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Metabolic Changes Associated with Normal Pregnancy: Glucose Metabolism
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Terms in this set (233)
First trimester:
•Putting away maternal resources.
•Increased insulin production
•Lower fasting glucose levels

Second and Third Trimesters
•"Diabetogenic effect" of pregnancy
•Increased insulin resistance, decreased tolerance of glucose, decreased hepatic glycogen stores.
•Shunting glucose to the baby.

*normal pregnancy: compensates for this effect and has normal glucose level
cutting the cord at birth can cause hypoglycemia bc glucose strops going to the baby

Baby is getting lots of sugar (glucose) from mom so baby has increased production of insulin so when the cord is cute the sugar level getting to the baby drops and insulin level production remains the same leading to hypoglycemia
•Most common endocrine disorder associated with pregnancy
•Pregnancy will be classified high risk
•Can be successfully managed
•Strict maternal glucose control is key
•Interdisciplinary team

•Diabetes may be caused by either or both:
•Impaired insulin secretion
•Inadequate insulin action in target tissues

*hyperglycemia = teratogen
§Type 1 diabetes
§Type 2 diabetes
§White's Classification Class B, C, D, F, R, T (communicate with the provider to show complexity of condition before pregnancy

§Gestational diabetes (GDM)
§Carbohydrate intolerance with the onset or first recognition occurring during pregnancy (ACOG).
§White's Classification A1 or A2
*occurs in the 2nd half of pregnancy
*A1: less severe
*A2: most severe
First Trimester:

Later Pregnancy:
•Unexplained stillbirth or IUFD (intrauterine fetal death)
•Macrosomia (wt over 4,000g or greater than 90%)
•baby at risk for: Shoulder dystocia/birth trauma
•Hypertension, pre-eclampsia
•Polyhydramnios (excess amniotic fluid): rf placenta abruption and preterm birth
•Infections (yeast and UTI particularly): bc of sugar levels
•Ketoacidosis (Table 11.2)
First trimester
•Congenital anomaly
•Cardiovascular and central nervous systems: NTD -> echo and ultrasound to check for abnormalites

Later Pregnancy:
•Placental insufficiency
•Macrosomia & birth trauma
-brachial plexus injury, facial nerve injury, clavicle or humerus fractures

Neonatal Risks:
•Extreme prematurity
•Respiratory distress
•hyperglycemia: interferes with surfactant production
•Physical examination
•Laboratory tests
-Fasting or random blood glucose
-Routine prenatal labs +
-24 urine for total protein and Cr. Cl.
-UA with culture
-•Glycosylated hemoglobin A1c: Ideally 6-6.5
•More frequent prenatal visits
-First & Second trimester every 1-2 weeks
-Third trimester 1-2 visits per week.
•Diet (Patient Teaching)
•Exercise: low impact and discuss with dietician
•Insulin (Patient Teaching).
•Blood glucose monitoring
•Urine for Ketones, not Glucose
•Determination of birth date and mode of birth: vaginal preferred by c-section is most common
•Complications requiring hospitalization
•Fetal surveillance: NST before 37wks and L/S ration needed

*GDM -> RF preeclampsia
Gestational DiabetesDiagnosed in the second half of pregnancyMaternal Risk: •Less than for pre gestational diabetes •Preeclampsia •Cesarean section •Type 2 diabetes in later life. Fetal Risk: •Macrosomia & birth trauma •Neonatal hypoglycemia & hyperinsulinemia Screening for GDM: •All women with risk •24-28 weeks •1 hr 50g oral glucose test -Negative: less than 130-140 -positive: greater than or equal to 130-140 -If positive: 3 hour 100g oral glucose test neededGestational DiabetesAntepartum •Diet (2000-2500 kcal/day for normal weight moms) •Exercise •Monitoring blood glucose levels •Insulin/medication therapy: metformin •Fetal surveillance Intrapartum •Monitor patient closely: Blood glucose every hour •Complications •May require a cesarean birth •Preeclampsia or macroxomia Postpartum care: •Insulin requirements decrease substantially •Encourage breastfeeding •Contraception: to prevent close pregnancy -> spaced out by 2yrs •Increased risk for diabetes later in life: BG checks and continual screening neededHyperthyroidism•Graves' disease is 90% to 95% of cases •Rare in pregnancy •Goiter, weight loss, pulse >100 bpm. •Must be treated in pregnancy •Propylthriouracil (PTU) First trimester THEN: can lead to liver failure •Methimazole (MMI) Second & Third Trimester: monitor issues, teratogenic in first semester. But safe during 2nd and 3rd *post partum: check thyroid levels and may still be on meds and can breast feed on these medicationsHypothyroidismSymptoms: fatigue, lethargy, weight gain, cold intolerance, constipation, brittle hair (similar to those when not pregnant) •If untreated at risk for infertility and miscarriage •Preeclampsia, placental abruption, preterm birth and stillbirth. •Neonatal risk of low birth weight. •Treatment for hypothyroidism: •Levothyroxine (Synthroid) •Start with low dose and adjust up •Safe while breastfeeding •Take separate from iron supplements: bc it interferes with the uptakeMaternal Phenylketonuria: causesGenetic: •Autosomal recessive inborn error of metabolism. •This error causes a deficiency in one enzyme phenylalanine hydrolase. •Body is unable to metabolize phenylalanine (amino acid) in all protein foods. •Phenylalanine reaches toxic levels and interferes with brain development and function. •Universal screening of all newborns started in 1961.Maternal Phenylketonuria: effects and management•Untreated - causes mental retardation in neonate, microcephaly, intellectual impairment •Preconception: Recommended to restrict phenylalanine months before conception. •Maintain phenylalanine levels below 6mg/dL. •During pregnancy and breastfeeding: restrict maternal phenylalanine consumption (protein): dietician may be needed •Breastfeeding is safe if baby does not have PKU also: PKU babies can't metabolize protein in food *possible s/sx indicating: hyperpigmentation of hair and eyesAutoimmune: Systemic Lupus Erythematosus•Wait to conceive until remission has lasted six months: this doesn't cause this disease but can lead to flare ups •Maternal risks: miscarriage, preterm birth, preeclampsia •Fetal risks: stillbirth, IUGR, preterm birth. •s/sx: fatigue, muscle aches, wt gain, rash •Medical therapies should be kept to a minimum during pregnancy. • Glucocorticoids and NSAIDS may adversely effect if given long term • Hydroxychloroquine (Plaquenil) believed safe •Close monitoring during pregnancy • Monthly Ultrasound, more frequent NST and BPP •Birth by 39 weeks & vaginal birth is preferred •Careful Postpartum monitoring due to risk of flares •Contraception: Avoid OCP's in women with renal disease, vascular disease. IUD, progesterone only methods may work well.Myasthenia Gravis•Preconception counseling and planning is critical! •Greatest risk for complications is in first year after diagnosis •May exacerbate normal discomforts of pregnancy •Respiratory and fatigue •Same treatment regimen as for non-pregnant women •Labor and birth can be tolerated well -Avoid all meds causing muscle weakness (Magnseium sulfate! Caution with opioids!!). -Muscle weakness may cause difficulty pushing. -Neonate must be monitored for neonatal myasthenia.Normal cardiovascular changes in pregnancy include:•Increased intravascular volume •Decreased systemic vascular resistance •Cardiac output changes during labor and birth •Intravascular volume changes that occur just after childbirthFunctional Classification•Class I: Asymptomatic without limitation of physical activity. •Class II: Symptomatic with slight limitation of activity. •Class III: Symptomatic with marked limitation of activity. •Class IV: Symptomatic with inability to carry on any physical activity without discomfort. •Remember: A normal 30-45% increase in cardiac output occurs in early pregnancy, peaking between 25-30 weeks.Care Management: Cardiovascular disorders:Antepartum•Detailed history and physical at first visit. •Weekly prenatal visits •Minimize stress on the heart •Treat coexisting issues: Stress, HTN, anemia, hyperthyroidism, obesity. **Infections are treated promptly. •Watch for signs of cardiac decompensation & teach mom: decompensation is the greatest cause of infection •Nutritional evaluation and counseling. Treat anemia; sodium restriction may be required. •Cardiac medications: Prescribed as needed and safe. •Anti coagulants: Lovenox, heparin. (NO warfarin!) •Close to term, monitor fetal lung maturity & placental sufficiency.Care Management: Cardiovascular disorders: IntrapartumAssessments: •Vital signs & ABG's •Head to toe and pulmonary assessment •ECG, FHT, SaO2 •Pulse >100 or RR > 25 = concerning Environment: •Calm and supportive. •Honor the birth plan. •Provide comfort Positioning: •Head and shoulders elevated with lots of pillows for supportCardiovascular disorders: Intrapartum (Management for pain, abx)Pain Management: • Epidural • Avoid Hypotension Antibiotic prophylaxis: • Cyanotic heart disease, prosthetic valves • Ampicillin and Gentamycin Second Stage: • In Left lateral position •Episiotomy • Forceps/VacuumCardiovascular disorders: Intrapartum (things