakage).
Acute Abdomen in Pregnancy:
I. Definition of Acute Abdomen in Pregnancy
Acute abdomen refers to severe abdominal pain of sudden onset, requiring urgent medical or surgical intervention. In pregnancy, it presents a diagnostic challenge due to physiological changes, including the displacement of abdominal organs by the growing uterus. Acute abdomen may be caused by obstetric, gynecological, gastrointestinal, urological, or vascular conditions, some of which are life-threatening for both the mother and fetus.
II. Causes of Acute Abdomen in Pregnancy
Acute abdomen in pregnancy can be categorized based on the system affected:
A. Obstetric Causes (Pregnancy-Related)
Ectopic Pregnancy – Ruptured ectopic pregnancy leads to severe pain, vaginal bleeding, and shock.
Placental Abruption – Premature separation of the placenta causes severe abdominal pain, vaginal bleeding, and fetal distress.
Laparoscopic Surgery (Preferred in First and Second Trimesters) – For appendicitis, cholecystitis, ovarian torsion.
Laparotomy (If Required in Third Trimester or Severe Peritonitis).
Cesarean Section (If Fetal Distress with Uterine Rupture or Abruption).
VIII. Midwifery Nursing Care for Acute Abdomen in Pregnancy
A. Assessment
Monitor maternal pain intensity, fetal heart rate, and vital signs.
Observe for signs of sepsis (Fever, tachycardia, hypotension).
Monitor contractions to rule out preterm labor.
Assess for signs of fetal distress (Non-reactive NST, decreased fetal movements).
B. Nursing Diagnoses
Acute Pain related to inflammation or obstruction.
Risk for Preterm Labor related to abdominal distress.
Risk for Fetal Hypoxia related to maternal hemodynamic instability.
C. Nursing Interventions
Administer IV fluids, antibiotics, and pain medications as prescribed.
Ensure timely referral for surgical intervention if needed.
Provide emotional support and education on treatment options.
Monitor fetal well-being with continuous NST and Doppler ultrasound.
Hydramnios (Polyhydramnios) in Pregnancy:
I. Definition of Hydramnios (Polyhydramnios)
Hydramnios, also known as polyhydramnios, is a condition characterized by excessive accumulation of amniotic fluid in the amniotic sac during pregnancy. It is defined as amniotic fluid index (AFI) >25 cm or a single deepest pocket >8 cm on ultrasound. Hydramnios can lead to maternal discomfort, preterm labor, fetal malformations, and perinatal complications.
II. Classification of Hydramnios
Hydramnios is classified based on severity and onset:
A. Based on Severity
Mild Hydramnios – AFI 25-30 cm (Most common, often asymptomatic).
Moderate Hydramnios – AFI 30-35 cm (Increased maternal discomfort).
Severe Hydramnios – AFI >35 cm (High risk of complications like preterm labor and fetal abnormalities).
B. Based on Onset
Acute Hydramnios – Rapid accumulation of amniotic fluid in a short time (Occurs early in pregnancy, associated with fetal malformations).
Chronic Hydramnios – Gradual accumulation of amniotic fluid over time (More common, associated with maternal diabetes or fetal anomalies).
III. Causes of Hydramnios
A. Maternal Causes
Diabetes Mellitus – High fetal glucose levels cause polyuria, leading to excess amniotic fluid.
Rh Incompatibility – Causes fetal anemia and hydrops fetalis, leading to fluid accumulation.
Multiple Pregnancies (Twins, Triplets) – Increased fluid production due to high fetal urine output or twin-to-twin transfusion syndrome (TTTS).
B. Fetal Causes
Fetal Anomalies (Most Common Cause)
Anencephaly – Absence of fetal swallowing reflex leads to fluid buildup.
Given before 32 weeks (Contraindicated later due to risk of fetal ductus arteriosus closure).
Early Delivery (If Severe Complications Develop)
Induction of labor at 37-38 weeks if stable.
Emergency Cesarean Section if cord prolapse, placental abruption, or severe fetal distress occurs.
IX. Midwifery Nursing Care for Hydramnios
A. Assessment
Monitor fundal height, AFI levels, and fetal heart rate.
Check for signs of preterm labor (Contractions, cervical changes).
Assess for maternal respiratory discomfort and edema.
B. Nursing Diagnoses
Risk for Preterm Labor related to uterine overdistension.
Risk for Maternal Respiratory Distress related to diaphragm compression.
Risk for Fetal Distress related to umbilical cord prolapse.
C. Nursing Interventions
Educate the mother on fetal kick counts and warning signs (Preterm labor, sudden gush of fluid).
Provide emotional support (Anxiety due to risk of fetal anomalies).
Encourage side-lying position to reduce pressure on major blood vessels.
Assist in amnioreduction procedures (Monitor for fetal bradycardia post-procedure).
Oligohydramnios in Pregnancy:
I. Definition of Oligohydramnios
Oligohydramnios is a condition characterized by low levels of amniotic fluid during pregnancy, defined as Amniotic Fluid Index (AFI) <5 cm or Deepest Vertical Pocket (DVP) <2 cm on ultrasound. It is associated with fetal growth restriction, umbilical cord compression, and increased perinatal morbidity and mortality.
II. Classification of Oligohydramnios
Oligohydramnios is classified based on onset and severity:
A. Based on Severity
Mild Oligohydramnios – AFI 4-5 cm (Minimal impact, close monitoring needed).
Moderate Oligohydramnios – AFI 2-4 cm (May require intervention).
Severe Oligohydramnios – AFI <2 cm (High risk of fetal complications, urgent intervention needed).
B. Based on Onset
Early-Onset Oligohydramnios (Before 28 weeks)
Associated with fetal congenital anomalies, renal agenesis, and PROM (Preterm Rupture of Membranes).
High risk of pulmonary hypoplasia (Underdeveloped lungs) and limb deformities.
Late-Onset Oligohydramnios (After 28 weeks)
Associated with placental insufficiency, post-term pregnancy, or maternal hypertension.
Increases risk of fetal distress, cord compression, and meconium aspiration syndrome.
III. Causes of Oligohydramnios
A. Maternal Causes
Hypertension (Preeclampsia, Eclampsia, Chronic Hypertension) – Causes placental insufficiency, leading to reduced amniotic fluid production.
Dehydration or Hypovolemia – Maternal fluid imbalance can decrease placental perfusion.
Diabetes Mellitus – Poorly controlled diabetes can cause placental dysfunction, leading to low amniotic fluid.
Fetal Surveillance (NST, BPP, Doppler Studies every 1-2 weeks).
Monitor for Preterm Labor Symptoms (Contractions, Cervical Changes).
