MATERNAL AND CHILD NURSING

CHAPTER #1: HIGH RISK PREGNANCY Spontaneous abortion occurs in 15-20% of

recognized pregnancy.
A. RISK FACTORS “AWESOMEINFO”
Early abortion > before 12 weeks
 Age (>35 or <18)
 Weight (GDM, HTN, Macrosomia) Late abortion > between 12-20 weeks
 Substance use (Alcohol, Nicotine)
TERMS RELATED TO ABORTION
 Obstetrical history
 Multiparity (twins, trips, quads…) 1. Abortus – Aborted fetus
 External risk factors (environment) weighing less than 500g
 Income (Clinic visits, affordability)
 Nutritional status (Low nutrients
 Family history of genetic disease or 2. Occult pregnancy – Zygotes that were
previous baby with a birth defect ( aborted before pregnancy is diagnosed
 Pre-existing medical conditions 3. Blighted ovum – a small
 Infertility macerated fetus. Sometimes
there is no fetus surrounded
B. BLEEDING
by a fluid inside an open sac.
Hemorrhage – Rapid loss of more than 1%
of body weight in blood 4. Carneous mole - a zygote
that is surrounded by a
Rapid blood loss results in: capsule of clotted blood
a. Inadequate tissue perfusion 5. Fetus compressus - a
b. Deprivation of Glucose and Oxygen fetus compressed upon itself
in the Tissue & desiccated with dried
c. Build-up of waste products amniotic fluid
Perinatal Hemorrhage – occurs during
pregnancy, labor, and delivery
6. Fetus Papyraceous - a
1. Antepartum hemorrhage – occurs fetus that is so dry that it
anytime during pregnancy (early vs late) resembles a parchment
2. Intrapartum hemorrhage – occurs 7. Lithopedion -calcified
during labor and is most commonly due to: embryo
abruption placenta, uterine rupture, uterine
8. Immature infant - an
inversion, and CS complications
infant having a birth weight
3. Postpartum hemorrhage – Blood loss between 500-1,000 g.
greater than 500ml in a vaginal delivery or
1,00 ml in CS (early vs late) TYPES OF ABORTION
1. Elective Abortion or Therapeutic A. -
DIFFERENT BLEEDING DISORDERS
deliberate termination of a pregnancy
First Trimester – Abortion and Ectopic
2. Spontaneous Abortion - the loss of a fetus
Pregnancy
during pregnancy due to natural causes
Second Trimester – H-mole & Incompetent
Fetal causes - Developmental anomalies or
cervix
Chromosomal abnormalities
Third Trimester – Placenta Previa &
Maternal Causes - congenital or acquired
Abruptio placenta
conditions of the mother, including
C. ABORTION environmental factors
The termination of pregnancy before age of 1. Advancing maternal age
viability (23-24) 2. Structural abnormalities
3. Inadequate progesterone production

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 MATERNAL AND CHILD NURSING
4. Maternal infections/viral infection  Refers to the loss of the products of
5. Chronic and systemic maternal conception that can not be prevented
disease
S/Sx:
6. Exogenous factors
1. Moderate profuse bleeding
Signs of spontaneous abortion 2. Moderate to severe uterine cramping
 Bleeding 3. Open cervix or dilatation of the cervix
 Uterine cramps 4. Rupture of membrane
5. No tissue has passed yet
 Passage of products
Management
NOTE: Frequency of spontaneous abortion
increases further with maternal age. 1. Hospitalization
2. D&c
- Late implantation is also associated with
3. Oxytocin after d & c
a higher incidence of abortion.
4. Sympathetic understanding &
- The frequency of miscarriage decreases
emotional support
with an increasing gestational age.
- A woman who has a history of abortion
has a higher chance of having another 3. COMPLETE ABORTION
abortion than a woman who has not had an Refers to the spontaneous expulsion of the
abortion. products of conception after the fetus has died
COMPLICATIONS of ABORTION in utero
S/Sx: vaginal bleeding, abdominal pain,
- Hemorrhage passage of tissue
- Disseminated intravascular coagulation On examination on the clinic/hospital:
(DIC)
a) Light bleeding or some blood in the
vaginal vault
4 Stages: b) No tenderness in the cervix, uterus or
1. THREATENED ABORTION abdomen
c) None to mild uterine cramping
 Possible loss of the products of d) Closed cervix
conception. e) Empty uterus on ultrasound
 All vaginal bleeding in early pregnancy
without cervical changes is considered Management:
threatened abortion. 1. Usually needs no further medical or
surgical treatment.
S/Sx 1. Light vaginal bleeding 2. Observe closely for continued
2. None to mild uterine cramping bleeding or signs of infection.
Management, #1 Assess for: 3. Regular diet
a) Ask LMP 4. Advise patient to rest for a few days
b) Instruct the client to save all pads for to 2 weeks and refrain from
examination intercourse and douching for 2 weeks.
c) Ask for presence of clots 5. Tell patient that she may experience
d) Ask if there is pain/abdominal pain intermittent menstrual like flow and
cramps during the following week.
#2 Conservative Management - In any mild The next menstrual period usually
bleeding episode that occurs during the first occurs in 4-5 weeks.
trimester: 6. It is important that the expelled
a) Instruct client to have bedrest until 3 days products of conception are evaluated
after bleeding has stopped by a physician and confirmed to be
b) Coitus should be avoided up to 2 wks after intact and truly products of
bleeding stopped conception.
#3 Provide reassurance 7. Reassure patient that her next
2. INEVITABLE/IMMINENT pregnancy is likely to last to term if
ABORTION she is young and has no other risk
factors.