to avoid)•Terbutaline: puts extra strain on the heart •Ergot medications •Supine hypotension •Use of stirrups: imbalance of pressure in upper and lower body •Closed glottis pushing/Valsalva: this is when they hold their breath (you want them to encourage groaning and moaning)Cardiovascular disorders: PostpartumFirst 24-48 Hours: •Tailor care to mom's ability •Period of high risk for cardiac decompensation •Breastfeeding is preferred (watch her meds!). Discharge Planning: •Starts at admission! •Obtain resources and support as she requires. •Help her plan rest, nutrition, activity and sleep. •Teach her to continue monitoring for cardiac decompensation. First Postpartum Weeks: •Contraceptive planning: Progesterone only method or IUDCardiac Decompensation: Subjective Symptoms•Increasing fatigue or difficulty breathing with normal activities •Feeling of being smothered •Frequent cough •Palpitations; feeling that her heart is racing •Generalized edema: face, feet, fingers, legsCardiac Decompensation: Objective Signs•Irregular, weak, rapid pulse (>100bpm) •Progressive generalized edema •Crackles at lung bases after two breath cycles: Do not clear with cough •Orthopnea & increasing dyspnea •Rapid respirations (25breaths/min) •Moist, frequent cough. •Cyanosis of lips, nailbedsAnemia•Normal pregnancy related changes to Hematocrit: -Increase in plasma volume with relatively less increase in red cell volume -40-50% increase in plasma volume peaking at about 27-28 weeks gestation •20-30% increase in red cell mass •Physiologic anemia of pregnancy •Hemoglobin >11G/dL •Hematocrit >33%Iron deficiency anemia•Most common cause •Supplement with 325 mg iron po every day. •Diagnosed by checking ferritin levels •If woman cannot take PO, may need IV iron infusion or blood transfusion •Ferritin levels <12 mcg/dL + Hgb <11G/dL = iron deficiency anemia •Teach iron rich dietFolic acid deficiency anemia•Megaloblastic anemia •Prenatal supplements (600 mcg/day). •Usually occurs in third trimester •Women at risk •Poor nutrition •Crohn's DiseaseSickle cell hemoglobinopathy•Caused by sickle cell trait (SA hemoglobin pattern) •Sickle Cell Trait: •Often asymptomatic: 1 in 12 African Americans •Preconception genetic counseling •Sickle Cell Disease -1 in 708 African Americans -Folic acid 1 mg/day as soon as pregnancy is diagnosed -Risk for miscarriage, preterm birth, IUGR, stillbirth -Increased fetal surveillance -Preeclampsia and infection -Risk for crisesThalassemia•Most commonly beta thalassemia •Mediterranean or Middle Eastern descent. •Heterozygous form - generally more minor •Homozygous form - more serious. •Managed much like sickle cell •RF: preterm birthAsthma•Exacerbations and remissions •Hyperactive airways •Characterized as: -Mild intermittent -Mild persistent -Moderate persistent •Severe persistent •23% get better, 30% get worse •Risk to fetus: Preterm birth, SGA, IUGR, •Risk to mom: Preeclampsia, c/section. •Asthma control decreases risk.Asthma: Therapy objectives•Maintenance of adequate oxygenation. •Prevention of exacerbations •Medications may include: albuterol, Atrovent, glucocorticoids, beta adrenergic agents, oxygen •Monitoring fetal well being- •Especially for severe asthmaSkin disorders: normal skin changes and can be aggravated byNormal Pregnancy Related Skin Changes: •Melasma (chloasma) •Palmar erythema •Striae gravidarum •Vascular spiders May be aggravated by pregnancy: •Acne vulgaris •Neurofibromatosis •PsoriasisSkin disorders: Integumentary Disorders which may appear in PregnancyPruritis Gravidarum: •Not associated with poor outcomes •Treat symptoms Pruritic Urticarial Papules and Plaques of Pregnancy (PUPPP) •Not associated with poor outcomes •Treat symptoms Intrahepatic cholestasis of pregnancy •Associated with fetal asphyxia, meconium, stillbirth, preterm birth •Treatment: ursodeoxycholic acid + symptoms •Increased fetal surveillance and possible delivery at 37 weeks gestationHuman Immunodeficiency Virus & AIDS: Antepartum•Test all women: First visit and third trimester •Treat all HIV + women with HAART thru pregnancy and birth -Regardless of CD4 count. -Monitor hematocrits, white blood cell counts platelet counts •Vaccinate against HBV, Pneumococcal pneumonia, HIB influenza,. •Treat coexisting STI's •Teach good nutrition, rest, life balance to minimize stress. •Safe sex practicesHuman Immunodeficiency Virus & AIDS: Intrapartum•ART continues: Decrease viral load •C/section may be preferred depending upon viral load ->1000 copies per milliliter at 38 weeks = Cesarean is preferred -Zidovudine 3 hours before scheduled surgery -<1000 copies per milliliter at 36 weeks = May consider vaginal birth with IV Zidovudine throughout labor •No fetal scalp electrode, no scalp pH sampling, avoid forceps or vacuum. •Babies will be treated with Zidovudine X 6 weeks after birth. -Goal is to ↓viral loadHuman Immunodeficiency Virus & AIDS: Postpartum•Course depends upon degree of HIV symptoms. •Breastfeeding is not recommended. •Comprehensive discharge planning and connect with social services.Substance Use disorder•Defined as the continued use of substances despite related problems in physical, social, or interpersonal areas •Often a dual diagnosis -Substance abuse plus another psychiatric disorder •Damaging effects on the fetus are well documentedSubstance Use disorder: barrier to treatment and care managementBarriers to treatment: •Less than 10% of pregnant women receive treatment •Substance-abuse treatment programs •Long waiting lists and lack of health insurance •Drug use often denied Care management: •Drug testing during pregnancy •Screening for substance abuse •Initial care •Methadone maintenance program •Follow-up care •Non-judgmental attitude is crucial •Breastfeeding is contraindicatedHyperemesis Gravidarum•Defined: excessive vomiting accompanied by dehydration, electrolyte imbalance, ketonuria. •Etiology- 1st Trimester (10% entire pregnancy) -Unknown- hormones, GI changes, Psychosocial •Clinical manifestations: Weight Loss, dehydration, increased pulse, unable to keep food or liquids down. Electrolyte Imbalance, ketones in the urine (indicate dehydration) •Collaborative care •Initial care- IV hydration, electrolyte replacement; small freq meals (if tolerating po); high protein snack before bedtime, dry/bland foods; ginger tea; •Follow-up care *Diclegis: med may help, start at the lowest doseHemorrhagic Disorders•Hemorrhagic disorders in pregnancy are medical emergencies •Maternal blood loss decreases oxygen-carrying capacity -Increased risk for hypovolemia, anemia, infection, preterm labor, and preterm birth -Adversely affects oxygen delivery to fetus -Fetal risks include blood loss or anemia, hypoxemia, hypoxia, anoxia, and preterm birthEarly Pregnancy Bleeding•Miscarriage (spontaneous abortion): spotting needs to be monitored •Incidence and etiology •Types: Thereatened, Inevitible, Incomplete, Complete, & missed •Clinical manifestations •Care management -Assessment -Plan of care and implementation -Medical-surgical managementThreatened abortion-Spotting, possible cramps, cervix is closed -Heartbeat present, ultrasound shows a baby -tx: bed restInevitable abortion-cramping, spotting, cervix open and bleeding -Not reversibleIncomplete abortion-spotting, cramping, bleeding, cervix open and bleeding -No fetus present in ultra soundComplete abortion-spotting, bleeding, cervix is closed and no baby present in ultrasoundMissed abortion-Cervix is fine -No spotting or bleeding but baby has no heart beat and is not viableRecurrent Premature Dilation of the Cervix (Incompetent Cervix)Etiology: seen around 17-18wks •Anatomical: different, abnormal paps -> cervex needs to be manipulated, induced abortion, miscarriage •Previous cervical surgery/ procedures Medical-surgical management •Conservative management of bed rest, progesterone (smooth muscle relaxing), anti-inflammatory drugs (indocin: short term 3 days. this decreases pressure around the baby and decreases fluid), and antibiotics (phrophylactic) •Shirodkar or McDonald procedure •Prophylactic cerclage is placed at 12 to 15 weeks of gestation •Nursing care and home careEctopic Pregnancy•1-2% of all pregnancies •Fertilized ovum implanted outside uterine cavity •95% occur in uterine (fallopian) tube •Most located on ampullar •Other sites include: •Ovary (0.5%) •Abdominal cavity (1.5%) •Cervix (0.3%)Cerclage correction-this is a stitch that closes opening in premature dilation in cervix -nothing per vagina: bc stitch can be torn -stitch usually comes out when contracting -progesterone: shot is given weekly so smooth muscle relaxesHydatidiform mole (molar pregnancy)•Benign proliferative growth of the placental trophoblast- chorionic villi develop edematous, cystic clusters (may be invasive mole & choriocarcinoma): no fetal development •Two distinct types of hydatidiform moles are: •Complete (or classic): mole results from fertilization of egg with lost or inactivated nucleus •Partial mole: result of two sperm fertilizing a normal ovumHydatidiform mole (molar pregnancy): s/sx and management•s/sx: Vag bleed; Uterus larger than dates •If HCG doesn't decrease