complications of pregnancy, intrapartum, and postpartum

what classifies someone with a high risk pregnancy?

a woman with a concurrent disorder, pregnancy-related complication, or external factors that jeopardizes the health of a pregnant person and/or both

functional or transient murmurs can be heard throughout pregnancy and is can innocent finding (T/F)

true; is it due to increased blood flow past valves

left sided heart failure in a pregnant patient and its manifestations

occurs when there is mitral stenosis, mitral insufficiency, and aortic coarctation

the left ventricle cannot move the large volume of blood forward → left side becomes distended, systolic BP increases, pulmonary HTN → pulmonary edema and profound shortness of breath

are at risk for miscarriage, preterm labor, and death

management of left sided heart failure

• anticoagulant to prevent thrombus formation

  • low molecular weight heparin is the drug of choice

  • does not cross the placenta and is not teratogenic

• antihypertensives to control BP

• diuretics to reduce blood volume

• beta blockers to improve ventricular filling

right sided heart failure in pregnancy

caused by unrepaired congenital heart defect like pulmonary valve stenosis → decreased output to the lungs

presents with JVD, hepatomegaly, splenomegaly

should advised to not become pregnant if the anomaly has not been corrected

if pregnant, need oxygenation administration and frequent arterial blood gas assessments

assessment of a pregnant pt. with cardiac disease

• document their level of exercise before growing SOB

• cough present?

  • early sign of pulmonary edema

• edema present

  • normal in third trimester

• note JVD and cap. refill

why does the incidence of venous thromboembolic disease increase during pregnancy?

due to blood stasis in lower extremities from uterine pressure and hypercoagulability due to estrogen

fetal head at birth also puts pressure on lower extremity veins → damage to the walls of veins

deep vein thrombosis (DVT) in pregnancy

formation of a blood clot in the vein of the lower extremities

can lead to pulmonary embolism - preventable and a big reason for maternal crisis

mostly happen in PP period

signs of pulmonary embolism (PE)

• chest pain

• sudden onset of dyspnea

• cough with hemoptysis

• tachycardia

• dizziness or fainting

IS AN EMERGENCY

how to reduce risk of DVT and detect it

• avoid constrictive, knee-high stockings

• do not sit with legs crossed at the knee

• avoid standing in one position for a long period of time

do not do Homan’s sign; instead look for redness and pain in the calf and use doppler

management of DVT

• bedrest

• IV heparin for 24-48 hours

  • subQ heparin can be self injected after for the duration of the pregnancy

• avoid abdomen as an injection site

most common anemia in pregnancy

iron-deficiency

should be taking prenatal vitamins that contain 27g of iron to avoid this (increase fiber due to constipation and take with orange juice/vitamin C)

how can sickle-cell anemia complicate pregnancy?

cells will clump together → blockage in placental circulation will reduce blood flow to fetus → low birth weight and fetal death

assessment and nursing care of pregnant patient with sickle-cell

all patients are screened for this disorder at their first prenatal visit

need periodic clean catch urine due to their susceptibility for a UTI

monitor their nutritional intake throughout pregnancy to make sure they are getting sufficient folic acid

should NOT take a routine iron supplement

need hydration

interventions to prevent sickle cell crisis

periodic exchange or blood transfusions throughout pregnancy

exchange transfusion can also remove increased bilirubin resulting from the breakdown of RBCs

interventions for sickle-cell crisis

1. control pain

2. give O2 as needed

3. increase fluid volume to lower viscosity

what factors in pregnancy contribute to the development of asymptomatic UTIs in pregnancy?

ureter dilation due to progesterone → stasis of urine

small presence of glucose in the urine → ideal medium for growth

how to assess and manage UTIs in pregnancy

assess for frequency of pain when urinating, pain in lumbar region, N/V, and malaise

obtain a clean-catch urine sample for culture and sensitivity

education:

• void every 2 hours

• urinate as soon as you feel the need and empty the bladder completely

• wipe from front to back

• wear cotton NOT synthetic fiber underwear

• void after sex

• drink an increased amount of fluids to flush out infection

what respiratory condition tends to be more severe during pregnancy due to increased nasal congestion

acute nasopharyngitis aka common cold

what should pregnant patients with a common cold take to combat symptoms?

vitamin C and acetaminophen q 4hrs for aches and pains

do NOT take aspirin because it can interfere with blood clotting

symptoms of tuberculosis

• chronic cough

• substantial weight loss

• hemoptysis (coughing blood)

• low grade fever

• extreme fatigue

• waking at night with night sweats

management of tuberculosis in pregnancy

if PPD is positive, do chest x-ray (cover belly with lead cover) and sputum culture

take prescribed drugs (INH, rifampin, ethambutol)

if patient has had disease before, educate them on maintaining adequate levels of calcium during pregnancy to ensure TB pockets in lungs are not broken down (reactivates the disease)

should a person with hypothyroidism increase their dose of levothyroxine when pregnant?

yes; should be high enough to sustain the pregnancy

recommended diet and exercise for pregnant women with preexisting diabetes

• reduce saturated fats and cholesterol

• increase fiber intake

is vaginal bleeding during pregnancy normal?