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 MATERNAL AND CHILD NURSING
8. Advise the patient to return to the 1. Depending in the AOG, the products
emergency department if any of the of conception has to be removed from
following symptoms occur: profuse the uterus to prevent DIC.
vaginal bleeding, severe pelvic pain, 2. Up to 28 weeks gestation, missed
and temperature greater than 100°F abortion is frequently managed by
inserting a 20 mg suppository into the
4. INCOMPLETE ABORTION vagina every 3 or 4 hours as necessary
Expulsion of some parts and retention of to produce contractions
other parts of conceptus in utero 3. Late missed abortion
S/Sx: may be completed
with a dilute IV
1. Heavy vaginal bleeding infusion of oxytocin
2. Severe uterine cramping which causes
3. Open cervix contraction of the
4. Passage of tissue uterus and delivery of
5. Ultrasound shows that some of the the products of
products of conception are still inside conception
the uterus
Management:
Goal of intervention is prompt evacuation of 6. HABITUAL ABORTION
the uterus to prevent hemorrhage or infection - Abortion that occurs in 3 or more successive
pregnancies
1. D & C Management:
2. Monitor blood loss in patient’s who have 1. Treating the cause
inevitable and incomplete abortion. 2. Specific treatment according to the cause
3. Sympathetic understanding and emotional of abortion:
support.
a) Cervical cerclage
b) Fertility drugs
c) Aspirin or mini-heparin
d) Luteal phase progesterone support
e) Correction of defects before
pregnancy
f) treatment of medical illness to ensure
successful gestation

7. INFECTED ABORTION
Infection involving the products of
conception and the maternal
reproductive organs

5. MISSED ABORTION 8. SEPTIC ABORTION

Retention of all products of conception after  Dissemination of bacteria/toxins into
the death of fetus in the uterus the maternal circulatory and organ
S/Sx: 1. absence of FHT system.
2. signs of pregnancy disappear Causative Agent
Missed abortion should be suspected when - escherichia coli
the > uterus fails to enlarge and/or the - enterobacter aerogenes
fetal heart sounds are not heard at the - proteus vulgaris
appropriate time or disappears after it has - hemolytic streptococci
been initially heard - staphylococci
Other is, when the serum or uterine test for S/Sx:
HCG becomes negative earlier than expected
or does not double within 48-72 hours 1. Foul smelling vaginal discharge
Management: 2. Uterine cramping
3. Fever, chills, & peritonitis
4. Leukocytosis

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 MATERNAL AND CHILD NURSING
5. Critically ill patients may evidence implanted in the interstitial portion of the
septic or endotoxic shock tube
7. Tubo-abdominal - a zygote that
Management: originally implanted in the fimbriated end
1. Treat abortion of the fallopian tube gradually extends into
2. High dose IV antibiotic therapy the peritoneal cavity
3. D & C if accompanied by incomplete 8. tubo-ovarian - a zygote that is partly
abortion imparted in the tube and partly in the ovary
D. ECTOPIC PREGNANCY
 Implantation of the zygote outside the
uterine cavity or in an abnormal location
inside the uterus
 As much as 50% of women who have
experienced ectopic pregnancy will ever
carry pregnancy to term and 7.7% to 20%
will suffer a repeat ectopic pregnancy.
Causes:
1. Mechanical Factors - conditions that
delay the passage of the ovum in the oviducts
and prevent it from reaching the uterus in
time for implantation
2. Functional Factors
- External migration of the ovum
- Menstrual reflux
- Altered tubal motility associated with
the use of iud, etc.
3. Assisted Reproduction
- Ovulation induction associated with
fertility drugs
- Gamette intrafallopian transfer
- In vitro fertilization
- Ovum transfer
4. Failed Contraception
TYPES OF ECTOPIC PREGNANCY S/SX:
1. Tubal Most common: missed menstrual period

2. Ovarian o unilateral lower abdominal pain

3. Abdominal o irregular vaginal bleeding
4. Cervical 1. Normal pregnancy signs appear during the
Signs: first weeks after fertilization
2. Before the rupture
1. Highly vascularized, bleeding &
enlarged cervix  Brief amenorrhea occurs but some
2. Tight internal os & dilated external os spotting & bleeding may occur
3. Thin walled cervix  Pelvic & abdominal pain on the side of
4. Painless vaginal bleeding the affected tube
Seldom goes beyond 20 weeks gestation  Arias-stella reaction – uterus will not
enlarge as in normal pregnancy, decidua
5. Heterotypic pregnancy - a tubal will be formed but no trophoblast
pregnancy accompanied by intrauterine development
pregnancy
6. Tubo-uterine -results from the gradual
Rupturing or ruptured ectopic pregnancy
extension into the uterine cavity of
products of conception that originally  Isthmic pregnancy usually ruptures early
at 6 weeks

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 MATERNAL AND CHILD NURSING
 Ampullary ep ruptures at around 8-12 1. Care of a woman with bleeding, possible
weeks shock.
 Abdominal pregnancy may terminate 2. Pain relief
anytime 3. Post-operative care
 If fetus dies without extensive bleeding, 4. Meet emotional needs of patient
it may become infected, calcified or an 5. Provide information
adipocere
 Pain is sudden, severe, & knife-like E. HYDATIDIFORM MOLE
- Can radiate to the neck and shoulder  A benign disorder of the placenta
- Cervical pain during IE characterized by degeneration of the
 Spotting or bleeding = amount of chorion and death of the embryo
bleeding may not reflect the actual  Chorion proliferate and become
amount of blood loss grapelike vesicles that produce large
amounts of HCG
 Spontaneous expulsion occurs
between 16 & 18 weeks

Cullen’s sign
Bluish discoloration of the umbilicus due to
the presence of blood in the peritoneal cavity
 Hard or boardlike abdomen
 Signs of shock
TYPES:
DIAGNOSIS: 1. Complete Molar Pregnancy
1. Transvaginal UTZ  Have only placental parts and form
 Can reveal an extrauterine pregnancy when the sperm fertilizes an empty egg
 Should be repeated after 3 days if the  All of the fertilized egg’s chromosomes
first is not diagnostic for further come from the father and are duplicated
examination  Chorionic villi develop and proliferate
rapidly for unknown reasons causing a
2. Serial HCG determination rapid enlargement of the uterus
 HCG level is lower than expected for  Villi produce large amounts of hcg
gestational time and usually does not resulting in excessive nausea &
double normally vomiting

3. Pregnancy Tests
4. Serum Progesterone Levels 2. Partial Molar Pregnancy
5. Colpotomy  Embryo has 69 chromosomes
6. Laparoscopy  2 sperm cells fertilize an egg or an
7. Laboratory Findings: ↓Hgb, Hct, HCG; ↑ ovum fertilized by one sperm in
WBC which meiosis or reduction division
did not occur
TREATMENT  Placenta and fetus are formed but
1. Salpingectomy - in ruptured EP
development is not completed
2. Hysterectomy - in ruptured interstitial or
cervical pregnancy
3. Oophorectomy - in ovarian pregnancy
NURSING INTERVENTION:

