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high risk OB

Terms in this set (104)

Pregnancy induced hypertension
Pulmonary embolism
Hemorrhage
Three leading causes of maternal mortality have remained unchanged over last 50 years:
Age (< 20 and > 35 years of age)
lack of prenatal care
Low educational attainment
Unmarried status
Factors strongly related to maternal death:
Placenta previa (hemorrhage during labor)
Vasa previa (umbilical cord vessels branch over amniotic sac rather than inserting into placenta)
Fetal hemorrhage possibility
Transverse fetal lie
Umbilical cord prolapse (immediate delivery by cesarean indicated)
Classic uterine incision - vertical cut instead of horizontal
Extensive surgery for fibroids
Contraindications to labor and vaginal birth:
Fetal maturity
Cervical readiness
Prior to induction assessment must indicate:
Early ultrasounds
Accurate menstrual dating
Amniotic fluid studies
L S Ratio 2:1
Fetal maturity best determined by:
cervical exam
Cervical Readiness best evaluated by?
Dilation
Effacement
Fetal station
Cervical consistency
Cervical position
the bishop scoring system uses 5 factors to determine cervical readiness for labor?
Each factor is assigned a score of 0, 1, 2, or 3 according to specific criteria for each score
The numbers are then totaled for the composite score
Multipara usually has successful induction when score is 5 or higher
Primipara usually has successful induction if score is 7 or higher
If the total score is greater than 8, the success of induction approaches that of spontaneous labor.
how does the bishop scoring system work?
ripe or soft
Cervix has to be ....... prior to induction to make it likely to dilate with forces of labor
the night before the morning of induction in the hospital
Cervical ripening is done most frequently when?
Prostaglandin Agents - Dinoprostone (Prepidil, Cervidil)
Can be inserted as a suppository into the vagina (intravaginally)
Can also be given as a gel that is gently squirted into the opening of the cervix (intracervically)
Should be administered with the patient in or near a labor and delivery suite
remain recumbent for the first 30 minutes and should be monitored for a further 30 to 120 minutes
when giving cervidil what should the patient do?
60 minutes and peak within 4 hours
when using cervidil the contractions usually appear within?
The gel should be kept refrigerated and brought to room temperature immediately before use
The manufacturer recommends that no more than 3 doses be administered per 24 hours
how do you prepare cervidil for use?
Misoprostol (Cytotec)
A pill taken orally or placed in the vagina (using a smaller dose)
Also approved for treating ulcers
A safe, effective, and inexpensive agent
-Stripping of the Membranes
-amniotomy
surgical methods for cervical ripening?
Stripping of the Membranes
Causes an increase in the activity of hormones
Causes mechanical dilation of the cervix, which releases prostaglandin
Gloved finger inserted into internal os and rotating 360 degrees twice separating amniotic membranes lying against lower uterine segment
Does not require monitoring or other assessments
Often done as outpatient service
May not induce labor
If labor is initiated, it typically begins within 48 hours
May cause bleeding
how does the dr perform stripping of the membrane?
amniotomy
A cervical hook is inserted through the cervical os by sliding it along then hand and fingers (hook side toward the head)
-The membranes are scratched or hooked to effect rupture
The nature of the amniotic fluid is recorded (clear, bloody, meconium, thick or thin)
increases the production of or causes the release of prostaglandin locally
1 full minute
-The fetal heart rate is recorded before and after the procedure for ??
-The presenting part should be well applied to the cervix
-before an amniotomy is done A pelvic examination is performed to evaluate the cervix and station of the presenting part.
Pitocin Infusion
Usually effective at producing contractions
May cause hyper-stimulation of the uterus
Requires small, precise dosage
Must use an infusion pump
Facility protocol
Clinician order
Individual situation
Maternal-fetal response
Maximum rate and dosing interval based - Pitocin?
lower total dose
- When labor augmented with Pitocin, a ......... dose is usually needed to achieve an adequate contraction pattern
Preeclampsia
Eclampsia
Gestational Hypertension
Chronic Hypertension
ANTEPARTUM COMPLICATIONS Pregnancy Induced Hypertension is classified as what?