it can turn to malignant cancer •blood check for HCG levels Q1wk for a month, then monthly for 6 months and then check up to a year Medical-surgical management: •Most pass spontaneously •Suction curettage is safe, rapid, and effective if necessary •Induction of labor with oxytocin; prostaglandins not recommended •Don't get pregnant for a year: birth control or protectionGestational trophoblastic neoplasia (GTN)•Tumors classified as non-metastatic, metastatic low risk, and metastatic high risk •50% occur after hydatidiform mole; usually within a year •30% follow ectopic pregnancy or miscarriage •20% after apparently normal birth •100% cure rate of non-metastatic and low-risk metastatic GTNPlacenta previa•Placenta implanted in lower uterine segment near or over internal cervical os •Classification based on degree internal cervical os is covered by placenta •Complete placenta previa •Partial placenta previa •Marginal placenta previaPlacenta previa: risks, s/sx, maternal/fetal outcomes•Risks: previos c/s; AMA; hx of D&C (or suction curettage); smoking, multiple pregnancies increases risk bc of scar tissue that left behind •Clinical manifestations: Bright red vaginal bleeding Maternal and fetal outcomes •Maternal morbidity and mortality •Complications •Fetal risks include malpresentation and congenital anomalies •Preterm birthPlacenta previa: dx and managementDiagnosis and medical management: •Standard diagnosis is transabdominal (looking from the top) ultrasound examination •Accurate 93% to 97% Management includes: •Expectant management: observation and bed rest •Cesarean birth •Hospital and home care •Rhogam if mom is negative and bleeding occurs •nothing per vaginaPlacental abruption (premature separation of placenta/ Abruptio Placenta)•Risks: MVA, trauma, Battering, smoking, thrombophilias, twins, previous abruptio, cocaine, high doses of pitocin •Classification systems: Grades: 1 (mild), 2 (moderate), 3 (severe) •Clinical manifestations- boardlike abdomen, contractions, vaginal bleed with uterine pain (usually darker and less than previa) •Maternal, fetal, and neonatal outcome: delivery, Collaborative care: •Hospital care •Home care •Rhogam if negative after bleedCord insertion and placental variations•Velamentous Cord- insertion of cord is rare anomaly •Umbilical cord inserts into the fetal membranes (choriamniotic membranes), then travels within the membranes to the placenta (between the amnion and the chorion. The exposed vessels are not protected by Wharton's jelly - risk for rupture. •Associated with placenta previa and multiple gestation •Cord vessels branch at membranes and course onto placenta •Rupture of membranes or traction on cord may tear one or more fetal vessels •Fetus may rapidly bleed to death as a result *may not realize this until deliveryBattledore (marginal§insertion of cord §Increases risk of fetal hemorrhage, especially after marginal separation of placentaClotting problems•Recognition in antepartal period may decrease hemorrhagic problems in postpartum period •DIC (discriminated intermediate coagulation): Pathologic form of diffuse clotting causing widespread external and internal bleeding -over reaction of clotting casacade -s/sx: nose bleed (uncontrollable), bleeding from IV -common to see DIC when: septic, fetal death •von Willebrand's disease: Type of hemophilia that can affect womenTrauma During Pregnancy: Maternal physiologic characteristics•Requires strategies adapted for appropriate resuscitation, fluid therapy, positioning, assessments, and other interventions •Uterus and bladder positioning •Elevated levels of progesterone •Decreased tolerance for hypoxia and apnea •Cardiac output •Circulating blood volumeTrauma During Pregnancy: fetal physiologic characteristics•Careful monitoring of fetal status assists greatly in maternal assessment •Fetal monitor tracing works as "oximeter" of internal maternal well-beingWhat are the factors known to impact poor outcomes for racial and ethnic minorities?•Implicit bias •Institutional Bias •Communication barriers •Fragmentation of careNursing Considerations Regarding Blood Pressure MonitoringEquipment Considerations: •Ideal- Mercury manual cuff- Inflate >30mmHg high after radial pulse •Cuff size- assure appropriate site- cuff to cover 2/3 arm 80% Position Considerations: •Rest x 5-10min prior to taking BP •Patient should be seated supine or left lateral recumbent Patient Considerations: •No smoking prior to BP •No caffeine prior to BPChronic Hypertension◦Present BEFORE the pregnancy or diagnosed BEFORE week 20 of gestation ◦Stage 1 hypertension: Systolic between 130-139 or diastolic between 80-89 mm Hg ◦Stage 2 hypertension: Systolic at least 140 or diastolic at least 90 mm Hg ◦Blood pressures (BPs) persistently above 160/105 should be treated to goals between 120/80 and 160/105.Chronic Hypertension w/ Superimposed Preeclampsia◦Present BEFORE the pregnancy or diagnosed BEFORE week 20 of gestation AND ◦Signs & Symptoms present for Preeclampsia or eclampsia (appear AFTER 20 weeks)Chronic Hypertension: Associated with increased incidence•Superimposed preeclampsia •Cesarean section •PPH, GDM, Placental abruption •Increased perinatal mortality- stroke •Fetal effects: Growth restriction- Preterm birth, stillbirth, congenital defectManagement:Chronic Hypertension•For systolic blood pressures ≥160 mm Hg or diastolic pressures ≥105 mm Hg: •Labetalol, Nifedipine, or Methyldopa (assess for CI if they're currently on other meds) *NO ACE inhibitors •Low dose ASA 81mg daily starting between 12-28wks: decreases likelihood of developing disease •Serial BP monitoring- Check home monitor for accuracy •Lab assessments-protein in urine, creatinine •Delivery timing (depending on control- 37-39wks) •Fetal Surveillance: Kick Count, NST •HTN will age the placentaGestational Hypertension•Onset of hypertension without proteinuria after the 20th week of pregnancy •Previously normotensive •BP S >/= 140/ OR D >/= 90mmHg- persistent for 4 hrs •AsymptomaticManagement: Gestational Hypertension•Education on signs and symptoms of pre-eclampsia and eclampsia •BP at least once weekly with proteinuria assessment in the office •Twice weekly measurement of BP at home or in the office is suggested. •Fetal Surveillance: Kick Count, NST as indicatedPreeclampsia•Pregnancy-specific syndrome •BP S >/= 140/ OR D >/= 90mmHg- persistent for 4 hrs: Same as gestational HTN •Hypertension develops AFTER 20 weeks of gestation in previously normotensive women •A vasospastic systemic disorder categorized as Mild or Severe FeaturePreeclampsia: etiology and those at risk•Etiology: Signs & symptoms develop only during pregnancy and disappear after birth** Rare- Postpartum Preeclampsia does occur Who is at risk? •Family history •Multifetal pregnancy (twins, triplets or >) •African-American race •Obesity •<19 and </=40 years old: younger than 19 and older than 40 •Pre-existing medical or genetic conditions •Smokers, Maternal Infection, Lower Socioeconomic Status, New partnerPathophysiology:Preeclampsia•placenta thought to be the main cause •Potential to progress along a continuum from mild to severe •Multiple theories of etiology •Caused by disruptions in placental perfusion and endothelial cell dysfunction •Placental itching •Generalized vasospasm •Reduced kidney perfusionPre Eclampsia (Mild Features) Criteria•Systolic & diastolic blood pressures ≥140 OR ≥90 mm Hg, (respectively, occurring twice, 4 hours apart, after 20 weeks) WITH: •Proteinuria (ie, ≥300 mg per 24 hours, protein to creatinine ratio ≥0.3 day or 1+ urinary protein dipstick reading) OR: •OR in the Absence of Proteinuria- any of the following findings (next slide): Blood Pressure (x2, 4 hrs apart) Platelets Liver Function Renal Function Cerebral Function Pulmonary FunctionPre Eclampsia (Mild Features) Criteria: affected systems-Blood Pressure (x2, 4 hrs apart) ≥140 OR ≥90 mm Hg -Platelets: Platelet counts <100,000 µL -Liver Function: Elevated liver enzymes (twice normal) -Renal Function: Renal Insufficiency- elevated creatinine clearance, proteinuria -Cerebral Function: Cerebral disturbances- headache/ blurred vision -Pulmonary Function: Pulmonary edemaIdentify:Pre- Eclampsia (Mild Features)•Signs & Symptoms: Blurred vision, Headache, Epigastric pain •Exam Findings: Dependent edema, Pitting edema, Deep tendon reflexes (hyper), Clonus •Lab Findings: ALT, AST, Creatinine, Uric Acid, LDH, Platelets, UAManagement: Preeclampsia (mild feature)•Serial maternal assessment Serial BP (twice weekly) •Lab: Platelet counts, kidney function & liver enzymes (weekly). •Magnesium Sulfate if indicated * New ACOG bulletin:smooth muscle relaxer to help prevent seizures and protect mom's neuro system •Corticosteroids x 2 if preterm •Decrease activity- bed rest not recommended •Delivery when indicated •Fetal Surveillance: FKC Sheet, NST, BPP, Doppler *Mag admin: 2 RN check, assess LOC, urine output, resp, reflexes, clonus; have antidote at bedside (Ca gluconate)Preeclampsia (Severe Features) Criteria-Blood Pressure (x2, 4 hrs apart): ≥160 or 110 mm Hg, after 20 weeks gestation AND Any of the following: -Platelets: Platelet