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 MATERNAL AND CHILD NURSING

Cause: Unknown
Risk Factors/Incidence:
1. Geography
2. Age NURSING RESPONSIBILITIES:
3. Socioeconomic status 1. Care of a woman with bleeding
4. History of molar pregnancy 2. Give instructions on need for
Diagnosis: UTZ
S/SX: a) Follow up care for 1 year
1. Excessive nausea & vomiting b) Follow up hcg titer monitoring for 1
2. Vaginal bleeding year to rule out choriocarcinoma
3. Passage of grapelike vesicles around  Hcg level is monitored every 2 weeks
the 4th mo. until normal then monthly for 6
4. Extra large uterus months then every 2 months for
5. Signs of PIH before 20 weeks another 6 months
6. Absence of FHT, quickening, outline,  Chest x-ray every 3 months for 6
skeleton months
Treatment: careful D&C or hysterectomy; 3. Provide psychological support
HCG monitoring for 1 year
Complications:
F. INCOMPETENT CERVIX
1. Hemorrhage
Mechanical defect of the cervix where in
2. Infection
there occurs
3. Uterine perforation
4. Gestational trophoblastic tumors a. Painless cervical dilatation in the 2nd
trimester or early in the 3rd trimester
a) Choriocarcinoma - most severe
b. Prolapse & ballooning of the membranes
malignant complication that involve
in the vagina
the transformation of chorionic villi
c. Eventually leads to membrane rupture &
into cancer cells that invade & erode
expulsion of the products of conception
blood vessels & uterine muscle
b) Invasive mole - characterized by DIAGNOSIS:
excessive formation of trophoblastic 1. Manually by pelvic exam or IE to assess
villi that penetrates the myometrium the degree of dilatation & effeacement
c) Placental Site Trophoblastic Tumor 2. UTZ to view the cervical os & canal
 Arises from the site of the placenta Predisposing Factors
 These cells produce both prolactin 1. Cervical trauma
&hcg 2. Hormonal influences
 Main symptom is bleeding and may 3. Congenitally short cervix
follow an abortion, normal 4. Forced D&C
pregnancy and h-mole 5. Uterine anomalies
S/SX:
1. Painless vaginal bleeding or pinkish
show accompanied by cervical
dilatation
2. Rupture of membranes & passage of
amniotic fluid with subsequent loss of
the products of conception

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 MATERNAL AND CHILD NURSING
MANAGEMENT:
1. Cervical cerclage at around 14 weeks
gestation.
Prerequisites of cervical cerclage:
a. cervix not dilated beyond 3 cm
b. intact membranes
c. no vaginal bleeding & uterine
cramping
Types of Cervical Cerclage
1. Shirodkar suture - involves
colpotomy and bladder dissection
with the aim of a higher suture
placement
2. Mc Donald suture - a simple purse-
string suture around the cervix G. PLACENTA PREVIA
After Suturing the Cervix  Is the abnormal implantation of
1. Place the woman on bedrest for 24hrs placenta near or over the internal os
to several days after the procedure.  In the 3rd trimester, the lower uterine
2. Observe for bleeding, uterine segment begins to stretch and shorten
contractions & rupture of bag of in preparation for labor
water. →gradual thinning of the uterine segment
3. Report passage of fluids or signs or causes the placental villi attached to the
ruptured BOW. lower uterine wall to tear & eventually
4. It uterine contractions occur, separate from its attachment
ritodrine may be administered to →detachment of the portion of the
stop the contractions. placenta over the cervix results in
5. Restrict activities after application of bleeding
suture for the next 2 weeks. TYPES:
1. Complete or Total = placenta completely
covers the internal os when the cervix is fully
dilated
2. Partial Placenta Previa = placenta
partially covers the internal os
3. Marginal Placenta Previa = edge of the
placenta is lying at the margin of the internal
os
4. Low Lying Placenta Previa = placenta
implants near the internal os with its margin
located about 2cm to 5cm from the internal
os.

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 MATERNAL AND CHILD NURSING
o Small for gestational age
o Fetal hemorrhage
o Neonatal anemias
o Brain damage or neurological
abnormalities
o Fetal death
S/SX:
1. Sudden painless vaginal bleeding
2. Intermittent/gushes of bright red
vaginal bleeding & is rarely
continuous
3. The placement of the placenta in the
lower segment often prevents the fetal
head from entering the true pelvis
4. Decreased urinary output
UTZ is the earliest and safest diagnostic tool
for placenta previa
MANAGEMENT:
1. Internal exam by the physician only
under Double Set-Up
 indicated when UTZ is not available
 when the patient presents with
ongoing, but not life-threatening
vaginal bleeding in labor
CAUSES:  the mother has marginal previa and is
in well-established labor
1. Multiple Pregnancy
2. Maternal age over 35 years 2. Assess extent of blood loss
3. Decreased blood supply to the
endometrial lining a) visual estimates
4. Short umbilical cord b) V/S
5. Abnormal placentas = placenta c) tilt test
increta & accreta d) urine flow
6. Large placenta 3. If pregnancy is below 36 wks
7. Conditions that make implantation to Watchful waiting = delaying delivery until
the upper segment undesirable due to fetus has achieved lung maturity
decreased blood supply or scarring:
a) Multiparity 1. first choice of treatment if:
b) Previous molar pregnancy a) bleeding is minimal or less than 250 cc
c) Endometritis b) fetus is too immature to be delivered or
d) Previous C/S below 36 weeks
e) Abortion c) there is no evidence of fetal compromise
f) Repeated D&C
NURSING INTERVENTION:
Complications: a) Monitor:
1. DIC 1. FHR & activity
2. Infection 2. Vaginal bleeding
3. Abnormal adhesion of placenta 3. Uterine contractions
4. Renal failure R/T shock caused from 4. Maternal vital signs
hemorrhage or DIC 5. Maternal I & O
5. Anemia b) Woman is placed on CBR
6. Postpartum hemorrhage c) Manage bleeding episodes
7. More lacerations a. keep woman on NPO
8. Fetal o neonatal effects b. monitor V/S, FHR, & vaginal bleeding
o Prematurity c. maintain on absolute bed rest
o C/s d. start IVF & BT as necessary

