Professional Documents
Culture Documents
Maternal Midterm
Maternal Midterm
Objectives:
1. Describe sudden complications of pregnancy that
place a pregnant woman and her fetus at high
risk.
2. Assess a woman who is experiencing a
complication of pregnancy.
3. Formulate nursing diagnoses that address the
needs of a woman and her family experiencing a
complication of pregnancy.
4. Identify expected outcomes to minimize the risks
to a pregnant woman and her fetus when a
sudden complication of pregnancy occurs.
5. Using the nursing process, plan nursing care.
3
Objectives:
6. Implement nursing care specific to a woman
who has developed a sudden complication of
pregnancy,
7. Evaluate expected outcomes for effectiveness
and achievement of care.
8. Integrate knowledge of complications of
pregnancy with the interplay of nursing process.
4
BLEEDING DURING
PREGNANCY
5
Threatened Miscarriage
• Symptoms:
1. Vaginal bleeding
➢Initially scant, bright red
2. Slight cramping
3. No cervical dilation
• Diagnostic tests:
1. Ultrasound
2. Blood test for hCG and is repeated in 48 hrs.
➢↑hCG means placenta is still intact.
16
Threatened Miscarriage
• Interventions:
1. Avoid strenuous activity for 24 – 48 hrs.
2. Restrict coitus for 2 wks.
17
Complete Miscarriage
Incomplete Miscarriage
• Part of the conceptus (usually the fetus) is
expelled, but the membrane or placenta is
retained in the uterus.
• Intervention:
1. D & C
2. Suction curettage
20
Missed Miscarriage
• Fetus dies in utero but is not expelled.
• Symptoms:
1. No increase in fundal height
2. FHS cannot be heard
3. May have had symptoms of
threatened miscarriage
• Interventions:
1. D & E
2. If pregnancy is ↑14 wks. Labor may
be induced by:
• Prostaglandin suppository or
misoprostol to dilate the cervix
• Oxytocin is administered
to stimulate uterine contraction
21
Complications of Miscarriage
1. Hemorrhage
➢Therapeutic Management:
1) Monitor V/S
2) Position the woman flat and massage the
uterine fundus to aid in contraction if
there is excessive bleeding.
3) D & C may be needed to
empty the uterus.
4) Blood transfusion may be
necessary to replace blood
loss.
22
Complications of Miscarriage
2. Infection (endometritis)
• Signs:
1) Fever
2) Abdominal pain or tenderness
3) Foul vaginal discharge
• Causative organism:
➢Escherichia coli (spread from the rectum
into the vagina).
23
Complications of Miscarriage
2. Infection (endometritis)
• Therapeutic management:
1) Antibiotic (Clindamycin)
2) Oxytocic agent (methylergonovine)
➢To encourage uterine contraction
3) Analgesic for abdominal discomfort.
4) Sitting in a Fowler’s position or walking
➢Encourages lochia drainage by gravity.
5) Wear gloves when helping the woman
change her perineal pads.
6) Use good handwashing techniques before &
after handling the contaminated pads.
24
Complications of Miscarriage
3. Septic Abortion
➢Abortion that is complicated by infection.
➢Occurs in women who tried self-abortion or
were aborted illegally using a non-sterile
instrument.
➢Therapeutic management:
1) Monitor urine output/hr. to assess kidney
function.
2) IVF is started to restore fluid volume
3) Broad spectrum antibiotic is started
• Penicillin (gm+), gentamicin (gm- aerobic),
Clindamycin (gm- anerobic)
4) TT and TIG is ordered for prophylaxis of tetanus
5) D & C will be performed.
25
Ectopic Pregnancy
• Implantation occurs outside
the uterine cavity.
• Sites of implantation:
1. Fallopian tube (most common)
2. Surface of ovary
3. Cervix
• Predisposing factors:
1. Smokers
2. Use of IUDs
3. Following in vitro fertilization
4. Who had 1 ectopic pregnancy
26
Ectopic Pregnancy
• Diagnostic tests:
1. Ultrasound
2. MRI (magnetic resonance imaging)
• Signs & Symptoms:
1. Sharp, stabbing pain in one of her lower
abdominal quadrants at the time of rupture
(6 – 12 wks. AOG).
2. Scant vaginal spotting
3. If internal bleeding progresses to acute
hemorrhage, a woman may experience:
➢Lightheadedness
➢Rapid pulse
➢Signs of shock
27
Ectopic Pregnancy
• Assessment findings:
1. Falling hCG or serum progesterone level
2. Rigid abdomen from peritoneal irritation
3. Umbilicus may develop a bluish tinge
(Cullen’s sign)
4. Movement of cervix on pelvic exam may
cause excruciating pain.