counts <100,000 µL- thrombocytopenia -Liver Function: Unexplained right-upper-quadrant- epigastric pain unresponsive to medications, or hepatic transaminase levels twice normal -Renal Function: Progressive renal insufficiency- elevated creatine clearance (pitting edema), proteinuria -Cerebral Function: New onset cerebral or visual disturbances (headache/blurred vision) -Pulmonary Function: Pulmonary edemaIdentify:Pre- Eclampsia (Severe Features)•Signs & Symptoms: Blurred vision, Headache, Epigastric pain (RUQ) •** Sx more severe •Exam Findings: Dependent edema, Pitting edema, Deep tendon reflexes, Clonus, Excessive weight gain •** Sx more severe •Lab Findings: ALT, AST, Creatinine, Uric Acid, LDH, Platelets, UAManagement: Preeclampsia (Severe Features) Features)•Mg So4- monitor toxicity •DTR- assessment •Betamethasone x 2: help with lung maturity •Bed rest/ NST, BPP, Dopplers •Serial Labs •Antihypertensives PRN •DeliveryEclampsia Criteria•Seizure activity or coma in woman diagnosed with preeclampsia •May be on continuum with preeclampsia or may present eclamptic •No history of pre-existing pathology •Eclamptic seizures can occur before, during, or after birthManagement: Eclampsia•Immediate care- prevent injury, stabilization: side rails go up •Treatment- MgSO4, Diazepam, Phenytoin, O2 •Nursing action during a convulsion •Prevention: Prenatal care for assessment and early interventionsHELLP Syndrome CriteriaLaboratory diagnostic variant of severe preeclampsia involves hepatic dysfunction, characterized by: •Hemolysis (H) of red blood cells •Elevated (E) •Liver enzymes (function) (L) •Low (L) •Platelets (P)Identify: HELLP Syndrome•S/SX: Nausea, Vomiting, Headache, Right Upper Quadrant pain, Chest/arm pain Associated with increased risk: •Pulmonary edema, Sepsis, Stroke •Renal failure •Liver hemorrhage or failure, Death, •Disseminated intravascular coagulation (DIC) •Placental abruption •Acute respiratory distress syndrome *hallmark signs: N/V, severe fatigueManagement: HELLP Syndrome•Tertiary Care Center- transfer if indicated •Close monitoring •Lab testing at minimum every 12 hrs •Corticosteroids (to increase platelet numbers), Mag So4 (decrease RF seizures) •Delivery soon after maternal stabilizationHypertension in Pregnancy:Fetal Considerations•Poor Fetal Growth •Preterm birth •Infant death •Acidosis •Life consequencesAntepartum Education -CHTN, GHTN, Preeclampsia, Superimposed PreE, Eclampsia, HELLPPatient Teaching: •How to Prevent hypertension in pregnancy •How to Assess Fetal well being- FKC Sheet •How to Recognize Signs & Symptoms •How to Assess BP at home- Range/ Log •When to Contact the provider •Importance of keeping prenatal appointments Recognizing Symptoms •Headache-Excessive weight gain •Blurred vision, Scotoma •RUQ Pain or Shoulder Pain •Sudden onset Nausea & Vomiting •Decreased Fetal Movement: bc of decrease in perfusionPostpartum Education & Follow Up-Gestational hypertension, pre-eclampsia, or superimposed preeclampsia◦Monitor BP: Up to PPD 3 day, PPD 7 -10 day, Monitor for s/sx Preeclampsia •Preconception counseling in future pregnancies •Encourage yearly assessments of BP, lipids, fasting glucose, and body-mass index- primary care •Educate All Patients on signs & symptoms of Preeclampsia •** PP PreeclampsiaPrevention of Hypertension Disorders in Future Pregnancy•Low Dose Aspirin (baby ASA) QD begin 12-28 wks •Calcium supplementation •1.5-2 gram/day before 32 wks •Dietary salt intake restriction- Ineffective •Decrease BMI if overweightRecommendations which May Impact Hypertension in Pregnancy•Extend health services up to 12 month PP •Enhance prenatal screening •Improved patient education & advocacy •Connect patients to resources •Earlier PP access •Target health program for @ risk populations-Black womenInternal Fetal Monitoring-Accurate HR monitor -If baby is higher risk or it's difficult to detect their HR, if mother is doing trial of labor -Increases RF infection -CI: if an infection is presentFetal Assessment During Labor•Anticipated effect was a decrease in cerebral palsy •Believed to be more sensitive than auscultation in predicting fetal compromiseFetal response for monitoring•Labor is a period of physiologic stress for fetus •Frequent monitoring of fetal status is part of nursing care during labor •Fetal oxygen supply must be maintained during labor to prevent fetal compromiseFetal oxygen supply can decrease:•Reduction of blood flow through maternal vessels as result of: -Maternal hypertension: chronic or pregnancy-induced hypertension -Hypotension caused by supine maternal position, hemorrhage, epidural analgesia, or anesthesia -Hypovolemia caused by hemorrhage -Reduction of oxygen content in maternal blood as result of hemorrhage or severe anemia -Alterations in fetal circulation with compression of umbilical cord -Reduction in blood flow to placenta.Basis of Fetal Heart Rate Regulation-Parasympathetic branch -Sympathetic branch -Baroreceptors -Chemoreceptors -Hormone regulationExternal Fetal Monitoring-Animal models suggest that cord occlusion leads to intrapartum asphyxia and cerebral palsy -Anticipated outcome of fetal heart rate monitoring -Screening & Diagnosis for intrapartum asphyxiaImportant result of electronic technology-Conversion of an auditory signal into visual waveform -Creation of a continuous visual pattern of the FHR permanently recorded on paperIndications for EFM1. Need to assess the fetal well being 2. Need to assess uterine activityCommon Indications for EFM:•Diabetes class B or higher •Chronic Hypertension •Intrauterine growth restriction •Maternal renal disease •History of fetal demise •Oligohydramnios •Decreased fetal movements •Preterm contractions •History of preterm deliveries •Labor or they think they're in labor •InductionAssessment of FHR is Systematic:1. Baseline rate 2. Variability 3. Periodic FHR changes (with ctx) 4. Non periodic FHR changes (without ctx) 5. Uterine activity 6. Accelerations 7. Decelerations if present *Accompanying clinical characteristics *UrgencyFetal HR tracing meaning-thick lines: 1 minute -One horizontal box: 10 seconds -One vertical box: 10 beatsFHR Baseline•Heart rate range that occurs between contractions •Mean rate in 10 min period •Normal: 110-160 BPM •Bradycardia- Baseline rate of < 110 BPM •Tachycardia- Baseline rate of > 160 BPM •Change in Baseline: change in rate that occurs greater than 10 minutesFHR Bradycardia: Causes•Medication •Viral infection •Heart failure •Maternal Hypoglycemia •Maternal Hypothermia •Prolapse cord •Uterine rupture/Placental abruption •Clinical Significance: Depends on underlying cause, oxygenation •Nursing Intervention: Depends on cause -IV fluids, Oxygenate mom, UA, blood draw to look for infectionsFHR Tachycardia: Causes•Can be early sign fetal hypoxia •Maternal fever •Fetal Anemia •Chorioamnionitis •Medications & drugs •Clinical Significance: Depends on underlying cause •Nursing Intervention: Depends on causeBaseline FHR variability•One of the most important indicators of fetal well-being •Requires mature fetal neurological system •Fluctuation of baseline FHR of 2 cycles/min or greater •Exception: sinusoidal pattern(ominious)AMPLITUDE RANGEUNDETECTABLE > UNDETECTABLE < 5 BPM 6-25 BPM > 25 BPMFHR Variability: decrease causes•Hypoxia and acidosis •Medications (ex: Narco) •Anticipated causes: •Prematurity •Fetal Sleep •Clinical Significance: Persistent minimal or absent variability with persistent decelerations is ominous. •Nursing Intervention: Depends on cause, Position Changes, Acoustic stimulator (Scalp stim in labor), hydration or foodFHR Variability-ABSENT: undetectable (baby's stressed, neuro system impacted) -Minimal: </=5 bpm (stay within 10 boxes) -Moderate: 6-25 bpm -Marked: > 25 bpm (more is not better, fetal anemia, no accels/deccels)Sinusoidal patternsmooth wave-like pattern of regular frequency and amplitude *may be due to medsFHR Accelerations•Accelerations: visually apparent abrupt increase in FHR above baseline -Abrupt- Onset to peak< 30 seconds: Calculated using most recently determined baseline rate -Acme is: > 15 bpm above baseline and lasts > 15 seconds (15 x 15 rule) -Also: < 2 minutes from the onset to return to baseline *less than 32wks (10x10)FHR Accelerations: causes•Fetal Movement •Vaginal Exam •Uterine contraction •Fetal reaction to external sounds •Palpations •Clinical Significance: Normal pattern and reassuring- signifies fetal well being •Nursing Intervention: NONE requiredFHR Decelerations: late vs earlyLate: Gradual onset: > 30 seconds from onset to nadir; delayed in timing-after peak of ctx *oxygenation Early: Gradual onset: > 30 sec from onset to nadir; nadir simultaneous with peak of ctx *head squeezedFHR Decelerations: variable vs prolonged-Variable: Abrupt onset: < 30 sec from onset to nadir, lasting > 15 sec but < 2 min; depth > 15 bpm *cord -Prolonged: Decrease of > 15 bpm lasting > 2 minutes but less than 10 minutesEarly decelerations-deceleration is coincident in timing with nadir occurring at the same time as the peak of the contraction -most cases the onset, nadir, and recovery are coincident with the