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 MATERNAL AND CHILD NURSING
d) If woman is in active labor, tocolytics are d) discourage bearing dow
administered to the mother 3. Position: T-Burg/Semi-Fowler’s
e) If the patient has a complete or partial
placenta previa, an amniocentesis is
generally performed weekly
 Outpatient Management:
a) Important requirements for outpatient
management:
1. patient lives close to the hospital
2. transportation is available 24 hours
b) Restrict activities at home
a) be in bed rest for most part of the day
b) no heavy lifting
c) no standing for long periods of time
7. Behavioral risk factors
d) sexual arousal, intercourse, or orgasm a. cigarette smoking, cocaine abuse
may initiate contractions b. maternal alcohol consumption
e) avoid enema & douche  Believed to be caused by degenerative
f) stop working changes in the spiral arterioles that
g) provide diversional activities consequently decrease blood supply to the
decidua
c) Inform patient & family to be observant TYPES:
for danger signs
1. any vaginal bleeding  Placental Separation
2. uterine contractions
A. Covert/Central A.P. - separation
3. decreased fetal activity
begins at the center of placental
d) Diet
attachment
1. ↑ iron
B. Overt or Marginal - separation
2. prenatal vitamins
begins at the edges of the placenta
3. ↑ fiber
2. SIGNS AND SYMPTOMS
e) Clinic visit
1. UTZ a) Grade 0 = no symptoms, diagnosed
2. nonstress test after delivery when placenta is
3. biophysical profile examined & found to have
Labor & Delivery: retroplacental clot
a) Delivery is implemented when:
b) Grade 1 = some external bleeding,
a. Fetus is mature uterine tetany & tenderness may or
b. There is persistent hemorrhage may not be noted, absence of fetal
c. Intrauterine infection distress & shock
d. Rupture of membranes c) Grade 2 = external bleeding, uterine
e. Persistent uterine contractions tetany, uterine tenderness, & fetal
i.Unresponsive to tocolytics distress
f. Mother develops coagulation d) Grade 3 = internal & external
defects bleeding, uterine tetany, maternal
g. Fetal distress occurs shock, probably fetal death &DIC
h. Fetal/congenital abnormalities that 3. Extent of Separation
are incompatible with life a) Mild = less than 1/6 of the placenta is
separated from the uterus
Method of Delivery > C/S
Nursing Care: - bleeding may or may not be present
1. Anticipate doctor’s order for - some uterine irritability w/ no fetal
a) UTZ distress
b) IVF - there may or may not be vaginal
2. In case of profuse bleeding bleeding
a) CBR w/o bathroom privileges
b) NPO - there may be some uterine tenderness
c) administer oxygen & vague back ache

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 MATERNAL AND CHILD NURSING
b) Moderate = 1/6 – 2/3 of the placenta  Preeclampsia = HPN of BP 140/90
is separated from the uterus that develops after 20 weeks of
gestation accompanied by proteinuria
- dark vaginal bleeding may be absent
or present  Eclampsia = all the signs and
- uterine tetany & tenderness symptoms of preeclampsia
- fetus will exhibit distress due to accompanied by convulsions or coma
uteroplacental insufficiency that is not caused by other conditions
 Superimposed Eclampsia &
c) Severe = more than 2/3 of the Preeclampsia = occurs when a
placenta is separated from the uterus woman having chronic HPN develops
causing uterine tenderness & rigidity preeclampsia nor eclampsia during
along with severe pain pregnancy
- dark vaginal bleeding, or may be  Chronic HPN = the presence of HPN
absent before pregnancy or HPN that
- entire separation will cause maternal develop before 20 weeks gestation in
shock, fetal death, severe pain & the absence of H-mole that persists
possible DIC after 12th week postpartum
SIGNS AND SYMPTOMS: PREDISPOSING FACTORS:
1. Vaginal bleeding 1. Disease of primiparas > ↑ incidence in
2. Abdominal pain primis below 20 & above 35 y/o
2. Preexisting diseases > diabetes,
 mild = mother may complain of labor chronic HPN, chronic renal disease
pains with slight uterine irritation 3. Low socioeconomic status &
 moderate = pain can develop inadequate prenatal care
gradually or abruptly 4. Poor nutrition
 severe = sudden & knifelike/sharp 5. Pregnancy complications
6. Hereditary
3. Board like abdomen (Cullen)
7. Black race
4. Signs of shock & fetal distress if bleeding
is severe

MANAGEMENT:
1. Hospitalization
2. If fetus is below 36 wks
a) Prolonging the pregnancy if:
1. Bleeding is not life threatening
2. Fetal heart sounds are normal
3. Mother is not in active labor
b) Manage bleeding episode
c) Monitor fetal condition
3. Delivery: C/S or vaginal
SIGN OF ECLAMPSIA
H. PREGNANCY INDUCED 1. All S/Sx of preeclampsia
HYPERTENSION 2. Convulsion followed by coma
3. Oliguria
 HPN = a BP reading in 2 occasions of 4. Pulmonary edema
at least 140/90 or a rise of 30mmHg Screening & early diagnosis:
systolic & 15mmHg diastolic Roll over test = given between 28-32 weeks
 Gestational HPN = BP of gestation
140/90mmHg develops for the first
time during pregnancy, but there is no - An ↑ in 20mmHg or greater in
proteinuria & with in 12 weeks diastolic BP (+)
postpartum the BP is normal
AMBULATORY MANAGEMENT:
 PIH = HPN that develops after the
1. Home management is allowed only if
20th week of gestation to a previously
normotensive woman - BP is 140/90 or below

