OB Module 4: Complications of Pregnancy Flashcards
OLDCART
Acronym for assessing symptoms or status changes in terms of:
Onset
Location
Duration
Characteristics
Aggravating Factors
Relieving Factors
Treatments Tried
During a crisis situation what things should be done
assess VS
assess pulse O2 and symptoms of oxygenation
assess mental status
assess tissue perfusion
assess fetal status
assess bleeding assessing for DIC
assess urine output (consider a Foley catheter)
labwork and testing
spread the liability
What does Spread the Liability mean
keep provider and supervisors informed of any status changes - spread the liability around
report less fluff and more sufficient data via OLDCART
What is a big indicator of the status of a mother
Fetal status as there would be decreased blood to the placenta
How often should crisis situation assessments be done if the issue is acute
repeat assessments at appropriate intervals
with acute it may be every 5 minutes
it could also be every 15 minutes or every hour
During a crisis, keep the provider informed of …
status changes
During a crisis, the patient and family may be frightened and need information and support, but do not…
offer false reassurance (no worrying is inappropriate)
*also do not offer information a nurse should/can not deliver like a diagnosis
Since a lot occurs in a short interval or even simultaneously during an emergency crisis, what may be useful to do?
Assign a scribe to note when everything is done for everything so that a complete record can be made
Palpable Blood Pressure
in an emergency situation when the BP drops significantly you will only be able to hear the systolic BP with diastolic going all the way to zero (ex: 60/0).
This is why we may use VS machines for repeated assessments but know their baseline
During a crisis you will probably need __ __ until the patient is stabilized
additional personnel
What should be removed from the room during a crisis?
Any non essential personnel - including egos that hinder communication
What is essential to working in a crisis
effective communication and teamwork
everyone in the room must be working toward achieving the patients best possible outcome
About how many women die daily, globally, from complications of childbirth?
880 Women
500 of which are in western, central, and sub Sahara Africa and 200+ in Asia
What is the Maternal Mortality Rate (MMR) in Europe and the US?
Europe - 1 in 11,900
US - 1 in 5500 (it has increased the last few years)
What would make most MMR deaths preventable
if attended by a trained and equipped provider, MD, or midwife
___ ___ countries have significantly higher mortality rates (1 in 45 births)
low income
What is the leading cause of maternal death?
Hemorrhage (27%)
What are some causes of maternal death?
Hemorrhage - 27%
HTN - 14%
Sepsis - 11%
Abortion
Embolism
Other Direct Medical Conditions Worsened by Pregnancy
Indirect Causes (28%) like Trauma, Suicide, Drug Overdose
Domestic violence increases __% with pregnancy
20%
Complications of the First Trimester that can Occur
Ectopic Pregnancy
Miscarriage
Hydatidform Mole Pregnancy
Hyperemisis gravidarum
Complications of the Second and Third Trimesters that can Occur
HTN Disorders of Pregnancy
Diabetes in Pregnancy
Preterm Labor
Hemorrhagic Disorders of Pregnancy
Hyperemisis gravidarum
Vasa previa
Uterine Rupture
Lacerations
PE
Cephalo pelvic disproportion
Cord Prolapse
Fetal Distress
Shoulder Dystocia
Ectopic Pregnancy
A gestation/pregnancy that is developing outside the uterus
still uncommon to see
“Tubal Pregnancy” is another name
Where does conception usually occur and then where does it move to implant usually?
Conception occurs in the outer 1/3 of the fallopian tubes
It will then divide and grow while working its way through the tube via cilia to get to the uterus to implant
What can increase the chance of ectopic pregnancy
anything that damaged the tubes like a surgical history or pelvic inflammatory disease
Where are some sites that ectopic pregnancies may implant
fallopian tubes (98%)
ovary (1%)
cervix (1%)
abdomen (0.75-1%)
What age group tends to have the highest incidence of ectopic pregnancies
Women 20-29 yo
What is the rate of ectopic pregnancy in the US
2% of all US pregnancies
rates are higher for nonwhite women and increase with age in both white and nonwhite women
What has happened to the incidence of ectopic pregnancy since 1970?
It has TRIPLED since 1970 d/t PID, STD, and IUD use increases
Most occurred pre 2000 but it is still high today
Ectopic pregnancy is responsible for __% of the maternal mortality in the US
10% (D/t hemorrhage bleeding)
What is the most common cause of maternal mortality before 20 weeks gestation
ectopic pregnancy
What is the rate of another ectopic pregnancy occurring following an ectopic pregnancy and why?
25%
This is because whatever was wrong the first time probably is unresolved and can cause it to happen again
What is the most common ectopic pregnancy implantation site
fallopian tubes (98%)
Risk Factors for an Ectopic Pregnancy
PID and Endometriosis
Use of IUDs
Tubal Surgery
Tubal Tumor and Congenital Tubal Anomalies (Accessory tubes, excessively long tubes)
History of previous ectopic pregnancies, abdominal or pelvic surgery, ruptured appendicitis, therapeutic abortion, or infertility
S/S of Ectopic Pregnancy
Abdominal Pain
Amenorrhea
Abnormal Vaginal Bleeding
Swelling in 1 Leg
Shoulder Pain
Are the s/s of Ectopic pregnancy bilateral or generalized?
