Lecture Thirteen: Care of the Client Experiencing Dysfunctional Childbirth, Endocrine, Metabolic and

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Lecture Thirteen Care of the Client Experiencing
Dysfunctional Childbirth, Endocrine, Metabolic
and Cardiac Dysfunctions in Pregnancy, Maternal
Hemorrhage, and Perinatal Infection.

• NURS 2208
• T. Dennis RNC, MSN

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Objectives

• Identify stressors related to dysfunctions in the
  maternity client.
• Utilize knowledge of pathophysiology of disease
  processes to care for maternity clients with
  dysfunctions.
• Utilize the nursing process to meet the needs of
  maternity clients with dysfunctions.
• Assess comfort, physical safety, fluid and
  electrolyte, nutrition, emotional safety and
  security, love and belonging needs of maternity
  clients.

• Apply principles of teaching /learning in the
  promotion and restoration of optimal health in
  maternity clients.
• Identify the purposes, actions, side effects of
  medication utilized in the care of maternity
  clients with dysfunctions.
• Incorporate therapeutic nutrition in the care of
  the maternity client with dysfunctions.

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Dysfunctional Childbirth

• Rh Sensitization
• ABO Incompatibility
• Surgery During Pregnancy
• Trauma
• The Battered Pregnant Woman
• Precipitous Birth
• Dystocia
• Anxiety and Fear
• Dysfunctional Uterine Contractions
• Precipitate Labor and Birth
• Postterm Pregnancy
• Fetal Malposition

• Fetal Malpresentation
• Developmental Abnormalities
• Multiple Pregnancy
• Fetal Distress
• Intrauterine Fetal Death
• Placental Problems
• Cephalopelvic Disproportion
• Umbilical Cord Problems
• Amniotic Fluid Related Complications
• Lacerations
• Placenta Accreta

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Rh Sensitization (pg. 419-423)

• An antigen-antibody immunologic reaction within
  the body.
• Occurs when an event allows Rh positive fetal
  cells to enter the circulation of an Rh negative
  woman (Rh positive blood transfusion,
  amniocentesis, tubal pregnancy).
• Known antigens are controlled by three pairs of
  genes Cc, Dd and Ee.
• An Rh negative mother whose fetus is Rh positive
  may develop anti D antibodies in response to the
  small amount of blood that may cross the placenta
  even in a normal pregnancy (lt 0.5 ml).
• Exposure causes the development of gamma M
  immunoglobulin (IgM).
• IgM antibodies are large and do not cross the
  placenta.
• Once a woman is isoimmunized, she is immunized
  for life.

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Rh Sensitization

• The secondary response is development of immune
  globulin G (IgG) anti-D antibody.
• IgG crosses the placenta coating the Rh positive
  cells and causing hemolysis.
• The hemolysis creates fetal anemia.
• The fetus responds by increasing red cell
  production of nucleated RBCs causing
  erythroblastosis fetalis.
• Erythroblastosis fetalis is a hemolytic disease
  of the newborn characterized by anemia, jaundice,
  enlargement of the liver and spleen, and
  generalized edema. Caused by isoimmunization from
  Rh incompatibility or ABO incompatibility.

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Rh Sensitization

• Fetal-Neonatal Risks
• Infant death due to hemolytic disease secondary
  to Rh incompatibility.
• RBC destruction leads to hyperbilirubinemia and
  anemia which leads to severe fetal edema called
  hydrops fetalis.
• Congestive heart failure may occur as well as
  icterus gravis leading to kernicterus.
• Rh sensitization is seen less due to the use of
  Rhogam ( Rh immune globulin.
• Given at 28 weeks gestation, after amniocentesis
  or an episode of bleeding and 72 hours post
  delivery.

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Screening for Rh incompatibility and Sensitization

• First prenatal visit includes information
  concerning previous pregnancies.
• Maternal blood type (ABO) Rh factor and antibody
  screen
• An antibody screen (indirect Coombs test).

• Fetal assessment includes percutaneous umbilical
  cord blood sampling (PUBS), amniocentesis,
  amniotic fluid analysis, and ultrasound.
• Fetal acites and subcutaneous edema may be seen
  on ultrasound.
• A sinusoidal pattern on fetal monitoring.

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Clinical Therapy (pg 421)

• Goal is a mature fetus who has not developed
  severe hemolysis in utero.
• Antepartum management includes early delivery and
  intrauterine transfusion (fetal distress, fetal
  hematoma, fetal-maternal hemorrhage, fetal death
  and chorioamnionitis.
• Postpartal management treat the unsensitized
  woman and isoimmune hemolytic disease in the
  newborn.
• RhoGam is given to destroy fetal cells in the
  maternal circulation before sensitization occurs,
  blocking antibody production.
• A Kliehauer-Betke test is performed to estimate
  the size of a fetomaternal bleed.

