ABNORMAL OBSTETRICS

RISK FACTORS ASSOCIATED WITH PREGNANCY BLEEDING COMPLICATIONS IN PREGNANCY First Trimester Abortion Ectopic Pregnancy Second Trimester Hydatidiform Mole Incompetent Cervix Third Trimester Abruptio/Ablatio Placenta Placenta Previa HYPERTENSIVE DISORDER IN PREGNANCY Gestational Hypertension Chronic Hypertension Pregnancy Induced Hypertension >Pre-eclampsia >Eclampsia METABOLIC DISORDER IN PREGNANCY >Diabetes Mellitus MEDICAL CONDITIONS COMPLICATING PREGNANCY >Heart Disease >Anemias >Infertility Risk Pregnancy is a pregnancy with a pre-existing or developing condition that threatens the progression of the pregnancy, labor and delivery of a healthy term infant. Risk Factors are characteristics or circumstances of a person or group that are associated with an increased risk of developing or affected by a morbid process. At Risk Individual is a person with an increased expectation of disease or complication.

Risk Factors associated with Pregnancy: Maternal age factor Teenage pregnancy of 16 yrs. and below is considered a high risk pregnancy from both physical and psychosocial standpoint Physical Because of the physical task of adolescence Rapid growth during adolescence Rapid growth of the fetus Psychosocial Lack of motivation Denial Ignorance Rebellion against authority Failure to complete education Dependence on others for support Failure to establish a stable family life High rate of marital failure High incidence of repeated out of wedlock pregnancy Risk Factors associated with Pregnancy: Advanced age of 35 yrs and above is a high risk of pregnancy because of increased incidence of :

Placenta previa Chromosomal abnormalities Abruptio / Ablatio placenta Hypertension Toxemia Low birth weight babies

Parity First pregnancy is the period of highest risk Second / Third and Fourth pregnancy the risk of death for the mother is at its lowest Fifth pregnancy marked increase especially when the pregnant mother is over 40 years of age. Civil status and Cultural groups Unwed mothers and widow Difficulty in providing financial support Inability to give personal care Cultural minorities lack information about Sexual behavior Marriage and family life Parenthood and pregnancy responsibilities Nutritional inadequacies Absence of immunizations Lack of prenatal care Socioeconomic Status Poverty the frontrunner of societal ills which stem directly or indirectly the risk factor of pregnancy Lack of money is the principal cause of low birth weight infants that influence morbidity and mortality rate. COMPLICATIONS OF PREGNANCY

A. FIRST TRIMESTER BLEEDING:

1. ABORTION - THE EXPULSION OF THE PRODUCTS OF CONCEPTION BEFORE THE AGE OF VIABILITY ( FETUS CAN SURVIVE EXTRAUTERINE LIFE) - FETUS IS LESS THAN 20 WEEKS OR LESS THAN 500 GRAMS

Abortus a fetus that is aborted before it is 500 gms in weight Blighted ovum a small macerated fetus, (sometimes there is no fetus) surrounded by a fluid inside an open sac Maceration a dead fetus undergoing necrosis Fetus Papyraceous a fetus that is so dry that it resembles a parchment Lithopedion a calcified embryo Occult pregnancy refers to those zygotes that were aborted before pregnancy is diagnosed

CAUSES OF ABORTION: 1. ABNORMAL DEVLOPMENT OF THE ZYGOTE WHICH WOULD HAVE RESULTED IN SEVERE CONGENITAL ANOMALIES 2. ABNORMALITY IN THE IMPLANTATION PROCESS - IUD 3. TRAUMA PSYCHOLOGICAL, PHYSICAL 4. HORMONAL IMBALANCE ( LOW PROGESTERONE) 5. INTAKE OF DRUGS CYTOTEC 6. INFECTIOUS DISEASES GERMAN MEASLES, PTB, HERPES

7. PRESENCE OF VENEREAL DISEASES 8. ABNORMALITY IN THE REPRODUCTIVE SYSTEM INCOMPETENT CERVIX 8. SEVERE MALNUTRITION EARLY ABORTION HAPPENS BEFORE 16 WEEKS LATE ABORTION HAPPENS BETWEEN 16 20 WEEKS Types of Abortion: SPONTANEOUS - UNINTENDED TERMINATION OF PREGNANCY AT ANY TIME BEFORE THE FETUS HAS ATTAINED VIABILITY. THREATENED POSSIBLE LOSS OF THE PRODUCTS OF CONCEPTION S/SX: SLIGHT BLEEDING; MILD UTERINE CRAMPING BUT NO CERVICAL DILATATION ON VAGINAL EXAMINATION; NO PASSAGE OF TISSUE Management: Bed rest Save all pads No coitus up to 2 weeks after bleeding has stopped INEVITABLE OR IMMINENT ABORTION - is a loss of pregnancy that cannot be prevented. Clinical Manifestations: Moderate to profuse Bleeding Moderate to severe uterine cramping Cervix dilated Membranes rupture