B. Severe Oligohydramnios (Interventional Management)
Amnioinfusion (Intrauterine Fluid Injection)
Saline or Ringer’s lactate is infused into the amniotic sac via a catheter to improve cushioning and reduce cord compression.
Labor Induction (If Fetal Distress or Post-Term Pregnancy)
At 37-38 weeks in stable cases.
Emergency Cesarean Section if fetal distress or cord compression is severe.
IX. Midwifery Nursing Care for Oligohydramnios
A. Assessment
Monitor maternal hydration and blood pressure.
Assess for signs of fetal distress (Reduced movements, abnormal CTG).
Observe for PROM/PPROM symptoms (Leaking fluid, infection signs).
B. Nursing Interventions
Encourage maternal hydration to improve fluid levels.
Educate mother on fetal movement counting.
Provide emotional support (Anxiety due to fetal complications).
Assist in amnioinfusion procedures if required.
Multiple Pregnancy:
I. Definition of Multiple Pregnancy
Multiple pregnancy occurs when a woman carries two or more fetuses simultaneously. It results from fertilization of multiple ova (Dizygotic twins or more) or division of a single fertilized ovum (Monozygotic twins or more). Multiple gestations are associated with higher maternal and fetal risks, including preterm birth, preeclampsia, fetal growth restriction, and neonatal complications.
II. Classification of Multiple Pregnancy
A. Based on Zygosity (Genetic Origin)
Dizygotic (Fraternal) Twins (Most Common, ~70%)
Develop from two separate eggs fertilized by two different sperms.
Each twin has its own placenta (dichorionic) and amniotic sac (diamniotic).
Always non-identical and can be same or different sex.
Influenced by maternal age, family history, race, and fertility treatments.
Monozygotic (Identical) Twins (~30%)
Develop from a single fertilized egg that splits into two embryos.
Genetically identical, always same sex.
May share placenta and/or amniotic sac, depending on when division occurs.
B. Based on Chorionicity and Amnionicity (Placental and Amniotic Sac Configuration)
Dichorionic-Diamniotic (DCDA) Twins
Each fetus has its own placenta and amniotic sac.
Occurs in all dizygotic twins and early-splitting monozygotic twins (Day 1-3 after fertilization).
Lowest risk among multiple pregnancies.
Monochorionic-Diamniotic (MCDA) Twins
Twins share a placenta but have separate amniotic sacs.
Occurs when monozygotic twins split between Day 4-8.
Risk of Twin-to-Twin Transfusion Syndrome (TTTS).
Monochorionic-Monoamniotic (MCMA) Twins
Twins share both placenta and amniotic sac.
Occurs when monozygotic twins split between Day 8-13.
High risk of cord entanglement, TTTS, and preterm labor.
Conjoined Twins (Rare, <1%)
Occurs when splitting happens after Day 13.
Twins remain physically connected at some body part.
III. Causes and Risk Factors for Multiple Pregnancy
Increased placental demands lead to higher maternal blood volume, increasing the risk of hypertension and anemia.
Overdistension of the uterus increases the likelihood of preterm labor and uterine rupture.
Increased risk of umbilical cord abnormalities, especially in monochorionic twins (Cord entanglement in MCMA twins).
Twin-to-Twin Transfusion Syndrome (TTTS) may occur in monochorionic twins, leading to unequal blood flow and growth restriction.
V. Clinical Features of Multiple Pregnancy
A. Maternal Symptoms
Excessive nausea and vomiting (Hyperemesis Gravidarum) due to higher hCG levels.
Rapid and excessive weight gain.
Large-for-gestational-age uterus (Fundal height greater than expected).
Increased fetal movements (Early and more pronounced movements).
B. Fetal and Neonatal Effects
Preterm Birth (Common, >50% in twin pregnancies, higher in triplets and beyond).
Low Birth Weight (<2500g in most twins, <1500g in triplets).
Twin-to-Twin Transfusion Syndrome (TTTS) in Monochorionic Twins – One twin becomes overloaded with blood (Polycythemia), while the other suffers anemia and growth restriction.
Cord Entanglement and Fetal Demise (MCMA Twins).
VI. Diagnosis of Multiple Pregnancy
A. Clinical Examination
Fundal height larger than expected for gestational age.
Multiple fetal heart tones heard on Doppler.
B. Ultrasonography (Gold Standard Test)
First-trimester ultrasound confirms number of fetuses, chorionicity, and amnionicity.
Iron and folic acid supplementation to prevent anemia.
Avoid excessive physical strain, and monitor for preterm labor signs.
Delivery Plan Based on Chorionicity
Dichorionic-Diamniotic (DCDA) Twins:Vaginal delivery possible if both twins in cephalic presentation.
Monochorionic-Diamniotic (MCDA) Twins:Elective delivery at 36-37 weeks.
Monochorionic-Monoamniotic (MCMA) Twins:Planned C-section at 32-34 weeks due to high cord entanglement risk.
Triplets or Higher-Order Multiples:Elective C-section recommended.
IX. Midwifery Nursing Care for Multiple Pregnancy
Monitor maternal BP, weight gain, and fetal growth.
Educate on preterm labor warning signs.
Provide psychological support due to higher pregnancy anxiety.
Assist in early identification and management of complications like TTTS.
Support lactation counseling for breastfeeding multiples.
Abnormalities of Placenta and Umbilical Cord:
I. Definition of Placental and Umbilical Cord Abnormalities
Placental and umbilical cord abnormalities refer to structural, functional, or positional defects that can affect maternal-fetal circulation, leading to complications such as intrauterine growth restriction (IUGR), preterm labor, fetal distress, or stillbirth. These abnormalities can impact oxygen and nutrient exchange, increasing risks for both mother and baby.
II. Classification of Placental Abnormalities
A. Abnormalities of Placental Location
Placenta Previa – The placenta partially or completely covers the cervix, leading to painless vaginal bleeding in late pregnancy.
Placenta Accreta Spectrum – Abnormal attachment of the placenta to the uterine wall, causing difficulty in placental separation after birth.
Placenta Accreta – Placenta adheres to the myometrium.
Placenta Increta – Placenta invades the myometrium.
Placenta Percreta – Placenta penetrates through the uterus into surrounding organs (e.g., bladder).
B. Abnormalities of Placental Shape and Development
Succenturiate Lobe – The placenta has an extra lobe, increasing the risk of retained placenta and postpartum hemorrhage (PPH).
Bilobed Placenta – Placenta is divided into two equal lobes, connected by blood vessels.
Circumvallate Placenta – The placental edges curl inward, increasing the risk of placental abruption and fetal distress.
C. Abnormalities of Placental Function
Placental Insufficiency – The placenta fails to provide adequate oxygen and nutrients, leading to IUGR and fetal hypoxia.
Chorioamnionitis – Infection of the placenta and amniotic fluid, leading to preterm labor, neonatal sepsis, and maternal fever.
