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in which the mother or fetus has a significantly increased chance of morbidity, mortality or both before, during or amount. There are no associated symptoms such as cramping, backache and no cervical dilatation until 29 days after birth or an increased chance of subsequent disability Treatment Complete bed rest, restriction of activities Psychosocial Factors Restrict coitus for 2 weeks following bleeding Emotional aspects Imminent Abortion - Products of conceptions will be expelled if uterine contraction & cervical dilatation Race black mother have smaller newborns Occupation and income occurs, the loss of the products of conception is inevitable, cramping, backache and vaginal bleeding Teenage mothers Treatment Save and bring to the hospital any tissue fragments Paternal Factors DM, Rho O immunization D/C, IVF, replace blood loss High Risk Factors that Contribute to Perinatal Morbidity & Mortality Hereditary abnormality Small for dates Congenital anomaly, anemia, blood dyscracias, pre-eclampsia Severe social problem (teenage pregnancy, drug addiction) No antenatal care Younger than 18 years old and older than 35 years old Teratogenic viral disease Fifth subsequent pregnancy Prolonged infertility Significant stressful or dangerous events (critical accident, excessive exposure to addiction) Heavy cigarette smoking Conception within 2 months of a previous delivery Neonatal Factors Prolonged rupture of membranes Abnormal presentation and delivery Prolonged difficult labor Prolapse cord Birth asphyxia Fetal heart rate fluctuation Meconium staining Fetal acidosis APGAR score less than 7 Preterm labor Post term labor Small for dates infants Large for dates infants Any respiratory distress or apnea Obvious congenital anomalies Convulsions, limpness, difficulty in sucking or swallowing Distention and vomiting Anemia Jaundice in first 24 hours Fetal Factors Congenital anomalies Short cord Cord compression Hydramnios Abnormal presentation of position Immaturity Prematurity Fetal infection Complete Abortion the entire content of conception are expelled, fetus, membranes and placenta Incomplete Abortion part of the coneptus is expelled but the membranes or placenta is retained Missed Abortion the fetus dies in utero but is not expelled Causes: Weight loss, decrease in breast size Painless vaginal bleeding Complication is DIC Habitual Abortion loss of three or more successive pregnancies Causes Defective ova and spermatozoa Hormonal (decreased thyroid function) Decreased nutrition Deviations of the uterus Listeriosis gram + rod, L. monocytogenes Causes of Early Spontaneous Abortion Abnormal fetal formation due to a teratogenic factor on a chromosomal aberration Implantation abnormality due to maternal diseases, endocrine imbalances, inadequate endometrial formation or from an inappropriate site of implantation. With inadequate implantation, the placental circulation will not be well established and fetal formation will be inadequate Abortion may occur if the corpus luteum fails to produce enough progesterone to maintain the decidua basalis Trauma resulting in placental detachment Severe fright or stress increases maternal epinephrine which leads to extensive vasoconstriction and to necrosis of decidua basalis Infection rubella, toxoplasmosis, influenza, polio cross the placenta Endocrine disorders decreased estrogen and progesterone Uterine tumors Sepsis Cervical incompetence Drug ingestion and irradiation Chromosomal abnormalities (defective genes) Poor nutritional status Deviations of the uterus Psychological factors
HEMORRHAGIC DISORDERS ABORTION termination of pregnancy before viability (is reached at about the 28th week of gestation when the fetus weighs more than 600 g or more) of the fetus Spontaneous Abortion abortion that occurs from natural causes Duration Intensity Description Frequency Associated symptoms Action
PLACENTA PREVIA Low implantation of the placenta Low Implantation implantation in the lower rather than in the upper portion of the uterus Partial Placenta Previa implantation that occludes a portion of the cervical OS Total Placenta Previa implantation that totally obstructs the cervical OS Repeated D&C and CS Complications hemorrhage, infection, isoimmunization Reduced vascularity of the upper segment due to scarring or tumor necessitating lower implantation Illegal Abortion is an abortion performed in an uncontrolled setting usually by a person other than a physicin and performed Bleeding may be due to retraction of the lower segments and concomitant without illegal sanction separation of placenta Causes It is the result of the placenta s inability to stretch to accommodate the differing ECTOPIC PREGNANCY one in which implantation occurs outside the uterine cavity shape of the lower uterine segment Increases parity and increased gestation PID caused by IUD Smoking Adhesions of fallopian tube from previous infection Residing in high altitude Endometriosis Causes Congenital formations Kleihauer-Betke Test to detect whether blood is fetal or maternal in origin Scars from tubal surgery Bleeding occurs on the 7th month of gestation Uterine tumors dressing in the proximal end of the tube Bleeding is usually abrupt & painless and it is not associated with increased Symptoms th activity 6 to 12 week of pregnancy 4 to 