Management: Hospitalization D&C Oxytocin after D & C Emotional support

TYPES OF INEVITABLE ABORTION: 1) Complete all products of conception are expelled. Sxs of complete abortion: Moderate bleeding Mild uterine cramping Passage of tissue Management: Sympathetic understanding & emotional support 2) Incomplete not all products of conception are expelled from the uterus. Signs and Sxs: Profuse vaginal bleeding Severe uterine cramping Open cervix Passage of tissue Other products are retained Treatment and MX: D and C Oxytocin after D & C Emotional support Missed Abortion Retention of all products of conception after the death of the fetus in the uterus S/Sx: - No FHT

- Signs of pregnancy disappear Management: D&C Septic Abortion Abortion complicated by infection S/Sx: - Foul smelling vaginal dischrage - Uterine cramping - Fever Management: - Treat abortion - Antibiotics HABITUAL OR RECURRENT PREGNANCY LOSS SPONTANEOUS ABORTION IN THREE OR MORE SUCCESSIVE PREGNANCIES USUALLY DUE TO INCOMPETENT CERVIX. B. Induced Abortion is an intentional loss of pregnancy through direct stimulation either by chemical or mechanical means. Types of induced abortion: 1)Therapeutic abortion to preserve the life of the mother 2) Elective abortion Reasons for Induced Abortion: Therapeutic to end a pregnancy that is life threatening to the mother To end a pregnancy of a fetus found to have severe congenital abnormalities that may be incompatible with life To end an unwanted pregnancy that is a result of rape or incest To end a pregnancy because of womans choice not to have a child yet Prevention of abortion: Prepregnancy correction of maternal disorders Immunization against infectious diseases Proper early antenatal care Treatment of pregnancy complications Correction of cervical incompetency Complications: Hemorrhage Sepsis Rh sensitization ECTOPIC PREGNANCY - ANY PREGNANCY THAT OCCURS OUTSIDE THE UTERINE CAVITY. ---SECOND LEADING CAUSE OF BLEEDING IN EARLY PREGNANCY. TYPES: 1. AMPULAR 4. CERVICAL 2. INTESTINAL 5. ABDOMINAL 3. OVARIAN Predisposing causes: Salpingitis Peritubal adhesions Previous ectopic pregnancy Previous tubal surgery Multiple previous abortion Tumors that distort the tubes External migration of the ovum Intrauterine device (IUD) Signs and Sxs:

 Vaginal spotting or bleeding Cul de sac mass Absence of amniotic sac Amenorrhea or abnormal menstruation followed by slight uterine bleeding Signs of tubal rupture: Severe sharp knife like pain in the lower quadrant of the abdomen Abdominal rigidity Nausea and vomiting Low hgb. And hct. Sharp localized pain in the cervix on internal examination ( wiggling sign) Signs of hemorrhage: - Cullens sign bluish discoloration of the umbilicus due to the presence of blood in the peritoneal cavity -Hard or rigid boardlike abdomen . Signs of shock: - Falling BP, rapid pulse - Light headedness - Pallor - Cyanotic nail beds - Cold clammy skin Diagnostic Aids: Culdocentesis aspiration of bloody fluid from Cul de sac of Douglas Ultrasound reveals presence of the gestational sac outside of the uterine cavity Treatment and management: If not yet ruptured: Salpingostomy removal of a conceptus less than 2 cm located at the distal portion of the fallopian tube by performing a linear incision over the ectopic pregnancy. The conceptus will extrude from the incision & removed manually. Salpingotomy longitudinal incision is made over the ectopic pregnancy & the conceptus is removed using forceps or gentle suction Fimbrial evacuation removal of the conceptus by milking & suctioning of the fallopian tube If ruptured: - removal of the ruptured tube because the presence of a scar if tube is repaired & left can lead to another tubal pregnancy. Surgical treatment: -Salpingotomy -Salpingectomy removal of the oviducts Prevent and treat hemorrhage which is the main danger of ectopic pregnancy. Blood transfusion Place patient flat in bed with legs elevated Monitor Vital signs, I & O, & amount of blood loss Prevent infection as the woman who lost so much blood is susceptible to infection Contraception must be started upon discharge from hospital. Ovulation begins as early as 19 days or 3 weeks after resection of ectopic pregnancy. B. SECOND TRIMESTER BLEEDING 1. GESTATIONAL TROPHOBLASTIC DISEASE (HYDATIDIFORM MOLE OR HMOLE)) - A benign disorder characterized by degeneration of the chorion & death of the embryo. The chorionic villi will rapidly proliferate and become GRAPELIKE VESICLES THAT PRODUCE LARGE AMOUNTS OF HCG. CAUSES:

1. SPERM + OVUM + DUPLICATION =46 (COMPLETE ( 23) ( 0) MOLE) 2. SPERM + OVUM =69 (PARTIAL (46) (23) MOLE) 3. SPERM ( 23) OVUM + + ( 23) =69 (PARTIAL SPERM MOLE) ( 23) Predisposing factors: 17 years old below and 35 yrs. Above Low socioeconomic status Low protein intake Previous mole Higher incidence in Asian women TYPES: 1. COMPLETE MOLE IF AN EMBRYO FORMS, IT DIES EARLY AT ONLY 1 TO 2 MM IN SIZE WITH NO FETAL BLOOD PRESENT IN THE VILLI. 2. PARTIAL MOLE NO EMBRYO PRESENT BUT FETAL BLOOD MAY BE PRESENT. HAS 69 CHROMOSOMES (TRIPLOID FORMATION) Signs and Sxs: Rapid increase in uterine size greater than gestational age of the fetus Marked increase HCG titer; NV:400,00 iu Excessive nausea and vomiting due to elevated HCG Brownish vaginal discharge around 4th month containing grapelike vesicles No FHT, no fetal movement No fetal parts Bleeding which may vary from spotting to profuse hemorrhage is a common sign No fetal skeleton Increase WBC Hypertension & other sx of preeclampsia Symptoms of PIH before 24th week gestation **difference bet.H-mole & pre-eclampsia - before 20 weeks =H mole - after 20 weeks up to 2 weeks post partum = preeclampsia Treatment and management: D and C to remove the mole. ( If the woman is more than 40 yrs old, hysterectomy is done since she has a higher chance of developing CHOROCARCINOMA Monitor HCG for 1 year ( HCG shld be negative 2-6 weeks after removal of H-mole.) -when HCG level is normal it is monitored monthly for 6 mos, then every 2 mos until 2 years Chest X ray every 3 mos for 6 mos. The lungs are the most common site of metastasis of choriocarcinoma Chemotherapy ( Methotrexate) if: -HCG titers are increased for 3 consecutive weeks or double at anytime -HCG titers remain elevated 3-4 mos. after delivery The woman is advised not to get pregnant for 1 year, contraceptive method shld NOT be the pills. Pills contain estrogen which promote regrowth of the chorionic villi. Hysterectomy is the method of tx for women above 40 yrs old because of the higher incidence of malignancies & to clients who have completed childbearing & require sterilization.