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Nursing Care Management

• Nursing assessment to determine clients
  knowledge base on blood type.
• Knowledge Deficit related to lack of
  understanding of the need for RhIgG and when it
  should be administered.
• Ineffective Coping related to depression
  secondary to development of indications of the
  need for fetal exchange instruction.
• Educate the client concerning times RhoGam is
  needed.
• Provide emotional support to client and family.
• Administer RhoGam as ordered.
• Evaluation includes the client understanding of
  the need for administration of Rhogam.

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Rh Immune Globulin

• RhoGAM, Gamulin Rh, HyRho-D
• Action Suppression of the immune response in
  non-sensitized women with Rh-negative blood who
  receive Rh positive blood cells because of
  fetomaternal hemorrhage, transfusion, or
  accident.
• Indications Suppress antibody formation in women
  with Rh-negative blood after birth,
  miscarriage/pregnancy termination, abdominal
  trauma, ectopic pregnancy, amniocentesis,
  version, or chorionic villi sampling.
• Dosage and route Standard dose is 1 vial (300µg)
  IM gluteal or deltoid microdose 1 vial (50µg) IM
  deltoid
• Adverse Effects myalgia, lethargy, localized
  tenderness or stiffness at the injection site.

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Nursing Considerations

• Give standard dose to mother within 72 hours of
  birth if baby is Rh positive, at 28 weeks
  gestation as prophylaxis, or after an incident or
  exposure risk that occurs after 28 weeks
  gestation (miscarriage, abortion, amniocentesis,
  after a version).
• Give microdose for first trimester miscarriage or
  abortion, ectopic pregnancy, chorionic villi
  sampling.
• Verify the client is Rh negative and has not been
  sensitized (that the Coombs test is negative) and
  that the baby is Rh positive.
• Provide explanation to the client about the
  procedure, including the purpose, possible side
  effects, and effect on future pregnancies.
• Have client sign a consent form per
  hospital/institution policy.
• Verify correct dosage, confirm lot number, and
  patient identity prior to injection. Verify with
  another RN and document.

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Question

• A womans blood type is O negative. Following
  the birth of her Rh positive infant, she is to
  receive anti-Rh(D) gamma globulin (RhoGAM). Which
  of the following nursing actions is correct?
  Administer the medication
• subcutaneously.
• within 72 hours after birth.
• only if the indirect Coombs is positive.
• only if the infants blood type is A or B.

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ABO Incompatibility (pg. 423-424)

• Is more common than Rh isoimmunization and causes
  less severe problems in the newborn.
• Occurs when the fetal blood is A, B, or AB and
  the mother is O type blood. (O type clients
  already have anti-A and Anti-B antibodies which
  are transferred across the placenta to the
  fetus).
• Occurs in 20 to 25 of the population.
• Due to the maternal antibodies present in her
  serum and interaction between the antigen sites
  on the fetal red blood cells.
• Infants display hyperbilirubinemia.
• Treated with phototherapy, fewer than 1 of
  affected fetuses require exchange transfusion
  after birth.

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Nursing Considerations

• Nursing assessment to determine clients
  knowledge base on blood type.
• Knowledge Deficit related to lack of
  understanding of the need for administration of
  phototherapy for infant..
• Ineffective Coping related to depression
  secondary to development of indications of the
  need for phototherapy or fetal exchange
  instruction.
• Educate the client concerning possible need for
  phototherapy for newborn.
• Provide emotional support to client and family.

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Question

• A 22 year old client is expecting her second
  baby in two weeks. Her blood type is O positive.
  The nurse might expect blood incompatibility
  problems if the fetus blood is
• Rh negative.
• type A positive.
• type O negative.
• type O positive.

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Surgery During Pregnancy (pg. 425-426)

• Should be delayed if acceptable but may not be
  possible.
• Some evidence of increased first trimester
  abortion and low birth weight infants.
• Most common reason is appendicitis followed by
  cholecystectomy.
• The pregnant client is at risk for vomiting and
  aspiration.
• Urinary catheters prevent injury to the bladder.
• Fetal heart tones should be monitored before,
  during and after surgery.
• Left lateral position is optimal.

