high risk pregnancy/childbirth, IPV, perinatal grief & loss (SIDS)

what medications do you use for postpartum hemorrhage (PPH)?

1. oxytocin

2. methergine

3. hemabate

4. misoprostol

5. TXA

oxytocin action/indication

contracts the uterus to decrease bleeding

oxytocin side effects

• water intoxication

• n/v

oxytocin contraindications

none

misoprostol action/indication

• prostaglandin (used in inflammatory response)

• given PO - takes hours to take action

• contracts the uterus

misoprostol side effects

• HA

• N/V/D

• fever/chills → can’t tell if mom has infection

misoprostol contraindications

none

methergine action/indication

contracts the uterus

methergine side effect

• HTN

• hypotension

• n/v/d

• HA

methergine contraindication

• htn

• pre-e

• cardiac disease

hemabate action/indication

• prostaglandin

• contracts uterus

hemabate side effects

• HA

• n/v

• fever/chills

• diarrhea (often give with lomotil)

hemabate contraindications

avoid in

• asthma

• HTN

TXA action/indication

• prevents clot breakdown

• anti-fibrinolytic (reverse lysine receptor sites on plasminogen)

TXA side effects

• HA

• n/d

• stomach pain

• fever/chills

TXA contraindications

subarachnoid hemorrhage

what medications are used for preterm labor (PTL)?

• magnesium sulfate

• terbutaline

• indomethacin

• nifedipine

• betamethasone

magnesium sulfate MOA

• CNS depressant (relaxes smooth muscle)

• used for neuroprotection

magnesium sulfate adverse effects

• hot flashes, sweating, burning at insertion site

• N/V

• dry mouth

• drowsiness, blurred vision, diplopia, HA

• hypoclacemia

• dyspnea

• transient hypotension

magnesium sulfate nursing considerations

• assess baselines

• monitor for toxicity (slurred speech, decrease DTR, dec LOC)

• therapeutic range: 4-7.5 mEq/L

• calcium gluconate for toxicity

• IV intake no more than 125 mL/hr

• contraindicated with myasthenia gravis

terbutaline MOA

• beta-adrenergic agonist

• relax smooth muscle

• inhibit uterine activity

• bronchodilation

terbutaline adverse affects

• maternal tachycardia, chest discomfort, palpitations

• tremors/nervousness

• HA

• N/V

• hypokalemia

• hyperglycemia

• hypotension

• fetal tachycardia, hyperinsulinemia, hypoglycemia

terbutaline nursing considerations

• contraindicated in cardiac disease, diabetes, severe htn, pre-e, or eclampsia

• use caution if hyperthyroid

• avoid if significant hemorrhage

• monitor HR>130, BP<90/60, hyperglycemia, and fetal tachycardia

indomethacin MOA

• prostaglandin synthesis inhibitor (NSAID)

• uterine smooth muscle relaxant

indomethacin adverse effects

• N/V

• heartburn

• GI bleeding, thrombocytopenia, asthma in aspirin sensitive pts

• in the fetus: ductus arteriosus constriction, oligohydramnios d/t dec fetal urine production

• neonatal pulmonary htn

indomethacin nursing considerations

• long acting formulation dec adverse effects

• used if only less than 32 wks gestation

• administer for 48 hours or less

• avoid if you have renal/hepatic/peptic ulcer disease

• monitor amniotic fluid volume

• administer with food

• monitor for s/s of PPH

nifedipine MOA

• calcium channel blocker

• relaxes uterine smooth muscle by blocking calcium entry

nifedipine adverse effects

• maternal hypotension

• HA

• flushing, dizziness

• nausea

• fetal hypotension

nifedipine nursing considerations

• avoid concurrent use with mag

• do not give with terbutaline

betamethasone MOA

• corticosteroids

• has enzymes for lung surfactant synthesis/proteins to increase lung maturity and decrease risk of RDS in preterm infants

betamethasone adverse effects

• maternal hyperglycemia

• increase WBC

• increased plts

• pain at injection site

betamethasone nursing considerations

• risk/benefit assessment if diabetic

• baseline wbc, plts, and randome glucose

• give w/in 7 days of expected delivery of preterm when 24-34 wks GA

• rescue dose after 14 days if not delivered and still less than 34 wks

• inc risk of maternal infection, endometritis, and chorioamnionitis for prolonged ROM

what are the neonatal side effects of betamethasone?

DFM, decreased breathing, and HR variation but no changes in fetoplacental vessels

when do you begin to calculate QBL?

immediately after neonate’s birth but before the delivery of the placenta

what is the equation used to calculate blood loss of a blood-soaked item?

wet item gram weight - dry item gram weight = milliliters of blood of item

(1 gm = 1mL)

postpartum hemorrhage s/s

• change of alertness from baseline: confusion, lethargy

• tachycardia, tachypnea, hypotension, narrow pulse pressure, O2 less than 95%

• cool, damp, pale skin

• soft boggy, displaced fundus

• bloody lochia (heavy, saturation of one pad per hour)

• severe pelvic/rectal pain

• decreased urine output

what are the four common reasons for PPH?