Placental Abruption – Premature separation of the placenta from the uterine wall, causing painful vaginal bleeding, fetal distress, or stillbirth.
III. Classification of Umbilical Cord Abnormalities
A. Structural Abnormalities
Short Cord (<35 cm) – Increases the risk of cord rupture, fetal distress, and difficulty in delivery.
Long Cord (>80 cm) – Increases risk of cord prolapse, knots, and entanglement.
Velamentous Cord Insertion – The cord inserts into the fetal membranes instead of the placenta, making blood vessels vulnerable to rupture (Vasa Previa).
Marginal Cord Insertion (Battledore Placenta) – The cord attaches at the placental edge, increasing risk of fetal growth restriction and preterm labor.
B. Vascular Abnormalities
Single Umbilical Artery (SUA) – Instead of two arteries and one vein, the umbilical cord has only one artery, increasing the risk of congenital anomalies, IUGR, and preterm birth.
Umbilical Cord Knots – True knots (tight) can restrict blood flow, causing fetal distress or stillbirth.
Umbilical Cord Prolapse – The cord slips ahead of the fetal head, leading to cord compression and emergency cesarean section.
IV. Causes and Risk Factors for Placental and Cord Abnormalities
A. Maternal Factors
Previous cesarean sections (Increases risk of placenta previa and accreta).
Advanced maternal age (>35 years).
Multiple pregnancies (Increases risk of abnormal cord insertion).
Hypertension, preeclampsia, or diabetes (Contributes to placental insufficiency).
Substance use (Smoking, alcohol, drug abuse) (Increases risk of placental abruption and insufficiency).
B. Fetal Factors
Congenital anomalies (Associated with SUA and velamentous insertion).
Malpresentations (Breech, transverse lie increases risk of cord prolapse).
Twin-to-Twin Transfusion Syndrome (TTTS, Common in monochorionic twins).
C. Placental Factors
Previous history of placental abnormalities.
Uterine scarring from surgery, myomectomy, or infections.
V. Pathophysiology of Placental and Cord Abnormalities
Placental location abnormalities (Placenta previa) obstruct the cervical opening, leading to third-trimester bleeding.
Placental attachment defects (Placenta accreta spectrum) cause incomplete placental separation, increasing risk of postpartum hemorrhage.
Placental detachment (Abruptio placentae) leads to fetal hypoxia, preterm labor, and maternal hemorrhage.
Cord abnormalities (Velamentous insertion, single artery, knots) compromise fetal blood flow, leading to IUGR and fetal distress.
Complete Blood Count (CBC) – Detects maternal anemia from bleeding.
Coagulation Profile – Checks for clotting abnormalities in abruptio placentae.
Blood Group & Rh Typing – Essential in cases of bleeding for transfusion planning.
VIII. Complications of Placental and Cord Abnormalities
A. Maternal Complications
Postpartum Hemorrhage (PPH) – High risk in placenta previa and accreta.
Hypovolemic Shock (From excessive bleeding in abruptio placentae).
Increased Cesarean Deliveries (Due to placental or cord abnormalities).
Sepsis (In chorioamnionitis cases).
B. Fetal and Neonatal Complications
Preterm Birth (Common in placental abnormalities).
Stillbirth (In severe cases of abruptio placentae or cord accidents).
Neonatal Hypoxia (Due to cord compression or placental insufficiency).
IX. Management of Placental and Cord Abnormalities
Antenatal Care
Serial ultrasounds to monitor placental function and cord abnormalities.
Corticosteroids for fetal lung maturity if preterm birth is anticipated.
Delivery Planning
Placenta Previa:Elective cesarean at 37 weeks.
Placenta Accreta Spectrum:Cesarean hysterectomy if placenta cannot be removed safely.
Umbilical Cord Prolapse:Emergency C-section for fetal distress.
X. Midwifery Nursing Care for Placental and Cord Abnormalities
Monitor maternal bleeding, fetal heart rate, and uterine contractions.
Prepare for emergency interventions (Blood transfusions, C-section).
Educate the mother on recognizing fetal distress signs.
Intrauterine Growth Restriction (IUGR):
I. Definition of Intrauterine Growth Restriction (IUGR)
Intrauterine Growth Restriction (IUGR) is a condition in which fetal growth is slower than expected for gestational age, leading to a fetal weight below the 10th percentile for gestational age. IUGR increases the risk of perinatal morbidity, mortality, stillbirth, neonatal complications, and long-term developmental delays.
II. Classification of IUGR
A. Based on Growth Pattern
Symmetric IUGR (20-30%)
Fetus is proportionally small (Head and body grow at the same reduced rate).
Usually caused by early pregnancy insults (Chromosomal abnormalities, congenital infections, severe malnutrition).
Associated with permanent growth restriction and neurological impairment.
Asymmetric IUGR (70-80%)
Head circumference is normal, but the body and abdomen are small.
Caused by placental insufficiency (Maternal hypertension, preeclampsia, smoking, malnutrition, diabetes).
Fetus adapts by diverting blood to vital organs (Brain, heart, adrenal glands), known as the brain-sparing effect.
Better prognosis if delivered early.
B. Based on Onset
Early-Onset IUGR (<28 weeks gestation)
More severe and associated with chromosomal abnormalities, severe maternal diseases, and congenital infections.
Higher risk of stillbirth and neonatal complications.
Late-Onset IUGR (>28 weeks gestation)
More common and usually due to placental insufficiency or maternal hypertension.
Better prognosis with timely intervention.
III. Causes of IUGR
A. Maternal Causes
Hypertension (Chronic, Gestational, or Preeclampsia) – Reduces placental blood flow, leading to placental insufficiency.
Smoking, Alcohol, Drug Abuse – Causes vasoconstriction and poor placental function.
Malnutrition (Low Protein & Iron Deficiency) – Decreases fetal nutrient supply.
Corticosteroids (If delivery expected before 34 weeks for lung maturity).
Maternal Nutrition & Hydration (Iron, protein, and folic acid supplements).
Left Lateral Positioning to Improve Placental Perfusion.
Delivery Planning
Mild IUGR (Normal Doppler):Deliver at 38-39 weeks (Vaginal).
Severe IUGR with abnormal Doppler:Deliver at 34-36 weeks (Induction or Cesarean).
Fetal Distress or Absent Doppler Flow:Immediate Cesarean Section.
IX. Midwifery Nursing Care for IUGR
A. Assessment
Monitor maternal weight gain and fundal height.
Observe for signs of fetal distress (Reduced movements, abnormal CTG).
Assess maternal BP for preeclampsia.
B. Nursing Interventions
Educate mother on fetal movement counting (Kick count monitoring).
Ensure proper maternal nutrition and hydration.