Systolic blood pressure >/=140 mm Hg Diastolic blood Pressure >/=90 mm Hg
Occurring after 20 weeks gestation
Accompanied by proteinuria
- >/=0.3 g in 24 hour specimen
- >/=1+ with random dipstick
Formally edema considered classical sign
Presently edema considered nonspecific
how do you diagnose preeclampsia?
Preeclampsia progresses to true eclampsia when patient has seizure
Seizure is generalized tonic-clonic and cannot be attributed to any other cause
PIH may occur postpartum
what is eclampsia?
delivery of fetus
Only known cure for preeclampsia or eclampsia is???
>/=140/90 mm Hg after 20 weeks gestation
No proteinuria - difference between this and preeclampsia
May have trace on random dipstick
how do you diagnose Gestational Hypertension?
Blood Pressure >/= 140/90 mm Hg that is known before pregnancy
chronic hypertension in pregnancy is characterized as what?
-first pregnancy
- Young primigravida
- Maternal age > 35 years
- African American
- Positive family history
- Chronic hypertension
-Renal disease
- Diabetes
- Multifetal pregnancy
- Autoimmune disorders
- Father previously fathered pregnancy in another female complicated by PIH
Pregnancy Induced Hypertension - Risk factors
pregnancy-induced hypertension (PIH)
Loss of normal vasodilation capability
Increased levels of vasoconstrictors (partially produced by placenta)
Decreased levels of vasodilators
Concurrent vasospasm
BP begins to rise after 20 weeks gestation
-Hyperreflexia- Caused by altered cerebral perfusion 2º arterial vasospasms
-Headache, Seizures
-Renal failure
-Abruptio placentae - Decreased placental perfusion resulting in infarcts
-Disseminated Intravascular Coagulation (DIC) - Decreased placental perfusion resulting in infarcts
-Pulmonary embolism
-Confusion
-Visual disturbances (spots, blurred, double vision) -Indicate arterial spasms and edema in retina
-Decreased urinary output - As a result from decreased renal perfusion, Results in tissue necrosis with proteinuria
-Ruptured liver - Decreased perfusion leads to hepatic edema and sub-capsular hemorrhage
* May be evident with epigastric pain
Pregnancy Induced Hypertension - Clinical Manifestations
Hypertension first
Then proteinuria
classic signs on preeclampsia diagnosis?
Should be uniform
Seated, arm supported, cuff appropriate size for arm
Hospitalization may be necessary for serial observations of blood pressure
Serial checks differentiates true blood pressure elevation from those induced by anxiety
how do you measure Blood Pressure for pregnancy?
BP >/= 140/90 mm Hg
1+ proteinuria may occur
Liver enzymes may be elevated minimally
Edema may be present
Diagnosis - Mild pre-eclampsia
BP >/= 160/110 mm Hg - Measurements 6 hours apart
Proteinuria >/= 5 g in 24 hour specimen
Proteinuria >/= 3+ on random dipstick
Oliguria
Visual Disturbances -Vascular constriction and narrowing of small arteries with retinal examination
Elevated Liver Enzyme Studies (ALT, AST)
Hyperreflexia
Decreased platelets (impaired coagulation)
Increased hematocrit - Resulting from fluid shift to interstitial spaces
Generalized edema - May be severe, Facial edema may be subtle, Edema to lower exts expected in healthy pregancy
Rapid weight gain
Diagnosis - Severe preeclampsia
Regular diet without salt or fluid restriction usually prescribed
Diet appropriate for hypertension and diabetes prescribed for women who also have these disorders
High-protein, moderate-sodium - Used with severe preeclampsia
Pregnancy Induced Hypertension - Nutritional Considerations
Initial evaluation of severity done in hospital
May be managed at home if preeclampsia is mild - Mom and fetus stable, Mom can adhere to treatment plan, Mom can return for frequent visits
Pregnancy Induced Hypertension - Treatment
Client monitors her blood pressure
Measures weight and tests urine protein daily
Remote NSTs performed daily or bi-weekly
Mom keeps record of fetal movements called "kick count"
Mom should report decrease in fetal movements or no movement felt in 4 hour period
Blood pressure assessments 2-4 times per day, Family and patient taught to assess blood pressure in same arm, same position, with appropriate size cuff
Daily weights at same time, similar clothing, same scales
Urine dipstick for protein daily, First voided specimen
Physician may request more frequent testing
Sonography for fetal growth and quality of amniotic fluid or as part of biophysical profile
If < 34 weeks and delivery considered, amniocentesis done to evaluate pulmonary maturity (L/S Ratio)
Advised to report signs of worsening preeclampsia
-Home care of mild preeclampsia?