5. Pain in the shoulders from blood in the
peritoneal cavity causing
irritation to the phrenic nerve.
6. Tender mass palpable in
Douglas’ cul-de-sac on
vaginal exam.
28
Ectopic Pregnancy
• Therapeutic Management:
1. For unruptured ectopic pregnancy:
1) Methotrexate
➢Attacks and destroy fast-growing cells.
➢Treatment is continued until hCG titer is
negative.
2) Mifepristone
➢Cause sloughing of the tubal implantation
site.
29
Ectopic Pregnancy
• Therapeutic Management:
2. For ruptured ectopic pregnancy:
1) IVF with large-gauge catheter to restore
intravascular volume (19 gauge needle)
2) Blood transfusion can be started after
cross-matching
3) Laparoscopy
➢To ligate the bleeding vessels
➢To remove or repair the damaged fallopian tube.
4) Women with Rh-negative blood should receive
Rh (D) immune globulin (RhIG) after ectopic
pregnancy for isoimmunization protection in
future childbearing.
30
GESTATIONAL TROPHOBLASTIC
DISEASE (Hydatidiform Mole)
• Signs & Symptoms:
1. Rapid increase of uterine size
2. No FHT is heard
3. Level of hCG continue to be strongly (+)
after day 100 of pregnancy (1 – 2 milli-IU)
4. Marked nausea & vomiting due to high hCG.
5. Symptoms of PIH:
1) Hypertension
2) Edema
3) Proteinuria
6. Vaginal spotting of dark brown blood
accompanied with clear fluid-filled vesicles.
35
GESTATIONAL TROPHOBLASTIC
DISEASE (Hydatidiform Mole)
• Therapeutic Management:
1. Suction & curettage
2. Pelvic exam, chest X-ray, and a serum test for
hCG
3. Level of hCG is analyzed every 2 wks. until
normal; reassessed every 4 wks. For 6 – 12
months thereafter.
4. Health care providers usually will continue to test
hCG levels after a pregnancy loss to ensure they
return back to <5.0.
5. A contraceptive method is used for 12 months.
6. Methotrexate may be prescribed for
prophylaxis.
36
Placenta Previa
• Therapeutic Management:
• Immediate Care Measures:
1. Place woman immediately on bed rest on a
side-lying position.
2. Assess for the following:
➢Duration of pregnancy
➢Time the bleeding began
➢Woman’s estimation of the amount of blood
➢Accompanying pain if any
➢Color of the blood
50
Placenta Previa
• Therapeutic Management:
• Immediate Care Measures:
1. Place woman immediately on bed rest on a
side-lying position.
2. Assess for the following (continued…)
➢Woman’s actions to halt bleeding, if any.
➢Any prior episodes of bleeding during the
pregnancy.
➢Prior cervical surgery for premature cervical
dilatation
3. Inspect the perineum for bleeding.
51
Placenta Previa
• Therapeutic Management:
• Immediate Care Measures:
4. Determine vaginal blood loss by weighing
perineal pads before and after use.
5. Identify the origin of the blood (maternal or
fetal) through Apt or Kleihauer-Betke test
(test strip procedures)
• is a blood test used to measure the amount of fetal
hemoglobin transferred from a fetus to a
mother's bloodstream.
• It is usually performed on Rh-negative mothers to
determine the required dose of Rho(D) immune globulin
(RhIg) to inhibit formation of Rh antibodies in the mother
and prevent Rh disease in future Rh-positive children.
52
Placenta Previa
• Therapeutic Management:
• Immediate Care Measures:
• Rho(D) immune globulin (RhIg)
• Administer 1 syringe (1,500 units) at
approximately 26 to 28 weeks' gestation,
followed by another full dose, preferably within
72 h following delivery, if the infant is Rh
positive.
53
Placenta Previa
• Therapeutic Management:
• Immediate Care Measures:
Placenta Previa
• Therapeutic Management:
• Immediate Care Measures:
10. Begin IVF therapy
11. Attach an external fetal monitor and begin
recording FHT and uterine contractions.
12. Blood test for:
• Hemoglobin
• Hematocrit
• Prothrombin time, partial thromboplastin time,
fibrinogen, platelet count
• Blood type and cross-matching
• Antibody screen
55
Placenta Previa
• Therapeutic Management:
• Immediate Care Measures:
13. Determine the placental location for
possible vaginal delivery through
ultrasound.
14. Vaginal exam is done in an operating
room.
