ECTOPIC PREGNANCY

An ectopic pregnancy typically occurs in one of the tubes that carry eggs
from the ovaries to the uterus (fallopian tubes). This type of ectopic
pregnancy is known as a tubal pregnancy. In some cases, however, an
ectopic pregnancy occurs in the abdominal cavity, ovary or neck of the
uterus (cervix).

Signs and Symptoms

Missed period
Breast tenderness
Nausea
Positive pregnancy test
Pelvic and abdominal pain
Light vaginal bleeding



Pathophysiology

Effective transport of embryos in the fallopian tube requires a delicately regulated
complex interaction between the tubal epithelium, tubal fluid, and tubal contents. This
interaction ultimately generates a mechanical force, composed of tubal peristalsis,
ciliary motion, and tubal fluid flow, to drive the embryo towards the uterine cavity. This
process is subject to dysfunction at many different points that can ultimately manifest
as ectopic pregnancy.
Oocyte migration difficulty is most often associated with abnormal fallopian tube
anatomy. This can result from tubal pathology (e.g., chronic salpingitis, salpingitis
isthmica nodosa), tubal surgery (e.g. reconstruction, sterilisation), or in utero DES
exposure. It is thought that alterations in molecular signalling between the oocyte and
the implantation site may make an ectopic pregnancy more likely. A number of
molecular factors are under investigation for possible involvement in premature
implantation. These factors include cellular and extracellular matrix proteins such as
lectin, integrin, matrix-degrading cumulus, prostaglandins, growth factors, and
cytokines.
Studies have not supported a role for chromosomal abnormalities in abnormal
implantation. Karyotypes of the chorionic villi from 30 viable surgically removed ectopic
pregnancies did not find any difference compared with the control intrauterine
pregnancies.
As the ectopic grows, the outer layer of the fallopian tube stretches. This ultimately
leads to tubal rupture and bleeding.

Laboratory Test And Diagnosis

A pelvic exam, which can detect tenderness in the uterus or fallopian
tubes, less enlargement of the uterus than expected for a pregnancy, or
a mass in the pelvic area.
A pelvic ultrasound(transvaginal or abdominal), which uses sound
waves to produce a picture of the organs and structures in the lower
abdomen.
Two or more blood tests of pregnancy hormone (human chorionic
gonadotropin, or hCG) levels, taken 48 hours apart. During the early
weeks of a normal pregnancy, hCG levels double every 2 days. Low or
slowly increasing levels of hCG in the blood suggest an early abnormal
pregnancy, such as an ectopic pregnancy or a miscarriage. If hCG
levels are abnormally low, further testing is done to find the cause.

Nursing Diagnosis

Acute pain related to severe abdominal bleeding secondary to tubal rupture
Fear related risk of mortality and possible treatment alternatives.
Hemorrhage related to ectopic rupture

General Nursing Interventions

1. Fluid volume
Ensure a patent IVF and blood transfusion line
Obtain blood samples for laboratory workouts as ordered (CBC and
typing)
Monitor vital signs
Monitor I&O
2. Grief
Encourage verbalization of feelings
Be available to provide emotional support at all times
Include family and significant others in the therapy
Suggest referrals if necessary (clergy, psychiatrists, work groups)
3. Pain
Administer analgesics as ordered
Use of relaxation techniques and diversional activities

ANEMIA
defined as a decrease in amount of reb blood
cells (RBCs) or the amount of hemoglobin in
the blood. It can also be defined as a lowered
ability of the blood to carry oxygen. When anemia
comes on slowly the symptoms are often vague
and may include: feeling tired,
weakness, shortness of breath or a poor ability to
exercise. Anemia that comes on quickly often has
greater symptoms which may
include: confusion ,feeling like one is going to pass
out ,and an increased desire to drink fluids.
Signs and Symptoms

dizziness
weakness and fatigue
shortness of breath with activity
dizziness
occasional chest pains
cold, clammy skin

Causes

Iron deficiency
Kidney disease
Pregnancy
Poor nutrition
Deficiency of vitamin B12 known as pernicious anemia
Sickle cell anemia
Thalassemia
Alcohol
Bone marrow related anemia
Aplastic anemia
Hemolytic anemia
Active bleeding, eg. heavy bleeding during menstration

Diagnosis

Anemia is typically diagnosed on a complete blood count. Apart
from reporting the number of red blood cells and the hemoglobin level,
the automatic counters also measure the size of the red blood cells
by flow cytometry, which is an important tool in distinguishing between
the causes of anemia. Examination of a stained blood smear using
a microscope can also be helpful, and it is sometimes a necessity in
regions of the world where automated analysis is less accessible. In
modern counters, four parameters (RBC count, hemoglobin
concentration,MCV and RDW) are measured, allowing others
(hematocrit, MCH and MCHC) to be calculated, and compared to
values adjusted for age and sex. Some counters estimate hematocrit
from direct measurements.