Prognosis: Favorable if HCG titers do not recur after evacuation of the mole Unfavorable if malignancy develops and is untreated Complications of H-Mole: Gestational Trophoblastic Tumors persistent trophoblastic proliferation after Hmole. 1. Choriocarcinoma most severe malignant complication that involve the transformation of chorion into cancer cells that invade & erode blood vessels & uterine muscles. 2. Invasive mole locally invasive & is characterized by excessive formation of trophoblastic villi that penetrates the myometrium. Develops during the first 6 months after H-mole. 3. Placental Site Trophoblastic Tumor arises from the site of the placenta. Management of all trophoblastic tumors is HYSTERECTOMY NURSING MANAGEMENT: MAINTAIN F & E BALANCE. 2. EMPHASIZE THAT PREGNANCY SHOULD BE AVOIDED FOR 1 YEAR ( GREATER CHANCE OF IT RECURRING & MAY EVEN LEAD TO CHORIOCARCINOMA) 3. ADMINISTER BLOOD REPLACEMENT AS ORDERED. 4. PROVIDE EMOTIONAL SUPPORT 5. USE MECHANICAL EQUIPMENTS AGAINST PREGNANCY ( Ex. Condom) INCOMPETENT CERVIX OR PREMATURE CERVICAL DILATATION: - PAINLESS CERVICAL EFFACEMENT & DILATATION IN EARLY MIDTRIMESTER RESULTING IN EXPULSION OF PRODUCTS OF CONCEPTION. - MOST COMMON CAUSE OF HABITUAL ABORTION CAUSES: 1. INCREASED MATERNAL AGE 2. CONGENITAL MALDEVELOPMENT OF THE CERVIX short cervix 3. TRAUMA TO THE CERVIX (HISTORY OF REPEATED D & CS; CERVICAL LACERATIONS WITH PREVIOUS PREGNANCIES) Signs and Sxs: Slight vaginal bleeding Presence of uterine contractions in midtrimester Rupture of the bag of waters Expulsion of the conceptus Presence of painless cervical dilatation Relaxed cervical os on pelvic examination MX: 1. CERVICAL CERCLAGE MEDICAL MANAGEMENT WHEREIN THE PHYSICIAN SUTURES A CERTAIN PART OF THE CERVIX BETWEEN 14 AND 16 WEEKS GESTATION TO PREVENT CERVICAL DILATATION. a) MCDONALDS ( temporary) NYLON SUTURES ARE PLACED HORIZONTALLY & VERTICALLY ACROSS THE CERVIX & PULLED TIGHT TO REDUCE THE CERVICAL CANAL TO A FEW MILLIMETERS IN DIAMETER. b) SHIRODKAR ( permanent) STERILE TAPE IS THREADED IN A PURSE-STRING MANNER UNDER THE SUBMUCUS LAYER OF THE CERVIX & SUTURED IN PLACE TO ACHIEVE A CLOSED CERVIX. c) After suturing the cervix: a. Place woman on bed rest for 24 hours

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b. Observe for bleeding, uterine contractions, and rupture of BOW c. If BOW ruptures the sutures are removed d. If uterine contractions occur, the woman is given ritodrine to stop the contractions e. Post-op care: Restrict activities for the next 2 weeks including coitus Pre-requisites of Cervical Cerclage: Cervix not dilated Intact membranes No vaginal bleeding & uterine cramping THIRD TRIMESTER BLEEDING 1. PLACENTA PREVIA - LOW IMPLANTATION OF THE PLACENTA TYPES: 1. LOW-LYING IMPLANTATION OF THE PLACENTA IN THE LOWER RATHER THAN IN THE UPPER PORTION OF THE UTERUS 2. MARGINAL PLACENTA EDGE APPROACHES THAT OF THE CERVICAL OS 3. PARTIAL IMPLANTATION THAT OCCLUDES A PORTION OF THE CERVICAL OS 4. COMPLETE ( TOTALIS) PLACENTA THAT TOTALLY OBSTRUCTS THE CERVICAL OS Predisposing factors: Multiparity Advanced maternal age over 35 yo Multiple pregnancy Uterine tumor Cigarette smoking Scarring from previous previous CS Decreased vascularity of upper uterine segment Past uterine D&C Signs and Sxs: Painless, bright red vaginal bleeding during the 3rd trimester Abdomen soft, non tender Ultrasound reveals placenta previa NURSING MANAGEMENT: 1. MONITOR VITAL SIGNS & BLEEDING ( WEIGH UNUSED PERINEAL PAD, THEN WEIGH PERINEAL PAD SOAKED IN BLOOD, THEN SUBTRACT. THE DIFFERENCE IS THE WEIGHT OF THE BLOOD LOSS.) 2. PROVIDE STRICT BED REST TO MINIMIZE THE RISK TO FETUS.( CBR without BRPs ) 3. OBSERVE FOR FURTHER BLEEDING EPISODES.( PREPARE FOR BT) ( Hgb & Hct) 4. AVOID VAGINAL EXAMINATIONS ( NO IE). IF IE IS INDICATED, IT SHOULD BE DONE IN A DOUBLE SET-UP ENVIRONMENT. ( MEANING: OR/DR) WHEREIN THE PATIENT HAS ALREADY SIGNED A CONSENT FORM, PRE-OP MEDS HAVE BEEN GIVEN, ABDOMINAL PREP HAS BEEN DONE SO THAT IF THE PLACENTA IS ACCIDENTALLY DETACHED BECAUSE OF MANIPULATIONS, CS CAN BE DONE IMMEDIATELY. 5. PROVIDE EMOTIONAL SUPPORT DURING THE GRIEVING PROCESS. ** CLASSICAL CESARIAN SECTION ( UTERUS IS INCISED IN THE VERTICAL SEGMENT) IS DONE IN CASE OF SEVERE BLEEDING.** ** BLEEDING WITH PLACENTA PREVIA OCCURS WHEN THE LOWER UTERINE SEGMENT BEGINS TO DIFFERENTIATE FROM THE UPPER SEGMENT LATE IN PREGNANCY ( APPROXIMATELY WEEK 30) & THE CERVIX BEGINS TO DILATE. THE BLEEDING PLACES THE MOTHER AT RISK FOR HEMORRHAGE. BECAUSE THE PLACENTA IS LOOSENED, THE FETAL OXYGEN MAY BE COMPROMISED IMMEDIATE CARE MEASURES:

** TO ENSURE AN ADEQUATE BLOOD SUPPLY TO THE MOTHER & FETUS, PLACE THE WOMAN ON BED REST IN A LEFT SIDE LYING POSITION.** Assess fetal lung maturity Observe for PP hemorrhage Observe strict aseptic technique Complications of placenta previa: Hemorrhage Infection Prematurity ABRUPTIO PLACENTA - ABRUPT SEPARATION OF AN OTHERWISE NORMALLY IMPLANTED PLACENTA AFTER 20 WEEKS AOG. TYPES: 1. MARGINAL ( OVERT) SEPARATION BEGINS AT THE EDGES OF THE PLACENTA ALLOWING BLOOD TO ESCAPE FROM THE UTERUS. BLEEDING IS EXTERNAL. 2. CENTRAL ( COVERT) PLACENTA SEPARATES AT THE CENTER RESULTING IN BLOOD BEING TRAPPED BEHIND THE PLACENTA. BLEEDING THEN IS INTERNAL AND NOT OBVIOUS. CAUSES: 1.MATERNAL HYPERTENSION ( CHRONIC OR PREGNACY INDUCED) 2. ADVANCED MATERNAL AGE 3. GRAND MULTIPARITY MORE THAN 5 PREGNANCIES 4. TRAUMA TO THE UTERUS 5. SUDDEN RELEASE OF AMNIOTIC FLUID THAT CAUSE SUDDEN DECOMPRESSION OF TE UTERUS. 6. SHORT UMBILICAL CORD 7. CIGARETTE SMOKING & COCAINE ABUSE S/SX: 1. SHARP PAIN IN THE FUNDAL AREA AS THE PLACENTA SEPARATES 2.PAINFUL DARK RED VAGINAL BLEEDING IN COVERT TYPE 3.PAINFUL BRIGHT RED VAGINAL BLEEDING IN OVERT TYPE 4.HARD, RIGID, FIRM,BOARD-LIKE ABDOMEN CAUSED BY ACCUMULATION OF BLOOD BEHIND THE PLACENTA WITH FETAL PARTS HARD TO PALPATE. 5. ABNORMAL TENDERNESS DUE TO DISTENTION OF THE UTERUS WITH BLOOD. 6. SIGNS OF SHOCK & FETAL DISTRESS AS THE PLACENTA SEPARATES. CLASSIFICATION ACCORDING TO PLACENTAL SEPARATION: 1. GRADE 0 = NO SYMPTOMS OF PLACENTAL SEPARATION, DIAGNOSED AFTER DELIVERY WHEN PLACENTA IS EXAMINED & FOUNDTO HAVE DARK, ADHERENT CLOT ON THE SURFACE. 2. GRADE 1 = SOME EXTERNAL BLEEDING, NO FETAL DISTRESS, NO SHOCK, SLIGHT PLACENTAL SEPARATION GRADE 2 = EXTERNAL BLEEDING, MODERATE PLACENTAL SEPARATION, UTERINE TENDERNESS, FETAL DISTRESS GRADE 3 = INTERNAL & EXTERNAL BLEEDING, MATERNAL SHOCK, FETAL DEATH, DIC MX: 1. WHEN PLACENTA ABRUPTIO IS SUSPECTED OR DIAGNOSED, HOSPITALIZATION IS A MUST. 2. BEDREST OR SIDE LYING POSITION FOR OPTIMUM PLACENTAL PERFUSION. 3. MONITOR VITAL SIGNS, FHT, AMOUNT OF BLOOD LOSS GIVE MASK O2 IF FETAL DISTRESS IS PRESENT. 4. DELIVERY:

3. 4.