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 MATERNAL AND CHILD NURSING
- ↓proteinuria C. Postpartum
- no fetal growth retardation 1. Head of bed is elevated
- good fetal movement 2. Progressive ambulation may be
permitted.
2. Bed rest 3. Stool softeners, ↑ fluid intake
3. Consult clinic 4. breastfeeding is not C/I
4. Diet
• Magnesium sulfate is the drug of
choice J. DIABETES MELLITUS
• Calcium Gluconate is the antidote Refers to a group of metabolic diseases
characterized by hyperglycemia resulting
from defects in insulin secretion, insulin
I. CARDIAC DISEASE IN PREGNANCY action or both
The degree of disability experienced by the Effect of Pregnancy on Diabetes
woman with cardiac disease often is more During the course of pregnancy, the placenta
important in the treatment & prognosis produces:
during pregnancy than is the diagnosis of the
type of cardiovascular disease 1. HPL
Common Signs of Cardiac Disease 2. estrogen & progesterone
Left Sided (PUMP) 3. placenta insulinase
1. dyspnea, orthopnea Classifications:
2. Rales, cough
3. Chest pain  Type I > includes those cases that are
4. Arrythmias, syncope primarily caused by pancreatic islet
5. Extreme fatigue, pallor, cyanosis beta cell destruction & that are prone
Right Sided (RECEIVE) to ketoacidosis
1. Edema  Type II > is the most prevalent form
2. Neck vein engorgement of the disease
3. Hepatomegaly - includes individuals who have
insulin resistance & usually relative
Classifications of Cardiac Disease insulin deficiency
Class I: asymptomatic without limitation of  Pregestational Diabetes > label
physical activity sometimes given to type I or type 2
Class II: symptomatic with slight limitation diabetes that existed before
of activity pregnancy
Class III: symptomatic with marked  Gestational Diabetes > any degree of
limitation of activity glucose intolerance with the onset or
Class IV: symptomatic with inability to first recognition occurring during
carry on any physical activity without pregnancy
discomfort
PREGESTATIONAL DIABETES
NURSING INTERVENTIONS:  Women who have pregestational
A. Antepartum diabetes may have either type I or
 Therapy is focused on minimizing type 2 diabetes which may or may not
stress on the heart which is greatest be complicated by vascular disease,
between 28-32 weeks as the retinopathy, nephropathy or other
hemodynamic changes reach their diabetic sequelae
maximum  Insulin requirements steadily
 Health Teaching Topics increase after the first trimester
1. sleep & rest  Insulin resistance begins as early as
2. activity restrictions 14-16 weeks of gestation &
3. treatment of infections continues to rise until it stabilizes
4. diet during the last few weeks of
5. medications pregnancy
B. Intrapartum RISK AND COMPLICATION:
1. Positioning 1. Poor glycemic control
2. Oxygen therapy as needed

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 MATERNAL AND CHILD NURSING
2. Hypertensive disorders  [ ] Soft ang uterus = massage, yelo,
3. Infections stimulation
4. Ketoacidosis  [ ] Incompetent cervix = tinatahi
 [ ] Parity and viability are the "same"
Complications in Fetus  [ ] Kinacalcify ng body pag foreign
1. IUGR  [ ] Thalasemia = an inherited (i.e., passed
2. RDS from parents to children through genes) blood
3. Sudden and unexpected stillbirth disorder caused when the body doesn't make
4. Risk of birth injuries R/T increased enough of a protein called hemoglobin, an
fetal size important part of red blood cells. no
RISK FACTORS OF GDM hemoglobin (120 days BT)
1. Maternal age  [ ] Exogenous factors = outside the body
2. Obesity factors
 [ ] Teratogenic = makakaproblem sa baby at
3. Family history
mother
4. Obstetric hx of an infant weighing  [ ] Iatrogenic effect = effects from medical
more than 4,500g treatments (phlebitis)
5. Hydramnios  [ ] Implantation = thick endomytrium
6. Unexplained stillbirth  [ ] DIC = Disseminated Intravascular
7. Miscarriage Coagulation = caused by abortion
8. Infant with congenital anomalies - naubusan sila ng platelet due to coag, kaya
magcacause ng hemorrhage
 [ ] Clots could be a product of conception
ANTEPARTUM CARE:
 [ ] Hallmarks of infection
>aimed at strict blood glucose control - kallor = heat,
Target Blood Glucose Levels During - dollor = pain,
Pregnancy - rommor = redness, pallor = paleness
Premeal >65 but <105  [ ] Cervical cervlage = pagtahi para di mag
Postmeal(1 hr) <130 – 155 open
Postmeal(2 hrs) <130  [ ] Aspirin to prevent DIC
 [ ] Triads of shock: hypovulemia,
tachypnea, tachycardia
NOTES DURING DISCUSSION:  [ ] Ectopic pregnancy = methotrexate
 [ ] Salpingectomy = removal of fallopian
 Weight Gain: tube
1st Trimester: 1lb/month (3-4lbs)  [ ] Cullen sign = bluish discoloration in the
2nd Trimester: 0.9 -1lb/week (10-12lb) ambilicus due to presence of blood in the
3rd Trimester: 0.5 -1lb/week (8-11lb) peritoneal cavity
 Inadequate Tissue Perfusion: Confusion,  [ ] Grey turner's sign = bleeding on the
Necrosis, Cyanosis abdominal or flank area
 [ ] Colpotomy = a type of incision that is
 Pernicious Anemia - a relatively rare
made in the wall of the vagina.
autoimmune disorder that causes  [ ] Idiopathic origin = unkown origin
diminishment in dietary vitamin B12  [ ] HMole = vomitting = compression +
(cobalamin) absorption, resulting in B12 high HCG
deficiency and subsequent megaloblastic  [ ] Hmole may lead to other gr on the
anemia. It affects people of all ages body
worldwide, particularly those over 60.
 Sickle cell anemia is one of a group of
inherited disorders known as sickle cell
disease. It affects the shape of red blood
cells, which carry oxygen to all parts of
the body. Red blood cells are usually
round and flexible, so they move easily
through blood vessels.
 [ ] Peri = whole process of pregnancy
 [ ] Black eye = periorbital hematoma
 [ ] Eye bulge = periorbital edema
 [ ] Uterine rupture = fundal push,
multigravid, oxytocin, pag-ire
 [ ] Uterine inversion = abunay (lumabas

