Chapter 21Complications Occurring Before Labor and Delivery Flashcards
Exam 2
Preterm Premature Rupture of Membranes (PPROM) #1-
Preterm Rupture of Membranes: What is it?
Preterm rupture of membranes (PROM) is the rupture of membranes prior to the start of contractions at or after 37 weeks.
Preterm Premature Rupture of Membranes (PPROM) #1:
What does PROM increase the risk for?
PROM increases the risk of:
prolapsed cord,
placental abruption,
chorioamnionitis, and
cord compression.
Preterm Premature Rupture of Membranes (PPROM) #1:
What is PRETERM premature rupture of membranes (PPROM)?
Preterm premature rupture of membranes (PPROM) is the rupture of membranes prior to 37 weeks of gestation.
Preterm Premature Rupture of Membranes (PPROM) #1:
What are major concerns for patients with PPROM?
Major concerns for patients with PPROM include
infection,
cord prolapse,
fetal malpresentation, and
precipitous labor.
Preterm Premature Rupture of Membranes (PPROM) #1:
What are the identifiable risk factors of PRROM?
Most patients with PPROM do not have identifiable risk factors.
Preterm Premature Rupture of Membranes (PPROM) #1:
Who is the incidence of PPROM higher in?
The incidence of PPROM, is higher in patients who smoke,
had a previous pregnancy with PPROM,
infections of the genital tract, and
had any vaginal bleeding during pregnancy.
Preterm Premature Rupture of Membranes #2:
Treatment for PPROM includes:
Corticosteroids
Antibiotic therapy
Tocolytics
Preterm Premature Rupture of Membranes #2:
Treatment for PPROM includes:
What is the treatment of PPROM in pregnancies under 34 weeks? Why?
Corticosteroids in pregnancies under 34 weeks gestation to promote fetal lung maturity.
Preterm Premature Rupture of Membranes #2:
Treatment for PPROM includes: What is used because of infection?
Antibiotic therapy because PPROM may have been caused by infection.
Preterm Premature Rupture of Membranes #2:
Treatment for PPROM includes:
What is used off label? How long and why?
What is thought about the use of this drug?
Tocolytics may be used off label for 48 hours to allow time for a full course of corticosteroids to be administered to the patient. Use of tocolytics for PPROM is controversial.
Preterm Premature Rupture of Membranes #2:
What should nurses monitor patients for closely in patients with PPROM?
Nurses should monitor patients with PPROM closely for signs of infection.
Preterm Labor #1:
What is preterm labor?
Preterm labor is contractions that cause cervical dilation prior to 37 weeks and may be spontaneous or induced.
Preterm Labor #1:
Approximately how many births are preterm labor?
Approximately 10% of births are preterm.
Common Reasons for Premature Induction of Labor:
Placental Problems
History of uterine scarring
Fetal grown restriction
Chronic hypertension
Preeclampsia
Poorly controlled gestational diabetes
Pregestational diabetes, poor controlled or with vascular complications
Preterm premature rupture of membranes
Preterm Labor #2: Symptoms of Labor Include:
Irregular contractions, often mild
Report of “menstrual-like” cramping
Low back pain
Feelings of vagina or pelvic pressure
Light bleeding or spotting
Bloody show
Preterm Labor #2:
Diagnosis of preterm labor may include:
Cervical dilation of 3 cm or more
Cervical shortening on ultrasound
Positive fetal fibronectin test (fFN):
Preterm Labor #2
Diagnosis of preterm labor may include:
Positive fetal fibronectin test (fFN):
Evaluation of a protein concentrated between the placenta and the decidua of the uterus
Preterm Labor: Risk Factors
Risk Factors for Spontaneous Preterm Birth
Low maternal education level
Low maternal income level
Infection
Family history of preterm birth
Pregnancy with more than one fetus
There are more….
Preterm Labor: Treatment
What do interventions include:
Interventions include suppression of labor, physical activity restriction, and management of medications.
Preterm Labor: Treatment
What is commonly recommended to be restricted in preterm labor?