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Surgery During Pregnancy (pg. 425-426)

• Nursing assessment and diagnosis
• Altered tissue perfusion (fetal) related to the
  effects of general anesthesia on fetal
  oxygenation
• Anxiety related to lack of knowledge of
  preoperative and postoperative procedures.
• Fear related to the possible effect of surgery on
  fetal outcome.
• Nursing Plan and Implementation
• Education to review pre and post operative
  considerations.
• Monitoring two patients as opposed to one.
• Monitor vital signs every 4 hrs.
• Maintain a side-lying position.

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Question

• A woman in her third trimester of pregnancy is
  scheduled for an open reduction of her fractured
  radius and ulna. Her postoperative nursing care
  will include
• maintaining her in a side lying position.
• using minimal narcotics to reduce teratogenic
  effects.
• administering oxygen for 24 hours following
  surgery.
• providing a bedpan in order to help her maintain
  bedrest.

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Trauma (pg. 426-428)

• Accidents and injury are the leading causes of
  death in women of reproductive age.
• Domestic abuse may be the etiology of trauma.
• Early pregnancy fainting and fatigue may increase
  the chance of injury.
• Late in pregnancy poor coordination, may fall.
• Maternal mortality most often occurs from head
  trauma and hemorrhage.
• Uterine rupture and abruption results from strong
  deceleration in automobile accidents.
• Complications caused by trauma are more common
  after assault than after MVAs.

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Trauma (pg. 426-428)

• Clinical Therapy
• Stabilize the injury and promote well-being for
  both mother and fetus.
• Ensuring airway adequacy, maintaining ventilation
  and adequate circulatory volume, controlling
  acute bleeding, and splinting fractures to
  prevent vascular or tissue injury.
• Once the mother is stabilized, fetal status is
  assessed.
• Monitor for 4 hours if no contractions, bleeding
  or leaking of amniotic fluid. If any of the above
  a 24 to 48 hr stay is required.
• Fetomaternal hemorrhage occurs 4 to 5 times more
  often in women who have experienced trauma.
• A Kleihauer-Betke test is used to detect fetal
  cells.
• Perimortem birth by c-section is indicated after
  4 minutes of CPR.

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Trauma (pg. 426-428)

• Nursing assessment and diagnosis
• Pain related to the effects of the trauma
  experienced
• Constipation related to immobility secondary to
  the effects of the accident.
• Fear related to the effects of the trauma
  experienced.
• Nursing Plan and Implementation
• Education to explain need for monitoring and
  bedrest.
• Monitoring two patients as opposed to one.

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Question

• A woman at 34 weeks gestation is admitted to the
  Emergency department accompanied by her husband.
  The husband tells the physician that his wife
  fell down the porch stairs. The client is having
  no vaginal bleeding, uterine contractions, or
  leaking of amniotic fluid. In addition to
  monitoring the clients vital signs, the nurse
  should also
• monitor the fetal heart rate and uterine activity
  for 4 hours.
• perform a nitrazine test.
• check her deep tendon reflexes.
• check for cervical dilatation.

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The Battered Pregnant Woman (pg 428)

• Abuse often begins or increases with pregnancy.
• Affects one in six women.
• May result in loss of pregnancy, preterm labor,
  low birth weight infants, fetal injury and fetal
  death.
• Indicators of abuse chronic psychosomatic
  symptoms, nonspecific or vague complaints, old
  scars or bruising around the head, chest, arms,
  abdomen and genitalia.
• Decrease in eye contact, silence when the partner
  is in the room, history of nervousness, insomnia,
  drug overdose or alcohol problems are also sign
  of battery.
• Goals of treatment are to identify the woman at
  risk, increase her decision making abilities, to
  decrease the potential for further abuse, and
  provide a safe environment for mother and child.

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Care of the Client with TORCH Infection (pg. 429)

• Toxoplasmosis, Rubella, Cytomegalovirus, and
  Herpes simplex virus.
• Exposure of the pregnant client during the first
  12 weeks of pregnancy may cause developmental
  anomalies.
• Toxoplasmosis protozoa, miscarriage likely, Use
  good handwashing, do not eat raw meat or exposure
  to cat litter.
• Rubella virus (three day measles), congenital
  anomalies, vaccination at least three months
  prior to pregnancy.
• Cytomegalovirus virus, fetal death or severe
  generalized diseases, respiratory or sexually
  transmitted maternally, no immunity develops and
  may recur in subsequent pregnancies.
• Herpes Simplex virus, skin lesions, mental
  retardation, and microcephaly.

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Precipitous Birth (pg. 576-579)

• DO not leave the client alone.
• Auxiliary personnel should call the CNM or
  physician, bring equipment needed, open packs,
  and set up the warmer.
• Provide a sterile field.
• Apply gentle pressure to the fetal head and
  supports the perineum with the other hand.
• After delivery of the head, check for cord.
• Suction mouth then nose.
• Very slippery. Clamp cord. Cut cord.
• Place infant on mothers abdomen.
• Obtain blood for cord gases.
• Observe for signs of placental separation.
• Documentation.

