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NURS 330: Obstetrics > LEC 6: Health Challenges in Labour and Birth > Flashcards

LEC 6: Health Challenges in Labour and Birth Flashcards

1
Q

Preterm Labour and Preterm Birth

A
  • Leading cause of mortality and morbidity (around 75% to 85%)
  • Rate of PTB is 7% in SK
  • Incidence in USA is worse
  • Rate of PTB is increasing
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2
Q

What is the rate of PTB increasing?

A
  • Assisted reproductive technology (ART)
  • Increasing role of infectionin PTL/ PTB
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3
Q

What causes preterm labour?

A
  • Race
  • Age extremes (<17 or >35)
  • Smoking, alcohol, drugs
  • Infection, inflamamtation, toxicology
  • Stress
  • Prenatal care, nutrition, and oral health
  • Cervical surgery or abnormalities
  • Placental problems (previa, abruption)
  • Genetics
  • Previous PTB (Most common cause)
  • Hypertensive disorder of pregnancy
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4
Q

Risk Factors Associated with Preterm Labour and Birth

A
  • African-American race
    • More than double the risk
  • Maternal age extremes
    • Less than 16 years and more than 40 years old
  • Low socioeconimic status
  • Alcohol or other drug use, especially cocaine
  • Poor maternal nutrition
  • Maternal periodontal disease
  • Cigaretter smoking
  • History or prior preterm birth
    • Triples the risk
  • Uterine abnormalities
  • Preexisting diabetes or hypertension
  • Multiple gestation
  • Premature rupture of membranes
  • Late or no prenatal care
  • Short cervical length
  • Sexually transmitted infections: gonorrhea, Chlamydia, trichomoniasis
  • Bacterial vaginosis
    • 50% increased risk
  • Chorioamnionitis
  • Hydramnios
  • Hypertensive disorders or pregnancy
  • Cervical insufficiency
  • Short interpregnancy interval: less than 1 year between births
  • Placental problems, sucha s placenta previa and placental abruption
  • Maternal anemia
  • UTIs
  • Intimate partner violence
  • Stress, acute and chronic
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5
Q

Common Symptoms of Preterm Labour

A
  • Low abdominal pain, cramps, backache
    • Common symptoms
  • Bleeding, spotting, show, ROM
  • Pelvic pressure
    • Baby pushing down
  • Increased amount/ changes in vaginal discharge
  • Contractions every 10 minutes or more often
  • Thorough assessment and diagnosis is key
  • Signs and symptoms of PTL are often subtle
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6
Q
A
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7
Q

Fetal Fibronectin ( ƒFN)

A
  • Glycoprotein released into cervical/ vaginal fluid in response to inflammation or separationof amniotic membranes
  • Normal in cervico-vaginal secretions until 22 weeks gestation and again near the time of labour
  • Negative = lacck of ƒFN​ = pregnancy is likely to continue for at least another two weeks (98%)​
  • Positive ƒFN = present 24 through 34 weeks getationindicates increase risk of preterm delivery
  • Absence is a better prodictor
  • Not done on everyone- if they think its pre-term labour, then it is done
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8
Q

Managment of Pre-Term Labour (PTL)

A
  • Need to ask- Should labour be stopped?
    • Is mom bleeding?
    • What is the gestational age of baby?
  • Assess and monitor VS, contractions, fetus
  • Avoid stimulation
    • Vaginal exams, also increase risk for infection
    • Sexual intercourse
    • Nipple stimulation
    • Keep bladder empty
  • Bedrest
  • Hydration- IV
  • Magnesium sulfate
  • Sedation
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9
Q

Managment of PTL: Tocolytics

A
  • Indomathacin
    • Anti-prostaglandin inhibits uterine activity
    • Effective in delaying delivery x 48 hours
    • Not recommended for long term use- PDA
  • Calcium Channel Blockers- Nifedipine (Adalat)
    • Blocks the passage of calcium which relaxes the uterine muscles
  • Progesterone (in trials)
    • May prevent and reduce incidence of PTB if previous history of PTB
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10
Q

Cervical Insufficiency (Incompetent Cervix)

A
  • Premature painless dilation of cervix
  • 20 to 28 weeks
  • 2nd trimester abortions
    • Anomalies of cervix
      • DES, 2nd trimester abortions, invasive cervical biopsy
    • Infections
    • Multiple gestation, polyhydramnios
  • Diagnosis
    • Heaviness in pelvic area
    • Preterm Preamture Rupture of Membrane (PPROM)
    • Ultrasound
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11
Q
A
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12
Q