10 weeks following a missed menstrual period the growing zygote ruptures the slender tube or the growing Prone to post partum hemorrhage because the placental site is in the lower uterine segment trophoblast cells break through the narrow base of the fallopian tube with resultant invasion and destruction of the blood vessel The woman usually experience a sharp, stabbing pain in one of the lower ABRUPTIO PLACENTA Premature separation of the placenta; this occurs after the 20th 28th week of abdominal quadrants and notes a little vaginal spotting pregnancy Symptoms Light headedness, amenorrhea, VS indicative of shock Chronic hypertensive disease Rapid pulse, rapid respiration, falling blood pressure Pre-eclampsia Umbilicus may have a purplish tinge (CULBU S SIGN) Direct trauma as in automobile accident Extensive vaginal and abdominal pain High multiparity 5 above Movement of the cervix on pelvic exam causes excoriating pain Previous abruption placenta Leukocytosis Rapid decrease in uterine volume caused for instance by a sudden release of excessive amniotic fluid ND 2 TRIMESTER BLEEDING Causes Increasing pressure in the intervillus spaces which may result in hemorrhage & HYDATIDIFORM MOLE proliferation and degeneration of the trophoblast villi as the cells degenerate they become filled with placental separation fluid appearing as a fluid filled, grape-sized vesicles and the embryo fails to develop Pressure exerted in the vena cava by the enlarging uterus Complication choriocarsinoma Deficiencies of folic acid and vitamin C Symptoms Vascular engorgement during the vena caval syndrome and sudden (+) HCG hyperemesis increased uterine fundal height in advance of length of gestation uteropacental vasodilation Increased BP, edema, proteinuria (appears before the 24th week of pregnancy, No FHB, no fetal movement) Cocaine use Vaginal bleeding with clear fluid filled vesicles Rapid decrease in uterine volume with sudden release of amniotic fluid External bleeding if the placenta separates that at the edges and blood escapes INCOMPETENT CERVIX one that dilates prematurely and therefore can t hold the fetus until term freely from the cervix. If the center of the placenta separates first, blood will Causes endocrine, trauma to cervix (D&C), congenital developmental factors, habitual abortion pool under the placenta & be hidden from view. Blood may infiltrate the uterine Treatment cervical circlage, McDonald s or Shiordkar s Barter procedure Symptoms musculature (convelaire uterus or uteroplacental apoplexy) forming a hard Symptoms board-like uterus with no apparent or minimally apparent bleeding. Dilation is usually painless Shock usually follows Presence of show followed by rupture of the membranes and discharges of the amniotic fluid Sharp stabbing pain high in the fundus, DIC Uterine contractions began Decreased plasma fibrinogen Maternal This occurs in the fifth month of pregnancy Convelaine uterus Complications Renal failure THIRD TRIMESTER BLEEDING Blood incompatibilities Immunologic factors Rejection theory Maternal lupus anticoagulant factors
Shock Differential Diagnosis PLACENTA PREVIA Painless bleeding Bright red blood First episode of bleeding is slight Signs of blood loss comparable to extent of bleeding Uterus soft and non-tender Fetal parts palpable FHR countable Placenta palpable Blood clotting defect absent
ABRUPTIO PLACENTA Bleeding accompanied by pain Dark red blood First episode of bleeding is profuse Signs of blood loss out of proportion to amount of visible blood Uterus painful to touch Fetal parts difficult to palpate FHR irregular or absent Placenta not palpable Blood clotting defect present
Maternal absorption of toxins from the placenta Diet increased carbohydrates, decreased protein Deleterious substances in the blood Autoimmune disease which implies that placental antigens cross-react with kidney antigens
PLACENTA ACCRETA When the placenta is deeply embedded in the uterine wall GENERAL PRINCIPLES OF NURSING INTERVENTION: BLEEDING DISORDERS Constant monitoring of vital signs; blood pressure and pulse is imperative Observe patient for behaviors indicative of shock such as pallor, clammy skin, perspiration, dyspnea and restlessness Count pads to assess amount of bleeding. Any tissue or clots expelled should be saved Prepare for IVF Prepare equipment for exam Have O2 available Collect and organize all data including history, lab and studies Lateral position not supine to prevent pressure on the vena cava Assess coping mechanism of patient in crisis Give emotional support Sustained presence Clear explanation of procedures Communicating her status to her family Prepare patient for possible fetal loss Assess her expression of anger, denial, silence, guilt, depression or self blame Encourage to verbalize feelings Inform regarding causes of abortion to eliminate guilt CBR TOXEMIA OF PREGNANCY Occurs on the 24th week of gestation rd 3 most frequent cause of maternal mortality Due to poor nutrition and deficiency in pyridoxine (vitamin b6) Hypertensive disease of pregnancy Etiology Impairment of uroplacental circulation secondary to uterine distention Operation of the hormonal mechanism (increase amount of estrogen & progesterone secreted by the placenta may affect kidney function and produce edema) Stress Increased maternal fetal corticosteroids