Nursing Diagnosis

1. Ineffective tissue perfussion

Nursing Intervention:
Monitor vital signs, capillary refill, skin color, mucous membranes.
Exalt the position of head of in bed
Examine and document the presence of pain.
Observation of a delay in verbal response, confusion, or restlessness
Observe and document the presence of the cold.
Maintain the ambient temperature to keep warm the body needs.
Provide oxygen as needed.

2. Activity Intolerance

Nursing Intervention:
Assess the capability of doing the activity
Monitor vital signs during and after activity, and noted a physiological
response to activity (increased heart rate increased blood pressure, or
rapid breathing).
Provide information to the patient or family to stop doing activities if
teladi symptoms of increased heart rate, increased blood pressure,
rapid breathing, dizziness or fatigue).
Provide support to perform their daily activities according to the ability
of the child.
Creating a schedule of activities involving other health team.

TORCH


Maternal infection during pregnancy may significantly
contribute to fetal morbidity and mortality.
One of the most common infections during pregnancy,

T Toxoplasmosis
O Other infections like hepatitis A, infectious hepatitis,
hepatitis C, or syphilis
R Rubella
C Cytomegalovirus
H Herpes simplex virus

Pathophysiology

These infectious organisms are capable of
crossing the placental barrier and adversely
affecting the development of the fetus.
Spontaneous abortion or fetal and newborn
abnormalities may occur.In some instances, the
infection can also cause infertility or sterility in the
mother.

Signs and Symptoms

Influenza-type symptoms
Rash
Lymphedema and lymphadenopathy

Laboratory and diagnostic findings

Serologic and culture testing will reveal infection.

General Nusing Intervention

Carefully screen for infections during pregnancy and treat possible infections as ordered.
At the prenatal visit, the pregnant woman should have a rubella titer drawn. A titer of 1:8 provides
evidence of immunity. If the titer is below 1:8, rubella vaccine is offered to the woman before discharge
postpartum. Those women who required the vaccine should be cautioned not to become pregnant for at
least 3 months after receiving the vaccine.
Cytomegalovirus currently has no effective therapy. This is important to remember because the highest
rate of maternal infections occurs between the ages of 15 and 35. Usually the infection is asymptomatic
Women who are presumed to be susceptible to varicella-zoster (chickenpox) should have immune
testing. Varicella-zoster immune globulin should be administered to those who are susceptible or who
have been exposed. Varicella-zoster immune globulin should be administered to the exposed newborn
within 72 hours of birth.
All pregnant women should be screened for HbsAg, the hepatitis B surface antigen. The Hep B immune
globulin can prevent infection in both mother and newborn. An initial injection can be given to the
newborn, followed by doses at 1 month and 6 month of age. Adult receive 3 injections given over 6-12
months period.
Provide client and family teaching regarding the diagnosis of infection
to
promote compliance with the treatment plan.
Explain how maternal infections are acquired and transmitted to the
developing fetus during pregnancy.
Demonstrate proper handwashing technique, stressing that is the
single most successful means of preventing infection.
Discuss hygienic and dietary measures that reduce the risk of infection.
Explain the organism, test, treatment, and fetal effects of the specific
infection to the client and family.
Include the client in planning solutions for possible fetal effects.
Discuss safe sex with the client and partner.
Seek the couples input for development of a plan for follow-up care.

THE FOUR STAGES OF
LABOR
First Stage of Labor

Thinning (effacement) and opening (dilation) of the
cervix
During the first stage of labor, contractions help your cervix to
thin and begin to open. This is called effacement and dilation.
As your cervix dilates, your health care provider will measure
the opening in centimeters. One centimeter is a little less than
half an inch. During this stage, your cervix will widen to about
10 centimeters. This first stage of labor usually lasts about 12
to 13 hours for a first baby, and 7 to 8 hours for a second child.

1. Early labor

Your cervix opens to 4 centimeters. You will probably spend
most of early labor at home. Try to keep doing your usual
activities. Relax, rest, drink clear fluids, eat light meals if you
want to, and keep track of your contractions. Contractions
may go away if you change activity, but over time they'll get
stronger. When you notice a clear change in how frequent,
how strong, and how long your contractions are, and when
you can no longer talk during a contraction, you are probably
moving into active labor.
Three Parts Of First Stage Labor
2. Active labor
Your cervix opens from 4 to 7 centimeters. This is when you should
head to the hospital. When you have contractions every 3 to 4 minutes
and they each last about 60 seconds, it often means that your cervix is
opening faster (about 1 centimeter per hour). You may not want to talk
as you become more involved in dealing with your contractions. As
your labor progresses, your bag of waters may break, causing a gush
of fluid. After the bag of waters breaks, you can expect your
contractions to speed up.Slow, easy breathing is usually helpful at this
time. Focusing on positive, relaxing images or music may also be
helpful. Changing positions, massage, and hot or cold compresses
can help you feel better. Walking, standing, or sitting upright will help
labor progress. Relaxing during and between contractions saves your
energy and helps the cervix to open. Many hospitals have whirlpool or
soaking tubs that may help you relax and ease discomfort.
3. Transition to second stage