Cervical Insufficiency Treatment

A
  • Bedrest, pelvic rest, avoid heavy lifting
  • Cervical cerclage (suture)
    • Infection, blood loss, PPROM, preterm labour
    • Damage to the cervix
    • Not appropriate if vaginal bleeding, infection, uterine contractions, membranes have ruptured
    • Depending on style C-section or suture removed
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13
Q

Corticostroids in Preterm Labour

A
  • All pregnant women between 24 and 34 weeks gestation, who are at risk of preterm delivery within 7 days should be considered candidates for antenatal treatment with a single course of corticosteroids
  • A single course of corticosteroids reduces perinatal mortality, respiratory distress syndrom (RDS) and intraventricular hemorrhage
  • Batamethasone 12mg IM q24h x 2 doses or Dexamethasone 6mg IM q12h x4 doses
    • Most effective if given at least 24 hours before delivery
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14
Q

Magnesium Sulfate (MgSO4) for Fetal Neuroprotection

A
  • New evidence that antenatal MgSO4 is neuro protective
  • Whem women present with imminent preterm birth at <31 +6 weeks
    • Active labor with >4cm dilation with or without PROM
    • Planned preterm borth for fetal or maternal indications
  • 4g IV loading dose over 30 mins then 1g/hour maintenance until delivery
  • NOT to stop the labour BUT for fetal neuro protection
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15
Q

Bleeding in Pregnancy

A
  • Spontaneous abrotion (miscarriage)
  • Ectopic pregnancy
  • Gestational trophoblastic disease
  • Placenta previa
  • Abruption placentae
  • Uterine rupture
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16
Q

Bleeding in the First and Second Trimester

A
  • Abortion: Expulsion of fetus before 20 weeks gestation OR Expulsion of fetus less than 500g
  • Spontaneous: occur naturally
  • Therapeutic/ Induced: medical or surgical means
17
Q

Threatened Abortion

A
  • Have some bleeding but the cervix is not dilated and the placenta is still attached to the uterine wall
  • Can resolve on its own with rest and monitoring.
18
Q

Emanate Abortion

A
  • Placenta has started to separate and cervix is dilated and there is more bleeding
  • Can progress to an incomplete abortion, fetus or embryo has passed out of the uterus but the placenta remain OR complete where all the products of contraception has passed
19
Q

Missed Abortion

A
  • Situation where the non-viable embryo starts in the uterus for at least 6 weeks
20
Q

Habitual Abortion

A

Someone who has a history of three or more spontaneous abortions

21
Q

Spontaneous Abrotion Care

A
  • Tretment can range from no treatment to hospitalization
  • If minimal bleeding
    • ​Bed rest and abstinence from sex
  • If persistent/ heavy bleeding, fever = Emergent situation
    • ​Cytotec (misoprostol)/RU 486/Cervidil​
    • Abortion pill; 2 pill therapy
    • +/- WinRho
      • Need to know moms blood type
      • If mom is negative- will give WinRho
    • IV therapy or blood transfusions
    • •Surgical Dilatation and curettage (D&C) or suction evacuation (D&E)
    • Cervix dilated and the curettage goes into the uterus and scraps out any remain products of conception
    • Upside: Faster, reduce the duration of bleeding BUT most of the time is usually not the treatment of choice
22
Q

Ecotopic Pregnancy

A
  • Implantation of fertilized ovum outside uterus
    • Can be any where outside the uterus
    • Most often outside the fallopian tubes
    • Is a mdical emergency
  • Initially symptomsof preganncy )positive hCG)
    • As the embryo grows can lead to a rupture
    • Happen within 4 to 8 weeks
  • Rupture and bleeding into the abdominal cavity
    • Rsults in sharp unilateral pain and decreased BP, syncope
    • Referred shoulder pain, lower abdominal pain
    • Vaginal bleeding
    • Hypovolemic shock
    • Emergent situation
23
Q

Gestational Trophoblastic Disease

A
  • RARE (<1/1000) pathologic tumor of childbearing age women
    • Abnormal development of the placenta
    • Trophoblastic cells that obliterate the pregnancy
    • Hydatidifirm mole (benign)
    • Can develop into choricocarcinoma (rare)
  • Classic signs of pregnancy ++ eacerbated
    • Uterine enlergment greater than gestational age, vaginal
    • Bleeding, passage of clots
    • Hyperemesis gravidarum
    • Development of pre-exlampsia prior to 24 weeks
24
Q
A
25
Q