Pathology Renal lesion has been described consisting of cloudy swelling of the capillary endothelial cell and the deposit of amorphous material between these cells and the basement membrane. The vascular lumen is thus diminished. Presence of small thrombi the lungs. Enlarged blanched kidneys are seen. There are ischemic glomerular capillaries adherent to the thickened basement membrane Degeneration of the endothelial cells is apparent. The tubular cells show hyaline degeneration. The dilated tubules contain protein and casts together with occasional red blood cells and WBC Arteriolar spasm is present resulting to hypertension BUN and Creatinine is increased A-G ratio, CO2 glomerular filtration rate, urine output secretion of ADH, ACTH Tissue hypoxemia may result in the maternal vital organs, poor placental perfusion may reduce the fetus nutrients & O2 supply The degeneration changes that develop in kidney glomerulus due to the vasospasm lead to permeability of the glomerular membrane. This in turn allows the serum proteins, albumins and globin to cross into the urine (proteinuria a result of resistance in the glomerular arterioles & narrowing of the lumina of the glomerular capillaries.) The degenerative changes also lead to glomerular filtration. Tubular reabsorption of Na occur leading to edema. Edema is further increased as more protein is lost, the hydrostatic pressure of the circulating blood decreases and fluid diffuse from the circulatory system into the intracellular spaces to equalize the pressure (edema) General spasm of arteries Degenerative changes in glomeruli Decreased glomerular filtration Tubular reabsorption of Na Edema Hypertension Hemorrhages into brain, liver and kidneys Increased permeability of glomerular membrane Proteinuria Loss of serum protein via the urine
Complication known to predispose women to development of toxemia Diabetes with vascular or renal involvement Acute hydramnios Hydatidiform mole Obesity (+) family history Essential hypertension 140/90 or more than 30 mmHg above baseline Age and parity below 18 and above 35 Race greater among non-white
Pernicious vomiting Vomiting that is prolonged past the third month of pregnancy or is so severe that dehydration, ketonuria and significant weight loss occurs within the first three months
Treatment Causes Bed rest sodium tends to be excreted at a more rapid rate during rest than activity. This results in lowered levels of High level of HCG hormone produced by the trophoblasts plasma sodium and diuresis occurs Because the degenerative products resulting from the functioning of trophoblasts as they invade the Diet moderate salt restriction. Stringent restriction of slat may activate the Angiotensin system and result in increase BP, endormetrium are foreign to the maternal system, they contribute to the development of this increase CHO, increase CHON, decrease fat and salt extreme physiologic response Diuretics (IVF) to evaluate the fluid and decrease edema. It is effective in decreasing the reabsorption of Na. This results Rejection Theory common in woman carrying unwanted children than those carrying wanted in decreased levels of sodium in the plasma. Fluids then shift from the intracellular space into the circulatory system and children edema is decreased. If therapy continues, however, the physiological reserves of Na are depleted, the body s homeostatic mechanisms are disturbed and the body attempts to conserve fluid loss. Symptoms Also stimulate the release of rennin which increased the permeability of glomerular vessels which leads to increased Concentration of Na, K, Cl and bicarbonate may be decreased proteinuria and activates angiotension which increases BP Hypokalemic alkalosis may result Monitor the BP, FHB and signs of labor Weight loss, severe protein and vitamin deficiency Insert urethral catheter Depletion of CHO leads to ketosis Weigh daily the patient Jaundice and hemorrhage due to deficiencies of vitamin C and B complex Monitor blood concentration Convulsion precautions Treatment Objectives of Nursing Management Measure intake and output hourly Fluid replacement Control of vomiting Give magnesium sulfate a cathartic I and O recording Correction of dehydration It reduces edema by causing a shift in fluid from the extracellular spaces into the intestine. It also has a CNS Give sedatives and Restoration of electrolyte imbalance depressant action that lessens the possibility of convulsions and a vasodilating effect that lowers BP. antiemetics Maintenance of adequate nutrition It depresses the myoneural junction thus decreasing hyperreflexia and resulting in vasodilatation Psychologic support It relieves cerebral vasospasm It increases cerebral blood flow The principle cause of fetal death in utero of SGA infants is uteroplacental insufficiency which causes a decrease in blood supply. The woman is hospitalized and Placed on strict bed rest Hypotensive drugs and sedatives may be utilized Encouraged to lie on her side to increase renal and uterine blood flow which may encourage diuresis and return her blood pressure to within normal limits Monitor FHB VS, monitor intake and output regularly DIABETES MELITTUS AND PREGNANCY Inability to metabolize glucose properly because of insulin deficiency ECLAMPSIA Cerebral irritation which results from the increasing cerebral edema Glomerular filtration of glucose is