In simple terms, risk is the possibility of Indirect causes include anemia, malaria,

something bad is happening. Risk involves and heart disease.

uncertainty about the effects/implications of
an activity with respect to something that
humans value (such as health, well-being, Causes of Death in Children
wealth, property or the environment), often
focusing on negative, undesirable  37% - Neonatal
consequences.  19% - Pneumonia
 17% Diarrhea
According to WHO, “ A risk factor is defined  10% - Other
as any ascertainable characteristics or  8% - Malaria
circumstance of a person (or group of such
 4% - Measles
persons) known to be associated with an
 3% - Injuries
abnormal risk of developing, or being
adversely affected by a morbid process”.  3% - HIV/Aids
High risk pregnancy is defined as one of
which is complicated by a factor or factors
that adversely affects the pregnancy Causes of neonatal deaths:
outcome- maternal or perinatal or both. Neonatal – 37%
 28% - Pre-term
Mother and Newborns (0-28 days) dying  26% - Sepsis or pneumonia
every year…  23% - Asphyxia
 8% - Congenital
Mother Newborns
 7% - Tetanus
560,000 Global 4,000,000
 7% - Other
4,600 Philippines 33,620
 3% - Diarrhea

Main causes of maternal death: Neonatal events account for most of the
direct causes of under-five mortalities
1. Hypertensive disorder of pregnancy
2. Post-partum hemorrhage
3. Pregnancy with abortive outcomes Predisposing Factors
 Poor maternal health
Main causes of neonatal death:  Inadequate care during pregnancy
 Inappropriate management of
1. Pre-term complications during pregnancy and
2. Infection delivery
3. Asphyxia  Poor hygiene during and after delivery
 Lack of poor newborn care

>80% of Maternal Deaths are due to

5 DIRECT OBSTETRIC COMPLICATIONS
 28% - Hemorrhage
 19% - Unsafe Abortion What Do We Want to Achieve?
 17% - Eclampsia
 10% - Obstructed Labor
 11% - Infection
 15% - Other
 MILLENIUM DEVELOPMENT GOALS Maternal, Newborn Child Health Nutrition
(MDGs) (MNCHN) Strategy
Goal 1: Eradicate Extreme Poverty and  It is a program of the DOH Based on
Hunger administrative order 2008-0029, or the
“Implementing Health Reforms for
Goal 2: Achieve Universal Primary Education
Rapid Reduction of Maternal and
Goal 3: Promote Gender Equality Neonatal Mortality”.

GOAL 4: REDUCE CHILD MORTALITY

GOAL 5: IMPROVE MATERNAL HEALTH GOAL OF MNCHN

Goal 6: Combat HIV and AIDS, malaria &  Modify community behavior on the
other diseases prevention of occurrences of diseases
and complication to reduce risk factors
Goal 7: Ensure environmental sustainability
 Educate the community
Goal 8: Develop a global partnership for  Conduct an impact assessment of
development MNCHN
 Raise self responsibility for health
maintenance
MDG 4: Reduce Child Mortality
By 2030, end preventable deaths of
UNIFIED STRATEGY to save mothers,
newborns and children under 5 years of age,
newborns and children
with all countries aiming to reduce neonatal
mortality to at least as low as 12 per 1000 live  Targeting high-risk and low performing
births and under 5 mortalities to at least as areas to fast-track attainment of goals
low as 25 per 1000 live births.  Empowering mothers to utilize life-
saving packages
 Developing incentive mechanisms to
MDG 5: Improve Maternal Health influence positive behavior from health
By 2030, reduce the global maternal mortality providers and consumers
ratio to less than 70 per 100,000 live births.

3 LEVELS OF CARE OF MNCHN

BOTH MATERNAL AND CHILD 1. Community Level Service Providers
 By 2030, end the epidemics of aids,  Give primary health care services. Ex.
tuberculosis, malaria, and neglected RHU, BHS
tropical diseases and combat hepatitis,
waterborne diseases, and other 2. Basic Emergency Obstetric and
communicable diseases. Newborn Care (BeMONC)
 By 2030, reduce by one-third  Operates 24 hours basis with staff
premature mortality from non- complement of skilled health
communicable diseases through professionals such as doctors, nurses,
prevention and treatment and promote midwives, and medical technologists.
mental health and well-being.
 Capable network of facilities and
providers can be based in hospitals,
RHU, BHS, lying in clinic or birthing
The DOH Strategy for Meeting the MDG Goal homes.
in Maternal and Newborn Death Reduction
3. Comprehensive Emergency Obstetric Midwife
and Newborn Care (CeMONC)
 Assistant
- Capable facilities or networks of  Health education
facilities are end referral facilities capable of  Prenatal & postnatal care
managing complicated deliveries and  Networking & referral for community
newborn emergencies. It should be able to
perform the six obstetric functions as well as
provide cesarean delivery services, blood EmONC is the foundation for all other
banking and transfusion services and other efforts
highly specialized obstetric interventions.
 Family Planning
- It is also capable of providing  Antenatal Care
newborn emergency interventions which  Skilled Attendant at Labor and Delivery
include, at the minimum, the following:  Birth Plan
a) Newborn resuscitation  Newborn Care
b) Treatment of neonatal sepsis/infection  Postpartum Care
c) Oxygen support for neonate  Breastfeeding Immunization Nutrition
d) Management of low birth weight or
preterm newborn
e) Other specialized newborn services

