Maternity Final New Stuff

Postpartum hemorrhage

Loss of over 500mL of blood after birth

Excessive postpartum hemorrhage

Loss of over 100mL of blood after birth

Early (primary) postpartum hemorrhage

Occurs within first 24 hours after birth

Late (secondary) postpartum hemorrhage

Occurs 24 hours or more after birth

Cause of early PPH

uterine atony, uterine prolapse, incomplete placental separation

Cause of late PPH

subinvolution of the uterus

What is uterine subinvolution

delayed return of enlarged uterus to its normal size and function

What are the signs and symptoms of uterine subinvolution

prolonged lochia, doul odor, pain, fever, irregular bleeding, excessive bleeding, hemorrhage

What are the 4 T’s (problems related to PPH)

• tone

• tissue

• trauma

• thrombin

PPH - tone

Uterine atony: relaxation of the uterine smooth muscle.

This smooth muscle should contract after birth to prevent hemorrhage. Uterine atony is the most common cause of PPH

What causes uterine atony

Polyhydramnious, multiple gestation, macrosomia, rapid labor, prolonged labor, high parity

PPH - tissue

Placental tissue is considered retained if it has not been delivered from 30-60 mins after birth, despite massage and gentle traction. Retained tissue prevents the uterus from clamping down

Causes of retained placenta

Placenta acreta, increta, and percreta. Also placental abruption and placenta previa

PPH - Trauma

Lacerations of cervix, vagina, and perineum, or hematomas, uterine inversion, or uterine rupture are all types of uterine trauma that can cause PPH. Trauma can also occur if a retained placenta has to be removed manually

PPH - Thrombin

Abnormalities of coagulation related to thrombin. Such as Hemophilia A

PPH r/t uterine tone treatment

• Uterine massage

• mechanical therapies (bakri balloon to occlude bleeding)

• utertonic agents (misoprostol, ergot alkaloids, oxytocin, prostaglandins)

PPH r/t trauma treatment

• Suture

PPH r/t tissue treatment

• Remove retained placental fragment

Invasive placenta types

• Placenta acreta (attaches deeply into uterus)

• Placenta increta (attaches into muscle)

• Placenta perceta (attaches through uterine wall and can attach to organs)

PPH general nursing care

• Vital signs

• massage fundus

• expel clots

• ensure bladder is empty

• replace fluids through IV

• administer meds

• assist with suturing

• prepare for OR

TORCH complex

• Toxoplasmosis

• Other

• Rubella

• Cytomegalovirus

• Herpes simplex virus (HSV)

What does the TORCH complex mean?

The TORCH complex refers to infections that can cause congential conditions in the fetus if mom is infected with them during the pregnancy.

Toxoplasmosis

• Caused by toxoplasma gondii

• Protozoan parasite

• Biggest risk factors: cat feces, undercooked meats, unwashed vegetables

“Other”

Major bacterial causative agents of neonatal sepsis:

• Group B Strep

• Hep B

• HIV

• Syphillis

• Varicella Zoster

• Chlamydia

• Gonorrhea

Group B Strep

• Lives in human GI and GU tracts

• Can cause UTI, chorioamnionitis, endometritis, pneumonia, and meningitis for mom during pregnancy

• Can cause sepsis, pneumonia, meninigitis, bacteremia, and focal infections in the baby after birth

How is group B strep treated if mom has risk factors?

intrapartum antibiotics are given but only prevent early-onset disease

Hepatitis B

• Hepatitis B is the most important hepatitis infection in pregnancy

• most commonly passed during birth

• can lead to liver failure and hepatocellular carcinoma

• more common to become chronic in neonates than it is in adults

How is hepatitis B treated if mom screens positive?

Baby gets HBV vaccine and immune globulin shortly after birth

HIV

• Causes AIDS

• attacks cells of immune system and compromises it

• the person loses their ability to fight infections

• usually transitted to baby intrapartum but can be passed through breast milk

How do we prevent tramission of HIV from mom to baby

• Test ALL MOMS for HIV

• If positive, put her on HIV meds (antiretrovirals)

• If viral load is low she can deliver vaginally

• If viral load is high she must have a c-section

• Mom needs to be given IV HIV meds during birth

• Mom cannot breastfeed

• Baby is started on oral AZT at birth for 6 weeks

Syphillis

• Rate increasing

• Usually transmitted vaginally, anally, or orally

• Can be transmitted through needles, kissing, blood transfusion, organ transplant

• Can stay dormant for 20 years

• At first it causes a painless ulcer and swollen glands, then progresses to fever and hair loss

• Mostly affects infants in utero but can become infected during birth or through contact with infected lesion

• Causes weeping from eyes, ears, and mouth in baby. Also causes rash, mulberry molar, snuffles, and bulging of facial bones

