Complications - Community College of Philadelphia
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Transcript Complications - Community College of Philadelphia
Complications
Antepartum
Intrapartum
Postpartum
Maternal Mortality
According to official US vital statistics, the risk of death
from complications of pregnancy decreased
approximately 99% during the 20th century.
However, this progress halted in 1982, and since then,
there has been no improvement in the maternal
mortality ratio for the US.
In the most recent global figures from the World Health
Organization, the US ranked 20th in maternal mortality,
behind most countries of Western Europe as well as
Canada, Australia, Israel, and Singapore.
September 2001, the first National Summit on Safe
Motherhood
Maternal Mortality
Many consider a maternal death to be a sentinel event,
reflecting a breakdown in the health care system in its
broadest sense.
Mortality caused by pregnancy and its complications
remains an important issue for…the health care
system, and as a public health indicator.
There continues to be striking racial disparity in
maternal mortality.
September 2001, the first National Summit on Safe
Motherhood
Causes of Maternal Mortality
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Hemorrhage, Embolism, Hypertensive
Disorders and Infection are in the top
five causes of maternal mortality
Antepartum Bleeding
Multiple Etiologies
Placenta Previa
Abruption
Pre-term Labor
Ectopic pregnancy
Infections
Cervical Polyp/Erosion
Cancer/Molar pregnancy
Trauma
Ruptured Uterus
Physiologic (implantation bleed, show)
Bleeding-Ectopic Pregnancy
Bleeding-Ectopic Pregnancy
Blastocyst implants outside the
endometrial lining of the uterus
Fallopian tube (95%)
Ovaries, Cervix, Abdomen
Rare, but possible to have ectopic and
intrauterine pregnancy simultaneously
Bleeding-Ectopic Pregnancy
Defining Characteristics
Any bleeding early in pregnancy
• Ectopic is a possibility until proved otherwise
• Often brownish bleeding, but may be any color or
even absent
May or may not have pain until rupture
Abnormally low hCG levels
Confirmed by ultrasound or laparoscopy
Bleeding-Ectopic Pregnancy
Ruptured ectopic pregnancy
Sudden, sharp, severe lower
abdominal pain
Hypotension/shock
Abdominal tenderness
Marked cervical motion tenderness
Neck/shoulder pain w/ inspiration
This is a life-threatening situation
Bleeding - Abortion
Abortion
medical term for all pregnancy loss prior to
20 weeks
Types
Spontaneous (Miscarriage)
Missed (embryo/fetus dies, not passed)
Threatened (bleeding, cervical os closed)
Inevitable (bleeding, cervical os open)
Therapeutic (pregnancy termination)
Bleeding - Abortion
Spontaneous Abortion
Defining Characteristics
• Bleeding (pink, red or brown)
• Cramping
• Starts light, then crescendos
• Becomes light again after tissue passed
• Passage of tissue or clots
• All passed tissue is saved
• Sent for chromosomes/pathology
>9 weeks likely to need D&E
Bleeding - Abortion
Spontaneous Abortion
Nursing Interventions
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Vital signs
S/Sx of infection
Pad Count
Pain assessment/management
Grief counseling
• Talk about difference for men and women
• Anticipatory Guidance
Bleeding - Placenta Previa
Bleeding - Placenta Previa
Placenta implants low in the uterus
Marginal Previa/Low Lying Placenta
• Next to, but not covering the cervical os
Partial Previa
• Covers part of the internal cervical os
Complete Previa
• Covers all of the internal cervical os
Bleeding - Placenta Previa
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Bleeding - Placenta Previa
Malpresentation
• Transverse position
• Breech presentations
Placenta takes up the space where
the fetal head should be
Bleeding - Placenta Previa
Cesarean section likely
Definite if complete previa
• Vessels will tear with dilation/effacement
• Gross maternal & fetal hemorrhage
Possible vaginal birth if partial previa
• Fetal head may tamponade the blood
vessels enough to allow vaginal birth
• Unlikely in current practice environment
Bleeding - Placenta Previa
Classic defining characteristics
Digital vaginal exam contraindicated
Painless bright red vaginal bleeding
Risk of perforating the placenta
Gross hemorrhage
Cesarean section scheduled prior to onset
of labor
May need to assess for fetal lung maturity
Bleeding - Placenta Previa
Essential points to teach patients
Complete pelvic rest – Huh?