increased, causing glycosuria, rate of insulin secretion is increased Signs and Symptoms and the fasting blood sugar is lowered. The woman appears to have a decreased insulin Increased temperature Sensation of constriction of the thorax Insulin does not seem normally effective during pregnancy, a phenomenon that is probably cause by Increased blood pressure Twitching of facial muscles the absence of hormone human placental lactogen (chorionic somatomammotropin). Hyperactive reflexes Brief sharp cry This resistance to insulin prevents the blood sugar in a normal pregnancy from falling to dangerous Epigastric pain and nausea is a Fixed expression of the eyes limits, despite the increased insulin secretion result of vascular congestion Blurring of vision of the liver Severe headache Effects of Pregnancy on the Diabetes Decreased urinary output Insulin requirement increase especially in third trimester HYPEREMESIS GRAVIDARUM Aggravated excessive physiologic nausea and vomiting Decreased renal threshold Hypoglycemia is likely to occur during the first half of pregnancy
Ketoacidosis, pre-coma and coma during last trimester Dietary fluctuations due to nausea, vomiting and cravings Pregnancy gen. lowers CHO metabolism Stress of pregnancy may produce abnormal glucose tolerance Pregnancy is a stimulus to the pancreas, the amount of circulating insulin accordingly High estrogen level of pregnancy may predispose to diabetes, because estrogen affects glucose tolerance to the liver Possible acceleration of hypertension, nephropathy and retinopathy
With vascular involvement Benign retinopathy Leg calcification DYSTOCIA may be due to CPD due to macrosomatic of the fetus ANEMIA may be due to vascular involvement and nausea & vomiting INFECTION (UTI) due to poor diabetic control & acidosis, hyaline membrane due to prematurity, lethal congenital anomalies (heart) & neurologic defects MICROSOMATIC (LGA) due to increased maternal levels of blood sugar from which the fetus derives its glucose. These elevated levels provide & relentless stimulus to the fetal Islets of Langherhans to produce insulin. The sustained fetal hyperinsulinism, hyperglycemia lead to excessive growth and deposition of fats HEART DISEASE AND PREGNANCY Ranks fourth as a cause of maternal mortality The two most frequent heart conditions that affect pregnancy outcome are rheumatic fever with valvular involvement & uncorrected coarctation of the aorta Pregnancy taxes the circulatory system of every woman increasing the cardiac output about 30%. Most of this increase occurs in the first 6 months of pregnancy and this increased blood volume & continues to be maintained. Increased heart rate increased cardiac output increased total blood volume.
Effects of Diabetes on Pregnancy Maternal Complication Increased rate of toxemia Hydramnios, dystocia, increased morbidity, infection, ketoacidosis Fetal Complication Oversized babies, congenital anomalies, increased fetal mortality Edema more difficult to control Increase incidence of abortions Increase incidence of premature labors More rapid aging of placenta Management Evaluation of functioning assessment of fetal maturity and delivery Glucose tolerance testing fetoplacental Weight control Measurement of plasma insulin levels Blood pressure readings U/A for albumin and acetone, BUN U/A for glucose, protein & ketone bodies Ascertain nutritional status, strict dietary regulation Oral hypoglycemic agents are contraindicated Bed rest, control diabetes Adequate prenatal care
Four Categories of Heart Disease Patients who have no limitation of physical activity. Ordinary physical activity. Ordinary physical activity causes no discomfort. They do not have symptoms of Class I cardiac insufficiency & do not have anginal pain Patients have slight limitation of physical activity. Ordinary physical activity Class II causes excessive fatigue, palpitation and dyspnea or anginal pain Patients have a moderate to marked limitation of physical activity. During less Effects of Diabetes on the Fetus than ordinary activity they experience excessive fatigue, palpitation, dyspnea & Class III The increase size of the fetus is thought to be related to the hyperactivity of the fetal pancreas, which has been shown to anginal pain contain considerably more insulin than the diabetic mothers because of an increase in number of Islets of Langerhans Patients are unable to carry on any physical activity without experiencing Inadequate blood sugar control may contribute to damage of fetal pancreas discomfort. Even at rest they will experience symptoms of cardiac insuffficency Class IV Mortality rates increases if the fetus is left in utero until term or anginal pain. Women with Class III and IV heart disease are poor candidates for pregnancy Risk of Pregnancy The cardiac output may become so diminished that the vital organs (including the placenta) are no longer perfused adequately with arterial blood and their O2 and nutritional requirements are thus not met. The left side of the heart may not empty the pulmonary vessels adequately and they become engorged resulting in pulmonary HPN & pulmonary edema. Blood returning to the heart from the venous system may not be handled adequately, so that venous pressure escape the walls of engorged capillaries to form edema or ascites