Can Be Either
What is the abdominal pain like in ectopic pregnancies
vague, colicky, or cramping and can be localized to the L or R pelvic area or may be bilateral
Why does Amenorrhea occur in ectopic pregnancies
It is still a pregnancy so there is still a corpus luteum suppressing ovulation
Shoulder pain during an ectopic pregnancy is a ___ pain that is also seen in tubal ligation for sterilization as well
Referred
What may be done for an ectopic pregnancy if the fallopian tube is intact?
treatment may be surgical or via methotrexate (a chemo agent) to dissolve the pregnancy while maintaining tube patency and potential fertility
Methotrexate
a chemotherapy agent sometimes given to ectopic pregnancies with intact fallopian tubes to dissolve the pregnancy while maintaining tube patency and potential fertility
What may be done for an ectopic pregnancy if the fallopian tube ruptures
Surgery is REQUIRED if the tube ruptures
S/S of a Ruptured Fallopian Tube
Abdominal Pain
N/V
Diarrhea
Unilateral Palpable Pelvic Mas (Hematoma)
Dizziness
Hypovolemic Shock
Types of Spontaneous Abortions (Miscarriage)
early
Late
Habitual Abortion
Chromosomal Aberrations Related Miscarriage
Threatened Abortion
Inevitable Abortion
Incomplete Abortion
Complete Abortion
Septic Abortion
Missed
Autolysis
Early Spon Abortion
miscarriage before 12 weeks of gestations
Late Spon Abortion
miscarriage between 12-20 weeks of gestation
Habitual Abortion
When a woman has 3 or more consecutive spontaneous abortions
What is estimated to make up/cause 50% of all spontaneous abortions
Chromosomal Aberrations with autosomal trisomy being most common
Threatened Abortions
The cervix is NOT dilated and the placenta is still attached to the uterine wall, but SOME bleeding occurs - so it may be vessel bleeding rather than from the cervix
It is suggested if a woman has vaginal spotting or bleeding early in pregnancy
occurs in about 20% of all diagnosed pregnancies - half abort
Inevitable Abortion
The placenta has separated from the uterine wall, the cervix has dilated and bleeding has increased more than in a threatened abortion
Occurs when the cervix has begun to dilate, uterine contractions are painful and bleeding increases
The membranes rupture as the process proceeds
Is a threatened abortion preventable
potentially
Is an inevitable abortion preventable
no (we cannot stop all of the changes that occurred)
What is the main different between a threatened and inevitable abortion?
the cervix began to dilate
Is the rupture in an inevitable abortion large?
no the pregnancy was not very large to begin with
Incomplete Abortion
The embryo or fetus has passed out of the uterus, BUT the placenta remains
Cervical dilation results in partial expulsion of the products of conception, with some of the products retained in the uterus
Excessive vaginal bleeding occurs and risk of infection increases
What has to be done with an incomplete abortion
we have to go in and evacuate the rest of the contents via dilation and curettage - dilation of the cervix and scraping of the uterine cavity to free the placenta
Complete Spon Abortion
all products of conception are entirely expelled (placenta, baby, membranes)
very few physical complications occur but emotional support is necessary as the mom will be devastated
Septic Spon Abortion
immediate termination of pregnancy by method appropriate to duration of pregnancy needed - the infection is caused by products of conception being retained and causing infection
cervical culture and sensitivity studies are done and broad spectrum antibiotic therapy is started
treatment for septic shock is done if needed
Why is it so easy for sepsis to occur in a pregnant woman?
because the area is very vascularized so it can infect very easily
Why do we start the mom of a septic abortion on both aerobic and anaerobic broad spectrum antibiotics to begin?
The vaginal vault is aerobic but the uterine cavity is anaerobic and since we do not know what the infective agent is until CS comes back we can do this
Missed Abortion
the fetus dies but continues to be retained in the uterus 8 weeks or longer
Autolysis Abortion
step 4 weeks post missed abortion where the infant dead cells will start to breakdown and release enzymes that breakdown clotting factors and lead to DIC in the mom
Why may habitual abortions happen?
when a mom gets to the 2nd trimester and the weight of the pregnancy is actually more than the cevix can hold
at 15-20 weeks the cervix will try to dilate and let the pregnancy past it
What is done to try and prevent habitual abortions
A purse string suture (Cerclage, Shirodkar, McDonald Procedure) to maintain the pregnancy
McDonald Procedure (Cerclage/Shirodkar)
a thick purse string sized suture the size of a shoelace is made around the cervix to pull it closed or near closed and a know is made to cut later through the vaginal vault
when near delivery we cut the know to allow a normal vaginal delivery
can prevent habitual abortions
What is a problem with the McDonald procedure in regard to location
should we have to abdominally rather than vaginally to the top of the cervix to make the suture (if for some reason the cervix was damaged for some reason before) then a C Section will be required and the suture is permanent to maintain all future pregnancies and is not removed or cut
Hydatidiform Mole (Molar Pregnancy)
Disorder of the placenta where it does not appropriately form or forms a malformation early on in the pregnancy
What does a molar pregnancy being a trophoblastic disease mean
there is a developmental error of placenta causing the development of cyst like clear vesicles resembling a bunch of grapes to occur
highly vascular and looks like brain tissue
2 Types of molar Pregnancy
Complete
Partial
Complete Molar Pregnancy
all vesicles and no fetus
Partial Molar Pregnancy
has vesicles and a rarely viable fetus
What happens to most fetuses during a molar pregnancy ?
most fetus are not well nourished and the size of the uterus can get so big so rapid due to the vesicle growth that pregnancy cannot make it to term due to mass and uterine intolerance
Is molar pregnancy carcinogenic?