15. Have O2 equipment available.
56
Placenta Previa
• Therapeutic Management:
• Continuing Care Measures:
16. If labor has begun, bleeding is continuing,
or the fetus is being compromised, birth
must be accomplished regardless of
gestational age.
17. Woman remains in the hospital on bed
rest for close observation for 48 hrs.
18. Betamethasone may be prescribed for the
mother to encourage the maturity of fetal
lungs if the fetus is less than 34 wks.
PREMATURE SEPARATION OF THE
PLACENTA
(ABRUPTIO PLACENTA)
• Premature separation of the placenta (abruptio
placentae)
• placenta appears to have been implanted correctly.
Suddenly, however, it begins to separate and bleeding
results.
• is the most frequent cause of perinatal death (Ananth,
Lavery, Vintzileos, et al., 2016).
• The separation generally occurs late in pregnancy; even
as late as during the first or second stage of labor.
PREMATURE SEPARATION OF THE
PLACENTA (ABRUPTIO PLACENTAE)
• Always be alert to both the amount and kind of
pain and vaginal bleeding a woman is having in
labor.
• The primary cause:
• Unknown
• Predisposing factors:
1. high parity
2. advanced maternal age
3. short umbilical cord
PREMATURE SEPARATION OF THE
PLACENTA (ABRUPTIO PLACENTAE)
• Predisposing factors:
4. chronic hypertensive disease
5. hypertension of pregnancy
6. direct trauma (as from an automobile accident or
intimate partner violence)
7. vasoconstriction from cocaine or cigarette use
8. thrombophilic conditions that lead to thrombosis
formation (Boisramé, Sananès, Fritz, et al., 2014)
PREMATURE SEPARATION OF THE
PLACENTA (ABRUPTIO PLACENTAE)
• Predisposing factors:
9. chorioamnionitis or infection of the fetal membranes
and fluid (Hackney, Kuo, Petersen, et al., 2016).
10. rapid decrease in uterine volume, such as occurs
with sudden release of amniotic fluid as can happen
with polyhydramnios.
o Usually, the fetal head is low enough in the pelvis that when
membranes rupture, this prevents loss of the total volume of
the amniotic fluid at one time, so normally a rapid reduction
in amniotic fluid does not occur.
Assessment
1. sharp, stabbing pain high in the uterine fundus as
the initial separation occurs.
2. If labor begins with the separation, each
contraction will be accompanied by pain over and
above the pain of the contraction.
3. Tenderness can be felt on uterine palpation.
4. Heavy bleeding usually accompanies premature
separation of the placenta, although it may not be
readily apparent.
• External bleeding will only be evident if the
placenta separates first at the edges.
Assessment
5. If the center of the placenta separates first, blood
can pool under the placenta, and although
bleeding is just as intense, it will be hidden from
view.
• Whether blood is evident or not, signs of hypovolemic
shock usually follow quickly.
6. The uterus becomes tense and feels rigid to the
touch.
7. If blood infiltrates the uterine musculature,
Couvelaire uterus or uteroplacental apoplexy,
forming a hard, boardlike uterus occurs.
Assessment
8. As bleeding progresses, a woman’s reserve of
blood fibrinogen becomes diminished as her body
attempts to accomplish effective clot formation,
and DIC syndrome can occur.
▪ s/sx of Disseminated Intravascular Coagulation
✓ bleeding, bruising, low blood pressure, shortness of
breath, or confusion.
✓ blood clots may reduce blood flow and block blood
from reaching bodily organs resulting to multiple
organ failure.
Assessment
• If a woman is being admitted to the hospital after
experiencing symptoms at home, assess:
1. when the time the bleeding began
2. whether pain accompanied it
3. the amount and kind of bleeding,
4. if trauma could have led to the placental separation.
Assessment
• Initial blood work should include:
1. hemoglobin level
✓ Normal adult female = 12 – 16 gm/dl
2. typing and cross-matching
3. fibrinogen level and fibrin breakdown products to detect
DIC.
✓ normal level of fibrinogen in the blood = 1.5 to 3.0 grams per
liter
✓ D-Dimer is a fibrin degradation product. It is named as such
because it contains two cross-linked D fragments of the fibrin
protein.
Assessment
• D-dimer Range
• In Conventional Units: ≤ 250 ng/mL D-dimer units (DDU)
• In SI Units: ≤ 0.50 mcg/mL fibrinogen equivalent units
(FEU)
• Increased levels imply increased fibrinolysis and can be
seen in DIC and thrombotic states.