Your cervix opens from 7 to 10 centimeters. For most women,
this is the hardest or most painful part of labor. This is when
your cervix opens to its fullest. Contractions last about 60 to
90 seconds and come every 2 to 3 minutes. There is very little
time to rest and you may feel overwhelmed by the strength of
the contractions. You may feel tired, frustrated, or irritated,
and may not want to be touched. You may feel sweaty, sick to
your stomach, shaky, hot, or cold. Although you may find slow,
easy breathing to be most effective throughout labor, you may
also find an uneven breathing pattern most helpful at this time.
Second Stage of Labor

Your baby moves through the birth canal

The second stage of labor begins when the cervix is completely
dilated (open), and ends with the birth of your baby. Contractions
push the baby down the birth canal, and you may feel intense
pressure, similar to an urge to have a bowel movement.Your health
care provider may ask you to push with each contraction. The
contractions continue to be strong, but they may spread out a bit
and give you time to rest. The length of the second stage depends
on whether or not you've given birth before and how many times,
and the position and size of the baby.The intensity at the end of the
first stage of labor will continue in this pushing phase. You may be
irritable during a contraction and alternate between wanting to be
touched and talked to, and wanting to be left alone. It is
Third Stage of Labor

Afterbirth
After the birth of your baby, your uterus continues to contract
to push out the placenta (afterbirth). The placenta usually
delivers about 5 to 15 minutes after the baby arrives.
Fourth Stage of Labor

Recovery
Your baby is born, the placenta has delivered, and you and
your partner will probably feel joy, relief, and fatigue. Most
babies are ready to nurse within a short period after birth.
Others wait a little longer. If you are planning to breastfeed,
we strongly encourage you to try to nurse as soon as possible
after your baby is born. Nursing right after birth will help your
uterus to contract and will decrease the amount of bleeding.

Cardinal Movements in Labor

The mechanisms of labor, also known as the
cardinal movements, refer to the changes in position of
fetal head during its passage through the birth canal.
Because of the asymmetry of the shape of both the fetal
head and the maternal bony pelvis, such rotations are
required for the fetus to successfully negotiate the birth
canal. Although labor and birth comprise a continuous
process, seven discrete cardinal movements of the fetus
are described: engagement, descent, flexion, internal
rotation, extension, external rotation or restitution, and
expulsion.
Engagement
Engagement refers to passage of the widest diameter of the presenting part to
a level below the plane of the pelvic inlet. In the cephalic presentation with a
well-flexed head, the largest transverse diameter of the fetal head is the
biparietal diameter (9.5 cm). In the breech, the widest diameter is the
bitrochanteric diameter.

Descent
Descent refers to the downward passage of the presenting part through the
pelvis. Descent of the fetus is not continuous; the greatest rates of descent
occur during the deceleration phase of the first stage of labor and during the
second stage of labor.

Flexion
Flexion of the fetal head occurs passively as the head descends owing to the
shape of the bony pelvis and the resistance offered by the soft tissues of the
pelvic floor. Although flexion of the fetal head onto the chest is present to
some degree in most fetuses before labor, complete flexion usually occurs
only during the course of labor. The result of complete flexion is to present
the smallest diameter of the fetal head (the suboccipitobregmatic diameter)
for optimal passage through the pelvis.
Internal Rotation
Internal rotation refers to rotation of the presenting part from its original position
as it enters the pelvic inlet (usually OT) to the anteroposterior position as it
passes through the pelvis. As with flexion, internal rotation is a passive
movement resulting from the shape of the pelvis and the pelvic floor
musculature. The pelvic floor musculature, including the coccygeus and
ileococcygeus muscles, forms a V-shaped hammock that diverges anteriorly.
As the head descends, the occiput of the fetus rotates toward the
symphysis pubis (or, less commonly, toward the hollow of the sacrum),
thereby allowing the widest portion of the fetus to negotiate the pelvis at its
widest dimension. Owing to the angle of inclination between the maternal
lumbar spine and pelvic inlet, the fetal head engages in an asynclitic fashion
(i.e., with one parietal eminence lower than the other).

Extension
Extension occurs once the fetus has descended to the level of the introitus.
This descent brings the base of the occiput into contact with the inferior
margin at the symphysis pubis. At this point, the birth canal curves upward.
The fetal head is delivered by extension and rotates around the symphysis
pubis. The forces responsible for this motion are the downward force
exerted on the fetus by the uterine contractions along with the upward
forces exerted by the muscles of the pelvic floor.
External Rotation
External rotation, also known as restitution, refers to the return of the fetal head
to the correct anatomic position in relation to the fetal torso. This can occur
to either side depending on the orientation of the fetus. This is again a
passive movement resulting from a release of the forces exerted on the fetal
head by the maternal bony pelvis and its musculature and mediated by the
basal tone of the fetal musculature.

Expulsion
Expulsion refers to delivery of the rest of the fetus. After delivery of the head
and external rotation, further descent brings the anterior shoulder to the
level of the symphysis pubis. The anterior shoulder is delivered in much the
same manner as the head, with rotation of the shoulder under the
symphysis pubis. After the shoulder, the rest of the body is usually delivered
without difficulty.
END