Support psychological well-being (Anxiety about fetal growth restriction).
Assist in preparation for early delivery if needed.
Intrauterine Fetal Death (IUFD):
I. Definition of Intrauterine Fetal Death (IUFD)
Intrauterine fetal death (IUFD) refers to the death of a fetus in utero after 20 weeks of gestation but before delivery. IUFD is different from miscarriage (pregnancy loss before 20 weeks) and stillbirth (IUFD followed by delivery of the deceased fetus). It is a devastating event for both parents and healthcare providers and requires prompt diagnosis, counseling, and management.
II. Classification of IUFD
A. Based on Timing of Death
Early IUFD – Occurs between 20-27 weeks of gestation.
Late IUFD – Occurs between 28 weeks and term (≥37 weeks).
B. Based on Causes
Maternal Causes – Includes medical conditions, infections, trauma, or complications.
Fetal Causes – Includes genetic abnormalities, infections, and congenital anomalies.
Placental Causes – Includes placental insufficiency, abruption, or cord accidents.
III. Causes and Risk Factors of IUFD
A. Maternal Causes
Hypertensive Disorders (Preeclampsia, Eclampsia, Chronic Hypertension) → Leads to placental insufficiency, fetal hypoxia, and stillbirth.
Complete Blood Count (CBC) – To check for maternal infection or anemia.
Coagulation Profile (DIC Screening) – Prolonged IUFD may cause disseminated intravascular coagulation (DIC), a life-threatening condition.
TORCH Panel & Blood Cultures – To rule out fetal infections.
Maternal Glucose and Hypertension Screening – To check for underlying conditions.
VII. Complications of IUFD
A. Maternal Complications
Disseminated Intravascular Coagulation (DIC) – A serious clotting disorder seen in prolonged IUFD.
Infection & Sepsis – If fetal retention leads to chorioamnionitis.
Psychological Trauma & Depression – A major concern requiring emotional support and counseling.
Postpartum Hemorrhage (PPH) – Due to poor uterine contraction after delivery.
B. Fetal and Neonatal Complications
Stillbirth (Delivery of non-viable fetus).
Future Pregnancy Risks (Higher chance of recurrence in next pregnancy).
VIII. Management of IUFD
A. Expectant Management (For Recent IUFD <24 Hours)
In some cases, spontaneous labor may begin within 2 weeks.
Regular monitoring for maternal DIC and infection risk.
B. Medical Induction of Labor (Preferred)
Misoprostol (Prostaglandin E1) or Oxytocin is used to induce labor and facilitate vaginal delivery.
Dilatation & Evacuation (D&E) for second-trimester IUFD if vaginal delivery is not possible.
C. Surgical Management (In Some Cases)
Cesarean Section – Only performed if previous multiple C-sections, placenta previa, or maternal indications exist.
D. Postpartum Care
Psychological Counseling & Grief Support – Emotional care for parents.
Autopsy & Genetic Testing – If the cause is unknown, autopsy can help identify genetic or anatomical abnormalities.
IX. Midwifery Nursing Care for IUFD
A. Assessment
Monitor maternal emotional state and provide support.
Assess for signs of infection or DIC in prolonged IUFD.
Monitor uterine contractions and progress of labor during induction.
B. Nursing Interventions
Provide emotional and psychological support to the grieving family.
Educate parents on IUFD causes, recurrence risk, and future pregnancy care.
Monitor for postpartum complications (Hemorrhage, Infection, DIC).
Encourage autopsy and genetic testing if the cause of IUFD is unknown.
Gynecological Conditions Complicating Pregnancy:
I. Definition of Gynecological Conditions Complicating Pregnancy
Gynecological conditions complicating pregnancy refer to pre-existing or newly diagnosed disorders of the female reproductive system that affect maternal and fetal outcomes. These conditions can lead to pregnancy complications such as preterm labor, fetal growth restriction (IUGR), miscarriage, and increased risk of cesarean delivery.
II. Classification of Gynecological Conditions in Pregnancy
A. Pre-existing Gynecological Disorders Affecting Pregnancy
Uterine Abnormalities (Congenital & Acquired)
Bicornuate Uterus, Septate Uterus, Uterine Didelphys – May cause recurrent miscarriages or preterm labor.
Asherman’s Syndrome (Intrauterine Adhesions) – Associated with pregnancy loss and abnormal placentation.
Ovarian Cysts and Tumors
Functional Cysts (Corpus Luteum Cyst, Follicular Cyst) – Usually resolve by second trimester but may cause ovarian torsion.
Dermoid Cyst (Teratoma) – May require surgical removal if large.
Ovarian Cancer – Rare in pregnancy but may need careful management.
Endometriosis
Leads to chronic pelvic pain, infertility, and higher risk of miscarriage, preterm labor, and placental abnormalities.
Uterine Fibroids (Leiomyomas)
Grow due to pregnancy hormones and may cause pain, miscarriage, preterm labor, or obstructed labor.
B. Infections Affecting Pregnancy (Gynecological Infections)
VIII. Management of Gynecological Conditions in Pregnancy
Antenatal Care
Frequent monitoring with serial ultrasounds for fetal growth and placental function.
Cervical cerclage (For Cervical Insufficiency to prevent pregnancy loss).
Antibiotics for infections (GBS prophylaxis at 36 weeks if needed).
Surgical removal of large ovarian cysts or fibroids (If causing complications).
Delivery Planning
Vaginal delivery possible in mild cases (PCOS, small fibroids).
Cesarean section for large fibroids, placenta previa, or fetal distress.
IX. Midwifery Nursing Care for Gynecological Conditions in Pregnancy
Educate the mother on warning signs (Bleeding, Preterm labor, Infection).
Monitor fetal growth and maternal vital signs.
Provide emotional support for women with recurrent pregnancy loss or infertility issues.
Assist in prenatal procedures (Cervical cerclage, STI screening, Ultrasound monitoring).
Mental Health Issues During Pregnancy:
I. Definition of Mental Health Issues During Pregnancy
Mental health issues during pregnancy, also called perinatal mental health disorders, refer to emotional, psychological, and psychiatric conditions that develop during pregnancy or worsen due to pregnancy-related hormonal and physiological changes. These conditions can impact maternal well-being, fetal development, and birth outcomes, making early screening, diagnosis, and management essential.
II. Classification of Mental Health Issues During Pregnancy
A. Mood Disorders
Depression (Antenatal Depression)
Persistent sadness, hopelessness, loss of interest, sleep disturbances, and fatigue.
Increased risk of poor maternal self-care, low birth weight (LBW), and preterm birth.
Bipolar Disorder
Characterized by alternating episodes of mania (elevated mood, impulsivity) and depression.
Untreated cases can lead to poor medication adherence, increased substance use, and risky behaviors.