Types of Placental Separation
Grading of Placental Separation
Therapeutic Management
• Because of the threat to both the woman and the fetus,
separation of the placenta is immediately an emergency
situation (Heavey & Dahl Maher, 2015).
1. A woman needs a large-gauge intravenous catheter
inserted for fluid replacement.
2. oxygen by mask to limit fetal anoxia.
3. Monitor fetal heart sounds externally
Therapeutic Management
4. record maternal vital signs every 5 to 15 minutes to
establish baselines and observe progress.
5. The baseline fibrinogen determination will be followed
by additional determinations up to the time of birth.
6. Keep a woman in a lateral, not supine, position to
prevent pressure on the vena cava and additional
interference with fetal circulation.
Therapeutic Management
7. Do not perform any abdominal, vaginal, or pelvic
examination on a woman with a diagnosed or
suspected placental separation.
• It is important not to disturb the injured placenta any further.
8. Unless the separation is minimal (grades 0 and 1), the
pregnancy must be ended because the fetus cannot
obtain adequate oxygen and nutrients.
Therapeutic Management
9. If vaginal birth does not seem imminent, cesarean birth
is the birth method of choice.
10. Intravenous administration of fibrinogen or
cryoprecipitate (which contains fibrinogen) can be used
to elevate a woman’s fibrinogen level prior to and
concurrently with surgery.
• If DIC has developed, cesarean birth may pose a grave risk
because of the possibility of hemorrhage during the surgery
and later from the surgical incision.
Fresh frozen plasma
1. Terbutaline
o is a drug approved to prevent and treat
bronchospasm but may be used as a tocolytic
agent (i.e., an agent to halt labor).
o should not be used for over 48 to 72 hours of
therapy because of a potential for serious
maternal heart problems and death.
o It should not be used in an outpatient or home
setting because its administration requires
constant professional assessment (Roman,
2013).
2. Magnesium sulfate,
o For fetal neuroprotection is used prior to 32
weeks to help prevent cerebral palsy in
premature infants (Nijman, van Vliet, Koullali,
et al., 2016).
3. Corticosteroid (betamethasone)
o the formation of lung surfactant appears to
accelerate, thus reducing the possibility of
respiratory distress syndrome or
bronchopulmonary dysplasia (Msan, Usta,
Mirza, et al., 2015).
3. Corticosteroid (betamethasone)
o If the pregnancy is under 34 weeks, a woman
may be given
▪ two doses of 12 mg betamethasone I.M. 24 hours
apart, or
▪ four doses of 6 mg dexamethasone I.M. 12 hours
apart.
Vasospasm
Decreased
Vasoconstriction Diffusion of fluid
glomeruli filtration
rate, increased from blood
permeability of stream into
glomeruli interstitial tissue
membranes
PATHOPHYSIOLOGY OF PIH (cont’d…)
Increased serum
Poor organ perfusion
blood, urea, Edema
nitrogen, Uric acid,
creatinine
RISK FACTORS:
1. Multiple pregnancy
2. Primiparas younger than 20 y.o. or older
than 40 y.o.
3. Women who have polyhydramnios
4. Low socioeconomic background
PREGNANCY-INDUCED HYPERTENSION
RISK FACTORS:
5. Women with underlying disease
• Heart disease
• Diabetes
• Essential hypertension
SIGNS & SYMPTOMS:
1. Hypertension
2. Edema
3. proteinuria
PREGNANCY-INDUCED HYPERTENSION
Gestational Hypertension
Bp 140/90 mmHg, or
Systolic Bp >30 mmHg; Diastolic > 15 mmHg
above pregnancy level
No proteinuria nor edema
Mild Preeclampsia
Bp 140/90 mmHg
Systolic Bp >30 mmHg; Diastolic > 15 mmHg
above pregnancy level
Proteinuria +1 to +2
Severe Preeclampsia
Bp 160/110 mmHg
Proteinuria: 3+ to 4+ on a random sample
Hepatic dysfunction
Severe Preeclampsia
cerebral edema
visual disturbances such as blurred vision or
seeing spots before the eyes may be reported.
severe headache
marked hyperreflexia
ankle clonus (i.e., a pulsed motion of the foot after
flexion).
Rating the ankle clonus:
• Mild = 2 movements; Moderate = 3–5 movements
Severe = Over 6 movements
PREGNANCY-INDUCED HYPERTENSION
Severe Preeclampsia
Extreme edema
is most readily palpated over bony surfaces, such
as over the tibia on the anterior leg, the ulnar
surface of the forearm, and the cheekbones, where
the sponginess of fluid-filled tissue can be palpated
against bone.