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Dystocia (pg. 606-634)

• Difficult labor due to mechanical factors
  produced by the fetus or maternal pelvis, or due
  to inadequate uterine or other muscular activity.
  
• Delivery requires the harmonious functioning of
  four components psychosocial factors,
  contractile forces, fetus, and maternal pelvis or
  birth passage.

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Dystocia (pg. 606-634)

• Risk Due to Anxiety and Fear
• Anxiety and fear may exacerbate pain, producing
  more pain and producing more anxiety and fear.
  ?catecholamines ?myometrial function
  ineffectual labor.
• Anxiety may be displayed as quiet, uninterested,
  denial like characteristics. Some families have
  used all emotional reserve in the pregnancy so
  they may be more vocal.
• The goal of clinical therapy is to provide
  therapies that will decrease the clients
  anxiety.

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Risk Due to Anxiety and Fear

• Nursing assessment and diagnosis
• Sensory/Perceptual Alteration related to
  reactivation of traumatic memories.
• Anxiety related to lack of knowledge of
  preoperative and postoperative procedures.
• Fear related to the possible effect of surgery on
  fetal outcome.
• Ineffective Individual Coping related to
  increased anxiety and stress associated with
  labor and birth process.
• Ineffective Family Coping related to anxiety
  associated with labor and birth.
• Nursing Plan and Implementation
• Supporting the laboring client and her family.
• Education, comfort measures, remain calm,
  outcomes positive..

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Dystocia Related to Dysfunctional Uterine
Contractions (pg. 610-612)

• The most common type of dystocia is related to
  dysfunctional (or uncoordinated) uterine
  contractions that result in a prolongation of
  labor.
• Dysfunctional contractions are irregular, of low
  amplitude, and slow progress which causes arrest
  of cervical dilatation. (Hypotonic contractrions)
• Cause unknown. May be familial.
• Protracted labor ctxs irregular with low
  amplitude, and cervical dilatation islt 1cm/hr.
• Arrest of Progress No change of cervical
  dilatation for 2 hours.
• The indication for Pitocin is evaluated.

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Dystocia Related to Dysfunctional Uterine
Contractions (pg. 610-612)

• Hypotonic contractions and soft tissue dystocia
  add to poor labor progress.
• Cephalopelvic disproportion (CPD) A condition in
  which the fetal head is of such a shape or size,
  or in such a position, that it cannot pass
  through the maternal pelvis.
• If CPD exists, oxytocin (Pitocin) should not be
  used.
• If CPD is ruled out, Amniotomy may be performed
  and oxytocin augmentation is begun.
• Amniotomy artificial rupture of membranes
  requires the temperature to be monitored more
  frequently (monitor every 2 hours).

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Oxytocin

• Oxytocin
• hormone normally produced by the posterior
  pituitary, responsible for stimulation of uterine
  contractions and the release of milk into the
  lactiferous ducts.
• Infused at a prescribed individualized dosage
  rate, and this rate is increased, decreased, or
  maintained at fixed intervals based on client
  vital signs, uterine response, and FHR.
• Objective is to establish an adequate contraction
  pattern that promotes labor progress, generally
  represented by contractions every 2 to 3 minutes
  that last 50 to 60 seconds with moderate
  intensification.

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Oxytocin

• Recommendations
• Oxytocin infusion is mixed 20 units in 1000cc
  D5LR or 9 units in 150 cc D5W.
• Infusion rate is 1mu/min per infusion pump
  (originally dripped by microdrip, nasal spray,
  buccal tablets).
• Dose may be increased to 2 mu/min then by 2mu/min
  every 15 minutes as needed to produce adequate
  labor pattern.
• Electronic fetal monitoring (EFM) is used to
  monitor the fetal heart rate and contraction
  pattern to provide ongoing information concerning
  the fetal response to the augmentation.
• Scalp pH may be done to determine fetal well
  being.
• Contractions are evaluated as hypotonic,
  adequate, hyperstimulated or tetanic.

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Dystocia Related to Dysfunctional Uterine
Contractions (pg. 610-612)

• Nursing assessment and diagnosis
• Assess maternal vital signs, contractions,
  cervical dilatation, fetal descent, and fetal
  heart rate characteristics.
• Assess for caput
• Assess stress and coping mechanisms.
• Assess for loss of control from client and
  family.
• Pain related to difficulty in relaxing secondary
  to uterine contractions.
• Anxiety related to lack of knowledge of
  preoperative and postoperative procedures.
• Fear related to the possible effect of surgery on
  fetal outcome.
• Ineffective Individual Coping related to
  increased anxiety and stress associated with
  labor and birth process.