Usually it is benign but it can be a choriocarcinoma - a rapid growing cancer form with a high rate of cure
What is the incidence of molar pregnancies like?
1 in 1000 pregnancies
Incidence increases x10 after age 45
S/S of Molar Pregnancy
apparently nL first trimester
uterine bleeding
possible anemia
SOB
uterine size often exceeds fundal heights expected for gestation
fetal activity and FHR tones absent if nonviable fetus
hyperemesis gravidarum common
preeclampsia developing before 24 weeks
very high levels of serum hCG levels
What is the most outstanding sign of molar pregnancy
uterine bleeding
Why can SOB occur in molar pregnancy
it relates to metastasis if it has become cancerous as the primary site for spread is to the lungs
Hyperemesis
hyperactive morning sickness from increased hormones from the placenta
What confirms a Hyatidiform pregnancy
ultrasound
What needs to be done once ultrasound confirms a molar pregnancy
IMMEDIATE EVACUATION of pregnancy and all products
Potential chemotherapy in follow up if the molar pregnancy was malignant
Why do we monitor serum hCG levels with an evacuated molar pregnancy
because if this number is higher than normal that means there are still placental products inside
they end up being checked every month for half a year and then every other month for the last 6 months
Why should pregnancy be avoided for a year following an evacuated molar pregnancy
to prevent hormonal tissue that survived from staying and encouraging to undergo metastasis in the next pregnancy
What is taken and compared to its pre-evacuation results?
baseline X ray of the lungs compared to pre evacuation x ray
What is a common symptoms of complete molar pregnancy
vaginal bleeding, often brownish (a characteristic “prune juice” appearance indicating older bleeding) but sometimes is red.
The hydropic vessels are passed and can come out of the uterus
How may a hydatidiform mole and a normal placenta compare when looking at them
It should look beefy on the fetal side normally but the molar pregnancy is more shiny, vesicle filled, and looks like liver tissue
Hyperemesis gravidarum
increased or prolonged N/V in pregnancy potential affecting the mother and fetus
How does hyperemesis compare to regular morning sickness
morning sickness usually lasts about 14 weeks and occurs in the morning
hyperemesis can be all day long and prolonged lasting the entire pregnancy
Etiology of Hyperemesis gravidarum
likely caused by a combination of factors:
high or rapidly increasing levels of hCG or estrogens
evidence of transient hyperthyroidism has also been noted
psychological and social factors like family conflict may also play a role (but not in all cases necessarily)
Treatment for Hyperemesis gravidarum
IV therapy to treat dehydration - adequacy of hydration addressed by measuring UO
Small frequent feedings as tolerated - high calorie tube feedings are optional (TPN)
Antiemetics often help, Zofran OD, Reglan, Phenergan, Scopolamine
Acupressure has been used successfully
Issue with the antiemetic zofran?
expensive (but can go under the tongue)
Benefit of the antiemetic Regland
they can go into the IV bag overnight
What form is the antiemetic Phenergan in
a suppository
What form is the antiemetic Scopolamine available in
patches
Hypertensive Disorders of Pregnancy
Any HTN disorder in pregnancy that causes:
BP >140/90
A rise of 30 mmHg in the systolic BP over a woman’s baseline BP (ex; if was 90/60 then 120 or 130 is concerning)
MABP >105 mmHg
Pregnancy induced HTN (PIH)
Hypertension without protein urea that develops AFTER 20 weeks of pregnancy or within the first 24 hours after delivery
Occurs since blood volume for mom increases 30-50% and if we dump this much with normal vascular tone and it does not relax then it will gradually increase out to 20 weeks or after delivery
PIH can compound with…
normal preexisting HTN
PIH superimposed on previous HTN …
results in a worsening of the woman’s HTN
Preeclampsia
At least 2 out of 3 of the classic triad:
- Elevated BP (vasospasm)
- Protein urea (damage to the vessels from spas causing protein leaks)
- Edema (allowing third spacing from damage - generalized not dependent)
What usually is causing preeclampsia, eclampsia, and HELLP syndrome
remarkable levels of vasospasms
When do Preeclampsia, Eclampsia, and HELLP syndrome begin
after 24 weeks usually
Eclampsia
HTN disorder when preeclampsia progresses to develop seizures that are life threatening, long, and recurring potentially
HELLP Syndrome
Worst case of the Preclampsia, Eclampsia, HELLP triad.
It involves:
Hemolysis
Elevated Liver enzymes
Low Platelets
this often goes along with increased BP
can be life threatening
HELLP syndrome may potentially be …
a most advanced form of preeclampsia or not
HELLP: Hemolysis
severe vasospasm and when blood goes through the small vessels the blood is damaged and bumps around
HELLP: Elevated Liver enzymes
very vascular organ so the vasospasm occurring can lead to rupture or damage
HELLP: Low Platelets
where things shear and damage the platelets attempt to help but eventually are used up trying to do micro repairs and the circulating volume of them drops
Why is HELLP Syndrome life threatening
you lose the ability to clot and can head into delivery and bleed out!