DIABETES MELLITUS Description Gestational or chemical diabetes (abnormal glucose tolerance test) Overt Diabetes (onset after age 20) Duration less than 10 years No vascular involvement Overt Diabetes Onset before age 20 10-20 years and no vascular involvement Overt Diabetes Onset before age 10 duration increased in 20 years
Intrapartal Period during labor and delivery tremendous stress is normally exerted on the unborn fetus. This stress could be fatal to the fetus of a cardiac patient because of the possible decreased O2 and blood supply to it. Continuous monitoring of labor signs & FHB & contraction. Assess VS to determine if there is Fetal Neonatal Implications tachycardia & hyperventilation Assessment of pulmonary functions (if dyspnea, rales, cough are present) Increased infant mortality if maternal cardiac decompensation occurs Proper positioning to assure cardiac emptying & proper oxygenation (semi-fowler and side lying) Gives rise to premature labor and delivery Supportive therapies Uterine congestion Use of prophylactic antibiotics Hypoxia O2 by mask if dyspnea occurs Elevation of carbon dioxide content of blood Diuretics to decrease fluid retention The respiratory & metabolic acidosis suffered in utero as a result of sub-optional oxygenation of the fetus leads to cellular Sedatives for rest and reduction of anxiety damage and predisposes the traumatized fetus to intrauterine fetal distress once labor beings and O2 transport and Analgesics with tranquilizers to potentiate action to reduce pain exchange are further reduced. Digitalis if signs of cardiac decompensation occur Assistance during delivery Interventions the primary goal of nursing care is to preserve the cardiac reserve function of pregnant patient. To do this it is By low forceps necessary to maintain a balance between cardiac reserve and cardiac workload. Vaginal delivery reduces stress of pushing and decreasing possible trauma to the infant Minimize the duration of second stage of labor by encouraging & supported relaxation Specific Goals CS if indicated Assess the stress of pregnancy on the heart s functional capacity Psychologic support Compare the patients vital signs of pulse and respiration to the normal values expected during pregnancy Establish activity level of patient, including rest, and assess any changes in vital signs Postpartal Period Identify in order of priority the problems indicating cardiac decompensation Support the woman s adaptive coping mechanisms to deal with stress The most significant time for the cardiac patient due to the rapid shift from the physiologic Allow ample time for the patient to ask questions and encourage her to comment on her pregnancy & its progress readaptation process. Answer the patient s questions as fully as possible and in terms that she can understand There is an increase in cardiac output and blood volume as the extravascular fluid is returned to the Carefully explain all nursing actions to the women bloodstream for excretion Identify & utilize significant others to give physical and psychological support After delivery, the intra-abdominal pressure is reduced significantly, venous pressure is reduced, Identify the severity of the disease process splanchnic vessels engorge and blood flow moves into the blood stream. This mobilization of fluid Note cardiac classification of patient can place a great strain on the heart if excess interstitial fluid is present. This stress on the heart Identify problems in order of priority based on nursing diagnosis and patient input could lead to cardiac decompensation, especially during the first 48 hours postpartum. Nursing Care of the Pregnant Woman with Cardiac Disease Nursing Care Antepartal Period Assessment of post delivery heart status Adequate nutrition Proper positioning (semi-fowlers) Increase protein, increase iron and essential nutrients to meet the increased demands of pregnancy for increased Gradual & progressive activity program blood volume and oxygen Progressive performance of activities of daily living Decrease Na and calorie intake Progressive ambulation Promotion of rest Use of diet administration of stool softeners Protection from infection it is important to protect the heart from the additional stress of upper respiratory infections, Psychologic support encourage maternal infant bonding which could lead to cardiac failure due to overload of the heart s reserve capacity Education and assistance of mother in infant care Drug therapy drugs that will cross the placenta and are teratogens should not be used Prepare for discharge Restriction of activity decrease fatigue, thereby promoting adequate ventilation Determine whether there are significant others to assist the mother at home in caring for self Continuous monitoring of pregnancy for assessment of cardiac status and infant
Signs and Symptoms Rales (auscultated in lung bases) Peripheral edema Dyspnea (progressive) Exhaustion Frequent cough with or without hemoptysis Heart murmurs Palpitations She will usually wake up at night, anxious and coughing may have cyanosis of the nail beds
Psychologic support to decrease anxiety Patients and family regarding their preparation fro childbirth & offer them encouragement to boast their morale th nd The pregnant cardiac patient is most prone to cardiac decomposition between the 28 to 32 weeks of gestation. It is at that time that the cardiac workload is highest.
