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
2
Q
What is the rate of PTB increasing?
A
- Assisted reproductive technology (ART)
- Increasing role of infectionin PTL/ PTB
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
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
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
6
Q
A
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
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
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
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
- Anomalies of cervix
- Diagnosis
- Heaviness in pelvic area
- Preterm Preamture Rupture of Membrane (PPROM)
- Ultrasound
11
Q
A
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
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
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
15
Q
Bleeding in Pregnancy
A
- Spontaneous abrotion (miscarriage)
- Ectopic pregnancy
- Gestational trophoblastic disease
- Placenta previa
- Abruption placentae
- Uterine rupture
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
Antepartum Hemorrhage
* 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
Placenta Previa
* 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
Detection of Placenta Previ
* 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
Risk Factors for Placenta Previa
* Previous placenta previa
* Uterine abnormalities/ endometrial scarring
* Impeded endometrial vascularization
* Large placental mass
* Unknow
29
Abruption Placentae
* 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
Risk Factors for Abruption Placentae
* 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
Implications of Abruption Placentae: **Maternal**
* Intrapearum and postpartum hemorrhage
* DIC
* Hemorrhagic shock
32
Implications of Abruption Placentae: **Fetal-Neonatal**
* Sequelae of prematurity
* Hypoxia
* Anemia
* brain damage
* Fetal demise
33
Immediate Care for Abruption Placentae Bleed
* 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
Nursing Care
* 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
Vasa Previa
* 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
Uterine Rupture
Spontaneous rupture or rupture of previous scar
37
Risk Factors for Uterine Rupture
* Previous uterine srugery, inclduing cesarean
* Short inter delivery interval (less than 18 months)
* Grand multiparity
* Trauma
* Intrauterine manipulation
* Midforceps rotation of fetus
38
Presentation of Uterine Rupture
* 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