If there is swelling or puffiness at these points to a
palpating finger but the swelling cannot be
indented with finger pressure, the edema is
described as nonpitting.
PREGNANCY-INDUCED HYPERTENSION
Severe Preeclampsia
Extreme edema
1+ = If the tissue can be indented slightly, this is
pitting edema;
2+ = moderate indentation;
3+ = deep indentation;
4+ = indentation so deep it remains after removal
of the finger is pitting edema.
This accumulating edema will reduce a woman’s
urine output to approximately 400 to 600 ml per
24 hours.
PREGNANCY-INDUCED HYPERTENSION
Eclampsia
Seizure or coma occurs.
Signs & symptoms of preeclampsia
Nursing Diagnosis:
1. Ineffective tissue perfusion r/t
vasoconstriction of blood vessels
2. Deficient fluid volume r/t fluid loss to
subcutaneous tissue
PREGNANCY-INDUCED HYPERTENSION
Nursing Diagnosis:
3. Risk for fetal injury r/t reduced placental
perfusion 2° to vasospasm
4. Social isolation r/t prescribed bed rest
Nursing Intervention:
1. Mild preeclampsia
1) Monitor Antiplatelet Therapy
❖ Because of the increased tendency for platelets to
cluster along arterial walls, a mild antiplatelet agent,
such as low-dose aspirin, may prevent or delay the
development of preeclampsia (Leaf & Connors,
2015).
PREGNANCY-INDUCED HYPERTENSION
Nursing Intervention:
1. Mild preeclampsia
1) Monitor Antiplatelet Therapy
❖ Be certain they purchase low-dose aspirin (81 mg, sold
as baby aspirin) as excessive salicylic levels can cause
maternal bleeding at the time of birth.
2) Promote Bed Rest
❖ When the body is in a recumbent position, sodium
tends to be excreted at a faster rate than during
activity.
❖ Bed rest, therefore, is the best method of aiding
increased evacuation of sodium and encouraging
diuresis of edema fluid.
PREGNANCY-INDUCED HYPERTENSION
Nursing Intervention:
1. Mild preeclampsia
2) Promote Bed Rest
❖ Be certain women know to rest in a lateral
recumbent position to avoid uterine pressure on
the vena cava and prevent supine hypotension
syndrome.
PREGNANCY-INDUCED HYPERTENSION
Nursing Intervention:
1. Mild preeclampsia
3) Promote Good Nutrition
❖ Assess if a woman has someone to help her
prepare food, or either bed rest or nutrition
may be compromised.
4) Provide emotional support
PREGNANCY-INDUCED HYPERTENSION
Nursing Intervention:
2. Severe Preeclampsia
1) Support bed rest.
• Needs hospitalization so
bed rest can be enforced
and woman can be
observed closely.
• Restrict visitors to
support people (e.g.
husband)
• Raise side rails (padded)
to prevent injury
• Room needs to be dimly
lit.
PREGNANCY-INDUCED HYPERTENSION
Nursing Intervention:
2. Severe Preeclampsia
2) Monitor maternal well-being
Monitor Bp
Obtain blood studies as ordered.
o Obtain daily hematocrit levels as ordered
• this level will rise (>40%) if increased fluid is
leaving the bloodstream for interstitial tissue
[edema].
Assess weight: same time, daily
Indwelling catheter may be inserted.
PREGNANCY-INDUCED HYPERTENSION
Nursing Intervention:
2. Severe Preeclampsia
3) Monitor fetal well-being
External fetal monitor is attached
O2 adm. may be necessary to maintain adequate
fetal oxygenation
4) Support a nutritious diet
Moderate to high protein diet
Moderate sodium in the diet
IVF line should be initiated and maintained to serve
as an emergency route for drug adm.
PREGNANCY-INDUCED HYPERTENSION
Nursing Intervention:
2. Severe Preeclampsia
5) Administer medications to prevent eclampsia
a) Hydralazine (Apresoline) to reduce
hypertension (5 – 10 mg/IV)
Lowers Bp by peripheral dilatation
Can cause tachycardia
• Assess pulse & Bp before & after adm.
• Diastolic should not be lowered below 80 –
90 mmHg or inadequate placental perfusion
could occur.