** VAGINAL DELIVERY IF THERE IS NO SIGN OF FETAL DISTRESS, BLEEDING IS MINIMAL & VITAL SIGNS ARE STABLE. ** CESARIAN DELIVERY IF BLEEDING IS SEVERE, FETAL DISTRESS IS PRESENT & FETUS CANNOT BE DELIVERED IMMEDIATELY WITH VAGINAL METHOD. COMPLICATIONS: 1. COUVELAIRE UTERUS OR UTERINE APOPLEXY INFILTRATION OF BLOOD INTO THE UTERINE MUSCULATURE RESULTING IN THE UTERUS BECOMING HARD & COPPER COLORED. 2. HEMORRHAGE & SHOCK TREATED BY BLOOD TRANSFUSION 3. DIC MANAGED BY FIBRINOGEN & CRYOPRECIPITATE Disseminated Intravascular Coagulation (DIC) Disorder of blood clotting Fibrinogen levels fall below effective limits ( Hypofibrinogenemia) Symptoms Bruising or bleeding massive hemorrhage initiates coagulation process causing massive numbers of clots in peripheral vessels (may result in tissue damage from multiple thrombi), which in turn stimulate fibrolytic activity, resulting in decreased platelet and fibrinogen levels and signs and symptoms of local generalized bleeding (increased vaginal blood flow, oozing IV site, ecchymosis, hematuria, etc) monitor PT, PTT, and Hct, protect from injury; no IM injections HYDRAMNIOS / POLYHYDRAMNIOS - CHARACTERIZED BY EXCESSIVE AMOUNT OF AMNIOTIC FLUID, MORE THAN 2000 ML. - NORMAL AMOUNT OF AMNIOTIC FLUID AT TERM IS 500 TO 1200 ML CAUSES: 1. MULTIPLE PREGNANCY = ONE FETUS USURPS THE GREATER PART OF THE CIRCULATION RESULTING IN CARDIOMEGALY, WHICH IN TURN RESULTS IN INCREASED URINE OUTPUT. 2. FETAL ABNORMALITIES: a. ESOPHAGEAL ATRESIA FETAL SWALLOWING OF AMNIOTIC FLUID IS ONE OF THE MECHANISMS THAT REGULATE THE AMOUNT OF AMNIOTIC FLUID. IN ATRESIA, THE FETUS CANNOT SWALLOW b. SPINA BIFIDA INCREASED TRANSUDATION OF AMNIOTIC FLUID FROM THE EXPOSED MENINGES. S/SX: 1. EXCESSIVE UTERINE SIZE, OUT OF PROPORTION TO AOG WITH DIFFICULTY PALPATING FETAL PARTS & FINDING FHT PRIMARY CLINICAL FINDINGS 2. SHORTNESS OF BREATH CAUSED BY PRESSURE OF THE OVERLY DISTENDED UTERUS AGAINST THE DIAPHRAGM. 3. BACK PAIN, VARICOSITIES, CONSTIPATION, FREQUENCY OF URINATION & HEMORRHOIDS DIAGNOSTIC AIDS: 1. ULTRASOUND 2. RADIOGRAPHY COMPLICATIONS: 1. PREMATURE LABOR & DELIVERY 2. ABRUPTIO PLACENTA 3. POSTPARTUM HEMORRHAGE DUE TO OVERDISTENTION 4. CORD PROLAPSE MX: MILD TO MODERATE DEGREES USUALLY DOES NOT REQUIRE TREATMENT.

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2. HOSPITALIZATION IF SX INCLUDES DYSPNEA, ABDOMINAL PAIN, DIFFICULT AMBULATION. 3. AMNIOCENTESIS REMOVAL OF AMNIOTIC FLUID TO RELIEVE MATERNAL DISTRESS 4. INDOMETHACIN THERAPY A DRUG THAT DECREASES FETAL URINE FORMATION. SE: POTENTIAL PREMATURE CLOSURE OF THE DUCTUS ARTERIOSUS. 5. HEALTH INSTRUCTIONS FOR RELIEF OF SYMPTOMS: 1. PLACE IN SEMI-FOWLERS POSITION TO ASSIST IN BREATHING 2. EMPTY BLADDER FREQUENTLY STOPPED AT SLIDE 89, POWERPOINT!!!