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Dystocia Related to Dysfunctional Uterine
Contractions (pg. 610-612)

• Nursing Plan and Implementation
• Supporting the laboring client and her family.
• Suggest change of position, rocking in a chair,
  sitting up, walking.
• Provide warm shower, whirlpool, quiet
  environment, music, back-rub, therapeutic touch
  and visualization.
• Comfort measures including mouth care, linen
  changes, effleurage and relaxation exercises.
• One to one nursing is optimal.
• Address the clients questions with clear,
  accurate information to keep her and family up to
  date on treatment and progress.
• Address hyperstimulation Oxygen, stop pitocin,
  left side, fluid bolus, call the physician.

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Precipitate Labor and Birth (pg 612-614)

• Extremely rapid labor and birth within 3 hours.
• Cervical dilatation is 5 cms in the primigravida
  or more per hour or 10 cms in an hour for the
  multipara.
• Labor may be associated with cocaine abuse,
  abruptio placenta, meconium stained fluid and low
  apgar scores in the newborn.
• Extensive lacerations of the cervix, vagina, and
  perineum may occur.
• Intracranial trauma may occur due to rapid
  descent and resistance of the birth canal.
• Terbutaline or magnesium sulfate may be used to
  slow the labor process.

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Postterm Pregnancy (pg. 614-615)

• Pregnancy that extends more than 294 days or 42
  completed weeks past the first day of the last
  menstrual period.
• Postterm pregnancy occurs more frequently in
  primigravidas and clients over 35.
• Cause unknown,
• LGA or macrosomic babies resulting in induction,
  forcep or vacuum assisted vaginal birth or
  c-section.
• Placental changes cause decreased uteroplacental
  circulation, decreased amniotic fluid which
  increases risk of umbilical cord compression.
• Babies SGA due to decreased nutrition.
• Meconium staining leading to distress

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Postterm Pregnancy (pg. 614-615)

• Clinical Therapy
• After 40th week, begin NST, BPP, and doppler flow
  studies.
• Tests may be done 2 to 3 times a week.
• If problems noted, induction is scheduled.
• During labor ongoing assessment of FHR by
  electronic fetal monitoring (EFM).
• Ongoing assessment of labor progress to determine
  clues associated with macrosomic infant, meconium
  staining, and or resuscitation needs.
• Provide education and support to the client.

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Fetal Malposition (pg. 615-617)

• Persistent Occiput-Posterior (OP)
• Occurs in 25 of pregnancies at term.
• May cease labor progress or be delivered in a
  posterior position.
• Client experiences intense back pain throughout
  labor unless the baby rotates.
• May result in a 3rd or 4th degree laceration or
  extension of the midline episiotomy or fractured
  coccyx.

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Fetal Malpresentation (pg. 617-624)

• Three vertex attitudes are classified as abnormal
  presentations 1) Military (scinciput), 2) brow
  and 3) face.
• Brow fetal neck and cerebral injuries can occur.
• Face risks of CPD and prolonged labor are
  increased. Occurs most frequently in multiparas,
  preterm birth and anencephaly. Infant may have
  facial edema, bruising and petechiae.
• Breech Breech presentation is the most common
  malpresentation. Frank, Complete and Footling.
• Head trauma more likely in breech delivery,
  entrapment may occur, cord compression risk.
• External version is attempted at 37 to 38 weeks (
  carries risk of placental problems and preterm
  labor).

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Version (pg 652)

• External and Internal
• turning of the fetus
• Usually done at 37 weeks
• Criteria single fetus, breech is not engaged,
  adequate amniotic fluid, a reactive NST, and 37
  or more weeks gestation.
• Procedure Explain that the procedure is painful,
  may result in cesarean section, requires a fetal
  monitor tracing, frequent vital signs and may
  need terbutaline to stop labor.
• Aftercare includes Monitoring for contractions,
  kick count of fetus and monitoring for fetal
  movement.

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Developmental Abnormalities (pg624-625)

• Fetal macrosomia is defined as weight of more
  than 4000gms (8lbs, 14 oz) at birth.
• A client who is obese is 3 to 4 times more likely
  to have a macrosomic infant.
• Increased risk for prolonged labor, uterine
  rupture, CPD, fetal cerebral trauma, shoulder
  dystocia, brachial plexus injury and fractured
  clavicles.
• Shoulder dystocia is an obstetrical emergency.
  McRoberts maneuver is performed ( thighs flexed
  up to widen perineum and supra-pubic pressure is
  applied.
• Support and educate client and family.