Physical activity restriction is commonly recommended but lacks supportive evidence.
Preterm Labor: Treatment
Administration of what is not supported by current research?
Progesterone supplementation is not supported by current research.
Preterm Labor: Treatment
What may be administered to pregnant women? When?
Corticosteroids may be administered to pregnant patients at 23 to 34 weeks.
Preterm Labor: Treatment
What do corticosteroids promote?
Corticosteroids promote fetal lung maturity and reduce the risk of ventricular bleeding and necrotizing enterocolitis
Preterm Labor: Treatment
What are corticosteroids reserved for?
is reserved for pregnancies that would benefit from a 48-hour delay.
Preterm Labor: Treatment
What do antibiotics do and not do?
Antibiotics administered because preterm labor may be caused by infection, but they do not halt contractions.
Preterm Labor: Tocolytics #1
What are tocolytic agents used?
Indomethacin:
Nifedipine:
Terbutaline:
Preterm Labor: Tocolytics #1
More effective tocolytic agents:
Indomethacin- who is it contraindicated in?
Contraindicated with maternal bleeding disorders, renal dysfunction, asthma, and aspirin allergy.
Preterm Labor: Tocolytics #1
More effective tocolytic agents:
Nifedipine: Who is it contraindicated in?
Contraindicated with maternal hypotension, drug allergy, and certain cardiac conditions.
Preterm Labor: Tocolytics #1
More effective tocolytic agents:
Terbutaline: How long it is administered?
every 20 to 30 min until contractions cease for a total of 48 hours.
Preterm Labor: Tocolytics #1
More effective tocolytic agents:
Terbutaline: Who is it contraindicated in?
Contraindicated with some cardiac disease, poorly controlled diabetes, placenta previa, and placental abruption.
Preterm Labor: Tocolytics #1
What are they used for?
Suppress labor
Preterm Labor: Tocolytics #2
Less effective tocolytic agents:
Magnesium sulfate:
Nitrous oxide:
Preterm Labor: Tocolytics #2
Less effective tocolytic agents:
Magnesium sulfate: What are you monitoring for?
Monitoring for signs of toxicity is critical.
Preterm Labor: Tocolytics #2
Less effective tocolytic agents:
Magnesium sulfate: What must be readily available to reverse toxicity?
Calcium gluconate 1 g IV over 5 to 10 minutes must be readily available to reverse toxicity.
Preterm Labor: Tocolytics #2
Nitrous oxide:
What form are they in? How long it is used?
10 mg patch on abdomen for 1 hour.
If ineffective, add second patch.
Patches left in place for 24 hours and then removed.
Preterm Labor: Tocolytics #2
Nitrous oxide: Who are they contraindicated in?
Contraindicated in patients with hypotension and some cardiac problems.
Chorioamnionitis #1: What is it?
An infection of the amnion, chorion, or both that complicates almost 4% of pregnancies.
Chorioamnionitis #1 :
What is it commonly caused in?
Commonly caused by the ascent of bacteria through the cervix.
Chorioamnionitis #1 :
What are risk factors?
Some risk factors for chorioamnionitis include PPROM, PROM, multiple digital vaginal exams, prolonged labor, and preterm labor.
Chorioamnionitis #1 :
Maternal complications from chorioamnionitis include “
Maternal complications from chorioamnionitis include:
maternal sepsis and risk for postpartum hemorrhage.
Chorioamnionitis #1 : Neonatal complications include:
Neonatal complications include:
sepsis,
perinatal death,
asphyxia,
cerebral palsy,
pneumonia,
meningitis,
intraventricular hemorrhage,
and neurodevelopmental delay.
Chorioamnionitis #2:
What is diagnostic criteria? (Having to do with temperature)
Diagnostic criteria include maternal fever of 102.2 F once or of 100.4 F to 102 F twice plus one or more of the following:
Chorioamnionitis #2
Diagnostic criteria include maternal fever of 102.2 F once or of 100.4 F to 102 F twice plus one or more of the following:
fetal tachycardia,
maternal tachycardia,
uterine tenderness,
foul-smelling discharge,
or elevated white blood cell count (over 15,000 cells/mm3).