B. Anxiety Disorders
Generalized Anxiety Disorder (GAD)
Excessive worry about pregnancy, baby’s health, or labor and delivery.
Leads to sleep disturbances, irritability, and somatic symptoms like palpitations and headaches.
Panic Disorder
Sudden episodes of extreme fear, with rapid heartbeat, dizziness, and breathlessness.
Triggers stress-induced complications like hypertension and fetal distress.
Obsessive-Compulsive Disorder (OCD)
Recurrent obsessions (unwanted thoughts about harming the baby) and compulsions (repetitive behaviors like excessive hand washing).
May lead to excessive prenatal care visits due to health-related fears.
C. Psychotic Disorders
Schizophrenia
Severe mental disorder with hallucinations, delusions, and disorganized thinking.
Untreated cases increase the risk of poor prenatal care, substance abuse, and postpartum psychosis.
Perinatal Psychosis
A rare but severe psychiatric emergency occurring during pregnancy or postpartum.
Symptoms include paranoia, suicidal ideation, and loss of reality perception.
Requires immediate hospitalization and psychiatric care.
D. Trauma-Related Disorders
Post-Traumatic Stress Disorder (PTSD)
Can result from previous pregnancy loss, sexual abuse, domestic violence, or traumatic childbirth experiences.
Leads to nightmares, flashbacks, avoidance of medical care, and high stress levels.
E. Substance Use Disorders (SUDs)
Alcohol, tobacco, or drug abuse during pregnancy can harm fetal development.
Complications include fetal alcohol syndrome (FAS), neonatal withdrawal syndrome, and stillbirth.
III. Causes and Risk Factors for Mental Health Issues During Pregnancy
A. Biological Factors
Hormonal Changes – Increased estrogen and progesterone impact neurotransmitters, contributing to mood instability and depression.
Family History of Mental Illness – Higher risk of bipolar disorder, schizophrenia, and depression.
Previous History of Psychiatric Disorders – Women with pre-existing conditions may experience symptom recurrence or worsening.
B. Psychological and Emotional Factors
Fear of childbirth or parenting stress.
History of miscarriage, stillbirth, or traumatic birth experiences.
Lack of emotional support from partner, family, or society.
C. Social and Environmental Factors
Financial stress and unemployment.
Domestic violence or intimate partner abuse.
Unplanned or unwanted pregnancy.
D. Medical and Pregnancy-Related Factors
High-risk pregnancy (Preeclampsia, Gestational Diabetes, IUGR) – Can increase stress, anxiety, and depression.
Multiple pregnancies (Twins, Triplets) – Increased stress due to higher risk of complications.
IV. Pathophysiology of Mental Health Disorders in Pregnancy
Benzodiazepines (Only for severe anxiety, short-term use).
C. Lifestyle Modifications
Regular Exercise (Yoga, Walking) – Improves mood and reduces anxiety.
Healthy Diet (Omega-3, Vitamin D, Folate for brain function).
Adequate Sleep and Stress Reduction Techniques.
IX. Midwifery Nursing Care for Mental Health Disorders in Pregnancy
Screen all pregnant women for mental health issues.
Provide emotional support and educate about stress management.
Encourage adherence to prescribed medications and therapy.
Monitor for signs of self-harm or suicidal ideation.
Involve family and support networks in care planning.
Adolescent Pregnancy:
I. Definition of Adolescent Pregnancy
Adolescent pregnancy refers to pregnancy occurring in girls aged 10-19 years. It is considered high-risk due to the physical, emotional, social, and economic challenges associated with teenage motherhood. Adolescent mothers face higher risks of obstetric complications, poor neonatal outcomes, and long-term socio-economic disadvantages.
II. Epidemiology and Global Impact of Adolescent Pregnancy
High prevalence in low- and middle-income countries (LMICs) due to early marriage, lack of contraception, and low education levels.
Teen pregnancy rates are declining in high-income countries, but challenges persist due to unintended pregnancies and inadequate reproductive health education.
Complications of adolescent pregnancy contribute significantly to maternal and neonatal morbidity and mortality worldwide.
III. Causes and Risk Factors of Adolescent Pregnancy
A. Social and Cultural Factors
Early Marriage and Childbearing Norms – Common in some cultures where early marriage is socially and legally accepted.
Poverty and Low Socioeconomic Status – Financial insecurity increases vulnerability to early pregnancy due to lack of education and healthcare.
Lack of Comprehensive Sexual Education – Limited knowledge about contraception and reproductive health leads to unintended pregnancies.
Peer Pressure and Social Influence – Teenagers may engage in unprotected sexual activity due to peer pressure or misinformation.
Family Dysfunction and Neglect – Lack of parental guidance and support increases the risk of early pregnancy.
B. Biological and Health-Related Factors
Early Onset of Puberty – Increases the likelihood of early sexual activity and pregnancy.
Limited Access to Contraception – Due to stigma, lack of awareness, or restricted healthcare access.
Sexual Abuse and Coercion – Many adolescent pregnancies result from sexual violence, exploitation, or forced relationships.
Mental Health Issues – Teens with depression, low self-esteem, or substance abuse problems are at higher risk.
IV. Pathophysiology of Adolescent Pregnancy
Immature Reproductive System – The adolescent body may not be fully developed for pregnancy, increasing risks of obstructed labor, cephalopelvic disproportion (CPD), and maternal mortality.
Higher Metabolic and Nutritional Demands – Pregnancy increases the demand for iron, calcium, folic acid, and protein, leading to maternal malnutrition and fetal growth restriction (IUGR).
Hormonal Changes and Psychological Stress – Lead to increased risks of pregnancy-induced hypertension, depression, and postpartum mood disorders.
Immature Emotional and Cognitive Development – Results in poor decision-making, delayed prenatal care, and high dropout rates from school.
V. Clinical Features and Symptoms of Adolescent Pregnancy
A. Maternal Symptoms
Missed menstrual periods or irregular bleeding.
Nausea, vomiting, fatigue, and dizziness (Early pregnancy symptoms).
Weight gain and breast tenderness.
Psychological distress, depression, or anxiety about pregnancy.
B. Fetal and Neonatal Effects
Low Birth Weight (LBW) – Due to poor maternal nutrition and inadequate prenatal care.
Preterm Birth (Common in adolescent pregnancies).
Neonatal Asphyxia and Respiratory Distress Syndrome – Due to preterm birth and immature lung development.
Congenital Anomalies (If poor maternal nutrition or infections are present).
VI. Diagnosis of Adolescent Pregnancy
A. Clinical Examination
Positive pregnancy test (Urine or Serum hCG).
Pelvic exam confirms uterine enlargement corresponding to gestational age.
Weight and nutritional status assessment.
B. Imaging and Laboratory Investigations
Ultrasound (First-trimester dating scan, fetal viability, and anomaly scan).