PREGNANCY-INDUCED HYPERTENSION
Nursing Intervention:
2. Severe Preeclampsia
5) Administer medications to prevent eclampsia
b) Magnesium Sulfate (Loading dose 4–6 g
Maintenance dose 1–2 g/hr IV)
Muscle relaxant
Prevent seizures
• Has CNS depressant action by blocking peripheral
neuromuscular transmission
Reduces edema by causing a shift in fluid from
extracellular spaces into the intestine
PREGNANCY-INDUCED HYPERTENSION
Nursing Intervention:
2. Severe Preeclampsia
5) Administer medications to prevent eclampsia
b) Magnesium Sulfate
Symptoms of overdose:
1) Decreased urine output
2) Depressed RR
3) Reduced consciousness
4) Decreased tendon reflexes
I.V. Infusion Pump
PREGNANCY-INDUCED HYPERTENSION
Respirations stop
O2 therapy continued
Birth:
Labor may be induced as soon as the woman’s
condition stabilizes, usually 12 – 24 hrs. after
seizure.
Preferred method of delivery for eclamptic
patient is vaginal delivery
Cesarean birth is always more hazardous for the fetus than vaginal
birth because of the association of retained lung fluid.
C/S is preferred if fetus is in imminent danger.
PREGNANCY-INDUCED HYPERTENSION
2. Edema
4. Nausea
5. epigastric pain
6. general malaise
Maternal Complications
1. cerebral hemorrhages
2. aspiration pneumonia
3. hypoxic encephalopathy
▪ Fetal complications
1. growth restriction
2. preterm birth (Barnhart, 2015)
HELLP Syndrome
Therapy
1. transfusion of fresh frozen plasma or platelets
▪ to improve the platelet count.
2. intravenous glucose infusion
▪ If hypoglycemia is present
3. The infant is born as soon as feasible by either vaginal or
cesarean birth.
▪ Be alert that maternal hemorrhage may occur at birth because of
poor clotting ability.
▪ Epidural anesthesia may not be possible because of the low
platelet count and the high possibility of bleeding at the epidural
site.
GESTATIONAL CONDITION
2 GESTATIONAL CONDITION
Hyperemesis gravidarum
Extreme, persistent nausea and
vomiting during pregnancy beyond 1st
trimester that may lead to dehydration
and disturbances in nutrition
Causes:
pregnant with twins (or more)
have a hydatidiform mole
3 GESTATIONAL CONDITION
Hyperemesis gravidarum
Symptoms
Severe, persistent nausea during pregnancy, often leads to:
1. Weight loss
2. Lightheadedness or fainting
Exams and Tests
1. physical exam
2. Vital signs
❖Decreased Bp, increased PR
3. Ultrasound
4 GESTATIONAL CONDITION
Exams and Tests
The following laboratory tests will be done
to check for signs of dehydration:
1) Hematocrit (Normal for female: 36 - 44%)
2) Urine ketones
Ketones build up when the body needs to
break down fats and fatty acids to use as fuel.
This is most likely to occur when the body does
not get enough sugar or carbohydrates.
5 GESTATIONAL CONDITION
Treatment
1. Small, frequent meals and eating dry foods
such as crackers
help relieve uncomplicated nausea.
2. Increase fluid intake
Increase fluids during the times of the day
when least nauseated.
6 GESTATIONAL CONDITION
Treatment
3. Vitamin B6 (no more than 100 mg daily)
has been shown to decrease the nausea in early
pregnancy.
4. In severe cases, woman may be admitted to the
hospital, where fluids will be given through an IV.
Isotonic solution
❖ 0.9% NaCl (NSS)
❖ Dextrose 5% in Water (D5W)
❖ Lactated Ringer’s 5% Dextrose in Water ( D5LR)
7 GESTATIONAL CONDITION
Possible Complications
1. Dehydration
2. Poor weight gain during pregnancy.
3. Social or psychological problems may
be associated with this disorder of
pregnancy
If such problems exist, they need to be
identified and addressed appropriately.
Chapter 23
Dysfunctional labor
• Management:
1. Ultrasound
2. Monitor FHR & pattern
3. Assess characteristics of amniotic fluid if
membranes have ruptured
33
❖Uterine Tone
• The lowest intrauterine pressure between contractions is
called resting tone
• Normal resting tone is 5-10 mmHg;
• during labor resting tone may rise to 10-15 mmHg
• Pressure during contractions rises to ~25-100 mmHg (varies
with stage)
• A resting pressure above 20 mmHg causes decreased
uterine perfusion
39
Prolonged Descent
• Prolonged descent of the fetus occurs if the rate
of descent is less than 1.0 cm/hr in a nullipara or
2.0 cm/hr in a multipara.
• It can be suspected if the second stage lasts over
2 hours in a multipara (Zheng, 2012).