Associated Factors with Maternal Hypertensive Disorders of Pregnancy
Fetal Hydrops (autolysis disorders like rH issues)
Maternal Age >35
Nulliparity (most likely to occur in 1st pregnancy)
History of preeclampsia in self or family
Seen in women who change partners and have a baby with a new partner
Hydatidiform Mole
Multiple Pregnancy (large placenta more hormone)
Chronic HTN
Diabetes
S/S of Preeclampsia
Edema
Proteinuria
Elevated BP
HA
Nosebleeds/Epistaxis (coagulation factors depleted)
N/V
epigastric Pain
visual disturbances
hyperreflexia (CNS irritability from cerebral edema)
oliguria (from kidney infection)
What does the HA in preeclampsia come from and how does it feel
it comes from cerebral edema
it is a dull frontal HA unrelieved by tylenol
What is the epigastric pain associated with preeclampsia?
Associated when the liver is beginning to be affected
there is a high correlation with this symptom for movement to eclampsia
What is the mechanism of damage in preeclampsia and HELLP syndrome? what can it damage
SEVERE VASOSPASM
It can damage the placenta, liver, kidneys, and brain
What does HELLP stand for
Hemolysis
Elevated Liver enzymes
Low Platelets
Critical situation of Preeclampsia or HELLP requires
close monitoring often in the ICU unit
How to manage hypertensive states in pregnancy
bedrest in restful environment (does not cause remarkable change)
close monitoring of status since baby and mom are at risk
deliver if necessary
MgSO4
betablockers like labetolol
antihyptensive medications like apresoline
Why do we want to monitor both the patient and baby so closley with HTN disorders
because HTN disorders account for over 10% of all maternal deaths and both are at high risk
also HTN can degrade placenta early so we want to monitor the fetus as there is increased abruption risk
What is the only true cure for Hypertensive disorder states in pregnancy?
Delivery
But the baby can be remarkably immature since it can occur usually at 24 weeks!
Purpose of MgSO4 in treatment
to prevent the seizures of eclampsia
Issue with MgSO4
it is not same for pregnancy - it actually can cause CNS depression
but if we do not monitor or titrate doses respiratory arrest can occur - but we need to prevent siezure
Labetolol
A beta blocker that is used to treat HTN in pregnant women
Apresoline
IV
Used as antiHTN med
Given to HTN crisis but not often since it can decrease placental perfusion
How does gestational diabetes progress
it develops progressively as the pregnancy puts additional demands on the mothers system
Gestational diabetes occurs in ___ to __% of pregnancies
2-5%
When and how are pregnant women screened for gestational diabetes
Screened at 28 weeks gestation with a 1 hour glucose screen, and then a 3 hour glucose screen if the first one is abnormal
Some patients can do what regarding their gestational diabetes
some patients are able to control it via diet alone while others will need insulin
Risk Factors for Gestational Diabetes
obesity
family hx of diabetes
ethnicity (Hispanic, AA< Asian)
advanced maternal age >35 yo
prior GDM
prior LGA baby
GDM
Gestational Diabetes Mellitus
Gestational diabetes is first diagnosed …
during pregnancy
What two things happen simultaneously which leads to gestational diabetes
there is impaired glucose tolerance
there is increased insulin resistance
The mother’s pancreas in pregnancy is challenged by what leading to gestational diabetes
the normal changes in pregnancy (demand, etc)
In gestational both maternal and fetal ___ results
hyperglycemia
There is a __% chance gestational diabetic may develop DM later in life
40%
When is gestational diabetes reclassified?
After delivery and breastfeeding begins
How can patients control gestational diabetes
either through diet or some will require insulin
Can we use oral hypoglycemic agents for gestational diabetes?
No they have potential teratogenic effects on the fetus
Diabetes effects on pregnancy
Any diabetes (I and II) not just gestational:
PIH risk increases
Polyhydramnios (lots of amniotic fluid)
LGHA (Macrosomia)
IUGR (Intrauterine growth restriction)
Stillbirth
Congenital Anomalies (heart, CNS, skeletal) - especially in the Type I mother since it starts early
Infections
Ketoacidosis
Why do diabetic mothers often give birth to LGA children
the baby was in a nutrient rich environment so it gets a fat and large body
What can occur opposite to LGA from diabetes during gestation
IUGR if there is severe alterations in blood sugar leading the other way
How serious is DKA during pregnancy
if the mother is a type I diabetic and goes into DKA there is a very high fetal loss rate - even more so than fetal abruption -so DKA fluid resuscitation is given even more rapidly and aggressively treated
How is Gestational Diabetes diagnosed?
GTT - Glucose Tolerance Test - Over 1 hour 50 gm (glucola) is given at the 24-28 week gestation markand hope to see <135
OR
HbA1C Test
What 3 hour GTT levels are elevated when Fasting and after 1, 2, and 3 hours?
Fasting <105
1 hour <190
2 hour <165
3 hour <145
What is needed from the GTT to diagnose gestational diabetes
two or more elevated levels during the three hour test
Glycosylated Hemoglobin (HbA1C)
Reflects control of blood sugar in the past 4-12 weeks
Measures % of blood Hgb that has a glucose molecule attached
What is the normal Hgb glycosylation %?