-Prevent seizures
-Maintain pregnancy until safe to deliver fetus
-Bedrest
-Fetal evaluation
-Quiet environment, decreased external stimuli (lights, noise, visitors)
-Magnesium Sulfate - Administered IV, Used as an anticonvulsant
- Apresoline - Administered IV, Antihypertensive agent of choice
Hospital care of severe preeclampsia - Goals
during labor and the postpartum period
Most seizures occur when?
- Monitor continuously for signs of seizures
- Maintain side lying position
- Narcotic analgesics or epidural analgesia used to control seizure precipitating pain
- Induction of labor by IV oxytocin if condition deteriorates
- Vaginal birth delivery method of choice
- Oxytocin to stimulate labor and magnesium sulfate to prevent convulsions
- Continuous electronic fetal monitoring identifies fetal heart rate patterns suggestive of fetal compromise
- Pediatrician, neonatologist, or neonatal nurse practitioner must be available to care for newborn
Intrapartum Care For PIH
Administer a loading dose over 15-20 mins
Maintenance dose 40 g in 1000 ml LR IV via infusion pump at 2 g/h
how do you administer magnesium sulfate?
4-8 mg/dl
Maintain serum magnesium level of ?
Respirations < 12/MIN
Maternal SaO2 < 95%
Hypereflexia or absent DTR (patella)
Urinary Output < 30 ml/h
Toxic serum level >/= 8 mg/dL
Fetal Distress or drop in fetal HR
Significant drop in maternal HR or BP
Assess for MAGNESIUM TOXICITY - what is it?
Calcium Gluconate - 1g administered at 3 minute intervels or as ordered
Medical treatment for magnesium toxicity?
Monitor vital signs and auscultate lungs
Assess fetal heart rate patterns
Monitor urinary output and urine protein q1h
Weigh mom daily at the same time
Assess deep tendon reflexes
Strictly monitor I/O
Possible renal failure when output < 30 ml/h
Monitor closely for signs of labor
Monitor closely for signs of Abruptio Placentae
Nursing Care for eclampsia?
Diuretic
- Furosamide (Lasix) - Administered to treat pulmonary edema
Anticonvulsant
-Magnesium Sulfate
Inotropic Agent
- Digitalis - Administered to treat circulatory failure
medications for eclampsia?
Protect mom and fetus
- Remain with mom
- During the tonic phase, turn mom on her side
- Note the time and sequence of the seizure
- After the seizure, insert an airway
- Do not force an airway through clinched teeth
- Suction mom's mouth and nose
- Administer oxygen
- Observe fetal monitor patterns for signs of hypoxia
Interventions for Seizure Activity
Keep mom on side while unresponsive
Raise padded side rails
Deliver fetus when vital signs stabilize
Anticipate orders for chest x-ray after initial stabilization
Aspiration leading cause of maternal morbidity and mortality following seizure activity
Anticipate ABG analysis after initial stabilization
Post Seizure Care?
Laboratory diagnostic variant of severe pre-eclampsia
- Blood and hepatic problems
H - Hemolysis , Breakdown of red blood cells resulting from erythrocyte changes as they pass through damaged blood vessels, Causing a decrease in oxygenation
EL - Elevated liver enzymes, Sign of hepatic issues, Results from decreased hepatic blood flow
LP - low platelets < 100,000 / mm3, Inability of blood to clot , Resulting from platelets aggregating at sites of vascular damage
what is HELLP syndrome?
HELLP syndrome
Although variant of severe preeclampsia hypertension may be absent
May occur during postpartum period
Risk for hemorrhage, pulmonary edema, and hepatic rupture
- Avoid traumatizing liver with abd palpation
Sudden ↑ in intra-abdominal pressure
- Potential for rupture of sub-capsula hematoma resulting in
- Internal bleeding
- Hypovolemic shock
with HELLP syndrome the nurse should avoid doing what?