Strategy to Intermediate Results

 Every pregnancy is wanted, planned

Skilled Professionals Roles & and supported
Responsibilities  Every pregnancy is adequately
Physician managed
 Every delivery is FACILITY-BASED
 Team leader and managed by skilled health
 Perform all functions professionals - MD, RN, RM
 Supervisory function  Every mother and newborn pair
 Network and referral secures proper postpartum and
postnatal care
Nurse
 Assistant team leader
 Administrative function’
 Health education
 Networking & referral
 postpartum, and post abortion periods
GENETICS and newborns during the first week of
 It is introduced by Bateson in 1906. life, including management of endemic
 Derived from Greek word “gene” diseases like malaria, HIV/AIDS, TB
meaning ‘to become’ or ‘to grow into’ and anemia.
 It is the branch of biological sciences
which deals with the transmission of
characteristics from parents to  Guide for clinical decision making and
offspring includes recommendations on the
 It is defined as the study of genes and information to share with women and
of the statistical laws that governs the their families, little guidance is included
passage of genes from one generation on how to effectively communicate and
to next. counsel.

GENETIC COUNSELING
 It is a process offered to people with OBJECTIVES
genetic disease and their families and 1. Understand the woman and
to individuals, who are suspected of community he/she provides services
having the genetic conditions. A for both the overall context in which
qualified genetic counsellor will the live as well as their specific need.
conduct genetic tests, that evaluates 2. Counsel and communicate more
family history and medical records to effectively with women with their
identify the possibility of passing any partners and families during
genetic disorder to baby. These pregnancy, childbirth, post natal and
disorders are caused by defects in post abortion periods.
genes. For example: down syndrome 3. Use different skills, methods and
and sickle cell anemia. approaches to counselling in a variety
of situations, with women, their
INDICATIONS FOR GENETIC partners and families in effective and
COUNSELING appropriate ways.
1. Hereditary disease in patient or family 4. Support women, their partners and
2. Birth defects families to take actions for better
3. Mental retardation health and facilitate their process.
4. Advanced maternal age 5. Contribute to women and the
5. Early onset of cancer in family communities increased confidence and
6. Miscarriages satisfaction in the services he/she
7. Malformations provides.
8. Tendency for develop a neurologic
condition Integrated Management of Pregnancy and
Childbirth
WORLD HEALTH ORGANIZATION (WHO) Pregnancy, Childbirth, Postpartum
Developed a clinical guide entitled: and Newborn Care:
A guide for essential practice
“PREGNANCY, CHILDBIRTH,
POSTPARTUM, AND NEWBORN CARE: A
GUIDE FOR ESSENTIAL PRACTICE”

PCPNC
 It provide evidenced-based
recommendations to guide health care NATIONAL SAFE MOTHERHOOD
professionals in the management of PROGRAM
women during pregnancy, childbirth, October 17, 2018
VISION
 For Filipino women to have full access
to health services towards making their
pregnancy and delivery safer.
MISION
 To provide rational and responsive
policy direction to its local government
partners in the delivery of quality
maternal and newborn health services
with integrity and accountability using
proven and innovative approaches.
OBJECTIVES
 Collaborating with Local Government
Units in establishing sustainable, cost
effective approach of delivering health
services that ensure access of
disadvantaged women to acceptable
and high quality maternal and newborn
health services and enable them to
safely give birth in health facilities near
their home.
 Establishing core knowledge base and
support systems that facilitates the
delivery of quality maternal and
newborn health services in the
country.
NURSING CARE OF THE HIGH-RISK past history of pregnancy
PREGNANT CLIENT complications-can cause a pregnancy
to be categorized as high risk.