6-8% should be glycosylated - higher signals diabetes
Preterm Labor
labor between 20-37 weeks gestation
Associated Factors for Preterm Labopr
hx of preterm labor - we have to manage this aggressively
HTN
placental abnormality
PROM (increased risk for infection and sepsis)
amniotic fluid abnormality
low socioeconomic status
maternal age <18 or >40
low pre pregnancy weight
non Caucasian race
multiple pregnancy
short interval between pregnancies
inadequate or excessive weight gain in pregnancy
previous laceration of the cervix or uterus
maternal infection
maternal medical conditions
smoking
alcoholism or drug addiction
severe anemioa
maternal trauma or burns
uterine abnormalities
cervical incompetenece
Which preterm labor associated factor is more so regarding preterm delivery as we act before full term in stabilizing it
HTN
Treatment for preterm labor
bedrest
tocolysis
corticosteroids
antibiotics
What does Tocolysis do for preterm labor
minimizes contractions
What does corticosteroids do for preterm labor
it accelerates fetal lung maturity incase it is delivered
immature lungs would be the main reason for loss of preterm babies
What are some bleeding emergencies in pregnancy?
Placenta Previa
Placenta Abruptio
Vasa Previa
uterine Rupture
Lacerations
Placenta Previa
the placenta implants in the lower uterine segment , either partially or totally covering the cervix
What must be done is there is partial or complete placenta previa?
the baby must be delivered at 37 weeks by C section if not before
S/S Of Placenta Previa
sudden onset of painless bleeding or hemorrhage
may be accompanied by contractions
Vaginal exams are not done on women with…
known placenta previa
women with heavy vaginal bleeding and known placental location
since we could accidentally remove the placenta
The hallmark sign of placenta previa is ?
painless bleeding or hemorrhaging
Placenta previa may or may not be accompanied by ___
contractions
Why is there a high hemorrhage risk with placenta previa
there is cervical thinning and softening and changes that may make the placenta break away causing life threatening hemorrhaging
Why may a C Section not be needed for a low lying placenta or partial previa?
if in the 20 week ultrasound we see no anatomical issues the C section may not be needed as the placenta tends to migrate upward as the uterus enlarges
Why are C Sections always needed for complete previa
it cannot migrate upward in two directions at the same time so it is required
Predisposing Factors for Placenta Previa
Multiparity (scarring making implantation hard)
Maternal Age >35
Multiple Pregnancy (larger uterus makes likelihood higher)
erythroblastosis
Previous uterine surgery (scarring occurred)
Smoking
previous placenta previa (same factors as before)
previous therapeutic abortion
Placenta Abruptio
a premature separation of the normally implanted placenta
can be complete or partial
Bleeding during placenta abruptio can be…
obvious or concealed behind the placenta
can also lead to several L of blood lost in the uterus cavity with complete concealed abruptio
S/S of Placenta Abruptio
Board Like/Rigid Abdomen - especially with complete abruption
Severe, relentless abdominal pain out of proportion to labor
Back pain
Colicky, discoordinate uterine contractions
tetanic contractions
bleeding
pain localized or generalized
FHR periodic changes late, variable, prolonged, sinusoidal
loss of variability (irregularity)
aggressive fetal movement (they know somethings wrong)
increasing fundal height (from filling with blood)
maternal shock
may not show on ultrasound
What distinguishes placenta abruptio from placenta previa
severe pain out of proportion to contractions
Ultrasounds and Placenta Abruptio
It may or may not show up on ultrasound
if all the bleeding has come out there will be no clot present to distinguish it on the ultrasound
it can confirm a complete or central abruption because there are clots, but it cannot rule out abruptio if its partial since the blood left
Predisposing Factors to placenta abruptio
maternal HTN
preeclampsia
folic acid deficiency
severe abdominal trauma
short umbilical cord
malnutrition (poor placental health)
sudden decrease in uterine size
materanl age over 35
rough or difficult external version
cocaine use especially when it is crack
Folic acid is essential to…
normal formation of placenta and adhering to the uterine wall as well as preventing neural tube defects
Why is a short umbilical cord concerning?
it can cause placenta abrutpio
if the cord is short, mom goes into labor and the placenta is fundally located - as the baby drops the traction on the placenta can make it separate early
External Version
when we see a baby is transverse or breech so we manipulate the uterus to get the babies head down - but if it goes across the implantation site it can cause detachment of the placenta and thus placenta abruptio
Why is crack a big risk for the pregnant woman and for placenta abrutio?
it can cause bucking which is contractions similar to a grand mal seizure
Placenta abruptio warrants…
very close observation or C Section
__ __ for the mother and infant can be substantial in both previa and abrutio
blood loss
Vasa Previa
shearing of the umbilical vessels in utero
usually the vessels are abnormally implanted and cross through the membranes off of the surface of the placenta - the vessels come of the placenta but the cord is not formed until several cm out
So, at the time of ROM the vessels can end up shearing - Critical situation!