Chorioamnionitis #2
What is the treatment?
Prompt treatment with broad spectrum antibiotics (often ampicillin and gentamicin) indicated.
Postterm Pregnancy:
What is it?
A postterm pregnancy has reached or exceeded 42 weeks gestation.
Postterm Pregnancy: What are risks?
Risks include fetal macrosomia which creates a risk for protracted or arrested labor, dystocia, birth injury, operative birth, and postpartum hemorrhage.
Postterm Pregnancy:
What is treatment?
Treatment may include expectant management or induction of labor.
Postterm Pregnancy:
What is expectant management? What does it include?
Expectant management may include twice weekly assessment of fetus by NST and assessment of amniotic fluid volume or by biophysical profile beginning at 41 weeks.
Postterm Pregnancy:
How does induction of labor begin?
Induction of labor begins with an evaluation of the patient’s cervix using a Bishop score which evaluates cervical dilation, effacement, station, consistency, and position.
Postterm Pregnancy:
What does Bishop’s score do?
Bishop score which evaluates cervical dilation, effacement, station, consistency, and position.
Postterm Pregnancy:
How should Bishop score be?
A Bishop score of 6 or higher is considered favorable and has a greater chance of a successful vaginal birth.
Postterm Pregnancy: Cervical Ripening
What does that include?
- Pharmaceutical ripening
- Mechanical ripening
Postterm Pregnancy: Cervical Ripening
What does Pharmaceutical ripening include:
Prostaglandins
Postterm Pregnancy: Cervical Ripening
Pharmaceutical ripening includes:
When is Prostaglandins used?
Prostaglandins often used prior to oxytocin for labor induction.
Postterm Pregnancy: Cervical Ripening
Who are Pharmaceutical ripening contraindicated in?
Contraindicated for patients with previous cesarean birth or previous uterine surgery due to risk of uterine rupture.
Postterm Pregnancy: Cervical Ripening
What is a common prostaglandin? How is it administered?
A common prostaglandin is misoprostol, which may be administered vaginally or orally (usually 25 to 50 mcg every 3 to 6 hours).
Postterm Pregnancy: Cervical Ripening
Pharmaceutical ripening includes:
What should nurses monitor for?
Nurses should monitor for uterine tachysystole (excessively frequent contractions).
Postterm Pregnancy: Cervical Ripening
Mechanical ripening includes:
How is it done?
Insertion of a balloon catheter or hygroscopic dilators into the cervical canal.
Postterm Pregnancy: Cervical Ripening
Mechanical ripening includes:
What is there an increased risk for? Decreased risk for?
Increased risk for infection but decreased risk of uterine tachysystole.
Postterm Pregnancy: Labor Induction
After cervical ripening, what is administered?
After cervical ripening, oxytocin (Pitocin) is administered by IV.
Postterm Pregnancy: Labor Induction
What may oxytocin cause?
Oxytocin (Pitocin) may cause nausea and vomiting, headache, flushing, tachycardia, hypotension, arrhythmias, and uterine tachysystole.
Postterm Pregnancy: Labor Induction
What should you do if uterine tachysystole occurs?
Uterine tachysystole with oxytocin and a nonreassuring fetal heart rate change requires stopping the oxytocin infusion and notifying the obstetric provider.
Placental Abruption #1:
What is placental abruption?
How is it classified?
Placental abruption is the premature detachment of the placenta from the decidua of the uterus after 20 weeks of gestation and is often classified as mild or severe.
Placental Abruption #1:
Causes of placental abruption include:
Often unknown cause
Blunt force trauma
Smoking
Cocaine
Placental Abruption #1:
Prognosis: What is prognosis of mild abruption?
A mild abruption may have limited impact.
Placental Abruption #1:
Prognosis: What is prognosis of severe abruption?
A severe abruption may result in complete detachment of the placenta and risk the life of the patient and the fetus.