 When a woman enters pregnancy with

a chronic condition such as
cardiovascular or kidney disease, both
she and the fetus can be at risk for
complications because either the FACTORS THAT CAUSE A PREGANCY AS
pregnancy can complicate the disease HIGH RISK
or the disease can complicate the PSYCHOLOGICAL
pregnancy, affecting the Prepregnancy Pregnancy Labor and Birth
baby or a leaving a woman
less equipped to function in  History of  Loss of  Severely
the future or undergo a drug support frightened by
future pregnancy. dependence person labor and
 Nursing care for a woman (including  Illness of a birth
with a pre-existing illness alcohol) family experience
focuses on close  History of member  Inability to
observation of maternal intimate  Decrease participate
health and fetal well-being partner in self because of
education of a woman and abuse esteem anesthesia
her family about special  History of  Drug  Separation
danger signs to watch for mental abuse of infant at
during pregnancy and illness (including birth
actions to minimize  History of alcohol and  Lack of
complications whenever poor coping cigarette preparation
possible. mechanism smoking) for labor
 Cognitive  Poor  Birth of infant
challenged acceptance who is
HIGH-RISK PREGNANCY  Survivor of of disappointing
childhood pregnancy in some
 It is one in which a
sexual ways (such
concurrent disorder,
abuse as sex,
pregnancy-related
appearance,
complication, or external
or congenital
factor jeopardizes the health
anomalies)
of the woman, the fetus or
 Illness of
both.
newborn
 Some women enter
pregnancy with a chronic illness that
when superimposed on the pregnancy,
makes it high risk.
 Other women enter pregnancy in good
health but then develop a complication
of pregnancy that causes it to become
high risk.
 In some instances a combination of
particular circumstances-poverty, lack
of support people, poor coping
mechanisms, genetic inheritance, or
SOCIAL
Prepregnancy Pregnancy Labor and Birth
 Occupation involving  Refusal of or  Lack of support person
handling of toxic substance neglected  Inadequate home for
(including radiation and prenatal care infant care
anesthesia gases)  Exposure to  Unplanned cesarean birth
 Environmental environmental  Lack of access to
contaminants at home teratogens continued health care
 Isolated  Disruptive  Lack of access to
 Lower economic level family incidents emergency personnel or
 Poor access to  Decrease equipment
transportation for care economic
 Poor housing support
 Lack of support people  Conception less
than 1 year after
last pregnancy

PHYSICAL
Prepregnancy Pregnancy Labor and Birth
 Visual or hearing  Subject to trauma  Hemorrhage
challenges  Fluid or electrolyte  Infection
 pelvic inadequacy or imbalance  Fluid and electrolyte
misshape  Intake of teratogen imbalance
 uterine incompetency, such as drugs  Dystocia
position or structure  Multiple gestation  Precipitous birth
 secondary major illness  A bleeding  Lacerations of cervix
(heart disease, dm, kidney disruption or vagina
disease, hypertension,  Poor placental  Cephalopelvic
chronic infection such as formation or disproportion
TB, hemophilic or blood position  Internal fetal
disorder, malignancy)  Gestational dm monitoring
 Poor gynecologic or  Nutritional  Retained placenta
obstetric history deficiency of iron,
 History of previous poor folic acid, or protein
anomalies  Poor weight gain
 Obesity and underweight  Pregnancy induced
 History of inherited hypertension
disorder  Infection
 Pelvic inflammatory  Amniotic fluid
disease abnormality
 Younger than age 18 years  Post maturity
or older than 35 years
 Cigarette smoker
 Substance abuser
 A. PRE-GESTATIONAL CONDITIONS
AFFECTING PREGNANCY OUTCOMES

A woman with cardiac disease

How to diagnose?

Assessing a Pregnant Woman with

Cardiac Disease

How to Assess?
1. Ask for the history of:
 Rheumatic fever
 Heart lesion
 Dyspnea
 Paroxysmal nocturnal dyspnea
 Orthopnea
 Hemoptysis
 Prophylaxis with long acting
penicillin

What to expect during examination?

 Murmur
 Accentuated heart sound
 Arrhythmia
 Central cyanosis
 Displaced apex belt
 Manifestation of left side heart failure
ex. Gallop rhythm, crepitations over
lung bases and pleural effusion
 Manifestation of right side heart ex.
Congested neck vein, enlarged tender,
liver, ascites and edema lower limbs

Diagnostic Test
 Chest x-ray may show cardiac
enlargement, pulmonary congestion or
pleural effusion
 Electrocardiogram (ECG)
 Echo cardiograph (2d echo) shows
cardiac structure and functions

RHEUMATIC HEART DISEASE (RHD)

