Week 7 Part 3 - Eclampsia + Assisted Vaginal Birth

HDP: Intrapartum Management - Antihypertensive therapy goals

• Antihypertensive Therapy —> prevents CVA ​

• Goal: SBP to < 160 mm Hg and the DBP to < 110 mm Hg

  • if exceeds —> acute severe HTN —> treat immediately!!!​

• Ideal: SBP 130-155 mmHg and DBP 80 -105mmHg​

• Rationale: Rapid drop in maternal BP may cause a reduction in utero-placental perfusion —> fetal hypoxia

Intrapartum Acute HTN Treatment

• Labetalol (IV), 5 min onset, Contraindications: Pregnant person HF, or asthma, fetal bradycardia ​

• Nifepidine (PO), 30 min onset, SE: flushing, headaches, palpations, tocolysis —> can be adjunct w labetalol or by itself ​

• Hydralazine (IV), 5 min onset, SE: pregnant person hypotension

pre-eclampsia —> also on mag sulfate (anticonvulsant)

short acting agents that work quickly!

HDP Nursing management

• Review Investigations​ (can help recognize HELLP syndrome)

  • CBC (RBCs, Hbg, Hct + Plts)​

  • INR + PTT​ —> higher BAD

  • LFTs (ALT + AST)​

• Create a low-stress environment ​

  • Quite environment, dimmed lights, limit stimulation ​

• Freq monitor VS (hourly)​

• Continuous FHS​

HDP - epidural and fluid management

• Epidural? —> can reduce HTN​

• Fluid Management ​

  • Double concentration oxytocin to reduce input (high conc, in less fluid)​

  • AVOID standard bolus before regional analgesia (risk of overload, pulmonary edema)

    • usually bolus fluid given to prevent hypotension​

• Insert Urinary Catheter and monitor output for oliguria ​

  • What is the Cr and BUN? If elevated, this would indicate concerns related to the function of the kidneys. ​

  • Monitor urine hourly ( < 15-30 ml worrying)​

MgSO4 Therapy

• seizure prophylaxis ​

• Recommended for clients with severe HTN, headache or clonus, visual disturbances, RUQ pain and elevated liver enzymes, thrombocytopenia, renal insufficiency (e.g. increased Cr), HELLP

MgSO4 Administration

• Bolus 4g IV over 20 mins, then 1 g/hour in a continuous IV​

• Side Effects: weakness, paralysis, cardiac toxicity, loss of DTRs (deep tendon reflex), respiratory depression ​

• Monitor: DTRs (what if there is an EPI? —> check in upper extremities), RR. LOC, U/O (Mg excreted in urine)

MgSO4 Therapy Clinical Considerations

• MgSO4 + Ca Channel Blockers (e.g. nifedipine) —> Mg toxicity​

• MgSO4 + Renal Health Challenges —> Mg toxicity​

• CARDINAL SIGNS: Weakness, paralysis and cardiac toxicity, respiratory depression ​

• Antidote = Calcium Gluconate ​

• 10 mL of 10% calcium gluconate, IV over 3 minutes ​

Eclampsia

aura: confusion, numbness, dizzy, headache, pt describe as sense of something coming

tonic: muscle rigidity, back arched, LOC, incontinence, pallor, cyanosis

clonic: jerky movement, abnormal breathing

postictal: end of seizure —> baseline, exhausion, weak limbs, altered LOC

Eclampsia: Nurse Management

During​

• Call for help​

• Remain with client, reassure client​

• ABCs​

• Prepare to apply 02 and suction ​

• If they stop breathing, begin ventilatory support (bag)​

After​

• Administer 02 and suction secretions ​

• Position laterally (right or left)​

• Administer medications (i.e. 4g MgSO4 bolus)​

• Safety​

• Reorient to environment ​ + Low stimulation environment ​

• Frequent neurological assessment ​

What about baby?​

• FHR?​

• S&S of abruption?​

• Expedite delivery? ​

HDP Postpartum

• Delivery of placental is the cure… (preeclampsia / eclampsia) ​

• ¼ seizures occur in early post partum ​

• MgSO4 is usually continues for 24 – 48 hours after delivery ​

• BP takes days to recover

• ongoing monitoring + support ​

Assisted Vaginal Birth (AVB) ​

• aka operative vaginal delivery

• Use of vacuum or forceps to achieve a vaginal delivery in the second stage of labour (not within an RN’s Scope) ​

• ONLY when baby is head down

• Consideration pregnant person and fetal risks associated with using either instrument and risks of the alternative choice, a C/S

Assisted Vaginal Birth (AVB) ​Indications

• Atypical or abnormal FHR​

• Medical indications to avoid Valsalva manoeuvre (e.g., CVD, cardiac conditions) ​—> forceful breathing

• Inadequate progress of labour (Dystocia)​

• Lack of effective maternal expulsive effort​

• Assistance at CS if required ​

• Autorotation of fetal malposition possible (Vacuum only)​

• Suboptimal attitude or position of the fetal head may be corrected (Forceps only) ​

Assisted Vaginal Birth (AVB): Vacuum ​

• Vacuum extractors are soft cups of silicone and rubber ​

• Less likely to cause cephalohematoma and scalp injury than forceps ​

• Non-traumatic insertion of the device​

AVB Vacuum Head injuries

caput succedanneum —> Diffuse swelling of the scalp, crosses suture lines

cephalohematoma —> bleeding under periosteum (fibrous membrane) , does not cross lines

subgaleal hematoma —> above periosteum (in tissue), crosses line MOST DANGEROUS (can hold large amt of blood)

• pallor, tachycardia, hypotension —> hypovolemic shock

epidural hemorrhage —> bleeding between skull and dura, serious but rare

subdural hemorrhage

Assisted Vaginal Birth (AVB): Forceps ​

• Forceps are metal instruments ​

• Risk of soft tissue injury greater for pregnant person ​

• Risk of fetal laceration, bruise, and ocular injury, etc. ​

• use has decreased due to vacuums