• Nothing in vagina
• No nipple stimulation
• No orgasm
Report to the hospital immediately if
any vaginal bleeding
Report that you have a previa ASAP
Some hospitalized for duration
Bleeding - Placenta Previa
Risk of implantation into muscle
instead of decidua (accreta)
• 5-10% per Varney, 3rd Ed.
No plane of separation
Risk of hysterectomy at time of birth
Prior C/S increases risk of accreta
• The more C/S the higher the risk
Bleeding - Abruption
Also called Abruptio Placenta
Bleeding - Abruption
Premature separation of the normally
implanted placenta
Serious hemorrhage in the late
second and the third trimesters
Bleeding may be
Concealed
Obvious
Both
Bleeding - Abruption
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Bleeding - Abruption
Associated with
Sudden deceleration forces
• MVA
Severe abdominal trauma
• Battery
• Difficult external version
Sudden ↓ in uterine volume/size
• SROM in polyhydramnios
• Between birth of babies in multiple gestation
Maternal Hypertension
• Chronic, pre-eclampsia, Cocaine related
Bleeding - Abruption
Defining Characteristics
Pain is out of proportion to palpated or
monitored uterine activity
Board-like abdomen (+/-)
Uterine rigidity (+/-)
• Both may be absent if posterior placenta
Back pain (from extravasating blood)
Bleeding - Abruption
Defining Characteristics
Bleeding (maybe concealed)
Pain
Colicky uterine contractions
Violent/decreased/absent FM
FHT changes
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Tachycardia
Loss of variability
Variable and Late decelerations
Sinusoidal pattern
Bleeding - Abruption
Defining characteristics will depend on
the extent of abruption
Partial separation
May be able to stabilize and deliver
vaginally (often delivery is fast)
Complete separation
Requires immediate delivery to save
the life of the mother and fetus
Bleeding - Abruption
If risk for abruption (fall, MVA, etc)
Observation x 4 – 6 hours
• External fetal monitoring
• Uterine irritability
• FHT changes
• Physical s/sx
Abruption will usually present by 4 hrs
Bleeding – Previa &
Abruption
Nursing interventions
Get help/notify MD
Obtain IV access (16 g x 2)
• fluids
• blood products
Obtain blood for
• Type and cross-match for ≥ 3 units
• CBC with platelets/PT/PTT/Fibrinogen
• Plain tube for clotting time
Bleeding – Previa &
Abruption
Nursing interventions
Trendelenburg
VS (BP, Pulse)
FHT by external monitor
Apply oxygen
Cover with warm blankets
Open OR, set up for stat C/S
Insert foley catheter, measure I&O
Pre-term (Premature) Labor
Labor from 20 – 36 weeks
10% of all births in the US
Prematurity is the leading cause of perinatal
morbidity and mortality
Prematurity accounts for up to 50% of
neurologic problems in infancy
Rates vary by population studied
Modern medicine notoriously unsuccessful
at predicting and preventing preterm birth
Pre-term (Premature) Labor
Defining characteristics
Cramping
Change in backache
Change in discharge
Bleeding or spotting
Change in pressure/heaviness
Diarrhea
SROM
Pre-term (Premature) Labor
In absence of infection, attempts to stop
PTL (PML) are made
Bedrest (no research to support)
PO or IV fluids medications
• Dehydration associated with contractions
• Medications to stop contractions
If delivery is inevitable, attempts made to
speed fetal lung maturity
• Betamethasone IM given up to 34 weeks
• Gluteal injection
• Thick, oily, painful
Pre-term (Premature) Labor
Magnesium Sulfate (MgSO4) (IV)
Terbutaline (SQ, PO)
Risk for pulmonary edema
Nifedipine (SL, PO)
Hourly assessments for magnesium toxicity
and efficacy of medication
Ca++ channel blocker
Indomethacin (PO, PR)
Prostaglandin synthetase inhibitor
May cause premature closure of ductus and
oligohydramnios
Diabetes in Pregnancy
Pre-Gestational Diabetes
Type 1 – usually insulin dependent
Type 2 – may or may not require insulin
Gestational Diabetes
Onset after 20 weeks of pregnancy