An activity schedule that is gradual and progressive and appropriate to patient s needs Information regarding sexual relationship and contraception COMPLICATIONS DURING LABOR AND DELIVERY DYSTOCIA labors in which contractions deviates from the normal physiologic patterns of uterine activity. The contraction is either abnormally forced or ineffectual. Uterine Inertia sluggish contractions Causes Inappropriate use of analgesia (excessive or too early administration) Cephalopelvic disproportion (CPD) Poor fetal position (POP) Extension rather than Flexion of the fetal head Overdistention of the uterus due to multiple pregnancy, multiparity, hydramnious or obesity Maternal exhaustion Oversized fetus Cervical rigidity Maternal age (above 35) Full rectum or urinary bladder that impedes fetal descent Primary Uterine Inertia Hypertonic uterus Uncoordinated activity Labor is uncoordinated from the beginning, first stage is long Cervical dilatation is slow Patient complains bitterly of continuous pain Uterus is hypersensitive to palpation Contraction is not good from the start
Causes Scar from a previous CS Hysterectomy Plastic repair of the uterus Prolonged labor Faulty presentation Multiple pregnancy Unwise use of oxytocins Obstructed labor Traumatic maneuvers such as high forceps extractions, version Signs and Symptoms Presence of signs of shock Absence of FHB Contractions cease Uterus can be palpated as a separate mass Abdominal tenderness Persistent aching pain over the area of the lower segment Severe stabbing pain during strong labor contraction Pathological Retraction Ring indentation across the abdominal over the uterus; forewarning of uterine rupture; appears as a horizontal indentation across the abdomen AMNIOTIC FLUID EMBOLISM Amniotic fluid is forced into the maternal blood sinus thru some defect in the membranes or after partial premature separation of the placenta. Solid particles such as vernix caseosa, lanugo, and/or meconium in the amniotic fluid enter the maternal circulation and reach the lungs as small embolism. The woman in strong labor sits up suddenly grasps her chest because of inability to breath and sharp pain. She becomes pale and turns to bluish gray. There is cyanosis, dyspnea, and PP hemorrhage.
Secondary Uterine Inertia Tone of uterus is hypotonic PRECIPITATE DELIVERY (PPT) Contractions have been a good quality and proper duration Labor is completed in less than 3 hours Effacement and beginning dilatation have occurred, but the contractions gradually become infrequently and of poor It is apt to occur with multiplicity and may follow induction of the labor by oxytocin an amniotomy quality and dilatation stop Rapid labor poses risks to the fetus because subdural/intracranial hemorrhage may result from the Maternal Implication (Hyperactive Labor) sudden release of pressure and the woman may sustain lacerations of the birth canal. Forceful Lacerations of the cervix contractions may lead to premature separation of the placenta and both maternal and fetal risk. Uterine rupture Amniotic fluid embolism INVERSION OF THE UTERUS Post-partal hemorrhage The fundus is forced through the cervix so the uterus is turned inside out Fetal Neonatal Implications Causes Treatment Fetal hypoxia Pulling on the umbilical cord IVF Hypercapnia Insertion of the placenta at the fundus, so that as the Input and Output monitoring, VS, Bradycardia fetus is delivered it pulls the fundus down catheter Release of meconium in utero Atony of the uterus such that coughing forces the fundus Manage shock Suffocation & aspiration due to prolonged labor outward Never push the uterus Attempts to deliver the placenta before the uterus has Never attempt to replace RUPTURE OF THE UTERUS tearing of previously intact uterine musculature or an old uterine scar after the period of fetal contracted inversion viability
Never attempt to remove placenta Never pull on the umbilical cord Oxygen by mask, prepare for CPR, no oxytocin Cover the uterus with sterile gauze soaked in saline solution
Monitor FHB, labor patterns Assess presentation, position and lie Do amniotomy and allow labor under close supervision CS in fetal distress, CPD and placenta previa Prepare to receive two infants Correctly identify the first to be born infants
PROLAPSE OF THE CORD A loop of the umbilical cord slips down in front of the presenting fetal part Causes Premature rupture of the membranes Small fetus, long cord Fetal position other than cephalic presentation Placenta previa Intrauterine tumors that presents the presenting part from engaging Small fetus CPD Hydramnios Twin gestation
Maternal Implication Increase incidence in pre-eclampsia Abortions because of genetic defects or poor placentation and implantation Maternal anemia because the maternal system is maturing more than one fetus Placenta previa, hydramnios due to increase renal perfuse from cross-vessel anastomosis of monozygotic twins to due decreased area of choice of implantation Uterine dysfunction due to overstretched myometrium Abnormal fetal presentation Premature labor Shortness of breath Dyspnea on exertion Backache Pedal edema because of oversized fetus