Pain
- Upper right quadrant abd
- Lower chest
- Epigastric area
- Tenderness over liver
- Nausea and vomiting
- Severe edema
HELLP Syndrome - Clinical Manifestations, Life-threatening condition
Cardiac output increases up to 50%
Plasma volume increases by 50 % between 28-32 weeks gestation
Total erythrocyte count increases
Hematocrit decreases slightly resulting in anemia
- Hemodynamic changes of pregnancy increases the workload of the heart?
Postural hypotension
Dependent edema
Hemorrhoids
Enlarging uterus puts pressure on pelvic and femoral vessels
Impedes return blood flow causing stasis of blood in lower extremities
STASIS predisposes what?
Mitral Valve Prolapse (MVP)
Common cardiac condition
Associated with a variety of conditions
Leaflets of this into left atrium during ventricular contraction
Most people with this are asymptomatic
Limit physical activity
- Leads to increased risk for thrombus
- Elastic compression stockings or SCD's
- Prevent anemia, infection
- Careful assessment to detect development - Congestive Heart Failure , Pulmonary edema, Cardiac dysrhythmias
- Protect fetus from hypoxia and intrauterine growth retardation (IUGR)
Cardiovascular Disease - Medical Management
- Warfarin (Coumadin)
- Heparin - Requires monitoring of PT and PTT, platelet count
- Enoxaparin (Lovenox) - May be used rather than heparin
- Do not interchange Lovenox and Heparin
- Given subcutaneously
- Requires less-frequent monitoring - Requires monitoring of PT and PTT, platelet count
- Anti-dysrhythmics: safe to use
Digoxin
Adenosine
Calcium Channel Blockers
- Anti-infectives - Used for endocarditis
- Chosen according to infecting microorganism - Amoxicillin, Ampicillin, Penicillin, Gentamycin
- Diuretics - Used for pregnancy associated heart failure if uncontrolled by activity and sodium restriction
Furosemide (Lasix)
Thiazide
ACE inhibitors
Angio-tension Receptor Blockers
medications for cardiovascular disease in pregnancy
Labor beginning > 20 weeks gestation
But < end of 38 weeks gestation
No greater risk to mom than regular labor unless complications (infection, hemorrhage)
Different with neonate, everything immature
May result in birth of neonate not prepared for extra-uterine life
Pre term labor is characterized as what?
Contractions occurring q10 mins or less with or without pain
Low abdominal cramping with or without diarrhea
Intermittent sensation of pelvic pressure, urinary frequency
Low constant or intermittent backache
Increased vaginal discharge, may be pink-tinged
Leaking amniotic fluid
patient teaching related to preterm labor (what to expect if you experience this) -Should teach at first visit and reinforce at subsequent visits
Empty bladder
Assume a side-lying position, left-lateral preferred
Drink 3-4 eight ounce glasses of water
Palpate abdomen, if contractions 10 minutes apart or closer, contact healthcare provider
Rest for thirty minutes
Slowly resume activity, if symptoms disappear
Symptoms not subsided within 1 hour - call physician
immediate actions for pre term labor
Infections
Pregnancy complications
Sociodemographic factors
- Poverty, low educational level, lack of social support, smoking, little or no prenatal care, domestic violence, and stress
Causes of preterm labor and birth
Gestational age between 20 and 37 weeks
Contractions
Progressive cervical change
- Effacement of 80%
- Cervical dilation of 2 cm or greater
Three major diagnostic criteria for preterm labor and birth?
Engaging in sexual activity
Carrying heavy loads
Standing more than 50% of the time
Doing heavy housework or climbing stairs
Performing hard physical work
Being unable to stop and rest when tired
Activities resulting in preterm labor symptoms should be curtailed... what are some examples?
bed rest - Not a benign intervention and there is no evidence to support effectiveness in reducing preterm birth rates
Commonly used for prevention of preterm birth?
Modify environment for conveniences
Home uterine activity monitoring
home care for pre term birth
Tocolytics
- Magnesium Sulfate, Brethine (terbutaline)
Afford opportunity to begin administering glucocorticoids
- Accelerate fetal lung maturity
what meds suppress uterine activity?