How is syphillis treated

IV penicillin

Chronic varciella syndrome

• Passed through intrauterine exposure

• Most risk the week before birth and 2 days after - provide immunoglobulin

Chlamydia

• Most common STI

• Transmitted during birth

• Can cause conjuctivitis or pneumonia in baby

How is chlamidiya passed to baby treated

Erythromycin eye gel

Gonorrhea

• Causes conjuntivitis in newborn that can lead to blindness

• Usually apparent 2-5 days after birth

How is gonorrhea passed to baby treated

Cefotaxime (an agressive antibiotic)

Rubella

• If moms titres are low, she needs a vaccine postpartum

• Causes deafness, cataracts, and cardiac lesions in baby

Cytomegalovirus

• Hepres virus family

• Passed through saliva, semen, cervix mucous, breast milk

• Mostly affects first trimester development

Hepres simplex virus

• can be primary or recurrent

• recurrent is the highest risk to neonatal transmission

• usually transmitted through birth

How is herpes simplex virus passed to baby treated

IV acyclovir, supportive care

Gestational Diabetes puts the pregnancy at risk for what outcomes?

• Pre-eclampsia

• Shoulder dystocia birth

• C-section

• Large for gestational age baby

Gestational diabetes puts the baby at risk for what?

• Hypoglycemia

• Intrauterine growth restriction

• Intrauterine fetal death

When does screening for gestational diabetes take place?

24-48 weeks. Earlier if there are risk factors

Antepartum GDM interventions

• Maintain good glucose control

• Diet

• Exercise

• Monitor glucose levels

• Pharmacological therapy

• Fetal surveillance

Intrapartum GDM interventions

• Monitor blood glucose

• Fetal surveillance

• C section may be necessary

Postpartum GDM interventions

• Assess for carbohydrate intolerance

• Encourage breastfeeding

Pre-existing hypetension

Hypertension existing before pregnancy or before 20wks gestation

Gestational hypertension

Hypertension after 20wks gestation

Pre-eclamspia

Hypertensive vaspospastic disorder accompanied by proteinuria and end-organ dysfunction

Who is at risk for pre-eclampsia

• Nulliparity

• Age over 40 yrs

• Break of over 7 yrs between pregnancies

• Family or previous history

• Obesity

• GDM

• Multiparity

• Chronic hypertension

• Other pre-existing medical conditions

Pre-eclamspia cure

Birth

What is the pathogenic cause of pre-eclampsia

Poor perfusion resulting from vasospasm increases BP and impedes blood flow to all organs

What causes proteinuria in pre-eclampsia

Endothelial damage causes protein to be in the urine

What are some signs and symptoms of pre-eclampsia

• Sacral, pulmonary, facial, and brain edema

• Weight gain

• Clonus reflex

• Confusion

Mild pre-eclampsia

Proteinuria of 0.03g/L in at least 2 urine samples 6 hours apart

160/110 BP

Severe pre-eclampsia

• Proteinuria

• BP over 160/110

• Cerebral disturbances

• Epigastric pain

Eclampsia

Seizure activity or coma in woman with pre-eclampsia

HELLP syndrome

Laboratory diagnosis of severe pre-eclampsia

• Hemolysis (H)

• Elevated liver enzymes (EL)

• Low platelets (LP

General Pre-eclamspia nursing care

• Ensure correct BP assessment (same arm for testing)

• Ask questions about other system involvement

• Deep tendon reflexes

• Fetal health surveillance (nonstress, contraction stress, biophysical profile)

• Ultrasonography and fetal movement counting (less than 6 in 2hrs could be fetal compromise)

• Activity restriction WITHOUT BEDREST

• Diet (fiber, 6-8 glasses of water, nothing super salty)

Severe pre-eclampsia nursing care

• Hospital care

• Magnesium sulphate (nurse supervising at all times for mg toxicity)

• Control BP

• Catheter to measure intake and output (should be 30mL/hr)

• Vital signs (8-10 resp is low)

Eclampsia nursing care

• Monitor for signs (persistance headache, blurred vision, photophobia, severe epigastric or RUQ pain, altered mental status)