Fetal-Neonatal Implications Treatment CS if dilatation is incomplete Prematurity with increased incidence of RDS (hyaline membrane disease) Pillows under the buttocks (so as not to compress the umbilical cord) Cytoplasmic mass of organs is diminished & growth rate is decreased. Twins may suffer from Slipping a chair under the foot of the woman s bed and elevating it intellectual & motor impairment Assume a knee chest position or turn on her side Increased incidence of fetal anomalies Don t attempt to push any exposed cord back into the vagina, this may add to the compression by causing knotting & kinking Superfecundation fertilization of two ova within a short period but not at the same act of intercourse Cover any exposed portion with a sterile saline compress to prevent drying Superfetation fertilization of ova from two different ovulating cycles Check FHB Siamese Twins occurs when the division of the embryonic disk is incomplete Patient should never be left unattended Perinatal mortality is higher after delivery of twins than of single birth due to prematurity, anoxia and COMPLICATIONS INVOLVING THE PASSENGER prolapsed cord MULTIPLE GESTATION When two or more embryo develop in the uterus at the same time OCCIPITOPOSTERIOR POSITION Monozygote (identical) 2 amnions, 1 chorion The occiput is directed diagonally and posteriorly, ROP and LOP Dizygote (fraternal) 3 amnions, 2 chorion In these positions, in the process of internal rotation. The fetal head must rotate not throwing a 90 degree arc but not through an arc of approximately 135 degrees Identify a family history of twinning and history of medication taken to enhance fertility Measure the fundal height Posterior positions tend to occur in women with android, anthropoid or contracted pelvis A posteriorly presenting head does not fit the cervix as smugly as one in an anterior position, 2 separate heart beat are auscultated increasing the risk of prolapse of the umbilical cord During palpation many small parts on all side of the abdomen may be felt If rotation is incomplete, the head becomes arrested in the transverse position transverse arrest Management and Treatment in Multiple Gestation If anterior rotation does not take place at all, the occiput usually rotates to the direct occiput posterior position persistent occiput posterior Counseling about diet and daily activities 300 calories or more over the recommended daily dietary allowance BREECH PRESENTATION Bed rest for HPN and lateral position to increase uterine and kidney perfusion Pelvic rocking food posture and good body mechanics for back discomfort Causes Types IVF for nausea and vomiting Prematurity Complete Small but frequent meals Placenta previa Frank
High implantation of the placenta Gestational age under 40 weeks Abnormality in the fetus (hydrocephalus) Hydramnios (it allows free fetal movement) Congenital abnormality of the uterus Contracted pelvis Any space occupying mass prevents engagement Previous breech delivery Pendulous abdomen fetal head lies outside the pelvic rim causing breech presentation Multiple pregnancy Unknown factors SHOULDER, FACE AND BROW PRESENTATION DISPROPORTION Causes Oversized babies due to maternal diabetes Hydrocephalus Contracted pelvis CPD Maternal Implication for Malpresentation Risks of CPD and prolonged labor chance of infection Lacerations and fears
Placenta Circumvallata no chorion covers the fetal sides of the placenta. The umbilical cord enters the placenta at the usual mid-point and large vessels spread out from there. They end abruptly at the point where the chorion folds back into the surface. Battledore Placenta the cord is inserted marginally rather than centrally. As a result all fetal vessels transverse the placental surface in the direction Velamentous Insertion of the Cord a situation in which the cord instead of entering the placenta directly, separates into small vessel that reach the placenta by spreading across a fold of amnion Vasa Previa umbilical vessels of velamentous cord insertion across the cervical OS so they would deliver before the fetus HEMORRHAGE Loss of over 500 ml of blood during labor Causes Uterine atony Ruptured uterus Cervical lacerations Retained secundines or placental fragments Coagulopathy Folate deficiency UTERINE ATONY Causes Deep and prolonged inhalation anesthesia that may reduce effectiveness of the contractions Exhaustion form a prolonged labor Operative deliveries such as versions Mismanagement of the third stage of labor Precipitous labor and delivery Over distention of the uterus (hydramnios, large baby) LACERATIONS Degrees of Laceration First Degree Laceration involves the perineal skin and vaginal mucosa Second Degree Laceration involves perineal skin, vaginal mucosa, muscles and fascia of the perineal body Third Degree Laceration extends into the anal sphincter Fourth Degree Laceration extends through the rectal mucosa exposing the rectal lumen
Fetal Neonatal Implications Hypoxia Fetal mortality is increased due to injuries and infection Trauma resulting in tentorial tears, cerebral and neck compression, damage to trachea and larynx Caput succedaneum may develop Petechia and ecchymosis because of birth trauma High possibility of intracranial hemorrhage from a traumatic delivery of the head Spinal cord injuries caused by stretching and manipulation of the infant s head Hemorrhage into the fetal viscera Brachial plexus palsy Fracture of upper extremities Treatment and Management Midforceps delivery in +2 station Manual conversion if there is no CPD CS Monitor labor patterns, FHB Reassure couple, inform them of changes Adequate resuscitation equipment should be available ANOMALIES OF THE PLACENTA AND CORD Placenta Succenturiata has one or more accessory lobes connected to the main placenta by blood vessels. The placenta will appear torn at the edge.