Resolves by six weeks postpartum
• Emphasize f/u due to lifetime risk of DM
Usually controlled by
• Diet
• Exercise
• Blood glucose monitoring
Diabetes in Pregnancy
Universal screen at 28 weeks
1 hour glucose tolerance test (GTT)
LOTS of false positives
• Diagnostic 3 hour GTT
• 2 abnormal values = GDM
At risk women screened earlier
Known diabetics not screened
Diabetes in Pregnancy
insulin resistance during pregnancy
If pancreas cannot produce more
insulin to compensate for resistance
’d circulating glucose
Crosses placenta
’d fetal insulin
Insulin acts as growth hormone
Macrosomia
Diabetes in Pregnancy
Fat deposition is around the shoulder
girdle risk of shoulder dystocia
Hyperglycemia ’s risk of other
congenital anomalies
risk of neonatal hypoglycemia
Cord cut glucose levels fall rapidly
Neonate still has circulating insulin
Diabetes in Pregnancy
Tight glycemic control can reduce the
risk of pregnancy complications
Usually aim for
Fasting ≤ 95
2 hour postprandial ≤ 120
Usually checking QID
• Fasting, 2h post meals, hs
Hypertensive Disorders of
Pregnancy
Chronic Hypertension
Predates the pregnancy
• Risk for IUGR, risk for abruption
Gestational Hypertension
Pre-eclampsia (“Toxemia”)
BP without other symptoms
Mild, Severe
Eclampsia
Seizures
Hypertensive Disorders of
Pregnancy
Cause of Pre-eclampsia unknown
Many theories of etiology
Inappropriate response to
angiontension II
Inappropriate ratio of prostaglandins
Disordered placentation
Hypertensive Disorders of
Pregnancy
Risk factors for Pre-eclampsia
More common in primagravidas
Age extremes (<17, >35 years)
Multiple gestations
Seems to have genetic component
Poor nutrition
Chronic hypertension
Hypertensive Disorders of
Pregnancy
Defining Characteristics of
Pre-eclampsia
Onset after 20 weeks gestation
Classic Triad
• Edema, Proteinuria, Hypertension
Headache
Epigastric Pain
Visual ∆’s (scotoma – flashing lights)
Hypertensive Disorders of
Pregnancy
Mild Pre-eclampsia
140/90 or +15/+30 BP
Classic Triad, some edema
+1 proteinuria on a single dip
• (300mg/L in 24 hour urine collection)
May see other lab abnormalities
Hypertensive Disorders of
Pregnancy
Severe Pre-eclampsia
≥ 150/100 BP
3 – 4+ proteinuria on a single dip
• (5g/L in 24 hr collection)
Classic triad, marked edema
Other lab abnormalities common
Hypertensive Disorders of
Pregnancy
Care is supportive
Promote excellent nutrition
Lateral lie
• promotes diuresis and placental perfusion
Magnesium Sulfate
• Quiets neurologic system
• Decreases vasospasm
• Monitor for s/sx of toxicity
Seizure Precautions
Hourly vital signs
Prepare for delivery
Hypertensive Disorders of
Pregnancy
If progresses to eclampsia
Magnesium Sulfate (MgSO4)
Protect airway
Intrauterine stabilization of fetus
Protect from excess stimuli
May proceed to cesarean when stable
Likely transfer to intensive care unit
for postpartum stabilization
Hypertensive Disorders of
Pregnancy
HELLP syndrome
Hemolysis, Elevated Liver Enzymes,
Low Platelets
Atypical Pre-eclampsia presentation
May be complicated further by
Disseminated Intravascular
Coagulation
Cesarean Section
Problem with the 3 P’s of labor
Powers
• Inadequate, too strong, uncoordinated
Passenger
• Not tolerating labor, malpresentation, size or
congenital anomalies
Passage
• Mismatch with passenger, unsafe for mother to
labor
C/S in the absence of a medical indication
Current C/S rate ~ 30%
anecdotal reports approaching 50%
Cesarean Section
Types
Low Transverse
• Horizontal uterine incision
• Also called low cervical, low segment
• Most common, VBAC OK
Classical
• Vertical incision on uterus
• Uncommon, VBAC contraindicated
• Emergency, preterm, malpresentation
Cesarean Section
Planned
Unexpected, but not emergent
Labor contraindicated
Maternal choice (highly controversial)
Problem with 3 P’s, mother & baby stable
Urgent
Need to proceed to protect life or health
“Decision to incision” time <30 minutes