Placental Abruption #2:
What are the various degrees of separation of normally implanted placenta?
Partial separation
Marginal separation
Complete separation with concealed hemorrhage
Complete separation with heavy vaginal bleeding
Placental Previa #1:
When does placental previa occur?
Occurs when placental tissues overlies the internal cervical os.
Placental Previa #1:
What is a major complication of placental previa?
The major complication of placenta previa is maternal hemorrhage.
Placental Previa #1:
Risk factors for a placenta previa include:
Placenta previa in a prior pregnancy
Multiple gestation
Multiparity
Prior cesarean birth
Advanced maternal age
Treatment for infertility
Previous intrauterine surgical procedure
Maternal smoking or cocaine use
Placental Previa #2:
Signs of a placenta previa include:
Painless vaginal bleeding
Placental Previa #2:
What is contraindicated for patients with known or suspected placental previa?
A digital exam is contraindicated for patients with known or suspected placenta previa
because palpation is associated with acute bleeding.
Placental Previa #3:
What should nurses instruct patients about?
Nurses should instruct patients to seek care urgently if they experience bleeding or contractions.
Placental Previa #3:
When is birth generally recommended in patients with placental previa?
Birth is generally recommended from 36 to 37 weeks.
Placental Previa #2:
How is placental previa confirmed?
Placenta previa is confirmed by ultrasound.
Placental Previa #2:
Why is a digital exam contraindicated in patients with known or suspected placental previa?
A digital exam is contraindicated for patients with known or suspected placenta previa
because palpation is associated with acute bleeding.
Placental Previa #3:
What is treatment for placenta previa?
When does it occur?
Treatment may include the administration of corticosteroids prior to 34 weeks.
Placental Previa #3:
What is necessary for patients at time of admission who has known/suspected placental previa?
Because the rate of blood transfusions is high, patients may have their blood typed and cross-matched at the time of admission.
Placental Previa #3:
What type of birth is almost always indicated for placental previa?
Cesarean birth is almost always indicated for placenta previa.
Vasa Previa:
Type 2 previa
type 2 previa with a succenturiate placenta where the placenta is made of different lobes (usually 2) and blood vessels connect them
Vasa Previa:
Type 1 previa
Type 1 previa occurs with a velamentous cord insertion where blood vessels run along the fetal membrane over the cervix
Vasa Previa:
How many types of Vasa previa are there?
Type 1
Type 2
Type 3
Vasa Previa:
When does it occur?
Occurs when fetal blood vessels overlie the cervical os.
Vasa Previa:
Type 3 previa
A type 3 previa includes vessels that pass through the membranes at the margin of the placenta.
Vasa Previa:
What are complications of vasa previa?
Complications include fetal hemorrhage and exsanguination with rupture of membranes.
Vasa Previa:
What is treatment of vasa previa?
Treatment may include the administration of corticosteroids prior to 34 weeks and cesarean birth between 34 and 35 weeks, unless an early delivery indicated.
Disseminated Intravascular Coagulopathy (DIC):
What is it caused by?
DIC is caused by pathological activation of the clotting cascade
that results simultaneously in blood clots, platelet and clotting factor depletion, and thus bleeding.
Disseminated Intravascular Coagulopathy (DIC):
What does it result in?
DIC is caused by pathological activation of the clotting cascade
that results simultaneously in blood clots, platelet and clotting factor depletion, and thus bleeding.
Disseminated Intravascular Coagulopathy (DIC):
What complication is DIC considered?
DIC is always a complication of another pregnancy condition.
Disseminated Intravascular Coagulopathy (DIC):
Common antecedent conditions include:
Placental abruption
Postpartum hemorrhage
Preeclampsia/eclampsia/HELLP syndrome
Amniotic fluid embolism
Prolonged fetal demise
Maternal sepsis
Disseminated Intravascular Coagulopathy (DIC):
What is treatment of DIC and when does it occur?
Treatment of DIC usually happens rapidly and must address DIC and the underlying cause.