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Multiple Pregnancy (pg. 626-630)

• Twinning occurs in 2 of all pregnancies in the
  United States.
• The vanishing twin syndrome in first trimester.
• Second trimester loss is associated with
  congenital anomalies, growth restriction, and
  chromosomal abnormalities.
• Twin to twin transfusion may occur with blood
  being drained from one twin to the other.
• Cervical incompetence is increased, preterm labor
  is increased.
• Perinatal mortality decreases at 38 weeks,
  optimal delivery time.
• Clients with multiple gestations are more likely
  to develop spontaneous abortions, Hypertension,
  maternal anemia, hydramnios, and complications
  during labor and delivery.
• May be delivered vaginally or by cesarean
  section.
• During labor both twins are monitored.

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Ectopic Pregnancy
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Fetal Distress (pg. 630-631)

• Evidence that the fetus is in jeopardy (oxygen
  supply is insufficient to meet the physiologic
  demands of the fetus), such as a change in the
  fetal heart rate pattern or fetal activity.
• The most common initial signs of fetal distress
  are meconium stained fluid (in a vertex
  presentation) and changes in the fetal heart
  rate.
• For FHR changes, treatment centers on relieving
  the hypoxia (position change, administering O2 at
  10 to 12 l/min, dc the pitocin, ?fluid, and call
  the physician.

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Intrauterine Fetal Death (pg. 632-634)

• Intrauterine fetal demise (IUFD) accounts for ½
  perinatal mortality after 20 weeks gestation.
• Cause may be unknown or related to PIH, abruptio
  placentae, placenta previa, diabetes, infection,
  congenital anomalies, and isoimmune disease.
• Prolonged retention of the demise may lead to
  development of disseminated intravascular
  coagulation (DIC).
• Determined by ultrasound with absence of heart
  action (may also see overlapping of cranial bones
  Spaldings sign).
• Cessation of movement is frequently first
  indication of fetal death. Delivery is
  accomplished by induction or surgery depending on
  gestational age.

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Placental Problems (pg. 634-642)

• Abruptio placentae premature separation of a
  normally implanted placenta from the uterine
  wall. May be marginal, central or complete.
  Usually accompanied by complaints of uterine pain
  and vaginal bleeding . Client complains of mod to
  severe abdominal pain. Abdomen may be rigid on
  palpation.
• Placenta previa the placenta is improperly
  implanted in the lower uterine segment. Usually
  diagnosed by painless bright red bleeding.
• Other placental problems are classified as
  developmental or degenerative ( velamentous
  insertion of the umbilical cord versus
  calcifications and infarcts.

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Abruptio Placenta
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Placenta Previa
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Umbilical Cord Problems (pg.643-645)

• Prolapsed cord umbilical cord that becomes
  trapped in the vagina before the fetus is born.
• Pressure is placed on the umbilical cord as it is
  trapped between the presenting part and the
  maternal pelvis.
• Prevention is the optimal medical approach.
• Knee chest position is recommended as well as
  delivery by cesarean section.
• FHR status must be assessed immediately following
  rupture of membranes.
• On SVE, if cord is found the nurse gently places
  pressure on the fetal head to relieve pressure on
  the cord until delivery occurs.

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Amniotic Fluid Related Complications (pg. 645-646)

• Amniotic Fluid Embolism occurs when a bolus of
  amniotic fluid enters the maternal circulation
  and then the maternal lungs.
• Cause is unknown (possible immune response
  similar to anaphylactic shock).
• Hydramnios (Polyhydramnios) occurs when there is
  over 2000 mL of amniotic fluid.
• Cause unknown but associated with major
  congenital anomalies.
• Oligohydramnios less than normal amount of
  amniotic fluid (500 ml is considered normal).
• Cause unknown but associated with postmaturity,
  aaaiugr secondary to placental insufficiency, and
  fetal renal anomalies.

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Cephalopelvic Disproportion (pg. 647-648)

• Cephalopelvic Disproportion occurs when there is
  a narrowed diameter in the maternal pelvis.
• The narrowed diameter is called a contracture,
  and it may occur in the pelvic inlet, midpelvis,
  or outlet.
• If pelvic measurement are borderline, a trial of
  labor may be attempted.
• Failure of cervical dilatation or fetal descent
  would then necessitate a cesarean birth.