Complete Blood Count (CBC) – Checks for anemia.
Iron, Calcium, and Vitamin D Levels – Assess nutritional status.
Blood Sugar and Blood Pressure Monitoring – Screen for gestational diabetes and preeclampsia.
VII. Complications of Adolescent Pregnancy
A. Maternal Complications
Anemia – Due to increased iron demand and poor nutrition.
Gestational Hypertension and Preeclampsia – Increased due to vascular immaturity.
Obstructed Labor and Cephalopelvic Disproportion (CPD) – Pelvic bones may not be fully developed for childbirth.
Postpartum Hemorrhage (PPH) – Due to uterine atony or prolonged labor.
Postpartum Depression (PPD) – Teen mothers are at high risk of emotional distress and poor social support.
Unsafe Abortions (If pregnancy is unintended or unwanted) – High rates of complications due to unsafe procedures in restricted settings.
B. Fetal and Neonatal Complications
Preterm Birth and Low Birth Weight (LBW) – Due to poor maternal health and nutrition.
Stillbirth and Perinatal Mortality – Higher risk in low-resource settings.
Neonatal Hypoxia (Due to prolonged labor and fetal distress).
Neonatal Sepsis (If inadequate prenatal care or infections are present).
VIII. Management of Adolescent Pregnancy
A. Antenatal Care (ANC) and Monitoring
Early initiation of prenatal care – To monitor maternal and fetal health.
Nutritional Counseling and Supplements – Iron, calcium, folic acid, and vitamin D.
Screening for Infections (HIV, STIs, UTIs, Hepatitis B, Syphilis, Group B Streptococcus).
Blood Pressure and Blood Sugar Monitoring – Prevents preeclampsia and gestational diabetes.
Psychosocial Counseling and Support Groups – Reduce stress, anxiety, and depression.
B. Delivery Planning
Hospital-Based Delivery Recommended (Due to high-risk status).
Elective Cesarean Section (If CPD, fetal distress, or maternal complications are present).
Monitoring for Postpartum Hemorrhage (Due to uterine atony).
IX. Midwifery Nursing Care for Adolescent Pregnancy
A. Antenatal Care
Early detection of pregnancy and nutritional supplementation.
Educate adolescent mothers about prenatal care and safe childbirth.
Monitor fetal growth and maternal well-being.
B. Intrapartum Care
Prepare for complications like prolonged labor, CPD, or PPH.
Ensure emotional support and pain management during labor.
Monitor fetal heart rate for signs of distress.
C. Postpartum Care
Encourage proper breastfeeding techniques and newborn care.
Screen for postpartum depression and provide psychological counseling.
Educate on contraception, family planning, and sexual health.
X. Prevention Strategies for Adolescent Pregnancy
Comprehensive Sexual Education (School and Community-Based).
Access to Contraceptives (Oral Pills, IUCDs, Condoms, Emergency Contraception).
Adolescent Reproductive Health Clinics and Counseling.
Programs to Reduce Child Marriage and Gender-Based Violence.
Economic and Educational Empowerment of Girls.
Elderly Primigravida:
I. Definition of Elderly Primigravida
An elderly primigravida refers to a woman who becomes pregnant for the first time at or after the age of 35 years. This condition is associated with higher maternal and fetal risks, requiring specialized antenatal, intrapartum, and postpartum care.
II. Epidemiology and Global Trends
Increasing trend due to delayed childbearing, career priorities, late marriages, and advancements in assisted reproductive technologies (ART).
Higher prevalence in developed countries due to social, economic, and educational factors.
More likely to require fertility treatments such as in vitro fertilization (IVF), ovulation induction, and embryo transfer.
III. Causes and Risk Factors for Elderly Primigravida
A. Medical and Biological Factors
Advanced Age – Declining ovarian reserve and fertility issues after 35 years.
Reduced Uterine Receptivity – Increased risk of implantation failure and early pregnancy loss.
Chronic Health Conditions (Hypertension, Diabetes, Obesity) – Higher risk of pregnancy complications.
B. Social and Lifestyle Factors
Late Marriages and Career Priorities – Women may delay pregnancy due to personal and professional commitments.
Infertility Treatments (IVF, ICSI, Ovulation Induction) – Increase the likelihood of multiple pregnancies.
History of Recurrent Miscarriages or Pregnancy Loss – May delay conception until a viable pregnancy occurs.
Health-Conscious Lifestyle (Better Nutrition and Medical Care) – In some cases, elderly primigravida women may be healthier than younger counterparts.
IV. Pathophysiology of Pregnancy in Elderly Primigravida
Ovarian Aging and Reduced Egg Quality – Increases the risk of chromosomal abnormalities (e.g., Down syndrome, Trisomy 13 & 18).
Uterine Vascular Changes – Reduced endometrial blood flow and elasticity lead to higher risks of miscarriage, preeclampsia, and placental insufficiency.
Increased Risk of Hypertension and Diabetes – Preexisting hypertension and gestational diabetes mellitus (GDM) can cause fetal growth restriction (IUGR) and preterm birth.
Increased Incidence of Assisted Reproductive Technology (ART) Pregnancies – Higher chances of multiple pregnancies, increasing maternal and fetal risks.
Prolonged Labor and Uterine Dysfunction – Reduced myometrial efficiency leads to higher rates of prolonged labor, induction of labor, and cesarean section.
V. Clinical Features of Pregnancy in Elderly Primigravida
A. Maternal Symptoms
Increased fatigue and higher risk of pregnancy complications.
More severe morning sickness and pregnancy discomforts.
Higher anxiety and emotional distress related to pregnancy outcome.
Pre-existing medical conditions worsening during pregnancy (Hypertension, Diabetes, Obesity).
B. Fetal and Neonatal Effects
Increased risk of fetal chromosomal abnormalities (e.g., Down syndrome).
Higher chance of fetal growth restriction (IUGR) due to placental insufficiency.
Higher incidence of preterm birth and neonatal intensive care unit (NICU) admissions.
Increased risk of stillbirth and neonatal complications.
VI. Diagnosis and Screening of Elderly Primigravida
A. Clinical Examination
Detailed maternal history (Age, previous miscarriages, chronic illnesses, infertility treatments).
Regular blood pressure and weight monitoring to detect gestational hypertension and diabetes.
B. Laboratory Investigations
Routine blood tests (CBC, Blood Sugar, Kidney and Liver Function Tests, Thyroid Function Tests).
Gestational Diabetes Screening (Oral Glucose Tolerance Test – OGTT at 24-28 weeks).
Fetal Growth Restriction (IUGR) due to placental insufficiency.
Stillbirth and Neonatal Intensive Care Unit (NICU) Admission.