uterus) low pelvic muscle floor - try kegel
exercise

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 MATERNAL AND CHILD NURSING
 In diabetes, it has been shown that the
maternal-placental oxygen supply is
reduced
 In addition to impaired oxygen supply,
fetal oxygen demand is increased. This
phenomenon could be explained by
aerobic metabolism which is stimulated
by fetal hyperinsulinemia.
 Placental insulinase (another hormone
from the placenta that inactivates
insulin)
 Intrauterine growth restriction, or
IUGR, is when a baby in the womb (a
fetus) does not grow as expected. The
baby is not as big as would be expected
for the stage of the mother's pregnancy.
 The condition is most commonly caused
by inadequate maternal-fetal circulation,
with a resultant decrease in fetal growth.
Less common causes include
 Nitrazine paper test = to test the intrauterine infections such as
presence of BOW cytomegalovirus and rubella, and
 250cc = bleeding congenital anomalies such as trisomy 21
 Placenta previa =not vascularized and trisomy 18.
uterus  Respiratory distress syndrome (RDS)
 Disseminated intravascular is a breathing problem that sometimes
coagulation can be defined is a affects babies born six weeks or more
widespread hypercoagulable state that before their due dates. Their lungs aren't
can lead to both microvascular and developed enough to make surfactant, a
macrovascular clotting and liquid that coats the inside of the lungs
compromised blood flow, ultimately and keeps them open so that the baby
resulting in multiple organ dysfunction can breathe in air once he or she is born.
syndrome.  7 months for lung maturity
 A colpotomy is a type of incision that is  Uterus fibroids = scar
made in the wall of the vagina. It's a  Decidua Basalis = Maternal side
surgical technique that may be used for  Chorion = Fetal side
a number of procedures, including  Uterine wall – Decidua Basalis =
hysterectomy, tubal ligation, Placental Abruption
complications of endometriosis, and  Sheehan's syndrome (SS)
cervical cancer treatment. is postpartum hypopituitarism caused by
 Ritodrine, a tocolytic β2-adrenergic necrosis of the pituitary gland. It is
agonist agent used to delay or abolish usually the result of severe hypotension
preterm labour, has been implicated in or shock caused by massive hemorrhage
LFT abnormalities and two instances of during or after delivery. Patients with SS
liver injury. have varying degrees of anterior
 Human placental lactogen (hPL), also pituitary hormone deficiency.
called human chorionic  Hydrostatic Pressure: The pressure
somatomammotropin (hCS) or human exerted by a fluid at equilibrium at a
chorionic somatotropin, is a polypeptide given point within the fluid, due to the
placental hormone, the human form of force of gravity. Hydrostatic pressure
placental lactogen (chorionic increases in proportion to depth
somatomammotropin). Its structure and measured from the surface because of
function are similar to those of human the increasing weight of fluid exerting
growth hormone. downward force from above.
 Human placental lactogen is a  Oncotic pressure is the osmotic
physiologic antagonist to insulin during pressure generated by large molecules
pregnancy and (similar to cortisol) (especially proteins) in solution.
contributes in increasing insulin
resistance by the way of a postbinding
defect in the insulin receptor mechanism
during pregnancy.

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 MATERNAL AND CHILD NURSING
CHAPTER 2: COMPLICATION DURING  Latent phase that is longer than 20
DELIVERY hours in a nullipara or 14 hours in a
#1 DYSTOCIA multipara
Dystocia can arise from  Uterus tends to be in a hypertonic
A. POWER OR FORCE OF LABOR state
1. Hypotonic Contractions Management:
 The number of contractions is usually 1. Help the uterus to rest
low or infrequent 2. Giving of adequate fluid to the
 The resting tone of the uterus remains woman to prevent dehydration.
less than 10mmHg and the strength of 3. C/S or amniotomy & oxytocin
contractions does not rise above 25 infusion
mmHg
 Commonly occurs during the active 2. Protracted Active Phase
phase of labor 1. Usually associated with CPD or fetal
May occur in: malposition
a) A uterus that is over stretched by a 2. Occurs if cervical dilatation does not
multiple gestation occur at a rate of at least 1.2cm/hr in
b) Larger-than usual single fetus a nullipara or 1.5cm/hr in a multipara;
c) Hydramnios or if active phase lasts longer than 12
d) Lax uterus from grand multiparity hrs in a primigravida or 6 hrs in a
 Hypotonic contractions are not that multigravida
painful because of the lack of
intensity 3. Prolonged Deceleration Phase
 It increases the length of labor
 When deceleration extends beyond 3
Interventions:
hours in a nullipara or 1 hour in a
1. Administer oxytocin
multipara
2. Amniotomy
 Results from abnormal head position
3. In the first hour after birth, palpate the
uterus & assess lochia every 15 mins 4. Secondary Arrest of Dilatation
2. Hypertonic Contractions > No progress in cervical dilatation for more
than 2 hours
 Marked by an increase in resting tone
to more than 15mmHg
 Intensity of the contraction may be no Dysfunction at the 2nd Stage of Labor
stronger than that associated with A. Prolonged Descent
hypotonic contractions
 Most commonly seen in the latent occurs if the rate of descent is less than
phase of labor and is painful 1cm/hour in a nullipara or 2cm/hour in a
 A danger of hypertonic contractions multipara
is that the lack of relaxation between B. Arrest of Descent
contractions may not allow optimal
uterine artery filling results when no descent has occurred for 1
Management hour in a multipara or 2 hours in a nullipara
1. Rest & pain relief > most likely cause is CPD
2. Changing linen, client’s gowns,
C. Precipitate Labor
darkening room lights & decreasing
noise & stimulation  Can occur when uterine contractions
3. C/S are so strong that the woman gives
B. PASSENGER birth with only a few, rapidly
C. PASSAGEWAY occurring contractions.
> Continuous monitoring of the laboring  Likely to occur with
woman & fetus is essential because grandmultiparity, or after induction of
complications can arise at any point in labor labor by oxytocin or amniotomy
Risks:
#2 Dysfunction with the 1st Stage of Labor 1. Premature separation of placenta
2. Subdural hemorrhage to the fetus
1. Prolonged Latent Phase 3. Lacerations of the birth canal

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 MATERNAL AND CHILD NURSING
 Can be predicted from a labor graph area of the lower uterine
during the active phase of dilatation, segment
that is, if dilatation is greater than b. fetal heart sounds, lack of
5cm/hr in a nullipara or 10cm/hr in a contractions & changes in
multipara woman’s V/S
D. Uterine Rupture
 Administer emergency fluid
 Occurs when a uterus undergoes more replacement therapy as ordered
strain than it is capable of sustaining  Anticipate use of oxytocin
 Occurs most commonly when a  Prepare woman for possible
vertical scar from a previous CS or laparotomy
hysterotomy repair tears
Contributory factors: E. Inversion of the Uterus
1. Prolonged labor  Refers to the uterus’ turning inside
2. Multiple gestation out with either birth of the fetus or
3. Unwise use of oxytocin delivery of the placenta.
4. obstructed labor  May occur if traction is applied to the
5. traumatic maneuvers umbilical cord to remove the placenta
6. Abnormal presentation or if pressure is applied to the uterine
fundus when the uterus is not
contracted.
 May occur if the placenta is attached
at the fundus
 May occur in various degrees
 Uterus is not contracted
 If placenta is still attached never
attempt to remove it