beginning, peak, and end of the contraction -"Mirror images"Consider uterine contraction pattern periodic-Hypotonic: increase and prolonged period of rest -Tachysysole: too many contractions back to back *contractions too close together: RF uterine rupture, not enough rest period, increase RF PP hemorrhageFHR Early Decelerations: causes•Head Compression •Uterine contractions •Vaginal Exam •Fundal Pressure: pushing on abd area •IUPC/FSE: internal monitoring •Clinical Significance: -Normal Pattern: no abnormal association •Nursing Intervention: NONE required, just documentVariable Decelerations-visually apparent abrupt decrease below FHR baseline -Abrupt: defined as onset of deceleration to the beginning of the nadir of the deceleration < 30 seconds -decrease using most recently determined baseline FHR -deceleration is > 15 bpm below baseline, lasts > 15 seconds and < 2 minutes from onset to return to baseline -when associated with contractions the onset, depth, and duration commonly vary with successive contractionsFHR Variable Decelerations: causes•Cord compression: Positional, Knot, Prolapse**, AFI** •Clinical Significance: Occur in nearly 50% of all laboring patients, Depends on cause ** Nursing Intervention: •Maternal position changes: put on side •Discontinue pitocin •O2 •Vaginal exam (check cervix for a cord) •Amnioinfusion if appropriate •Delivery if indicatedProlonged deceleration-visually apparent decrease in FHR below the baseline rate -decrease using most recently determined baseline FHR -deceleration is a decrease of > 15 bpm, lasts > 2 minutes but less than 10 minutes -deceleration > 10 minutes is a baseline changeLate Decelerations•gradual decrease and return to baseline FHR associated with a contraction -gradual = onset of deceleration to nadir > 30 seconds -decrease calculated using most recently determined baseline -delayed in timing, nadir occurring after peak of contraction -in most cases the onset, nadir, and recovery are after the beginning, peak, and end of contraction -Usually symmetricalFHR Late Decelerations: causes•Uteroplacental Insufficiency- DM, Pre-eclampsia, Epidural, Infection, Uterine tachysystole, placenta previa, abruption, IUGR, placental age or affected by disease •Clinical Significance: Abnormal pattern associated with fetal hypoxia, acidemia and low Apgar scores •Nursing Intervention (not exclusive) 1st priority- -Maternal position change (least invasive first) -Discontinue pitocin (systemic) •IV fluids: to hydrate muscle to decrease contractions and relax uterus •O2 •Notify physician/ provider: usually leads to delivery via c-sectionFHR Combination Decelerations•Not all decelerations will match precisely with the defined criteria •Choose the one definition that most closely approximates the FHR pattern displayed •Some 10-20 minute segments may have two or more types: identify each type of deceleration appropriately.Recurrent vs. Persistent-Decelerations are defined as recurrent if they occur with > 50% of uterine contractions in any 20 minute segment -Persistent has been used in the past to describe repetitive FHR patterns but has not been precisely defined and therefore not recommended to use.Category I: NormalStrongly predictive of normal acid base status at the time of observation. Routine care RN: just documentCategory II: IndeterminateNot predictive of abnormal fetal acid base status, but requires continued surveillance and reevaluation -RN: intervention, O2, stop pitocin, most moms are hereCategory III: Abnormal-Predictive of abnormal fetal acid base status at the time of observation. -Depending on the clinical situation, efforts to expeditiously resolve the underlying cause of the abnormal fetal heart rate pattern should be made. *may be leading to delivery Absent variability, PLUS one of the below: ·Recurrent late ·Recurrent variables ·BradycardiaNon Stress Test-Normal fetus will produce characteristic heart rate patterns -Average baseline variability with accelerations in response to fetal movement is reassuring -No contraindications noted -Non-invasive, on monitors for 20 - 30 minutesNST Interpretation* Reactive -20 minutes (or 40 minutes: prolonged) -2 or more FHR accels above baseline of at least 15 bpm lasting at least 15 sec in 20 min -baseline rate with in normal range (110-160) -variability * Nonreactive test -Absence of any of the above -No accelerations of FHR during testing period -Nonreactive or inconclusive NST can be caused by fetal sleep -Indicates need for continued monitoring (20-40 min), juice, use of acoustic stimulation, repeat NST in several hours or further evaluation (ie. BPP, CST, prolonged monitoring)VEAL CHOPVariable ---> Cord Early ---> Head Accel ---> Ok Lates ---> PerfusionThe Five P's:-Passenger -Passageway -Powers -Position -Psychology#1 Passenger: FetusSize of the fetal head: •Bones in the fetal skull •Fontanels •Molding Presentation of the fetus: the part of the fetus that enters the pelvic inlet first and leads through the birth canal during labor: •Cephalic •Breech •Shoulder Fetal lie: the relation of the long axis (spine) of the fetus to the long axis (spine) of the mother •Longitudinal or vertical (ideal) •Transverse •Oblique Fetal attitude: the relation of the fetal body parts to one another •General flexion •Critical measurements of fetal head •Biparietal diameter •Suboccipitobregmatic diameter Fetal position: the relationship of a reference point on the presenting part to the four quadrants of the mother's pelvis •Position is denoted by a three-part letter abbreviation Fetal station: a measure of the degree of descent of the presenting part of the fetus through the birth canal Fetal engagement: usually corresponds to 0 station#2 Passageway: Birth Canal•Bony pelvis: 4 types -Gynecoid: optimal -Android: 2nd best -Anthropoid -Platypelloid: least optimal •Soft tissues#3 Powers•Primary powers: contractions -Frequency, duration, intensity -Effacement -Dilation -Ferguson reflex: the uncontrollable urge to push the baby out, happens when baby's head pushes down on pelvic floor •Secondary powers: bearing-down efforts: Valsalva maneuver#4 Positionmaternal position for labor and birth#5 Psychology-fear tension cycle -safety peace cycleProcess of Labor: Labor•process of moving fetus, placenta, and membranes out of the uterus and through the birth canal Signs preceding labor (Box 13.1). •Lightening: when the baby starts to drop •Bloody show & increased vaginal discharge •Backache •Urinary frequency •Energy surge •Weight loss (1-3.5 lbs) •Cervical ripening •?Rupture of Membranes: ~9cm •Onset of labor: Cannot be ascribed to a single causeStages of labor-First stage: •Latent (Early) phase •Active phase •Transition phase -Second stage -Third stage -Fourth stageMechanism of laborTurns and adjustments necessary in human birth processSeven cardinal movements of mechanism of labor1.Engagement 2.Descent 3.Flexion 4.Internal rotation 5.Extension 6.Restitution and external rotation 7.ExpulsionPhysiologic Adaptation to Labor: Fetal HR•Fetal heart rate (FHR): reliable and predictive information about the condition of the fetus related to oxygenation •Normal 110-160 beats/min. •Early decelerations and spontaneous accelerations •Normal variability. •Fetal circulation: Affected by maternal position, uterine contractions, condition of placenta & cord. •Fetal respirationPhysiologic Adaptation to Labor: Fetal respirations•Lung fluid cleared •Fetal PO2 oxygen pressure decreases •Fetal PCO2 increases •Arterial pH decreases •Bicarbonate level decreases •Fetal respiratory movements decrease.Maternal adaptation•Woman exhibits both objective and subjective symptoms •Cardiac output: increases by 10-15% in first stage, 30-50% in second stage. •Heart rate increase slightly in first and second stage. •Blood pressure: May increase during contractions with a return to baseline in between •White blood cell count increases •Respiratory rate increases •Temperature may be slightly elevated. •Proteinuria may occur •Gastric motility is decreased; mom may experience nausea and vomiting in transition/second stage. •Blood glucose decreasesPlane of pelvic inletThe diameters at the plane of the pelvic inlet, the midpelvis, and the outlet plus the axis of the birth canal determine whether vaginal birth is possible and the manner in which the fetus passes down the birth canal.Stages of labor: start and end-The first stage of labor lasts from the time dilation begins to the time when the cervix is fully dilated. -The second stage of labor lasts from the time of full cervical dilation to the birth of the infant. -The third stage of labor lasts from the infant's birth to the expulsion of the placenta. -The fourth stage of labor begins with the delivery of the placenta and includes at least the first 2 hours after birth.First Stage of Labor•Begins with regular uterine contractions •Ends with full cervical effacement (0-100%) and dilation (0-10cm) •Obstetric triage and EMTALA ("Legal Tip"): laboring women is given care •Maternal Fetal Triage IndexAdmission Care Management: labor-Assessment: True vs. false labor -Prenatal Data: •Records on file •Birth plan •Psychosocial •History & concerns -Interview: Key questionsPhysical Exam•Head to toe assessment (General Systems) •Vital signs (Table 16.2) Early: •Maternal BP, pulse, respirations, Fetal heart tones, uterine contractions, maternal tolerance every 30 mins. •Temperature every 2-4 hours •Vaginal exam as needed. Active & Transition •Maternal BP, pulse respirations, fetal heart tones, uterine contractions, maternal tolerance every 15-30. •Temperature every 2-4 hours •Vaginal exam as needed.1st stage of labor assessment•General systems assessment •Vital signs •Leopold maneuvers (abdominal palpation): Box 16.5 •Assessment of FHR and pattern Laboratory and diagnostic tests •Analysis of urine specimen: looking for protein in urine •Blood tests: Complete blood count (CBC): H&H and platelets (assess for anemia) •Human immunodeficiency virus (HIV) status is undocumented •Hepatitis B •RPR: syphallis •Type and screen Assessment of amniotic membranes and fluid •Nitrazine (pH from vaginal fluid, recent sex can lead to false positive) & Fern Test (sample under microscope): document color, odor, date and time water broke and if particulate mater was present •Other tests:If GBS status unknown, rapid test can be performed1st stage of labor RN care•Standards of care •Signs of complications (Box 16.7) •Physical nursing care during labor: General hygiene, Nutrient and fluid intake (Oral intake or Intravenous intake) Elimination: •Voiding: at least every 2 hours •Catheterization •Bowel elimination •Ambulation and positioningEvidence Based Care in Labor in Birth (Healthy Birth Practices)§Let Labor begin on its own §Move as is comfortable during labor §Continuous, high quality labor support §Avoid routine interventions §Use spontaneous, non-directed pushing §Keep mom and baby togetherLabor Pain§Physiology §Culture §Anxiety §Previous experience §Gate Control Theory §Comfort §Environment. §Assessment of pain in labor.Non Pharmacologic Modalities-Position Change -Urination -Relaxation -Environment -EncouragementPharmacologic Pain management-Sedatives: Barbituates Phenothiazines Benzodiazepines -Systemic Analgesia: Opioid agonists Opioid agonist-antagonists -Nerve Block Analgesia and Anesthesia: Local perineal infiltration (Lidocaine) Pudendal Spinal EpiduralRegional Anesthesia: RN procedures•Communicate with anesthesia •Check platelets •Fluid bolus per protocol/order •Obtain supplies •Baseline VS and FHT •Position woman •Frequent VS after initiation •Have ephedrine or phenylephrine ready (p. 348) •Reposition every 1-2 hours-peanut ball!Regional Anesthesia: Epidural (AE and risks)AE: •Inadequate pain relief or hot spot. •Hypotension and decreased placental perfusion •Urinary retention •Itching Risks: •Immobility •Hypotension/sedation •Respiratory arrest (high epidural) •Fever unrelated to infection •Operative vaginal birth •Medication reactions •InfectionSecond Stage of Labor•Infant is born •Begins with full cervical dilation (10 cm) •Complete effacement •The "pushing" stage •Ends with infant's birth *at 10cm with no urge to push lay them on side to rest until urge returnsSecond Stage of Labor: phases•Latent: relatively calm with passive descent of baby through birth canal (lay on left side) •Active: pushing and urge to bear down -Ferguson reflex: the urge to "bear down"Preparing for birth: RN•Maternal position: Supine, semi recumbent, or lithotomy positions are still widely used in Western societies despite evidence that an upright position shortens labor. •Bearing-down efforts -Valsalva maneuver - Avoid this! -Open glottis vs. closed glottis pushing •Fetal heart rate and contraction pattern -Every 5-10 mins •Maternal vital signs -Every 5-30 minutes •Effectiveness of pushing -Every push •Bloody show (mucus with blood) or vaginal distention, maternal response •Support of father or partner •Supplies, instruments, and equipmentBirth in a delivery room or birthing room•Lithotomy position: harder to push, mom flat •Crowning: see baby head •Ritgen maneuver: finger in the rectum •Nuchal cord: cord around baby neck, mom needs to stop pushing •Use of fundal pressure: contraindicated •Immediate assessments and care of newborn: moro reflex, lusty cry, immediate pink, 4 extremity flexedPerineal lacerations•First degree: laceration that extends through the skin and vaginal mucous membrane but not the underlying fascia and muscle •Second degree: laceration that extends through the fascia and muscles of the perineal body, but not the anal sphincter •Third degree: laceration that involves the external anal sphincter •Fourth degree: laceration that extends completely through the rectal mucosa, disrupting both the external and internal anal sphinctersThird Stage of Labor•Birth of the baby until the placenta is expelled (most dangerous time, RF hemorrhage) •The third stage is generally by far the shortest stage of labor •Usually expelled within 10 to 15 minutes after the birth; may be problematic if >30 minutes •Sudden gush of dark blood from the introitus •Apparent lengthening of the umbilical cord •Vaginal fullness •Placental examination and disposal •Cultural preferencesNursing Care in Third Stage•Assist mom to bear down when placenta is delivered •Administer oxytocin as ordered (active vs. passive management) •Provide pain medication •Provide hygiene •Provide explanation of procedures •Skin to skin!! •Facilitate bonding and breastfeedingFourth Stage of Labor•First 1 to 2 hours after birth •Assessment of maternal physical status •Vital signs q 15 mins for 2 hours •Fundal massage q 15 or if fundus is boggy •Check perineum, bladder, lochial flow. •Signs of potential problems -Excessive blood loss: Risk factors=large baby, grandmultiparity, induction, precipitous birth, multiples, polyhydramnios & postterm pregnancy. -Alterations in vital signs and consciousness •Care of the new mother •Care of the family: Family-newborn relationshipsTypes of pain during labor•Visceral pain: early labor, uterine contractions •Somatic Pain: stretching of tissues, vagina, pelvic floor pain •Referred Pain: back pain or any pain outside uterus or vaginaExpression of pain•Pain results in physiologic effects and sensory and emotional (affective) responses •Expressions of pain: crying, groaning, irritability, muscular excitability •Fear > Tension > Pain Cycle is key to understand. •Nurses must evaluate the woman's ability to cope with labor pain, not the fact that pain exists -Three R's - Rhythm, ritual, relaxation.Nonpharmacologic Pain Management•Provide sense of control over childbirth •Methods require practice for best results •Try variety of methods and seek alternatives,Cutaneous Stimulation Strategies: nonpharm-Counterpressure (back labor) -Effleurage (light touch massage) -Therapeutic touch and massage -Walking/Rocking -Changing positions (even with epidural) -Application of heat/cold -Transcutaneous electrical nerve stimulation (Figure 14.5) -Acupressure & Acupuncture -Hydrotherapy (nature's epidural) -Intradermal water block (Figure 14.7)Key Nursing Strategies for Labor Support•Provide companionship and reassurance •Positive reinforcement and praise •Encourage participation in nonpharmacologic methods •Provide fluids and nutrition as able •Assist with personal hygiene to facilitate comfort •Offer information and advice •Involve the birthing person in all decision making •Act as an interpreter for health care providers and, at times, partners. •Create a calm, relaxing environment. •Role model labor support for partners and families.Pharmacologic Pain Management: implementation•Should be implemented before pain becomes so severe •May use multiple methods as labor progresses •Pain vs. Suffering •Evaluating how the birthing person is coping is key to minimizing birth trauma.First Stage of Labor (Cervical Dilation and Effacement): pharm-Opioid agonist analgesics -Opioid agonist-antagonist analgesics -Epidural analgesia -Combined spinal/epidural analgesia -Nitrous oxideSecond Stage of Labor (Pushing and Birth of the Baby): pharm-Nitrous oxide Nerve block anesthesia and analgesia: -Local infiltration -Pudendal -Spinal (rare) -Epidural (rare) -Combined spinal/epidural (rare)•Sedatives•Purpose: Relieve anxiety and promote sleep. •Drug types: barbituates (secobarbital sodium or Seconal), phenothiazines (promethazine or Phenergan), benzodiazepines (diazepam or Valium) •Timing: Very early labor if labor is prolonged and mother is exhausted. •Nursing Considerations: Respiratory depression is a concern with barbituates and phenothiazides. Benzodiazepines can cause maternal amnesia. *rarely usedAnalgesia•Decreasing the sensation of pain, or raising the threshold for pain perception without loss of consciousness.Anesthesia•Pain perception is blocked by interrupting nerve pathways to the brain. May be partial or complete. Patient may be conscious or unconscious.Systemic Analgesia: Opioid Agonists•Purpose: To provide temporary pain relief and a sensation of euphoria. •Drug type: Opioid agonist analgesics: Morphine, fentanyl (Sublimaze), remifentanil (Ultiva) (See Medication Guides, Chapter 14). •Timing: Active labor (4-7 cms) *bc too late can slow labor down