Who bleeds and is effected by vasa previa
the infant
Since the baby has such small circulating blood (1 cup ~) volume, vasa previa can…
lead to bleeding to death very quickly
Satellite Placenta
placental attempt to migrate when realizing theyre in a bad spot
there are vessels between the main and satellite that can shear
What is the sign to be suspicious of vasa previa? What is warranted if you see this?
if you see very dark red blood with ROM associated with changes in the FHR
a c Section is warranted then
Uterine Rupture
can be partial or complete
potentially catastrophic for mother and child
sudden and severe
What may occur simultaneously with a uterine rupture?
placental abruption
What is the number 1 cause for uterine rupture
previous uterine surgery like a C Section
Uterine rupture can lead to needing what procedure
hysterectomy
Risk Factors for uterine Rupture
previous uterine surgery
trauma
uterine overdistention
uterine abnormalities
placenta percreta
choriocarcinoma (molar pregnancy that is malignant)
Placenta Percreta
when the placenta has gone beyond the normal level of implantation
Cephalo Pelvic Disproportion (CPD)
also called Cephalo Pelvic Dystocia
When the baby is too big to get through the pelvis or in a position that has trouble getting through
What are the three factors that can cause CPD?
- The maternal bony pelvis (the main issue usually)
- Fetal positioning
- soft tissue dystocia if mother is obese
S/S of CPD
arrest of dilation or descent
abnormal labor patterns
acute maternal discomfort (bone on bone pain)
maternal exhaustion
early FHR decelerations (head compression)
Nursing Interventions for CPD
repositioning
assess labor pattern
assess fetal status
keep provider appraised of progress or lack thereof
keep hydrated
consider analgesia and anesthesia to relax muscles
Cord Prolapse
Occurs when the umbilical cord escapes beyond the presenting part and becomes trapped between the presenting part and the bony pelvis
What can occur with cord prolapse and what can this lead to
blood vessels in the cord become compressed and the infant can become hypoxic and asphyxiate
What is warranted with a cord prolapse
immediate C Section
Can cord prolapse occur in ROM?
yes if the presenting part is not in a good spot
Nursing Care for a Cord prolapse
one person must do a continuous vaginal exam and hold the head up off of the cervix
put the patient in trendelenburg or in knee chest position
prepare for an immediate C Section
IV bolus (increase perfusion)
O2 via mask (10 L via non rebreather)
prepare for resuscitation of infant
What diagnoses Fetal Distress
electronic fetal monitoring
Causes for Fetal Distress
placental insufficiency
severe cord compression
hyperstimulation of the uterus (contracts blood vessels)
fetal exhaustion
___ in the FHR patterns can give indications of the cause for fetal distress
decelerations
If the fetal distress cause cannot be corrected then what must happen
A C Section
Nursing Interventions for fetal Distress
reposition the patient (could get them off cord)
Increase IV rate (improve perfusion)
Administer O2 (10L via non rebreather mask)
assess labor progress
assess cord prolapse
notify provider
prepare for delivery and resuscitation
turn off Pitocin (can make matters worse with contractions decreasing blood flow)
Why is assessing labor progress particularly important when dealing with fetal distress
if she is close to vaginal delivery it may be faster than doing a C Section
Shoulder Dystocia
When the head has come out but the anterior shoulder impacts on the anterior pubic bone (or posterior shoulder impacting the sacral prominence)
Turtle Sign
a classic sign of shoulder dystocia where there is retreating of the fetal head after it was delivered
warrants calling a code if seen
Maternal Risk factors for Shoulder Dystocia
abnormal pelvic anatomy
gestational diabetes since the baby may be fat and large
post date pregnancies since baby is larger
previous shoulder distocia
short statures leading to smaller dimensions
Fetal Risk Factors for shoulder dystocia
suspected macrosomia
Labor related risk factors for shoulder dystocia
assisted vaginal delivery (forceps or vacuum) - high correlation
protracted active phase of first stage labor
protracted second stage labor
protract may indicate a large baby
What can happen if the provider does the incorrect thing and tries to take ahold of the infants head and put traction on it to free the shoulder from shoulder dystocia?