Increased Risk of Perinatal Asphyxia and Neonatal Hypoglycemia.
VIII. Management of Pregnancy in Elderly Primigravida
A. Preconception Counseling
Encourage pre-pregnancy health optimization (Healthy diet, Exercise, Folic Acid 3 months before conception).
Screen for chronic conditions (Diabetes, Hypertension, Thyroid Disorders).
Genetic counseling for chromosomal abnormalities and prenatal diagnostic options.
B. Antenatal Care (ANC) and Monitoring
Frequent prenatal visits for high-risk monitoring.
Blood Pressure, Blood Sugar, and Urine Protein Monitoring (To detect preeclampsia and GDM early).
Fetal Growth Monitoring (Serial Ultrasounds for IUGR detection).
Screen for Thrombosis Risk (As maternal age increases risk of clot formation).
C. Intrapartum Care (Delivery Planning)
Early induction of labor (37-39 weeks) in case of maternal or fetal complications.
Cesarean section for CPD, failed induction, or fetal distress.
Monitor closely for postpartum hemorrhage (Uterine atony common in older mothers).
D. Postpartum Care
Monitor for postpartum depression (Higher risk in elderly mothers).
Counsel on contraception and family planning (Avoid unintended pregnancies in high-risk cases).
Lactation support and infant care education.
IX. Midwifery Nursing Care for Elderly Primigravida
Educate on pregnancy risks and encourage adherence to prenatal care.
Monitor maternal and fetal well-being through regular checkups.
Provide emotional and psychological support for pregnancy concerns.
Assist in labor and delivery, ensuring safe childbirth.
Support postpartum recovery, breastfeeding, and newborn care.
Grand Multiparity:
I. Definition of Grand Multiparity
Grand multiparity refers to a woman who has had five or more previous deliveries (para 5 or more) after 24 weeks of gestation. It is associated with higher maternal and fetal risks, including increased chances of pregnancy complications, postpartum hemorrhage (PPH), uterine rupture, and perinatal morbidity.
II. Epidemiology and Global Trends
More common in low- and middle-income countries where contraception use is low and cultural norms favor large families.
In developed countries, family planning services and modern contraceptive methods have reduced the incidence of grand multiparity.
Grand multiparous women have higher risks of maternal mortality and morbidity due to repeated pregnancies and childbirth-related complications.
III. Causes and Risk Factors for Grand Multiparity
A. Social and Cultural Factors
Desire for large families (Traditional or religious beliefs).
Lack of contraception access or knowledge.
Early marriage and high fertility rates.
B. Biological and Health-Related Factors
High fertility rate (Hyper-fertility, Short birth spacing).
Monitor glucose levels, administer insulin or IV glucose if required.
Amniotic Fluid Embolism
Immediate oxygen therapy, CPR, ICU care.
Policy for Referral Services.
I. Definition of Referral Services in Midwifery Nursing
Referral services in midwifery nursing refer to the organized and systematic transfer of a pregnant woman, mother, or newborn from a lower-level healthcare facility to a higher-level facility for specialized care, emergency management, or advanced medical interventions. These services aim to reduce maternal and neonatal morbidity and mortality by ensuring timely and appropriate healthcare access.
II. Objectives of Referral Services in Midwifery Nursing
Ensure timely access to specialized maternal and neonatal care.
Reduce preventable maternal and perinatal mortality and morbidity.
Strengthen the healthcare system by establishing an efficient referral chain.
Enhance communication and coordination between healthcare facilities.
Reduced fetal movements (<10 movements in 12 hours).
Preterm Labor or Premature Rupture of Membranes (PROM).
Congenital Anomalies requiring neonatal surgery (Neural tube defects, Gastroschisis, Omphalocele).
Suspected intrauterine growth restriction (IUGR) or intrauterine fetal demise (IUFD).
V. Steps in the Referral Process in Midwifery Nursing
A. Identification of High-Risk Cases
Regular screening and risk assessment during antenatal care (ANC).
Early identification of danger signs in pregnancy and labor.
B. Pre-Referral Stabilization & Emergency Management
Ensure vital signs are stable before transfer (Blood pressure, Pulse, Oxygen saturation, Temperature).
Administer IV fluids, oxygen therapy, and necessary medications (Antihypertensives, Uterotonics, Antibiotics).
Provide maternal or fetal resuscitation if required before transfer.
C. Communication and Coordination
Inform the receiving facility about the referral via phone or electronic systems.
Ensure proper documentation of maternal and fetal condition, referral reasons, and interventions done.
D. Safe Transport of Mother and Baby
Use a well-equipped ambulance with a skilled healthcare provider (Midwife, Nurse, or Paramedic).
Provide continuous maternal and fetal monitoring during transport.
E. Handover and Follow-Up Care
Ensure proper handover to the receiving healthcare team.
Follow up on maternal and neonatal outcomes after referral.
VI. Role of Midwives in Referral Services
A. Antenatal Care & Risk Identification
Conduct thorough antenatal check-ups and screen for high-risk factors.
Educate mothers on warning signs requiring urgent medical attention.
Encourage birth preparedness and emergency planning.
B. Emergency Obstetric Management & Stabilization
Administer life-saving interventions (Oxytocin for PPH, Magnesium sulfate for eclampsia, IV fluids for shock).
Ensure timely decision-making for referrals to prevent complications.
C. Communication & Coordination
Provide clear referral notes detailing maternal condition, interventions given, and urgency of transfer.
Coordinate with ambulance services and receiving hospital for smooth transition of care.
D. Transport & Safe Handover
Ensure proper documentation and patient escort during transport.
Monitor maternal and fetal well-being during transit.
Assist in proper handover upon arrival at the referral facility.
E. Post-Referral Follow-Up & Community Support
Assess maternal and neonatal condition after referral.
Encourage postnatal care and counseling on future pregnancies.
Promote contraceptive counseling and family planning services.
VII. Challenges in Referral Services & Possible Solutions
Challenges
Solutions
Delays in decision-making for referrals.
Strengthen midwifery-led screening and early detection of high-risk cases.
Poor transport facilities in rural areas.
Establish ambulance networks, community transport schemes, and telemedicine support.
Lack of communication between referring and receiving centers.
Implement digital referral tracking systems and telehealth support.
Inadequate maternal and newborn care infrastructure.
Upgrade maternity units and ensure essential drugs and equipment availability.
Limited midwifery staffing in remote areas.
Train community midwives and auxiliary nurse-midwives (ANMs) to manage referrals.
Drugs Used in the Management of High-Risk Pregnancies:
I. Introduction
High-risk pregnancies require specialized pharmacological interventions to ensure maternal and fetal well-being. Various medications are used for maternal conditions (hypertension, diabetes, infections, and clotting disorders) and fetal complications (preterm labor, fetal distress, and neonatal complications). The choice of drug depends on the specific condition, gestational age, and severity of complications.