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Lacerations (pg. 648-649)

• Lacerations of the cervix or vagina may be
  indicated by bright red bleeding in the presence
  of a well contracted uterus. Vaginal and perineal
  lacerations are categorized in terms of degree
• 1) First degree limited to fourchet, perineal
  skin, vaginal mucous membrane.
• 2) Second degree involves the perineal skin,
  vaginal mucous membrane, underlying fascia, and
  muscles of the perineal body may extend upward
  on one or both sides of the vagina.
• 3) Third degree extends through the perineal
  skin, vaginal mucous membranes, and perineal body
  and involves the anal sphincter it may extend up
  the anterior wall of the rectum.
• 4) Fourth degree Extends through the rectal
  mucosa to the lumen of the mucosa.

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Placenta Accreta (pg. 649)

• The chorionic villi attach directly to the
  myometrium of the uterus.
• Accreta, increta (myometrium invaded) and
  percreta (myometrium penetrated).
• Occurrence is one in 2500 births.
• Primary complication is maternal hemorrhage and
  failure of the placenta to separate after birth.
• Hysterectomy may be necessary treatment depending
  on involvement.

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Pregnancy Induced Hypertension (pg. 405-419)

• Hypertension is the most common medical disorder
  in pregnancy.
• Classifications Preeclampsia-eclampsia, chronic
  hypertension, chronic hypertension with
  superimposed preeclampsia, and late or transient
  hypertension.
• Preeclampsia and eclampsia are two categories of
  pregnancy induced hypertension (PIH).
• Preeclampsia progressive disease process unless
  there is intervention to control it.
• Eclampsia convulsion
• Cause remains unknown.

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Preeclampsia- eclampsia (pg. 405-419)

• A multisytemic disorder characterized by reduced
  perfusion to maternal organs.
• Characterized by the development of hypertension,
  proteinuria, and edema.
• Hypertension alone may be present in early
  disease process and is the basis for diagnosis.
• Definition of preeclampsia is an increase in
  systolic pressure of 30mm Hg or an increase of
  diastolic pressure of 15mm Hg over baseline.
• In the absence of baseline values, 140/90 has
  been accepted as hypertension.
• HELLP Syndrome (hemolysis, elevated liver
  enzymes, low platelet count) is associated with
  severe preeclampsia.

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Preeclampsia Eclampsia (pg. 405-419)

• May impact most organ systems.
• CNS changes are reflected by hyperreflexia,
  headache, blurred vision, and seizure resulting
  from cerebral edema.
• Intracerebral hemorrhage is the most common cause
  of death, retinal detachment may occur but has
  spontaneous reattachment with reduction in blood
  pressure and diuresis. Pulmonary edema may occur
  as well as abruptio placenta and DIC.
• Infants may be SGA because of intrauterine growth
  retardation or preterm necessitated by delivery.
• Other signs edema, nausea and vomiting,
  epigatric pain, irritability and emotional
  tension.
• Eclampsia characterized by convulsion or coma.
  May occur prior to labor or 48 hrs post partum.

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Preeclampsia Eclampsia (pg. 405-419)

• Only known cure for PIH is birth of the infant.
• Low dose aspirin is experimental.
• Monitor blood pressure, weight gain, urine
  protein, platelet count, fetal growth, and
  vaginal bleeding.
• Bedrest in left lateral recumbent position,diet
  balanced and high in protein, sodium intake
  moderate, evaluate fetal status (kick count,
  NST, BPP), BP 4 x a day, weight qd, urine
  dipstick qd, platelet count q 2 days, liver panel
  2 x a week. Monitor reflexes with vs or every
  hour when MgSO4 therapy.
• Anticonvulsants MgSO4
• Corticosteroids Betamethasone
• Antihypertensive Apresoline (hydralazine
  Hydrochloride)
• Fluid and electrolyte replacement KVO
• Postpartum management includes MgSO4.

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Diabetes Mellitis (pg. 356 366)

• The key point in care of the pregnant client with
  diabetes is scrupulous maternal plasma glucose
  control.
• Control is best achieved by home glucose
  monitoring, multiple daily insulin injections,
  and a careful diet.
• To reduce the incident of congenital anomalies
  and other problems in the neonate, the woman
  should have a normal blood glucose throughout the
  pregnancy.
• Diabetic clients need to be assessed more
  frequently than their low risk counterparts.
• The client needs to be educated and involved in
  their plan of care from the very beginning of the
  pregnancy. Client needs to be educated that her
  baby may be Larger than other infants of the same
  gestational age..