Nursing Responsibility
1. Start IV fluids..
2. Administer O2 by mask & assess V/S.
3. Be prepared to perform CPR.
4. Give tocolytic drugs.
5. Give antibiotics.
6. Inform patient that cesarean birth will
S/Sx: sudden, severe pain during a strong probably be necessary in any future
contraction pregnancy to prevent the possibility
 Complete rupture: of repeat inversion.
a. uterine contractions will F. Amniotic Fluid Embolism
immediately stop
b. 2 swellings will be visible  Occurs when amniotic fluid is forced
c. hemorrhage into an open maternal uterine blood
d. signs of shock sinus through some defect in the
membranes or after membrane
 Incomplete rupture: rupture or partial premature
separation of the placenta.
a. localized tenderness &
Possible Risk Factors:
persistent aching pain over the
1. Oxytocin administration

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 MATERNAL AND CHILD NURSING
2. Abruptio placenta
3. Hydramnios C. Induction & Augmentation of Labor
S/Sx: Induction of labor > means that labor is
1. Chest pain started artificially.
2. Inability to breathe Augmentation of labor > refers to assisting
3. Paleness & then turns to bluish gray labor that has started spontaneously to be
Management: more effective.
1. O2 administration Induction of Labor
2. CPR  May be necessary when the fetus is in
> Prognosis depends on the size of the danger or because labor does not
embolism, the speed with which the occur spontaneously & the fetus
emergency condition was detected, & the appears to be at term.
skill & speed of emergency interventions. Primary Reasons:
G. Prolapse Umbilical Cord 1. Presence of preeclampsia, eclampsia,
severe HPN
 A loop of the umbilical cord slips 2. Diabetes
down in front of the presenting fetal 3. Prolonged rupture of the membrane
part. 4. IUGR
 Can occur most often with the 5. Postmaturity
following conditions: 6. All situations that ↑ the risk for the
fetus to remain in utero
1.Prom
Conditions before Induction of Labor:
2.Fetal presentation other than cephalic 1. Fetus is in longitudinal lie
3.Placenta previa 2. Fetus is matured
4.Intrauterine tumors preventing the 3. Cervix is ripe
presenting part from engaging 4. Presenting part is engaged
5.Small fetus 5. There is no CPD
6.Cpd
Augmentation of Labor
7.Hydramnios  may be necessary if the contractions
8.Multiple gestation are hypotonic or infrequent to be
effective.
> Caution must be used in induction or
augmentation of labor because it carries the
risk of uterine rupture, ↓ in fetal blood supply,
or premature separation of the placenta
Cervical Ripening
Various Method s to Ripen the Cervix
1. Stripping the membranes or
separating the membranes from the
lower uterine segment manually.
2. Hygroscopic suppositories =
suppositories of seaweeds that swell
 To rule out cord prolapse, always on contact with cervical secretions
assess fetal heart sounds immediately 3. Application of a prostaglandin gel
after rupture of the membranes. (misoprostol) to the interior surface of
 Cord prolapse automatically leads to the cervix by a catheter or suppository
cord compression. or to the external surface by applying
 management is aimed toward it to a diaphragm
relieving pressure on the cord Induction of Labor by Oxytocin
 If cord has prolapsed to the extent that  Proportion is 10 IU in 1,000ml of
it is exposed to room air, drying will Ringer’s Lactate
begin  Usually administered through
 If cervix is fully dilated or dilatation “piggyback”
is incomplete at the time of the  Infusions are usually begun at a rate
prolapse, delivery is the management of 0.5 to 1 mU/min

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 MATERNAL AND CHILD NURSING
 If there is no response, the infusion is 5. Decreased urine output
gradually increased every 15-60 Forceps Birth
minutes by small increments of 1-2  May be necessary if any of the
mU/min until contractions begin following occurs:
 Do not ↑ the rate to more than 20 a) a woman is unable to push with
mU/min without checking for further contractions in the pelvic division of labor
instructions. b) cessation of descent in the 2nd stage
 After cervical dilatation reaches 4cm, of labor occurs
artificial rupture of the membranes c) a fetus is in an abnormal position
may be performed d) a fetus is in distress from a
 Continuously monitor FHR & uterine complication such as a prolapsed cord
contractions during the procedure > Forceps are applied after the fetal head
 Contractions should occur no more reaches the perineum
often than every 2 mins, should not be  Before forceps are applied
stronger than 50mmHg pressure, & a) membranes must be ruptured
should last no longer than 70 seconds, b) CPD must not be present
& the resting pressure between c) the cervix must be fully dilated
contractions should not exceed d) woman’s bladder must be empty
15mmHg by monitor Nursing Responsibilities:
 Oxytocin has an antidiuretic side 1. Record FHR before & after
effect application of forceps.
2. Assess woman’s cervix after forceps
delivery.
3. Record time & amount of the first
voiding.
4. Assess newborn after forceps birth.
5. Explain to the parents that a forceps
birth may leave a transient
erythematous mark on the newborn’s
cheek.
Postpartal Hemorrhage
 Any blood loss from the uterus
greater than 500ml within a 24 hour
period
 4 main causes
a) uterine atony
b) lacerations
c) retained placental fragments
d) DIC
Uterine Atony
If the uterus suddenly relaxes, there will be
an abrupt gush of blood from the placental
site
Therapeutic Management
1. Uterine massage
2. Oxytocin by IV
Helpful Measures
a. Offer a bedpan or assist the woman with
ambulating to the bathroom at least every 4
 Be certain that the drug is increased in hours to keep her bladder empty.
small increments only & monitor fetal b. Oxygen by face mask at a rate of 4L/min
heart sounds c. V/S monitoring and interpret them
Danger Signs of Oxytocin accurately , looking for trends.
1. Nausea & vomiting 3. Bimanual Massage
2. Dizziness & headache 4. Prostaglandin administration
3. Hypertonic contraction 5. Blood replacement
4. Fetal bradycardia or tachycardia 6. Hysterectomy