II. Drugs Used in Hypertensive Disorders of Pregnancy
1. Antihypertensive Medications
Used in chronic hypertension, gestational hypertension, preeclampsia, and eclampsia to prevent maternal and fetal complications.
A. Labetalol
Class: Beta-blocker with alpha-blocking properties.
Mechanism of Action: Lowers blood pressure without reducing placental perfusion.
Dosage: 100–400 mg orally twice daily or IV infusion in hypertensive emergencies.
Side Effects: Dizziness, nausea, bradycardia.
Contraindications: Asthma, heart block.
B. Nifedipine
Class: Calcium channel blocker.
Mechanism of Action: Relaxes blood vessels, reducing BP and preventing preterm contractions.
Dosage: 10-20 mg orally, repeated every 30 minutes in hypertensive crisis.
Side Effects: Headache, flushing, tachycardia.
C. Hydralazine
Class: Vasodilator.
Mechanism of Action: Reduces vascular resistance, lowering blood pressure.
Dosage:IV bolus 5–10 mg every 20 minutes for severe hypertension.
Side Effects: Reflex tachycardia, fluid retention.
2. Anticonvulsants for Preeclampsia & Eclampsia
A. Magnesium Sulfate
Mechanism of Action:CNS depressant, reduces seizures in eclampsia, and provides neuroprotection to preterm infants.
Dosage:Loading dose: 4–6 g IV over 15 minutes, then 1–2 g/hr continuous infusion.
Side Effects: Respiratory depression, hypotension, loss of deep tendon reflexes.
Antidote: Calcium gluconate IV.
III. Drugs Used in Preterm Labor and Its Prevention
1. Tocolytics (Drugs to Delay Preterm Labor)
Used to inhibit uterine contractions and delay delivery, allowing time for corticosteroids to mature fetal lungs.
A. Nifedipine (Calcium Channel Blocker)
Mechanism of Action: Blocks calcium channels in uterine muscles, reducing contractions.
Dosage: 10–20 mg orally every 6–8 hours.
Side Effects: Hypotension, flushing, palpitations.
B. Atosiban
Class: Oxytocin receptor antagonist.
Mechanism of Action: Prevents uterine contractions by blocking oxytocin receptors.
Dosage: IV infusion 6.75 mg bolus, followed by 18 mg/hr for 3 hours.
Side Effects: Nausea, headache, dizziness.
C. Terbutaline (Beta-Agonist)
Mechanism of Action: Relaxes uterine smooth muscle.
Dosage: 250 mcg subcutaneously every 20 minutes (up to 3 doses).
Side Effects: Tachycardia, hyperglycemia, pulmonary edema.
2. Corticosteroids for Fetal Lung Maturity
Used to enhance surfactant production in preterm infants (24–34 weeks gestation) to prevent respiratory distress syndrome (RDS).
A. Betamethasone
Mechanism of Action: Accelerates lung development by promoting surfactant production.
Dosage:12 mg intramuscularly (IM) every 24 hours for 2 doses.
Side Effects: Hyperglycemia, fluid retention.
B. Dexamethasone
Dosage: 6 mg IM every 12 hours for 4 doses.
Side Effects: Insomnia, weight gain, increased risk of infection.
IV. Drugs Used in Gestational Diabetes Mellitus (GDM)
1. Insulin Therapy (Gold Standard in GDM)
Regular Insulin (Short-acting): Given before meals.
NPH Insulin (Intermediate-acting): Given at night to control fasting glucose.
Dosage:0.5–1 unit/kg/day subcutaneously, adjusted based on glucose levels.
Side Effects: Hypoglycemia, weight gain.
2. Oral Hypoglycemic Agents
A. Metformin
Mechanism of Action: Reduces hepatic glucose production.
Dosage:500 mg–2000 mg per day, orally.
Side Effects: Diarrhea, nausea, lactic acidosis.
B. Glyburide
Mechanism of Action: Increases pancreatic insulin secretion.
Dosage: 2.5–10 mg/day orally.
Side Effects: Hypoglycemia, weight gain.
V. Drugs Used for Infection Control in High-Risk Pregnancies
HIV Prevention: Zidovudine, Nevirapine, Tenofovir (Given throughout pregnancy).
VI. Drugs Used in Postpartum Hemorrhage (PPH) and Uterine Atony
1. Uterotonics (Drugs to Contract Uterus and Prevent PPH)
A. Oxytocin (First-Line Drug for PPH Prevention & Treatment)
Mechanism of Action: Stimulates uterine contractions.
Dosage:10 IU IM or 20–40 IU IV infusion after delivery.
Side Effects: Water retention, hypotension.
B. Misoprostol
Mechanism of Action: Prostaglandin that increases uterine tone.
Dosage:600 mcg orally or 800 mcg rectally for PPH.
Side Effects: Fever, shivering, nausea.
C. Carboprost (Hemabate, PGF2α)
Dosage: 250 mcg IM every 15–30 minutes (max 8 doses).
Contraindications: Asthma, hypertension.
D. Tranexamic Acid (TXA)
Mechanism of Action: Antifibrinolytic, prevents excessive bleeding.
Dosage:1 g IV within 3 hours of PPH onset.
VII. Drugs Used in Rh Incompatibility
A. Anti-D Immunoglobulin (Rhogam)
Indication: Given to Rh-negative mothers to prevent hemolytic disease in newborns.
Dosage:
300 mcg IM at 28 weeks gestation.
Repeat within 72 hours postpartum if the baby is Rh-positive.
Side Effects: Mild pain, fever.
Maintenance of Records and Reports in Midwifery Nursing:
I. Definition of Records and Reports in Midwifery Nursing
Records and reports in midwifery nursing refer to the systematic documentation of maternal, fetal, and neonatal health data during antenatal, intrapartum, and postnatal care. Proper record-keeping ensures continuity of care, legal protection, quality assurance, and effective communication among healthcare providers.
II. Objectives of Record Maintenance in Midwifery Nursing
Ensure continuity of care by documenting maternal and fetal conditions.
Provide legal evidence in case of medico-legal issues.
Monitor and evaluate maternal and neonatal health trends.
Facilitate communication among healthcare professionals.
Improve clinical decision-making by maintaining accurate patient history.
Ensure adherence to national and international maternal health policies.
III. Types of Records and Reports in Midwifery Nursing
A. Antenatal Records (During Pregnancy)
Antenatal Case Sheet:
Personal details (Name, Age, Address, Contact).
Obstetric history (Gravida, Parity, Abortions, Living Children).
Menstrual history (Last Menstrual Period – LMP, Expected Delivery Date – EDD).
Maternal medical history (Hypertension, Diabetes, Infections, Previous Surgeries).