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Anemia in Pregnancy (pg. 366-370)

• Anemia indicates inadequate levels of hemoglobin
  in the blood.
• The common anemias of pregnancy are due either to
  insufficient hemoglobin production related to
  nutritional deficiency in iron or folic acid
  during pregnancy or to hemoglobin destruction in
  inherited disorders (sickle cell anemia and
  thalassemia).
• Maternal risks are susceptibility to infection,
  fatigue, ? chance of PIH and hemorrhage, and poor
  healing of episiotomy or incision.
• Neonatal risks include LBW, prematurity,
  stillbirth and neonatal death as well as
  decreased iron stores.
• Goal is prevention through diet and supplements,
  parenteral iron may be needed. (iron, folate)

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AIDS in Pregnancy (pg. 370-376)

• HIV infection, which is transmitted through blood
  and body fluids may also be transmitted
  transplacentally to the fetus.
• Signs and symptoms include fatigue, anemia,
  malaise, progressive weight loss,
  lymphadenopathy, diarrhea, fever, neurologic
  dysfunction, or Kaposis sarcoma.
• Weekly Nonstress testing should begin at 32
  weeks.
• AZT treatments are implemented during labor and
  given to the neonate post delivery.
• Nurses should employ blood and body fluid
  precautions (standard precautions) in caring for
  all women to avoid potential spread of infection.
• CONFIDENTIALITY is key and education (no
  breastfeeding).
• Support the stage of disease process.

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Heart Disease in Pregnancy (pg. 376-379)

• Cardiac disease during pregnancy requires careful
  assessment, limitation of activity, and knowing
  and reporting signs of impending cardiac
  decompensation by both the client and nurse.
• Signs and symptoms of Decompensation Frequent
  cough (wet), dyspnea (progressive), Edema
  (progressive to include face, eyes and
  extremities), Heart murmurs, palpitations and
  rales (progressiveness is the key to these
  symptoms because most occur in a mild degree in
  all pregnancies.

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Bleeding Disorders in Pregnancy (pg 386)

• Spontaneous abortion
• Ectopic Pregnancy
• Molar pregnancy

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Perinatal Infection (pg 65)

• Vulvovaginal Candidiasis Yeast infection, thick
  curdy vaginal discharge, severe itching-male may
  experience rash. Treatment is 150 mg of
  Fluconazole or intravaginal insertion of
  miconazole or nystatin.
• Bacterial Vaginosis bacterial infection of the
  vagina (formally Gardinella vaginalis)
  characterized by foul-smelling, grayish vaginal
  discharge that has a fishy odor.Flagyl is
  contraindicated in pregnancy and Clindamycin is
  used instead.
• Trichomoniasis parasitic protozoan that causes
  inflammation of the vagina, characterized by
  itching, burning vulvar tissue and yellow-green,
  frothy, odorous discharge. Treatment is Flagyl.

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Perinatal Infection (pg 65, 429-434)

• Gonorrhea infection caused by Neisseria
  gonorrhoeae. Majority of women asymptomatic but
  most common symptom is purulent, greenish yellow
  discharge, dysuria, and urinary frequency.
  Treatment for pregnant women is a cephalosporin
  and erythromycin.
• Herpes Genitalis Herpes simplex type 2 causes
  most cases of recurrent genital herpes. Primary
  episode is characterized by the development of
  single or multiple blister-like vesicles which
  usually occur in the genital area and affect the
  vaginal walls, cervix, urethra, and anus.
  Inflammation and pain secondary to the lesion may
  cause difficult urination and urinary retention.
  Treatment with Acyclovir is to prevent pain and
  secondary infection. Educate patient that
  active herpes may be transmitted to the baby
  during vaginal birth.

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Perinatal Infection (pg 65, 429-434)

• Syphilis chronic infection caused by a
  spirochete. Can be acquired congenitally through
  transplacental inoculation and can result form
  maternal exposure to infected exudate during
  sexual contact with open wounds or infected
  blood. Divided into early (chancre appears) and
  late stages (skin eruptions). Treatment is
  Penicillin to treat mother and fetus.

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Postpartal Hemorrhage (pg. 981-988)

• Early postpartal hemmorhage occurs in the first
  24 hours post delivery.
• Uterine atony (relaxation of the uterus) primary
  cause.
• Other causes lacerations, retained placental
  fragments, vulvar, vaginal, and pelvic hematomas,
  uterine rupture.
• Prevented by good prenatal care, early
  recognition and management.
• Oxytocin may be ordered to stimulate uterus to
  control bleeding.
• Blood transfusion, hysterectomy may be needed.
• Late postpartal hemmorrhage occurs from 24 hrs to
  6 weeks postpartum.
• Most oftendue to subinvolution which is due to
  retained placental fragments.

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Questions?