it can shear nerves from the neck to the arm causing permanent paralysis or damage in the limb
The single most common risk factor associated with shoulder dystocia is…
the use of a vacuum extractor or forceps during delivery
Overall incidence of shoulder dystocia increases…
with increasing large baby size
Shoulder dystocia occurs with equal frequency in ___ and ___ women, but it is more common in infants born to women with ___
primigravid and multigravida
diabetes
Maternal Complications of Shoulder Dystocia
Postpartum hemorrhage (lacerations occurring extending to rectum)
rectovaginal Fistula
Symphyseal (anterior pelvis) separation or diathesis with or without transient femoral neuropathy
Third or fourth degree episiotomy or tear
uterine rupture
Fetal complications of shoulder dystocia
brachial plexus palsy
calvicle fracture
fetal death
fetal hypoxia with or without permanent neurologic damage
fracture of the humerus
Brachial Plexus Palsy
shearing of the nerves going down the arm
Prevention of Shoulder Dystocia
Encourage weight gain within a “normal” range (makes a big child)
Induction of labor with larger infants
effective C Section
good control of diabetes in pregnancy (makes a big child)
What is the problem with the induction of labor to prevent shoulder dystocia
It may appear 2 pounds larger at term via ultrasound - but we are aiming at a moving target so we may induce labor and then find the infant was much smaller than we thought
Maneuvers for Shoulder Dystocia Delivery
- Deliver through the anterior shoulder
- McRoberts Positioning
- Episiotomy
- Suprapubic Pressure
- Rotational Maneuvers- internal maneuvers to rotate the shoulder off the bone like rubin II, Woods, and Reverse Woods
- Deliver the posterior shoulder
- Reposition mom into knee chest position
McRoberts Positioning
Hyperflexion of maternal hips up to nipple line (pelvis is bones connected so this increases ant-post dimensions)
Rubin II Maneuver
provider maneuver to get shoulder off pubic bone by trying to collapse shoulder and move baby at an angle to get through the pelvis (where clavicle fractures tend to occur)
Woods (Screw) Maneuver
put fingers behind anterior shoulder and fingers in front of posterior to make a screw motion
Reverse Woods (Screw) Maneuver
same as woods but opposite screw direction
Ina May Gaskin
most famous midwife in the world
noticed if you turn mom on hands and knees and put her in knee chest position than shoulder dystocia will correct itself (this position should get the reverse maneuvers then)
What are some extreme measures to fix shoulder dystocia
Deliberate clavicle Fracture
zavanelli maneuver
general anesthesia (relaxation, but has downfalls)
abdominal surgery with hysterotomy (rotates infant through incision)
symphysiotomy
Why may extreme measures to fix shoulder dystocia occur
because every moment of it is another moment the baby can become asphyxiated from cord compression
Zavanelli Maneuver
attempt to replace (push back in ) the babies head and do a C Section
Symphysiotomy
used in 3rd world countries more
intentionally excise fibrous cartilage of the symphysis pubis under local anesthesia to get the baby out of shoulder dystocia
only used in NA when all other things have failed and C Section is unavailable
How common is post partum hemorrhage (PPH)?
Common - 3-5% of pregnancies
PPH can even occur…
in patients without risk factors for hemorrhage (20%)
PPH is the cause of ___ of maternal deaths worldwide and __% of maternal deaths in the US
1/4 worldwide
12% in US
PPH requires
management of PPH with prompt diagnosis and treatment
rapid team based care to minimize morbidity and mortality regardless of cause
if not done a mom can bleed to death in minutes!!
Risk Factors for PPH
antepartum hemorrhage
augmented labor
chorioamnionitis
fetal macrosomia (hard to act like a tourniquet after that)
maternal anemia (less loss tolerance)
maternal obesity
multifetal gestation (d/t hyperextension occurring)
preeclampsia
primiparity
prolonged labor
Augmented Labor
when the uterus may not contract soon after L&D leading to a bleeding problem
S/S of PPH
Heavy BRIGHT RED BLOOD FLOW - only 500 to 1000 cc is loss depending on birth so measure and save all pads and chux
Flaccid (Atonic, boggy) fundus
changes in VS: low BP, elevated Pulse (30% blood loss, less if anemic before PPH)
Complaints of lightheadedness, nausea, air hunger, changes in orientation and alertness (means late PPH, 50% loss)
changes in lab values - H&H, platelets, coagulation profile, D Dimer
75% of PPH related to
uterine atony (lack of contraction/tone)
What should we do if the fundus is flaccid/not well contracted
massage it in a circular pattern
there is a stimulatory pacemaker near the fundus that can get contractions going
The 4 T’s
Mnemonic that can be used to ID and address the four most common causes of PPH:
Tone - Uterine Atony
Trauma - Laceration, Hematoma, inversion, Rupture
Tissue - Retained tissue or invasive placenta
Thrombin - Coagulopathy
How do the 4 T’s compare in causing PPH to one another?
- Tone - 70-80% - Major cause
- trauma - 20%
- Tissue - 10%
- Thrombin - 1%
How to manage PPH?
- Start with a fundal contraction assessment and massage since uterine atony is a common reason for PPH
- Pitocin
- Repeat fundus and flow and VS assessments 1 5-15 minutes depending on severity and findings
- initiate a team response: MD, Nurses, lab, anesthesia, supervisor, etc
What is the first line drug for PPH
Pitocin (or Tranexamic Acid)
Complications of PPH
Anemia
Sheehan Syndrome
Blood Transfusion
Death
Dilutional Coagulopathy (loss of clotting factors)
Fatigue
Myocardial sichemia
orthostatic hypotension
postpartum depression
Sheehan
lifelong hormonal issues
it is from anterior pituitary ischemia with delay or failure of lactation occurring
Types of Lacerations
Perineal
Periurethral
Vaginal
Cervical
Cervical Uterine
____ are responsible for 20% of PPH
lacerations
Lacerations are classified by ___ and ___ ___
depth and tissues involved
ex: 1st, 2nd,3rd,4th Degree
Periurethral lacerations are usually __degree
1st
1st Degree Laceration
involves the perineal skin and the vaginal mucosal membrane
so it is depth of skin but not tissue
2nd Degree Lacerations
involves the perineal skin and the vaginal mucosal membrane and the muscles of the perineum body - however the rectal sphincter remains in tact
Interruption of skin and muscle and extension into the vaginal vault, but no sphincter issue
3rd Degree Laceration
involves the perineal skin, vaginal mucosal membrane, muscles of the perineum body, and through the rectal sphincter (non intact)
excision occurs to the rectal sphincter but NOT the rectal mucosa
4th Degree Laceration
involves perineal skin, vaginal mucosal membrane, muscles of the perineum body, and through the rectal sphincter AND through the rectal mucosa
definitely needs repair
What degree laceration is a vaginorectal fistula
4th degree - needs repair
Sulcus Tears
another name for Vaginal Lacerations
__ and __ must be examined for lacerations
Vagina and Cervix
What laceration is repaired first; Perineal or Vaginal?