• With suspected uterine rupture <18 minutes
Nursing care depends on circumstances
Cesarean Section
Support person present in the OR
Remind not to touch sterile areas
Provide a stool to sit on behind drape
Keep on eye on them
Anesthesiologist/Nurse- Anesthetist
Excellent at communicating with client
Labor nurse usually becomes
circulating nurse in the OR
Cesarean Section
Post-operative recovery usually on L&D in
special PACU area
if both mother & newborn stable
• Kept together in PACU area
• Take care to promote thermoregulation
Assist to breastfeed in PACU if able
All postpartum assessments
All post-operative assessments
Client and/or support person may need to
verbalize about c/s
Amniotic Fluid Embolism
Amniotic Fluid enters systemic circulation
Unexplained
Hypertonic contractions
Sudden onset of
Respiratory distress
Bleeding/oozing (DIC)
Cyanosis
Pain Shock coma
Amniotic Fluid Embolism
Life threatening emergency
ABCs
Blood products
Intensive care, central monitoring
Often fatal to mother and baby
I have only seen this once
>40 units of PRBCs and FFPs
Near death experience reported
Shoulder Dystocia
Anterior shoulder stuck behind
maternal symphysis pubis
Unpredictable
Increased risk with
Prolonged labor
Macrosomic fetus
Poorly controlled maternal diabetes
Shoulder Dystocia
Defining Characteristics
Unexpectedly slow crowning
Turtle sign with birth of fetal head
• No restitution or external rotation
Have 4 – 6 minutes to get the baby
out before brain damage ensues
Shoulder Dystocia drills
Shoulder Dystocia
Nursing Interventions
Note time of birth of the head
Note all interventions used to relieve
Note which fetal shoulder impacted
Call for help
Provide suprapubic pressure when asked
• NOT fundal pressure
Sharply flex and abduct maternal legs onto
abdomen (McRoberts maneuver)
Anticipate neonatal resuscitation and
maternal postpartum hemorrhage
Postpartum Hemorrhage
Any blood loss significant enough to
cause signs and symptoms
Traditionally >500 cc for vaginal birth
and >1000 cc for cesarean section
May be resolved surgically if
Laceration repair
Retained placenta (late hemorrhage)
Placenta accreta
Thrombophlebitis
Pregnancy is a prime example of Virchow's
triad of increased risk for VTE
venous wall damage/irritation
change in flow
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Immobility
Local pressure
Varicose veins
Venous obstruction
Hydration, hypovolemia
blood hypercoagulability
• adaptations for hemostatsis in labor
Thrombophlebitis
Defining Characteristics
Pain in area of clot
• if peripheral, +/- erythema
• If peripheral, +/- edema
• If peripheral, +/- cord palpable
• Do NOT massage
• If peripheral, +/- homan’s sign
Possibly fever, chills
Thrombophlebitis
Nursing Interventions
Moist heat as ordered
Pain assessment/management
Observe for s/sx of PE
Administer anticoagulant therapy as
ordered – usually Lovenox/heparin
• Large molecule, does not cross placenta
and not secreted in breast milk
• Coumadin contraindicated in pregnancy
Endometritis
Postpartum infection of the
endometrium
Predisposing factors
Prolonged labor
Prolonged rupture of membranes
Cesarean birth
Trauma
Retained products of conception
Endometritis
May spread and become a systemic
infection leading to sepsis
A major cause of morbidity and
mortality
Endometritis
Defining Characteristics
Temperature >100.4
Alteration in VS
Fundal tenderness
Foul smelling vaginal discharge
Rigors, Malaise
+ blood cultures
Endometritis
Administer antibiotics as ordered
May be on triple antibiotics
Promote adequate hydration
Promote adequate nutrition
Protect mother-baby bonding and
interaction
Baby may also have infection
Promote activity as appropriate
REMEMBER!
Despite this depressing and
frightening lecture
The overwhelming majority of births
are straightforward
The human race has been around a
long time . . .
Birth works and babies come out or
we wouldn’t be here today!