4 cm
- Labor progressed to cervical dilation of ...... likely to lead to inevitable preterm birth
Preterm births in tertiary care centers lead to better neonatal and maternal outcomes
Women at risk should be transferred quickly to ensure best possible outcome
First dose of glucocorticoids should be given before transfer
Premature Rupture of Membranes (PROM)
Rupture of amniotic sac and leakage of amniotic fluid beginning at least 1 hour before onset of true labor, regardless of length of gestation
May be a normal occurrence that precedes term birth at 38 weeks or later, even if labor induction is needed to initiate labor
Preterm Premature Rupture of Membranes (PPROM)
Membranes ruptured earlier than the end of the 37th week of gestation
May occur with or without contractions
Etiology unknown
Diagnosed after woman complains of sudden gush or slow leak of vaginal fluid
Usually admitted to hospital until delivery
Maternal IV antibiotics administered for 48 hours followed by 5 days oral antibiotics - Ampicillin, Erythromycin, Amoxicillin, Azithromycin
Remember INFECTION #1 concern for both mom and infant during the intrapartum and postpartum periods
if Preterm Premature Rupture of Membranes happens what will you do?
Avoid sexual intercourse, orgasm, or insertion of anything into the vagina
Avoid breast stimulation - can cause contractions
Assess temperature QID
-Report if > 100 F - indicates infection
Maintain activity restriction
Assess for and report uterine contractions or vaginal drainage with a foul odor
Nursing considerations for PPROM?
Placenta accreta
Placenta increta
Placenta percreta
what causes a mother to be at risk for hemorrhage during the antepartum or intrapartum period?
Placenta accreta
immediate or delayed hemorrhage after birth because some of the placenta is still left in the mother.
placenta increta
extreme, placenta penetrates into the uterine muscle
placenta percreta
most extreme, placenta with penetrate through the uterus.
Prenatal ultrasound to identify before birth
A cesarean hysterectomy is often planned
how do you identify Placental Abnormalities?
prolapsed umbilical cord
cord slips down after the membranes rupture and becomes compressed between the fetus and pelvis
Prompt delivery of the fetus remains a priority
The key intervention is to relieve pressure on the cord without compression of the blood vessels and to expedite delivery
-may be visible or non-visible
Ruptured membranes and Fetal presenting part at high station
Fetus that poorly fits pelvic inlet because of small size or abnormal presentation
Excessive volume of amniotic fluid (hydramnios)
Factors that increase risk of prolapsed umbilical cord
Bradycardia and Variable decelerations
If the prolapse can not be palpated or seen but is suspected what happens to the FHR ?
Complete rupture - A direct communication between the uterine an peritoneal cavity
Incomplete rupture - Rupture into the peritoneum covering the uterus or into he broad ligament but not into the peritoneal cavity
Dehiscence - Partial separation of an old uterus scar - May be no S/S of rupture an found incidentally during a caesarean birth
what are the three variations of uterine rupture?
Signs of shock - decrease BP, increase HR/RR
Abdominal pain
A sense of tearing
Chest pain or pain in the shoulders
Abnormal fetal heart rate patterns
Cessation of contractions
Palpation of the fetus outside of the uterus
Uterine Rupture - Clinical Manifestations
Stabilize mom and baby
Perform a cesarean delivery
Large uterine rupture requires hysterectomy
Blood products and fluids are replaced if needed
Uterine Rupture - Management
Anaphylactoid Syndrome
Also known as amniotic fluid embolism (AFE)
Amniotic fluid is drawn into the maternal circulation and carried to the woman's lungs.
- Obstructs pulmonary vessels
- Critical complication associated with: Maternal sepsis, Preeclampsia, Cardiac disease
Requires rapid therapeutic management Cardiopulmonary resuscitation and support
Oxygen with mechanical ventilation
Correction of hypotension
Blood component therapy to correct coagulation defects
If a pregnant mother is in cardiac arrest - Immediate cesarean delivery is likely to improve survival odds for the baby
Anaphylactoid Syndrome
Clinical Manifestations
Abrupt respiratory distress
Depressed cardiac function
Circulatory collapse
Disseminated Intravascular Coagulation (DIC) - Because thromboplastin rich amniotic fluid interferes with normal blood clotting Often fatal and survivors may have neurologic deficits
-first 24 hours
- From 24 hours up to 6 weeks postpartum
Can sometimes be prevented by careful examination of factors that predispose the woman to excessive bleeding
Early postpartum hemorrhage (PPH) occurs?