Antepartum Hemorrhage

A
  • Vaginal bleeding >20 weeks- delivery
    • Not appropriate to do a vaginal exam if there is bleeding0 can potentially rupture the placenta
  • Two main causes- placental (can also be uterine, cervical)
    • Placenta previa
    • Abruptio placentae
  • A change in fetal status might be the first indication of maternal compensation secondary to hemorrhage
26
Q

Placenta Previa

A
  • When the placenta covers the cervical os
  • Location of implantation of the placenta
    • Total/ complete
      • Cannot deliver vaginaly
    • Parial
      • High risk
    • Marginal
    • Low-lying placenta
      • Has to do with how the uterus is growing and ends up moving away from the cervical os
27
Q

Detection of Placenta Previ

A
  • Routine ultrasound
  • Ultrasound at time of presentation with bleeding
  • Must be monitored frquently
    • 80+% migrate during pragnancy (low-lying placenta)
  • Goal is to get to 36 to 37 weeks gestation
28
Q

Risk Factors for Placenta Previa

A
  • Previous placenta previa
  • Uterine abnormalities/ endometrial scarring
  • Impeded endometrial vascularization
  • Large placental mass
  • Unknow
29
Q

Abruption Placentae

A
  • Premature separation of normally implanted placenta from uterinwall
    • Total/ Complete (Emergency)
      • Maternal hemorrhage
      • Fetal death
    • Parial
      • Fetus can tolerate up to 30 to 50% abruption
      • Mom can lose 1L to 2L of blood before she become shemodynamic unstable
30
Q

Risk Factors for Abruption Placentae

A
  • Previous abrutpion
  • Hypertension in pregnancy
  • Blunt abdominal trauma
    • MVA, IPV, Falls
  • Overdistended uterus
  • PPROM <34 weeks gestation
  • Previous C-section, especially short interpregnancy interval
  • Cocain or crack use, alcohol use
  • Smoking, especually >1 pack/day
  • Extremely short umbilical cord
  • Uterine abnormalites- fibroids at implantation site
  • Advanced maternal age (>35) pr parity
31
Q

Implications of Abruption Placentae: Maternal

A
  • Intrapearum and postpartum hemorrhage
  • DIC
  • Hemorrhagic shock
32
Q

Implications of Abruption Placentae: Fetal-Neonatal

A
  • Sequelae of prematurity
  • Hypoxia
  • Anemia
  • brain damage
  • Fetal demise
33
Q

Immediate Care for Abruption Placentae Bleed

A
  • When able, a complete history and physical
  • Assess maternal cardiovasc ular status frquently include O2 saturation, output Including vaginal bleeding) LOC
    • If bleeding heavily- doing vitals every 5 minutes
  • Fluid resuscitation if active bleeding or unstable
    • Want 1 or 2 large bore IVs
  • Monitor fetus and uterine activity electronically
34
Q

Nursing Care

A
  • Prepare equipment for examination
  • Oxygen per mask/ prongs
  • Obtain an order to type and cross match for blood
  • Assess coping mechanisms of woman and family, support
  • Review and evaluated diagnostic tests
    • Hgb, PT/PTT, type and cross mathc, watch for DIC
  • Prepare for cesarean, as needed
  • Neonatal resucitation team, as needed
  • Pain relief, as needed
  • Bed rest, may need hospitalization
  • Avoid sexual activity
  • No vaginal exames
  • Objectively and subjectively assess
    • Blood loss, pain, uterine contractilty, coping
35
Q

Vasa Previa

A
  • Occurs with velamatous insertion of cord
  • Vessels of umbilical cord divide some distance from placenta in placental membranes
  • Torn vessel leads to fetal hemorrhage
  • Leads to non-reassuring fetal status and high mortality
36
Q

Uterine Rupture

A

Spontaneous rupture or rupture of previous scar

37
Q

Risk Factors for Uterine Rupture

A
  • Previous uterine srugery, inclduing cesarean
  • Short inter delivery interval (less than 18 months)
  • Grand multiparity
  • Trauma
  • Intrauterine manipulation
  • Midforceps rotation of fetus
38
Q

Presentation of Uterine Rupture

A
  • May initially by asymptomatic
  • Abdominal pain not relieved by analgesia / anesthesia
  • Uterine activity may or may not stop, dilation will cease
  • Vomiting, syncope, vaginal bleeding, maternal/ fetal tachycardia, abnormal FHR, pallow (signs of shock)
  • Shape of abdomen changes
  • Fetal parts palpable through abdominal wall
  • Suspect uterine rupture if dramatic sharp, tearing pain, tense,a cute abdomen, shoulder pain
  • Complete cardiovascualr collapse

NURS 330: Obstetrics (19 decks)

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