NEVER; it is always a deviation from the normal, can be potentially serious, and can occur at any point during the pregnancy

is a potential emergency → could mean placenta loosened and is cutting off nourishment to fetus

evaluate for hypovolemic shock

most frequent cause of miscarriage in the first trimester

abnormal fetal development due to a teratogenic factor or chromosomal aberration

signs of hypovolemic shock due to significant blood loss

• increased pulse rate

• decreased blood pressure (less resistance due decreased volume)

• increased respiratory rate

• cold, clammy skin (vasoconstriction to maintain volume in central body core)

• decreased urine output

• dizziness or decreased LOC

• decreased central venous pressure

emergency interventions for bleeding in pregnancy

1. notify HCP

2. place patient flat on bed and start LR

3. administer oxygen

4. monitor uterine contractions and fetal HR

5. omit vaginal examination **

6. NPO → may need surgery

7. assess vitals q 15 minutes, I&Os

8. weigh perineal pads (save any tissue passed)

9. assist with ultrasound*

   1. sees if placenta is the source

threatened miscarriage

not a miscarriage

patient might have scant, bright red bleeding with slight cramping but no cervical dilation present

complete vs. incomplete miscarriage

when the entire products of conception (fetus, membranes, placenta) are expelled spontaneously without any assistance

vs.

part of the conceptus (usually fetus) is expelled but the membranes or placenta is retained; need dilation and curettage to remove the remainder

missed miscarriage

fetus dies in utero but it not expelled

usually discovered at the prenatal examination when the fundal height is measured and no increase in size can be demonstrated or when previously heard fetal heart sounds can no longer be heard

isoimmunization

the production of antibodies against Rh+ blood when the mother is Rh- and baby is Rh+

can be caused by dislodgment of the placenta, resulting in some fetal blood entering the mother’s circulation

complicates next pregnancy if fetus has Rh+ blood

what is given to ALL patients after a miscarriage and why?

Rh (D antigen) immunoglobulin (RhIG)

since the blood type of the fetus is unknown, it is a prophylactic measure to prevent buildup of antibodies in the event the conceptus was Rh+

ectopic pregnancy and its manifestations

when implantation occurs outside the uterine cavity (commonly in the fallopian tube)

LIFE THREATENING

will experience sharp stabbing pain in one of their lower abdominal quadrants at the time of rupture and scant vaginal spotting

cervical cerclage

used to treat cervical insufficiency or premature cervical dilation

done if women repeatedly has had miscarriages

placenta previa

when the placenta is implanted abnormally in the lower part of the uterus; can grow up or down

it is the most common cause of painless bleeding in the THIRD trimester of pregnancy

detected by a routine sonogram

place patient on bed rest immediately in side-lying position

needs a C-section

do not allow vaginal exams to minimize trauma

premature separation of the placenta (abruptio placentae)

can be caused by falls or car accidents

is an emergency → insert large-gauge IV catheter to start fluid replacement and give oxygen via mask

patient will experience sharp, stabbing pain high in the fundus; will have tenderness upon palpation and heavy vaginal bleeding

what is considered preterm labor?

labor that occurs before the end of week 37

terbutaline

tocolytic agent used to halt labor if patient is preterm

betamethasone

used to accelerate formation of lung surfactant and reduce the possibility of respiratory distress syndrome

given between when preterm contractions begin and when preterm birth occurs

gestational hypertension

when a pregnant patient develops an elevated blood pressure (140/90 or 30/15+ baseline) after 20 weeks of gestation but does not have proteinuria or edema; BP returns to normal after birth

management: labetalol or nifedipine

preeclampsia without severe features vs. with severe features

develops an elevated blood pressure (140/90 or 30/15+ baseline), have 1-2+ proteinuria, increased weight gain, and mild edema in upper extremities or face

vs.

BP is 160/110, 3-4+ proteinuria, oliguria with elevated Cr, blurred vision, HA, pulmonary or cardiac involvement, epigastric pain, thrombocytopenia, hepatic dysfunction

HELLP syndrome

a variation of the gestational hypertensive process; symptoms include:

• hemolysis → anemia

• elevated liver enzymes → epigastric pain

• low platelets → abnormal bleeding/clotting

factors contributing to lack of prenatal care in adolescent pregnancy

• view it as protecting the pregnancy (no one will suggest to terminate it)

• denial

• lack of knowledge of the important of prenatal care

• dependence on others for transportation

• awkward

• fear of pelvic exam

• difficulty relating to authority figures

adolescent pregnancy carries the increased incidence of:

• iron deficiency anemia

• preterm labor

• PP hemorrhage

• preeclampsia

• cephalopelvic disproportion

• lack of knowledge about infant care

• inability to adapt postpartally

what additional testing would you offer a pregnant patient over the age of 40?*

chromosomal assessment to screen for down syndrome or open spinal cord

may also be offered a more accurate noninvasive blood test (circulating free DNA (cfDNA)) to screen for chromosomal disorders as early as 10 weeks of gestation

dysfunctional labor and its causes

sluggishness of contractions or force of labor is less than usual; can occur at any point in labor and puts patient at risk for PP infection, hemorrhage, and infant mortality

can be caused by:

• primigravada status

• cephalopelvic disproportion

• posterior rather than anterior fetal position

• failure of uterine muscles to contract

• presence of a full rectum or urinary bladder

• exhausted from labor

• inappropriate use of analgesia

dystocia

a difficult labor

hypotonic uterine contractions

less than 3 contractions in 10 minutes

tend to occur after administration of analgesia, especially if cervix is not dilated to 3-4cm → increases length of labor

hypertonic contractions

marked by an increase in resting tone to more than 15mmHg but intensity may not be stronger

contractions occur more frequently → lack of relaxation may not allow uterine artery filling → fetal anoxia

precipitatous labor

when cervical dilation occurs at 5cm+/hour in a primipara or 10cm+/hr in a multipara

uterine contractions are strong and parent gives birth with only a few, rapidly occurring contractions (completed in less than 3 hours)

can lead to premature separation of placenta, laceration of perineum, risk for hemorrhage, and risk of subdural hemorrhage in fetus

induction vs. augmentation

labor is started artificially; should be avoided until 39 weeks but might be necessary if there is preeclampsia/eclampsia, severe HTN, diabetes, prolonged rupture, etc.

vs.

assisting labor that started spontaneously but it not effective

what conditions must be present for induction to begin?

• fetus in a longitudinal lie

• cervix is ripe - can be done by stripping/sweeping or inserting prostaglandins

• present part of fetal head is engaged (if not, cord could prolapse)

• no suspect cephalopelvic disproportion

• fetus is mature (39weeks+)

within how long of membrane rupture should delivery of the baby occur?

24 hours

dangers of hyperstimulation (aka tachysystole) with oxytocin and interventions

can interfere with placenta filling and fetal oxygenation (needs 60-90 seconds between contractions to receive oxygenation)

1. stop infusion**

2. turn patient onto their left side

3. administer fluid bolus to dilute oxytocin

4. administer O2

side effects of oxytocin (pitocin)

• peripheral vessel dilation → extreme hypotension

  • take HR and BP every hour

  • monitor uterine contractions and fetal HR

• decreased urine flow → water intoxication → headache and vomiting first signs

  • stop infusion and report

  • monitor I&Os

uterine rupture

rare but can happen when someone has a previous cesarean scar, prolonged labor, abnormal presentation, multiple gestation, traumatic maneuvers of forceps or traction

fetal death will follow if C-section is not done immediately

manifestations:

• sudden, severe pain during a strong labor contraction, feels like tearing

• hypotensive shock:

  • rapid, weak pulse

  • falling BP

  • cold and clammy skin

  • dilation of nostrils from air starvation

  • decreased/absent fetal heart sounds

manifestations and management of an inverted uterus

• large amount of blood gushes from the vagina

• fundus no longer palpable

• hypotension, dizziness, paleness, diaphoresis

• bleeding cannot be halted

you should:

• discontinue oxytocin

• insert IV line (need blood replacement)

• administer O2

• assess VS

• prepare to perform CPR if pt. goes into heart failure

amniotic fluid embolism

occurs when amniotic fluid is forced into an open uterine sinus after membrane rupture or partial premature separation of the placenta

assessment and management of umbilical cord prolapse

can be felt on vaginal exam, seen at vulva, or visualized on ultrasound; fetal HR will drop after ROM

is an EMERGENCY → leads to cord compression and decreased oxygenation to fetus

place a gloved hand in the vagina and manually elevate fetal head off of cord

place patient in knee-chest or Trendelenburg position

give oxygen

cover any exposed portion with sterile saline compress

amnioinfusion

the rapid addition of warmed sterile fluid through the cervix and into the uterus to supplement the amniotic fluid and reduce compression on the cord

during procedure:

• have patient lie in lateral recumbent position (to prevent supine hypotension)

• maintain aseptic technique

• monitor FHR and contractions

• record temperature every hour to detect infection

• assess if there is constant drainage from vagina

cause of shoulder dystocia

in the second stage of labor (and if baby has increased weight/height), when the head is born but the shoulders are too broad

the force of the birth can result in a fractured clavicle or a brachial plexus injury

risk factors for shoulder dystocia

it mostly occurs in patient’s with:

• diabetes

• multiparas

• fetuses that are large for gestational age

• postdate pregnancies

suspect this condition if second stage of labor is prolonged, if there is arrest in descent, or if the head moves past the perineum then retracts (turtle sign)

McRoberts maneuver

help patient deeply flex knees back and rotate thighs laterally to make a wide V

widens pelvic outlet and helps anterior shoulder be born

suprapubic pressure

downward and lateral pressure applied to patient’s pubic bone to dislodge and rotate shoulder

stand on the side closest to the fetal back

what are some medications and procedures used to induce labor?

• stripping / sweeping

  • helps cervix ripen by stimulating prostaglandins to soften the cervix

• Prepidil or Cervidil

  • prostaglandins that promote ripening of the cervix

• Misoprostol

  • assist in cervical ripening

• oxytocin (Pitocin)

  • initiates contractions