• With both a prolonged active phase of dilatation
and prolonged descent, contractions have been
of good quality and duration, effacement and
beginning dilatation have occurred, but then the
contractions become infrequent and of poor
quality, and dilatation stops.
47
Prolonged Descent
• If everything else is within normal limits except for
the suddenly faulty contractions and CPD and
poor fetal presentation have been ruled out by
ultrasound,
• then rest and fluid intake, as advocated for hypertonic
contractions, also applies.
48
Prolonged Descent
• If the membranes have not ruptured,
1. rupturing them at this point may be helpful.
2. Intravenous (IV) oxytocin may be used to induce the
uterus to contract effectively (see later discussion on
induction of labor by oxytocin).
3. A semi-Fowler’s position, squatting, kneeling, or more
effective pushing may speed descent.
49
Arrest of Descent
• Arrest of descent results when no descent
has occurred for 2 hours in a nullipara or 1
hour in a multipara.
• occurs when expected descent of the fetus does
not begin or engagement or movement beyond 0
station does not occur.
• Cause: CPD.
• Management:
1. Cesarean birth usually is necessary.
2. If there is no contraindication to vaginal birth,
oxytocin may be used to assist labor
50
1. Uterine rupture
2. Laceration of birth canal
3. Amniotic fluid embolism
4. Postpartum hemorrhage
52
• Fetal Complications:
1. Hypoxia
2. Intracranial hemorhage r/t rapid birth
53
Uterine Prolapse
• Uterine prolapse is falling or sliding of the
womb (uterus) from its normal position into
the vaginal area.
• Causes:
• Muscles, ligaments, and other structures hold the
uterus in the pelvis.
❖If these muscles and structures are weak, the uterus
drops into the vaginal canal (This is called prolapse).
• This condition is more common in women who
have had one or more vaginal births.
54
Uterine Prolapse
• Other things that can cause or lead to
uterine prolapse include:
1. Normal aging
2. Lack of estrogen after menopause
3. Anything that puts pressure on the
pelvic muscles, including chronic cough
and obesity
4. Pelvic tumor (rare)
❖Long-term constipation and the pushing
associated with it can make this condition worse.
55
Uterine Prolapse
Symptoms
1. Feeling like you are sitting on a small ball
2. Difficult or painful sexual intercourse
3. Frequent urination or a sudden urge to empty
the bladder
4. Low backache
5. Uterus and cervix that stick out through the
vaginal opening
6. Repeated bladder infections
7. Feeling of heaviness or pulling in the pelvis
8. Vaginal bleeding
9. Increased vaginal discharge
56
Uterine Prolapse
• Exams and Tests
• A pelvic examination is done while client is
bearing down, as if she was trying to push out
a baby.
❖This shows the doctor how far the uterus has
dropped.
• Mild uterine prolapse is when:
❖the cervix drops into the lower part of the vagina.
• Uterine prolapse is moderate when:
❖the cervix drops out of the vaginal opening.
57
Uterine Prolapse
• Mild uterine prolapse :
❖the cervix drops into the lower part of the vagina.
• Moderate uterine prolapse:
❖the cervix drops out of the vaginal opening.
• Complete uterine prolapse:
❖Cervix and the body of the uterus protrude
through the vagina, and the vagina is inverted.
58
UTERINE PROLAPSE
59
Uterine Prolapse
• Exams and Tests
❖The pelvic exam may also show that the bladder
and front wall of the vagina (cystocele), or rectum
and back wall of the vagina (rectocele) are
entering the vagina.
Uterine Prolapse
• Treatment
1. LIFESTYLE CHANGES
1) Weight loss is recommended in obese women
with uterine prolapse.
2) Heavy lifting or straining should be avoided,
because they can worsen symptoms.
3) Coughing can also make symptoms worse.
❖If you a chronic cough, ask your doctor how to prevent
or treat it.
❖If you smoke, try to quit. Smoking can cause a chronic
cough.
61
Uterine Prolapse
• Treatment
2. VAGINAL PESSARY
❖This device hold the uterus in place. It may be
temporary or permanent.
❖Vaginal pessaries are fitted for each individual
woman.
❖Some are similar to a diaphragm used for birth
control.
❖Pessaries must be cleaned from time to time,
sometimes by the doctor or nurse.