• Call for help

• Ensure patent airway

• Meds

• Assess fetal status

• Abruption is highly likely

Postpartum eclampsia nursing care

• If MgSO4 needed, infuse for 24 hrs PP

• Fluids and I+O

• Breastfeed

• Discharge only when there is clear evidence she is improving

• Monitor labs

• Follow up care after discharge

What causes most bleeding in first trimester

Spontaneous abortion or ectopic pregnancy

What causes most bleeding in third trimester

Placenta previa or abruption

Miscarriage (spontaneous abortion) causes

• Chromosomal abnormaility in baby

• Endocrine imbalance

• Immunological factors

• Systemic disorders

• Genetic factors

• Advanced age, parity

• Premature cervix dilation

• Inadequate nutrition

• Recreational drug use

• Reproductive tract abnormalities

Miscarriage

Pregnancy loss before 20wks gestation

Early miscarriage

Loss before 12 wks gestation

Late miscarriage

Loss between 12-20wks gestation

Types of pregnancy loss

• Threatened

• Inevitable

• Incomplete

• Missed

Threatened pregnancy loss

• Mild-moderate spotting and contractions

• Internal osse remains closed

• Monitor hcg and progesterone

Inevitable pregnancy loss

• Moderate-severe bleeding, cramping, tissue

• Everything in uterus being evacuated

• Empty by D and C

Incomplete pregnancy loss

• Heavy-severe bleeding, cramping, and tissue loss

• Cervix dilation

• D and C

Missed pregnancy loss

• No bleeding, cramping, tissue, or dilation

• Baby has died

• D and C or misoprostol

Premature cervical dilation

Passive and painless dilation of the cervix without contractions or labor

Premature cervical dilation treatment

Cerclage placement. The McDonald technique involves placing a suture around the cervix beneath the mucosa to constrict internal os of cervix.

Can be placed prophylactically or as a rescue

Ectopic pregnancy

Fertilized ovum implanted outside of the uterine cavity. Most occur in the fallopian tube

Signs of an ectopic pregnancy

• Abdominal pain

• Missed period

• Abnormal vaginal bleeding

Ectopic pregnancy treatment

• Methotrexate (folic acid antagonist) to stop cells from growing

• Salpingectomy (taking out the fallopian tube)

• Salpingostomy (cutting open the fallopian tube)

• Birth control for 3 months so fallopian tubes can heal

Placenta previa

Placenta implanted in lower uterus near or over the internal cervical os

Can be complete, marginal, or low lying

Signs of placenta previa

BRIGHT RED PAINLESS BLOOD

Placental abruption

Premature separation of placenta. Graded 1 (milkd) - 3 (severe)

Placental abruption signs

DARK RED PAINFUL BLOOD

Placental abruption classification

• Partial separation (concealed hemorrhage)

• Partial seperation (apparent hemmorhage) - blood slips out

• Complete seperation (concealed hemorrhage)

Induction of labor

Chemical or mechanical initiation of uterine contractions before their spontaneous onset

Augmentation of labor

Labor is already in progress, augmentation is done to move the process along and get her back into active labor

What are some reasons for an induction of labor?

• Post maturity of fetus

• Premature rupture of membranes with no contraction

• Chorioamnionitis

• Intrauterine growth restriction

• Materal disease

• Fetal demise (stillborn puts mom at risk for DIC)

• History of a rapid labor

• Geographical location

Contraindications for induction

• Transverse lie/prolapsed cord

• Abnormal FHR

• Cephalo-pelvic disproportion

• Placenta previa

• Uterine incision/surgery

• Active genital herpes

• Cervical cancer

• Previous uterine rupture

Precautions for induction

• Multiparity over 4

• Unripe cervix

• PP over pelvic inlet

• Breech position

• Overdistention of uterus

• Convenience

Induction risks

• increased c section risk

• fetal distress

• tachysystole

• rupture of the uterus

• fluid overload

• inadvertant delivery of preterm

What bishop score indicates a induction can be successful

above 6

What bishop score do we want for primids? multips?

primids - 9

multips - 5

Unfavorable cervix management

• Cervical ripening agents (intravaginal or intracervical prostaglandins)

• mechanical ripening (foley catheter intracervically, dilators)

• Strip membranes

• Artifical rupture of membranes

• IV oxytocin

Artifical rupture of membranes interventions

• Assess FHR before procedure

• Position her

• Reasses FHR

• Assess fluid

• Monitor for infection

• TACO (time, amount, color, odor)

IV oxytocin adverse effects

• Uterine tachysystole (>5 contractions in 10 mins, or less than 30 secs rest between)

• Placental abruption

• Uterine rupture

• Unnecessary c section

• post partum hemorrhage

• fetal hypoxia

IV oxytocin interventions

• STAY WITH HER AT ALL TIMES

• assess and document

• FHR and uterine monitoring

• Offer light snacks and drinks

• Encourage voiding

• Monitor Intake and output

Intimate partner violence

Physical, psychological, emotional, sexual abuse, isolation, control of the victims life

Signs of IPV

• Overuse of health services

• Vague concerns

• Missed appointments

• Unexplained injuries

• Untreated serious injuries

• injuries not matching descriptions

• partner not leaving patients side

• partner insisting on telling story

Cycle of violence

• Honeymoon phase

• Tension building

• Abusive incident