Management Uterine massage Offer bedpan Give oxytocin, O2 by mask, methergine Blood replacement Manual removal of retained placental fragment
Causes Precipitous deliveries Breech deliveries (forceps deliveries) Large babies When maternal tissue are fragile (e.g. cancer)
RETAINED PLACENTAL FRAGMENTS Placenta does not deliver, managed through D&C HYDRAMNIOS over 2000 ml amniotic fluid in uterine AMNIOTOMY The artificial rupturing of membranes to shorten labor INDUCTION OF LABOR deliberate initiation of uterine contractions prior to the spontaneous onset
Indications Pre-eclampsia Rh incompatibility Diabetes Premature rupture of membranes Post maturity n Antenatal death
Contraindications CPD Previous CS Previous uterine surgery Several fetal distress Placenta previa Abruptio placenta Invasive CS of the cervix Myomas cysts Lack of patient acceptance Unfavorable cervix Fetal weight below 2500 grams Abnormal presentation Grand multiparity Multiple gestation
Hemorrhage Infection Fetal risks Facial or brachial palsy Cord compression Intracranial hemorrhage VERSIONS Alteration of fetal position by abdominal or intrauterine manipulation to accomplish a more favorable fetal position for delivery An operative procedure in which the presenting part is maneuvered to another presentation External Podalic Version - Infant is rotated from a breech or transverse position to cephalic position by abdominal manipulation Internal Podalic Version - The OB insert gloved hand and arm inside the uterus
EPISIOTOMY Surgical incision of the perineum Purposes Easier to repair, heals faster and can be controlled directionally Trauma to fetal head is decreased Second stage of labor is shortened Stretching and tissue necrosis of the vaginal mucosa which can result in a fistula are prevented
Indications Prolapsed umbilical cord Transverse lie Delivery of second twin Compound presentation
FORCEPS DELIVERY It is used to provide traction, to rotate or both Dangers of Internal Version Low Forceps when the skull has reached the perineum and is visible during a contraction (+3 station) when progress is Uterine atony as a result of deep anesthesia slow and when the mother become exhausted Lacerations of the cervix Midforceps when the biparietal diameter of the fetal has passed through the inlet and skull has reached the ischial Abruption placenta spines (station 1 & 2) Infection High Forceps the head has entered the pelvis but is unengaged Fetal anoxia Fetal Indications Irregular heart rate Passage of meconium in cephalic presentation Prolapse of cord Fetal distress Premature fetal separation Prerequisite for forceps operation Fully dilated cervix Head engaged Vertex for face presentation Ruptured membranes No CPD Empty bladder and bowel line CESARIAN SECTION An operative procedure by which the fetus is delivered thru an incision in the abdominal wall and the uterus Indications Rh incompatibility Maternal Implications Fetal distress Fetopelvic Diabetes disproportion or CPD Prolapse of the cord Chronic nephritis Hydrocephalus Uterine dystocia Placenta previa or Types abruption placenta Previous uterine Classical Section the uterus is incised in the midline. (D) There is surgery more danger of rupture of uterine scar in subsequent pregnancy. Severe pre-eclampsia Low Segment Type incision is low cervical segment of the uterus. Older primi (A) Less danger of infection or hemorrhage, less likelihood of Pelvic tumors rupture of the uterus, better healing of the wound. VD/STD Elective Section Fractured pelvis Extra Peritoneal Section the lower segment is approached by Essential hypertension separating the bladder from the uterus not entering the peritoneal cavity
Maternal Implications Patient with a rigid perineum As arrest of the fetus head that requires rotation Prevention of laceration Ineffectual contractions of the second stage Cardiac mother Complications such as bleeding Intrapartal infections Acute pulmonary edema Exhaustion
Risks involved of application of forceps Maternal Risks Injury to bladder on rectum Lacerations of the vagina and cervix
CS hysterectomy Effects of Surgery on the Woman Stress response release epinephrine increase HR, bronchial dilatation, increase glucose level and Norepinephrine peripheral vasoconstriction blood to central circulation increase BP DYSFUNCTION OF THE FIRST STAGE OF LABOR Prolonged Latent Phase (e.g. rigid cervix, use of analgesia) hypertonicity
Prolonged Active Phase (CPD & fetal malposition) uterus is in hypotonic phase Prolonged Descent Phase (CPD & poor fetal positioning) Tx amniotomy, IVF (oxytocin), semi-fowler s position, squatting and kneeling position to increase descend DYSFUNCTION OF THE SECOND STAGE OF LABOR Prolonged deceleration phase Secondary arrest of dilatation Arrest of descent Failure of descent Treatment IVF, orange juice to provide glucose Lie on the side to prevent pressure on the vena cava Breathing techniques Empty bladder every 2 hours