vaginal laceration then perineal laceration
What is a concern regarding cervical lacerations?
it is a highly vascular area so it is prone to hematoma formation after trauma and more bleeding
We will need to tie off vessels open and bleeding
Care must be taken to ___ bleeding vessels as the repair progresses in order to prevent ___
compress; hematomas
Cervical lacerations can be…
extensions of a vaginal laceration and can extend up into the lower segment of the uterus or be confined to the cervix itself
What sites are the most common sites for laceration? What makes them more common?
3 o clock and 6 o clock
operative deliveries e.g. vacuum and forceps
Because the cervix is highly vascular, lacerations…
can cause significant blood loss with cervical lacerations
Lacerations can do what to the cervix ultimately?
damage the integrity of the cervix and its ability to maintain future pregnancies
Amniotic Fluid Embolism
when amniotic fluid as the placenta breaks away is still free flowing in the uterus and gets swept into circulation and goes to the lungs
can be sudden or extreme (more often) but can also be insidious as well (like is O2sat is 92-93%)
Amniotic fluid embolus are ___ embolus and are usually ___ and ___
pulmonary embolus and are usually bilateral and extensive
When is the most common time for an amniotic fluid embolus to occur
at the time of delivery
What is the mortality like with an amniotic fluid embolus
severe and life threatening complication
60-80% mortality rate
makes up 10% of maternal mortality
usually occurs near to or after delivery
S/S of Amniotic Fluid Embolus
sudden and severe respiratory distress
hypoxia
altered mental status
pain
hypotension (from blood not getting from from lungs to the heart)
shock and arrest
The sooner you get a mother with an amniotic fluid embolus on ____ the better
ventilators
What management does an amniotic fluid embolus need
100% O2, aggressive IVB fluids, hypotensive meds - AS QUICKLY AS POSSIBLE
May need to be on a ventilator
Intrapartum and Postpartum Infections
Amnionitis
Endometritis
Mastitis
Endometritis
an inflammation of the endometrium (inner layer of uterus)
Chorioamnionitis
infection of the chorion
How often does endometritis occur in women with vaginal deliveries versus C sections?
1-3% of vaginal deliveries - 27% of C Sections
What are the causative agents of chorioamnionitis and endometritis
both anaerobic and aerobic bacteria
these could enter through a vaginal exam near the cervix
S/S of Chorioamnionitis and Endometritis
Lochia that is foul smelling, bloody, scant or perfuse in amount - purulent as well
Fever
Tachycardia
Chills
Uterine tenderness (disproportionate to contractions or C Section and what is normal)
What is usually the first indicator of chorioamnionitis/endometritis
tachycardia (especially if fetus is still inside)
Risk Factors for chorioamnionitis and endometritis
C Section (Risk 20x greater)
prolonged premature ROM (no barrier and amniotic fluid is a medium for bacteria) (even higher after 24 hr)
prolonged labor preceding C Section
multiple vaginal exams in labor
compromised health status (anemia, low se status, use of tobacco, drugs or ROH)
use of internal fetal heart rate or contraction monitor (wick for bacteria to get in)
OB trauma (lacerations or episiotomy)
diabetes (4x more likely)
preexisting bacterial vaginosis or chlamydia infection (STDs)
instrument assisted birth (forceps or vacuum) (Ascend the bacteria)
manual removal of the placenta (hand went through the cervix)
lapses in sterile technique by the surgical staff
Mastitis
an infection of the connective tissue of the breasts that occurs primarily in lactating women
can progress to form abscesses even
When does mastitis tend to occur
several weeks after delivery
S/S of Mastitis
Redness (often wedge shaped because of the septal divisions in the breast)
swelling, warmth at the site
pain
fever headache
flu like symptoms (because breasts are vascular and they go systemic fast)
leukocyte count >1 million/mL or bacterial colony coutn >10000/mL
Risk Factors for Mastitis
Milk stasis
Actions that promote access/multiplication of bacteria
Change in the number of feedings / failure to empty the breasts
lowered maternal defenses
breast/nipple trauma
obstruction of ducts
What may cause milk stasis
failure to change feeding positions
failure to alternate breasts at feedings
poor suck
poor letdown (mom can perceive normal letdown)
What are some actions that promote access/multiplication of bacteria on the breast
poor handwashing technique
improper breast hygiene
failure to air dry breasts after breastfeeding
use of plastic lined breast pads (trap moisture)
What can lead to a change in the number of feedings or failure to empty the breasts?
attempted weening
missed feedings
prolonged sleeping including nighttime
favoring side of nipple soreness
can also contribute to milk stasis in the end
__ and __ can lower maternal defenses
fatigue
stress
What may cause breast/nipple trauma
incorrect positioning for breastfeeding
poor latch
failure to rotate position on ni9pple
incorrect or aggressive pumping technique
What can lead to obstruction of the milk ducts
restrictive clothing
constrictive bra
underwire bra