Late PPH occurs?
Uncontracted uterus- "boggy"
Large gush or slow, steady trickle of blood from vagina
Saturation of more than one peripad per 15 minutes
Severe, unrelieved perineal or rectal pain
Tachycardia
Early Signs of PPH?
Overdistention of uterus
Multiparity (>5)
Use of tocolytic drugs
Precipitate labor or delivery
Prolonged labor
Use of forceps or vacuum extractor
Cesarean birth or previous uterine surgery
Manual removal of placenta
Uterine inversion
Previous PPH
General anesthesia
Placenta previa, accreta, or low implantation
Drugs: oxytocin, prostaglandins, magnesium sulfate
Chorioamnionitis
Clotting disorders
Disseminated intravascular clotting
Uterine leiomyomas (fibroids)
Post-Partum Hemorrhage - Predisposing Factors
uterine atony
The relaxed muscles allow rapid bleeding from the endometrial arteries a the placental site
Bleeding continues until the uterine muscle fibers contract to stop the flow of blood
Fundus is difficult to locate
"Boggy" or soft feel to the fundus
Becomes firm when massaged but loses tone when massage stops
Excessive lochia and clots
uterine atony clinical manifestations:
Assessment of mother following delivery - Early intervention
Measures to contract the uterus - Administration of oxytocin as a prophylaxis, Massage the uterus until it is firm and to express clots that may have accumulated - Make sure the bladder is empty, full bladder may displace the uterus
Provide fluid replacement
how do you manage uterine atony?
Trauma to the birth canal
2nd most common cause of PPH?
Lacerations
Should always be suspected if excessive uterine bleeding continues when the fundus is contracted firmly and is at the expected location
Bleeding from these of the genital tract often is bright red, and can be heavy or appear as a steady trickle of blood
Hematomas

Small hematomas usually reabsorb naturally
Large hematomas may require surgical incision evacuation of the clots
Develop as a result of blood vessel injury in which vacuum extraction or forceps are used
The rapid bleeding into soft tissue can cause a visible discolored bulging mass that is sensitive to touch
Produce deep, severe, unrelieved pain and feeling of pressure
Mom demonstrates systemic signs of blood loss when the fundus is firm and the lochia is WNL
1500-2000ml , more than that can be considered hypovolemic
how much blood loss can a women tolerate during pregnancy?
Tachycardia
Hypotension
Tachypnea
Skin pale and cool to touch
Decreased urine output
Anxious / restless / confusion / lethargy
Hypovolemic Shock - Clinical Manifestations
Goals: Control and correct bleeding, Prevent hypovolemic shock from becoming irreversible
Insert a 2nd large bore IV line
IV fluid bolus
Vasopressors may be required for low blood pressure
Hypovolemic Shock - Management
Inactivity or bed rest
Obesity
Cesarean birth
Smoking
History of previous thrombosis
Varicose veins
Antiphospholipid antibody syndrome
Inherited thrombophilias
Diabetes mellitus
Trauma
Prolonged labor
Prolonged time in stirrups in second stage of labor
Maternal age 30 years or older
Increased parity (given birth)
Use of forceps
Factors that Increase the Risk of Thrombus Formation:
endometritis
Infection of the endometrium
cesarean surgical incision, episiotomies, and lacerations
common sites for wound infection PP?
mastitis
Infection of the breast
Fever, chills
Pain or redness of wounds
Purulent wound drainage or wound edges not approximated
Tachycardia
Uterine sub-involution
Abnormal duration of lochia, foul odor
Post-Partum Infection - Clinical Manifestations
IV antibiotic therapy - Then may discharge home on P.O. therapy
Obtain blood cultures - do this before giving antibiotics
Oral analgesics -Urinary analgesic (Pyridium)
Sitz bath - helps relieve epis pain or laceration pain
Moist heat compress
Post-Partum Infection - Management
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