62
Uterine Prolapse
Treatment
2. VAGINAL PESSARY
• Side effects of pessaries include:
1) Foul smelling discharge from the vagina
2) Irritation of the lining of the vagina
3) Ulcers in the vagina
4) Problems with normal sexual intercourse and
penetration
63
Uterine Prolapse
Treatment
3. SURGERY
• The specific type of surgery depends on:
1) Degree of prolapse
2) Desire for future pregnancies
3) Other medical conditions
4) The women's desire to retain vaginal function
5) The woman's age and general health
64
Uterine Prolapse
Treatment
3. SURGERY
1) sacrospinous fixation
• This procedure involves using nearby ligaments to
support the uterus.
2) vaginal hysterectomy
• is used to correct uterine prolapse.
• Any sagging of the vaginal walls, urethra, bladder, or
rectum can be surgically corrected at the same time.
65
Uterine Prolapse
Prevention
1. Kegel exercises
2. Estrogen therapy, either vaginal or oral, in
postmenopausal women
3. Weight loss
4. Avoid heavy lifting.
PROBLEMS WITH THE
PASSENGER
66
PROLAPSE OF THE UMBILICAL
CORD
69
Assessment:
70
Therapeutic Management:
73
Occipitoposterior Position
(ROP or LOP)
77
Breech Presentation
- Types:
1.Complete
2.Frank
3.Footling
- Complications:
1.Anoxia from prolapsed cord
2.Traumatic injury to the after-coming head
(possibility of intracranial haemorrhage or
anoxia)
78
Breech Presentation
- Complications:
3. Fracture of the spine or arm
4. Dysfunctional labor
5. Early rupture of the membranes
because of the poor fit of the presenting
part.
6. Meconium aspiration
79
Breech Presentation
- Assessment:
1.FHT heard high in the abdomen
2.Leopold’s, vaginal exam, or ultrasound
exam reveals the presentation.
3.Monitor FHR and uterine contractions
80
Breech Presentation
- Birth technique:
1.Vaginal delivery
▪ Birth of head is the most hazardous because
umbilicus precedes the head.
▪ Head compresses the cord
▪ 2nd danger is intracranial hemorrhage
2.Planned C/S – usual method
▪ secure consent
▪ NPO
81
82
Face Presentation
• Asynclitism
o Fetal head presenting at different angle.
• Face presentation
o Fetus is in poor flexion
o Back is arched
o Neck extended
o Complete extension
o Presenting the occipitomental diameter (13.5
cm)
83
Face Presentation
• Assessment:
1.Woman with contracted pelvis
2.Placenta previa
3.Relaxed uterus of a multipara
4.Prematurity, hydramnios, or fetal
malformation
5.A sonogram is done to confirm
84
Face Presentation
• Therapeutic management:
1.Observe infant for patent airway
▪ May have a great deal of facial edema
and may be purple from ecchymotic
bruising.
2.Gavage feeding
▪ Lip edema is so severe that the infant
is unable to suck for a day or 2.
3.Delivered by C/S 85
Transverse Lie
- Assessment:
1.Uterus is more horizontal than vertical
2.Confirmed by Leopold’s maneuver
3.Ultrasound
- Therapeutic management:
1.C/S
87
Oversized Fetus
(Macrosomia)
88
Oversized Fetus
(Macrosomia)
Complications:
1. Uterine dysfunction during labor/birth
• Overstretching of the fibers of the myometrium
2. Wide shoulders cause fetal pelvic disproportion
3. Uterine rupture from obstruction
4. Fractured clavicle of the baby because of
shoulder dystocia
5. Woman has an increased risk of hemorrhage
• Overdistended uterus may not contract
89
Problems With the Passage
A. INLET CONTRACTION
❖In primigravidas, the fetal head normally
engages between weeks 36 and 38 of
pregnancy.
❖If this occurs any time before labor begins, it
is proof the pelvic inlet is adequate.
o If engagement does not occur in a primigravida,
then either a fetal abnormality (larger than usual
head) or a pelvic abnormality (smaller than
usual pelvis) should be suspected.
❖Therapeutic Management::
1. Monitor fetal heart sounds and uterine
contractions frequently.
2. Urge the woman to void every 2 hours so her
urinary bladder is as empty as possible, allowing
the fetal head to use all the space available.
❖Procedure:
3. The breech and vertex of the fetus are located
and grasped transabdominally by the examiner’s
hands on the woman’s abdomen.
4. Gentle pressure is then exerted to rotate the
fetus in a forward direction to a cephalic lie.
❖Procedure:
1. With the fetal head at the perineum, a soft,
disk-shaped cup is pressed against the fetal
scalp and over the posterior fontanelle.
2. When vacuum pressure is applied, air beneath
the cup is suctioned out and the cup then
adheres so tightly to the fetal scalp that traction
on the vacuum cord leading to the cup extracts
the fetus.