It is a condition in which a permanent o Instruct to report coughing during
damage to heart valves is caused by pregnancy (because simple cough is a
rheumatic fever. The heart valve is damaged first manifestation of pulmonary edema
by a disease process that generally begins from heart failure).
with strep throat cause by bacteria called o Determine edema if it is caused by
streptococcus and may eventually cause by normal pregnancy (innocent edema) or
rheumatic fever. PIH (serious edema)
o Assist the client to undergo ECG,
CXR, or 2D echo
RHEUMATIC FEVER - Assure that CXR is safe as long as
a woman's abdomen is covered by
 It is an inflammatory disease that can
a lead apron during the exposure.
affect many connective tissues
specially in the heart, joints, skin or REST - client needs two rest periods a day:
brain. The infection often causes heart
damage, particularly scarring of the 1. FULLY RESTING- not getting up
heart valves, forcing the heart to work frequently to answer the door or
harder to pump blood. The heart valve telephone.
damage may start shortly after 2. FULL NIGHT'S SLEEP- not tossing or
untreated or under-treated turning on bed because of excess
streptococcal infection such as strep noise or heat in the room rest should
throat or scarlet fever. This can result be in left lateral recumbent position to
in narrowing or leaking of the heart prevent supine hypotensive syndrome.
valve making it harder for the heart to
function normally.
 The damage may resolve on its own, NUTRITION - watch out for nutritional intake
or it may be permanent, eventually not to gain so much weight because
causing congestive heart failure (a additional weight could overburden the heart
condition in which the heart cannot ------ limit salt intake
pump out all of the blood that enters it, ***salt is NOT severely restricted during
which leads to an accumulation of pregnancy because sodium is needed for
blood in the vessels leading to the maintaining fluid balance thus allowing
heart and fluid in the body tissues). retention of enough blood volume to supply
 People with RHD may have a murmur placenta.
or rub that may be heard during a
routine physical exam. The murmur is ---take prenatal vitamins specially iron
caused by the blood leaking around supplement to help prevent anemia.
the damages valve. The rub is caused ***anemia places an extra work to heart
when the inflamed heart tissues move because it requires the body to circulate more
or rub against each other. blood to supply oxygen to all body cells.

NURSING CARE FOR MOTHER WITH RHD NURSING CARE FOR MOTHER WITH RHD
ANTENATAL Medication
o Record baseline vital signs specially  Digoxin (to strengthen the client; to
bp. Get the bp in sitting or lying slow fetal heart rate if fetal tachycardia
position at first prenatal visit and take it is present)
in the same position and arm in the ***check the heart arte before digoxin
future visits for a most accurate administration. Withhold the meds if
comparison. below 60bpm.
  Antiembolic stockings and ambulation
may needed to increase venous return
 Penicillin Antibiotic
from the legs.
***client who is taking penicillin to
 In the postpartum period, agents to
prevent recurrence of rheumatic fever
encourage uterine involution such as
should continue taking the medication
oxytocin (Pitocin) must be used with
during pregnancy. Some physicians
caution because they tend to increase
begin a prophylactic penicillin antibiotic
blood pressure, and this necessities
as the day of delivery is near
increased heart action.
approaching as protection from
 Kegel exercises are acceptable for
subacute bacterial endocarditis. This is
perineal strengthening immediately.
because postpartum period always
BUT the woman should not begin
involves mild invasion of bacteria
postpartum exercises to improve
maybe streptococci that often
abdominal tone until her physician or
responsible for endocarditis.
nurse-midwife approves them.
***client needs to increase
 A stool softener can be prescribed to
maintenance dose because of
prevent straining with bowel
expanded volume during pregnancy
movement.
(3-%-50% increase of cardiac output
during pregnancy). Thus heart is being
stressed further by the increased
EFFECTS OF HEART DISEASE ON
circulatory load of pregnancy.
PREGANCY
Avoidance of Infection  Abortion
- Avoid visiting or being visited by a  Intrauterine growth retardation
people with infection  Still Birth
- Inform health personnel for any  Premature Labor
signs and symptoms of infection so  Intrauterine Fetal Demise (IUFD)
that antibiotic could be started
- Monthly screening for urine for
bacteria MANAGEMENT
***infection increases body temperature 
causing the client to expand more energy and
increase cardiac output, a situation that a
heart could too extreme to withstand.

NURSING CARE FOR MOTHER WITH RHD

LABOR AND BIRTH
Monitor fetal heart rate and uterine
contractions during labor in all women with
heart disease. Assess a woman's blood
pressure, pulse and respirations frequently. A
rapidly increasing pulse rate (100 bpm) is an
indication that a heart is pumping
ineffectively.

NURSING CARE FOR MOTHER WITH RHD

POSTPARTUM