Nursing Considerations: •Usually given IV push or with a PCA Pump. •Opioid agonists may cause respiratory depression, sedation, N/V, dizziness, hypotension, tachycardia in mother •Cross placenta readily to cause decreased FHT variability and/or respiratory depression at birth. •Have naloxone ready if given close to time of birthSystemic Analgesia: Opioid Agonist - Antagonists•Purpose: To provide temporary pain relief and a sensation of euphoria. •Drug type: Opioid agonist antagoists : Butorphanol tartrate (Stadol); Nalbuphine (Nubain) (See Medication Guides, Chapter 14). •Timing: Active labor (4-7 cms). (short acting so gives mom ~1hr break and then labor support needed) Nursing Considerations: •Usually given IV push •Less risk of respiratory depression in both mother and fetus than opioid agonists. •May have limited analgesic effect due to the antagonist qualities of the drug. •May precipitate withdrawal in individuals with opioid dependenceNerve Block Analgesia and Anesthesia: Local Infiltration•Purpose: Repair of episiotomy or tear in person without regional block. •Drug type: Lidocaine or chlorprocaine 1% solution, 10-20 mL SQ • Know where supplies are kept! •Timing: Immediately prior to repair Nursing Considerations: •Check allergies •Provider to infiltrate and suture •May be repeated.Pudendal Block•Purpose: Analgesia in second stage if forceps or episiotomy are needed; for repair of episiotomy/laceration. •Drug type: Lidocaine or chlorprocaine 1% solution, 10-20 mL intravaginally to pudendal nerve bilaterally. Potential Complications: •Sciatic nerve damage •Medication reaction •Rectal perforation •Broad ligament hematoma •All Quite Rare!! •Timing: Late second stage or for repair after birth Nursing Considerations: •Check allergies •Does not cause hemodynamic changes in mom or fetus. •Provider to infiltrate. •Urge to push diminished.Nerve Block Analgesia and Anesthesia: Spinal•Usually used for c/section if no epidural is in place. •Block complete in 5-10 mins •Anesthesia for 1-3 hours. •Risk for spinal headache. •Local anesthetic alone or combined with opioid agonistNerve Block Anesthesia: Epidural•Typically for labor and vaginal birth. •Timing: after labor is well established, before transition. •Combination of local anesthetic + opioid agonist. •Catheter inserted through introducer and left in the epidural space. •Continuous infusion of medication duration of labor Or Patient controlled administration is possible.Nerve Block (Neuraxial) Anesthesia: Epidural RN care•Obtain informed consent. •Legal Tip Evaluate woman for contraindications: •Allergies to meds •Hemorrhage •Maternal hypotension •Coagulopathy •Use of anticoagulants •Infection or tattoo at injection site •Increased intracranial pressure •Maternal refusal or inability to cooperate. •Some maternal cardiac conditions.Neuraxial Anesthesia: Special ConsiderationsMaternal Obesity •Early initiation may be advised if potential for emergent c/section exists. •Catheter placement for epidural/spinal can be difficult •For weights >300 lbs, multiple placement attempts may occur •Catheter more easily dislodged. •Neuraxial anesthesia is preferred over general anesthesia.Nerve Block Anesthesia: Nursing Care (prior)•Assist with informed consent •Assess vital signs, FHT, labor pattern, hydration •IV start. Infuse bolus per protocol or order (500-1000 cc LR over 15-30 min): to prevent hypotension •Review and report H&H, platelets. •Assess pain level •Assist woman to void •Have vasopressors availableNerve Block Anesthesia: Nursing Care (during initiation)•Assist woman to proper position •Explain the procedure and assist her to remain calm •Monitor vital signs and document •Have oxygen and suction available Assess for sx of anesthetic toxicity: •Lightheadedness •Dizziness •Tinnitus •Metallic taste •Numbness of mouth/tongue •Bizarre behavior/slurred speech •Convulsions •Loss of consciousnessNerve Block Anesthesia: Nursing Care (while block is active)•Monitor VS and FHT per protocol (q 5 mins X 30 mins) •Do not leave room until stable and recovered. •Assess pain level & for "hot spots" •Monitor bladder •Change positions every hour •Safety! •Side rails up •Bed low •Call bell in reach •Educate client and family - no getting up •Monitor insertion site •Monitor skin integrity •See p. 354, AWHONN GuidelinesNerve Block Anesthesia: Nursing Care (as block wears off)•Assess motor/sensory function •Monitor VS •Bladder function •Monitor insertion site •If trained: remove catheter when ordered. •Safety: Siderails up, call bell in reach. Educate woman and family. •Up with assist X2 prior to ad lib.Side Effects of Neuraxial Anesthesia: maternal•Hypotension •Local anesthetic toxicity •Fever •Urinary retention •Pruritis •Limited movement •Longer second stage labor •Increased use of oxytocin •Increased likelihood of forceps or vacuum •High or total spinal anesthesiaSide Effects of Neuraxial Anesthesia: fetal•In the case of maternal hypotension, decreased placental perfusion and non-reassuring FHR. •No evidence of impact on child's later neurologic development.Nitrous oxide•50:50 mix of oxygen and nitrous oxide •Decreases sensation of pain and provides euphoric feeling. •Side effects: Nausea, dizziness •Safe for mother and fetus; rapid acting, does not accumulate in tissues •Self-administered only •May be used during repair of laceration. *no RF resp depressionGeneral Anesthesia•Used rarely for vaginal births •Infrequently for elective cesarean section (6%) •Indications: Rapid birth due to maternal or fetal compromise; inability to initiate neuraxial anesthesia. Nursing Considerations: •Start IV with 18G infusion device •NPO status •Maintain woman in left tilt position (wedge under hip) •Administer oral antacid (sodium citrate/citric acid) -OR H2 receptor antagonist (Pepcid) -OR Metoclopromide (Reglan) as ordered. •Preoxygenate: 100% O2 for 2-3 mins •Intubation and placement of endotracheal tube: Cricoid pressure •Inhalation anesthesia •Rapid delivery of the baby: NICU needed •Post anesthesia care: Airway management, pain control, vital sign stabilization.General Anesthesia: complications•Fetal depression: Depth and duration •Uterine relaxation:Hemorrhage •Potential for chemical pneumonitis-after: Decrease in GI motility and acidic gastric secretionsLow birth weight: preterm birth-describes only birth weight: -2500 g or less -Easier to measure than preterm birth -Preterm birth is more dangerousAt RF preterm birth•Non white •< 15 yrs old or >35 yrs old •Low socioeconomical status •Unmarried •Less than high school education •Poor nutrition, smokersPredicting preterm labor and birth: Biochemical markers•fetal fibronectin- (24-34 6/7wk) •Salivary estriol •Cost of determining biochemical markers is high •Higher NEG predictive value •False +/ False - •Endocervical length- > 30mm (3cm) before 34wk •HUAMEtiology of preterm labor and birth•No identifiable risk factors •Infections- periodontal, UTI •Pregnancy Complications •Sociodemographic factors** •25% Indicated due to complications •25% PPROM: preterm premature rupture of membrane (water breaks) •50% Preventable **Preterm RN care management•Preventive strategies to address risk factors: Hydroxyprogesterone caproate (can lengthen pregnancy) •Education about early symptoms of PTL Resources for: •Poverty •Lack of education •Lack of support •Access to PNC •Domestic Violence •StressEarly Identification and diagnosis: for preterm labor•Gestational age between 20 and 37 weeks •Uterine activity (contractions)- Sx review •Obstetrical History •Defined as: Progressive cervical change -Effacement of 80% -Cervical dilation of 2 cm or greaterLifestyle modifications - EDUCATION to prevent PTL•Nothing per vagina • Minimize riding long distances in car •Do not carrying heavy loads •Do not standing more than 50% of time •No heavy housework or climbing stairs •No hard physical work •Must have adequate restBed rest and home care to prevent PTLBed rest: •Commonly used for prevention of preterm birth •Not a benign intervention •No evidence to support effectiveness in reducing preterm birth rates •ACOG statement -single course steroid; MgSo4 <32 wk neuro; 1st line tocolytics (Procardia) Home care: •Modify environment for conveniences •Home uterine activity monitoringSuppression of uterine activity: Tocolytics•Time to administer antenatal glucocorticoids •Accelerate fetal lung maturity •Reduce severity of sequelae in preterm births •Common meds-Terbutaline (CI if have heart condition), Magnesium sulfate, Indocin (max 2 or 3 doses, RF after 37wk closure of ductus arteriosus) (<32wk) & Procardia •Common side effects: HA, facial flushing, bleed, tachycardia •Adverse effects- RR depression, toxicity sx •Considerations: cardiac (check pulse), respiratory concernsPromotion of fetal lung maturity•Antenatal glucocorticoids -Betamethasone •NIH recommends for all women at risk for preterm-24-34wks (12mg IM q 24 x 2 dose) •Consideration: Increased risk of contractions and elevated BG Contraindicated: •Cord prolapse •Chorioamnionitis •Abruptio placentae •PPROM (generally not rec)Management of inevitable preterm birth•Cervical progress- >/=4cm •Prefer tertiary care facility for maternal/fetal outcomes •Transferred quickly once identified •First dose of glucocorticoids to be given before transferPremature Rupture of Membranes (PROM)•Rupture of amniotic sac and leakage of amniotic fluid beginning at least 1 hour before onset of labor at any gestational age •ROM before 37 weeks of gestationPremature Rupture of Membranes (PROM): dx and RN care•Etiology: Existing infection or can be unknown •Diagnosed: + pooling (fluid in vagina); ph >6.0-6.5 positive nitrazine ; positive fern Nursing Considerations: •Home- <3cm with no s/sx infection, ctx or malpresentation • Hospital •Varying protocols •hydration •assess for infection: bc infection tends to set in 24 hrs after ruptureDystocia•Defined as long, difficult, or abnormal labor •Dysfunctional labor from abnormal uterine contractions preventing normal progress of: -Cervical dilation -Effacement (primary powers) -Descent (secondary powers)Dysfunctional labor: Risks•Body build (obesity/ short stature) •Uterine abnormalities •Maternal issues- fatigue, anxiety •Timing of analgesic or anesthetic meds •Malpresentation and position of fetus •Cephalopelvic disproportion (CPD) •Overstimulation with oxytocinDysfunctional labor: Maternal causes•Hypertonic or primary dysfunctional labor (anxiety/ 1st time mother) -Treat: Pain meds, Rest 4-6hr •Hypotonic or secondary uterine inertia (CPD/ malpositions): can't get a labor pattern established -Assess position, ambulate, augment •Pelvic dystocia: Disproportion of the pelvis •Soft-tissue dystocia: Results from obstruction of birth passage by an anatomic abnormality other than bony pelvis (Fibroids, bladder, bandl's ring) •Position of the woman ** (laying on their back) •Psychologic responses: Hormones & neurotransmitters released in response to stress can cause dystocia •Abnormal labor patterns -Patterns: Assessed by plotting cervical dilation & fetal descent on labor graph -Precipitous labor: <3 hrs from onset of contractions to birthFetal causes of dystocia•Anomalies •Fetal Macrosomia: big babies •CPD-cephalopelvic disproportion (head doesn't fit through the pelvis) •Malposition •Malpresentation •Multifetal pregnancySigns of Dystocia•Unengaged fetal head in early labor in primips •Hypotonic uterine contraction pattern •Deflexion of fetal head ; OP ('back labor') •Uncontrollable pushing before C/C; OP •Failure of fetal decent •Edema of anterior portion (lip) of cervixExternal Version: RN considerations•After 37 wks •NST •USG •Terbutaline: this will prevent uterine contractions; check pulse (under 120), CI if mom has heart condition •CI: Uterine anomalies, previous c/s, CPD, placenta previa, multifetus or oligo **Rhogam •ensure there's enough fluid to cusion baby •no scars on the uterus •pelvis compatable for vaginal birthDystocia- Nursing Care Management•Version: External cephalic version/ Internal Version •Trial of labor •Induction •Augmentation •FSE/ IUPC, Amniotomy, foley, position changes •Assisted vaginal delivery- FAVD/ VAVDInduction - cervical ripening methods•Chemical agents—prostaglandins -Cytotec (PGE1) (prostaglandin 25-50mcg Intravag q 3-6hr) ** cheap -Cervidil (PGE2)- 10mcg intravag x 12 hr (can come out) -Prepidil gel- 2.5mL posterior fornix q 6hr •Mechanical methods: Foley cath- foley bulb (manual thinning of cervix) (6-12hr), laminaria •Amniotomy: Timing, FHT check, Temp monitoringInduction- Pitocin•Hormone normally produced by posterior pituitary gland •Stimulates uterine contractions •Used to induce labor or augment a labor progressing slowly because of inadequate uterine contractions •Desire fetal descent, progressive cervical changesPitocin: special caution•Multifetal presentation •Breech presentation •Presenting part above pelvic inlet •Abnormal fetal heart rate •Polyhydramnios •Grand multiparity •Maternal cardiac diseasePitocin Management•Informed consent •Titrated- differing protocols •Increase pit 1-2mu every 30-60 min. • It takes 30-40 min to reach a steady state. • Max 20 mu/min •>200 MVU's in 10 min period= adequate ctx intensity using IUPC Always reassess fetal and uterine response!! •Pitocin Fetal management: •FHT assessment •Fetal monitoring - •Q 15 min 1st stage labor (book- q30) •Q 5min 2nd stage labor (book- q15)Pitocin Maternal management•Assessment- VSS •Monitoring- Toco, I&O, Cervical exam Emergency: Recurrent Late/ Recurrent Variable/Brady/Tachy •D/c pitocin per guidelines •Turn woman to left side •IV bolus 500cc LR •Abnormal FHT pattern -O2 8-10u/min •Terbutaline if tachysystole (and no CI)Augmentation of Labor•Stimulation of uterine contractions after labor has started but progress is unsatisfactory •** s/p Epidural •Implemented for management of hypotonic uterine dysfunction •Common augmentation methods -Oxytocin infusion -Amniotomy: allows labors to progress, increase prostaglandin production; labor needs to be progressing, RF cord prolapse -Nipple stimulation: causes natural oxytocin productionForceps-assisted Vaginal DeliveryMaternal indications: •Cardiac conditions •Shorten second stage in event of dystocia -Compensate for deficient expulsive efforts -** Assess pp hematoma, lacerations and urethra injuries Fetal indications •Distress or certain abnormal presentations •Arrest of rotation •Delivery of head in a breech presentation -** Assess for bruising, facial palsyForceps-assisted Vaginal Delivery: RN and Risks-Nursing consideration: Empty bladder- assure fetal head is engaged & assess FHT. INFORM patient of risks and need for FAVD. -RISK of a FAVD: Laceration of cervix , laceration of vagina and perineum, injury to bladder, fetal outcomes. -Assess ** mother and baby post FAVD for injuries. -** assess for hematoma lacerations, urethral injuries- BABY facial bruising abrasions, facial palsyVacuum-assisted birth•Attachment of vacuum cup to fetal head, using negative pressure to assist birth of head •Preferred to FAVD when lacerations/ episiotomy present •Monitor pop offs-</=3 •Prerequisites: -Vertex presentation -Ruptured membranes -Absence of CPDCesarean birth•Preserve life or health of mother & fetus •Indications -Scheduled cesarean birth: For contraindictionals for SVD or R C/s -Unplanned cesarean birth: FTP (failure to progress), emergencies •Ethical consideration: forced cesarean birth •Surgical techniques Skin vs uterus •Classic: Lower-segment •Complications and risks- infection, PPH •Anesthesia: Spinal, Epidural & general •emergency: vertical •Normal: low transverseCesarean on demandIn the absence of a medical reason, cesarean delivery at the request of the mother should not be used over planned vaginal delivery, according to a committee opinion from the American Congress of Obstetricians and Gynecologists (ACOG).Vaginal birth after cesarean•Termed TOL (trial of labor ) or TOLAC (trial of labor after cesarean section)- PRIOR to successful VBAC •Absence of previous risk •dystocia, breech presentation, or fetal distress often are nonrecurring Criteria: •Previous low transverse •incision •Adequate pelvis •No other uterine scars •No previous uterine rupturePostterm: maternal and fetal risks•Extension of pregnancy beyond the end of 42 wks Maternal risks: •Dysfunctional labor •Related to excessively large infant •PPH •Birth canal trauma •Interventions more likely to be necessary •Fatigue and psychological reactions Fetal risks: •Prolonged labor, shoulder dystocia, birth trauma, and asphyxia from macrosomia •Compromising effects on fetus of an "aging" placentaPostterm: RN care•Still controversial •Some suggest induction at 41 to 42 weeks •Others allow pregnancy up to start of 43 week •Nursing considerations •Fetal assessment- Twice weekly** •NST, BPP, FKC, Doppler- WNL (to assess blood flow) •AFV- desire ~ 5-25cm with deepest pocket 2cmShoulder dystocia•Head is born, but anterior shoulder cannot pass under pubic arch •Who is at risk: DM, no prenatal care, big babies Maternal risk: •excessive blood loss, lacerations, extension of episiotomy, or endometritis Newborn risk: •Birth injuries- brachial plexusShoulder dystocia: careBreath elevate calm apply enLarge Maneuvers: McRoberts expands and opens the pelvis *Never use fundal pressure*Prolapsed umbilical cord•When cord lies below presenting part of fetus •Contributing factors include: -Long cord (longer than 100 cm) -Malpresentation (breech) -Transverse lie -Unengaged presenting part (must know station and engagement) ***S/SX Nursing Considerations: * Remove pressure off presenting cord * Maternal position change: transbelinberRupture of the uterus•Very serious obstetric injury •Most frequent causes: -Separation of scar of previous classic cesarean birth -Uterine trauma: accidents, surgery, abuse -Congenital uterine anomaly •Nursing Considerations: Emergency, Emotional support- loss of fertilityRupture of the uterus: during labor and birth•Intense spontaneous uterine contractions •Labor stimulation: oxytocin, prostaglandin •Overdistended uterus: multifetal gestation •Malpresentation: external or internal version •Difficult forceps-assisted birth •Trial of labor for previous c/s •More often in multigravidas than primigravidasAmniotic fluid embolism