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 MATERNAL AND CHILD NURSING
Lacerations Therapeutic Management
 Occur most often in the following 1. Methergine to improve uterine tone
circumstances and complete involution.
a) with difficult or precipitate labor  If uterine is tender upon palpation, it
b) in primigravidas suggests endometritis.
c) macrosomia Perineal Hematoma
d) with the use of lithotomy position  Collection of blood in the
& instruments subcutaneous layer of tissue of the
Kind: perineum.
1. Cervical Laceration  Most likely to occur after rapid,
• Usually found on the sides of the spontaneous births in women who
cervix have perineal varicosities.
 Repair is difficult because bleeding  It appears as an area of purplish
can be so intense that it obstructs discoloration and obvious swelling
visualization of the area. Therapeutic Management
2. Vaginal Laceration 1. Report presence of hematoma
> hard to repair because vaginal tissue 2. Assess the size with each inspection
is friable. 3. Analgesic can be ordered for pain
3. Perineal Lacerations relief
> occurs when a woman is placed in a 4. Apply ice pack
lithotomy position 5. Incision and ligation of bleeding
Classification: vessel.
 Classifications of tissue involved 6. Episiotomy incision line is opened to
a. first degree > vaginal mucous drain a hematoma.
membrane and skin of the perineum to the 7. Proper documentation.
fourchette Puerperal Infection
b. second degree > vagina, perineal  Infection of the reproductive tract
skin, fascia, levator ani muscle, and perineal  Predisposing Factors
body 1. Rupture of membranes more than 24
c. third degree > entire perineum and hours before birth
reaches the external sphincter of the rectum 2. Retained placental fragments
d. fourth degree > entire perineum, 3. Postpartal hemorrhage
rectal sphincter, and some of the mucous 4. Preexisting anemia
membrane of the rectum 5. Prolonged and difficult labor
Therapeutic Management 6. Internal fetal heart monitoring
1. Suturing as an episiotomy repair 7. Presence of local vaginal infection
2. Document the degree of laceration during birth
3. Diet should be high in fluid 8. Uterus was explored after birth for
4. No taking of temperature by anus placental fragments or abnormal
especially 3rd and 4th degree bleeding site
lacerations Prognosis for complete recovery depends on:
Retained Placental Fragments a) Virulence of the organism
 Placenta was not delivered entirely b) Woman’s general health
 May be detected by infection, and c) Portal of entry
sonogram d) Degree of uterine involution
Therapeutic Management e) Presence of laceration
1. D & C Therapeutic Management: antibiotic
2. Teach patient to observe for lochia Nursing Intervention
changes 1. Preventing infection
Subinvolution 2. Instruct on proper perineal care
 Incomplete return of the uterus to its 3. Prevent cross-infection
prepregnant size and shape 4. Each patient should have her own bed
 May result from a small retained pan
placental fragments, a mild 5. Health teaching on antibiotic and
endometritis, or an accompanying effects to infants
problem that is interfering with
complete contraction

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 MATERNAL AND CHILD NURSING
a) inform women that some
antibiotics are incompatible with
breastfeeding
b) alert them to observe for white
plaques or thrush in the mouth
c) assess the infant for early bruising
Endometritis
 Infection of the endometrium
 Basis is elevated oral temperature for
two consecutive 24 hour period,
excluding the first 24 hour period
after birth.
 S/Sx:
a) fever Therapeutic Management
b) chills 1. NGT
c) loss of appetite 2. IV or TPN
d) general malaise 3. Analgesics and large doses of
e) uterus not well contracted & is antibiotics
painful to touch Thrombophlebitis
f) strong afterpains  Inflammation of the lining of a blood
g) dark brown lochia and foul vessel with the formation of blood
smelling clots
Therapeutic Management  Occurs for the following reasons
1. Antibiotic 1. Fibrinogen level is still elevated from
2. Oxytocic agent pregnancy leading to increased blood
3. Increase fluid clotting.
4. Analgesic 2. Dilatation of lower extremity veins is
5. Fowler’s position still present as a result of pressure of
 Course of infection is about 7-10 days the fetal head during pregnancy and
 Danger is it can lead to tubal scarring birth.
and can interfere with future fertility. 3. The relative inactivity of the period or
a prolonged time spent in delivery or
Infection of the Perineum birthing room stirrups leads to
 Infection usually remains localized pooling, stasis, and clotting of blood
 Symptoms are usually the same to in the lower extremities
those of any suture line infection Incidence: Common in women who
 One or two stitches may be sloughed a) Are obese
away or an area of the suture line may b) Have varicose veins
be open with purulent discharge c) Had a previous thrombophlebitis
 Therapeutic Management d) Older than 30 years of age with
1. Removing perineal sutures to drain increased parity
the infection or encourage drainage e) Have high incidence of
2. Systemic or topical antibiotic thrombophlebitis in their family
3. Analgesic
4. Sitz bath or warm compres
5. Change perineal pads frequently
Peritonitis
 Infection of the peritoneal cavity and
usually an extension of endometritis
 Symptoms:
1) Rigid abdomen
2) Abdominal pain
3) High fever
4) Rapid pulse
5) Vomiting
6) Appearance of acutely ill Femoral Thrombophlebitis

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 MATERNAL AND CHILD NURSING
 Inflammation site is a vein, an 1. Encourage total bed rest
accompanying arterial spasm often 2. Antibiotics and anticoagulants can be
diminishes arterial circulation to the given
leg as well 3. Health teachings on preventive
 Formerly called milk leg or measures
phlegmasia alba doles Pulmonary Embolus
 S/Sx:  Obstruction of the pulmonary artery
a)  temperature by blood clot
b) Chills, pain  S/Sx:
c) Redness in the affected leg 10 days a) Sudden sharp chest pain
after birth b) Tachypnea
d) Leg will begin to swell below the c) Tachycardia
lesion at the point at which venous d) Orthopnea
circulation is blocked e) Cyanosis
e) Shiny and white skin and has a greater * Oxygen administration is needed & the
diameter than other leg patient is at high risk for cardiopulmonary
f) (+) Homan’s sign arrest
Therapeutic Management Mastitis
1. Bed rest  Infection of the breast
2. Administration of anticoagulant  Preventive Measures
3. Application of moist heat 1) Make sure the baby is positioned
Nursing Management correctly and grasps nipples properly.
1. Check for bed wrinkles. 2) Release the baby’s grasp on the nipple
2. Never massage the skin over the clot. before removing the baby from the
3. Application of heat breast.
4. Check bed for moisture 3) Handwashing
5. Provide reading materials about 4) Use Vit. E ointment to soften the
newborn nipples daily.
6. Analgesic and antibiotic  Therapeutic Management
7. anticoagulant 1. Antibiotic
2. Breast feeding is continued
3. Cold compress
4. Warm compress
Mastitis is not a permanent nor is a
contributory factor to development of breast
cancer and does not interfere with future
breast-feeding potential.

Pelvic Thrombophlebitis
 Involves the ovarian, uterine, or
hypogastric veins
 Occurs around the 14th or 15th day of
the puerperium
 Infection can be so severe it necroses
the vein and results in pelvic abscess
 May become systemic
 Nursing Intervention

NERVANZ CHRISTIAN D. DE GUZMAN | MATERNAL REVIEWER