• uterine atony

• retained placenta

• lacerations

• coagulopathy

name other common reasons for PPH

• full bladder

• overdistended uterus (macrosomia, multiples)

• prolonged labor

• infection

• magnesium sulfate (or similar)

placenta previa

when the placenta implants near or on the cervical os. leads to bleeding and need for C/S

placenta previa s/s

• bright red blood

• painless

placental abruption

when the placenta separates from the uterine wall prior to delivery and causes bleeding and fetal distress (reduces O2 and nutrient supply)

placental abruption s/s

• dark blood

• painful contractions

placental abruption risk factors

• maternal hypertension

• cocaine use

• blunt abdominal trauma

• smoking

• history of abruption

• preterm prelabor rupture of membranes

• twins

vasa previa

where unprotected blood vessels from the placenta pass over or near the cervia. these vessels can rupture with labor or membrane rupture, leading to severe fetal bleeding.

placenta accreta

placenta attaches and grows into the wall of the uterus

placenta increta

placenta invades the muscles of the uterus

placenta percreta

placenta penetrates and grows through the uterus, and can invade the bladder, bowel and other internal organs

cervical insufficiency

• one reason that miscarriages happen during the 2nd trimester

• passice, painless dilation of the cervix during second trimester or after 12 weeks gestations

• can be acquired or cogential

cervical insufficiency diagnosis

• measuring the length of the cervix is the method

• speculum/digital pelvic exams

• transvaginal US

• cervical funneling

cervical insufficiency interprofessional care management

• cerclage → stitching the cervix to constrict the internal os

• abdominal cerclage → suture placed at the junction of th elower uterine segment and the cervix

cerclage follow up care

• monitor s/s of PTL, infection, ROM

• return if painful contractions, PROM, perineal pain, or urge to push

hydatidiform mole etiology

• unknown

• may be related to ovular defect or nutrient deficiency

what are the types of hydatidiform mole?

complete or partial

hydatidiform mole clinical manifestation

• anemia

• excess N/V

• abd cramps

• pre-r

• abn large growing uterus

how do you diagnosis hydatidiform mole?

transvaginal US and serum hCG levels

hydatidiform mole interprofessional care management

• most abort spontaneously

• suction curettage

hydatidiform mole follow up care

• monitor beta-hCG levels

ectopic pregnancy

when the egg implants anywhere else besides the uterus. most commonly the fallopian tube. can cause bleeding due to rupture of organ as it grows

ectopic pregnancy clinical manifestations

• abd pain

• delayed menses

• abn vaginal bleeding (spotting)

how do you diagnosis an ectopic pregnancy?

• difficult to Dx

• quant beta-hcg levels and transvaginal US

• discriminatory zone- a beta-hCG level above normal intrauterine pregnancy should be on US

ectopic pregnancy interprofessional care management

• methotrexate

• surgery (depends on location and cause_

ectopic pregnancy follow up care

• methotrexate

• serial beta hcg lvls

• family share feelings and concerns

• wait 3 cycles for healing

why is methotrexate used for ectopic pregnancies?

it blocks the enzymes in the body that maintain the pregnancy preventing the tissue from growing and rupturing.

very preterm

less than 32 wks gestations

moderately preterm

32-34 wks gestation

late preterm

34 to 36 6/7 wks gestation

low birth weight

less than or equal to 2500 gm at birth

what does spontaneous preterm birth mean?

it is not medically induced

what does induced preterm birth mean?

medically induced labor because there is some risk of risk to mother or baby if the pregnancy continues

what are the risk factors to preterm labor and birth?

none

what are the methods used to predict PTL/PTB?

• measuring cervical length → cervical length greater than 30 mm in the 2nd/3rd trimester is unlikely to have ptb

• fetal fibronectin test → predicts who will not go into PT. negative tests have less than 1% chancepre of giving birth within two wks

prelabor rupture of membranes (PROM)

spont rupture of the amniotic sac and fluid leakage before labor onset at any gestational age

preterm prelabor rupture of membranes (PPROM)

membranes rupture before 37 wks of gestation

PROM/PPROM interprofessional care management

• PPROM less than 32 wks is managed expectantly and conservatively

• monitor for s/s of infection

• fetal assessment

• antenatal glucocorticoids for all women with PPROM

• 7 day broad spectrum abx

• administer mag for fetal neuroprotection

chorioamnionitis

amniotic cavity bacterial infection that can occur at any gestational age

chorioamnionitis s/s

• maternal fever

• maternal/fetal tachycardia

• uterine tenderness

• amniotic fluid foul odor

postterm pregnancy (postdates)

extends after 42 wks gestations

postdate risk factors

• first preg

• prior postterm

• male fetus

• obesity

• genetic predisposition

maternal and fetal risks of postterm pregnancy

• inc maternal morbidity

• dysfxn labor and birth canal trauma

• need for labor and birth interventions

• macrosomia

• prolonged labor

• shoulder dystocia

• postmaturity syndrome

postmaturity syndrome

• dec SQ fat

• no lanugo and vernix

• cracked peeling skin

• long nails

• mec

what are the reasons for elective labor induction?

• must be 39 wks gestation

• labor initiated w/o medical indication

• for convience

• risks

• bishop’s score

what are the reasons for an indicated labor induction?

• maternal/fetal reasons

• betamethasone for lung maturity if early induction

what are the methods to induce labor?

• cervical ripening

• amniotomy

• oxytocin

bishop’s score

the higher the score, the more favorable the cervical condition for labor induction. It assesses cervical dilation, effacement, consistency, position, and the baby's station. you need a score of 9 or more to increase the likelihood of a successful induction

external cephalic version (ECV)

• procedure to turn the fetus from breech or shoulder to vertex for birth

• 65% success rate at 36-37 wks

• US used during

• NST and informed consent before procdure

internal version

rarely used, safety questionable

operative vaginal birth

uses forcepts or vaccume extractor. if vacuumed used, baby will have chignon

meconium stained amniotic fluid

fetus passed dark green stool prior to birth that can indicate fetal distress and may require careful monitoring during labor to prevent complications. need neonatal resuscitation

what are the causes of meconium stained amniotic fluid?

• normal maturity

• hypoxia induced peristalsis

• umbilical cord compression

shoulder dystocia

head is born first, but anterior shoulder cannot pass under pubic arch

shoulder dystocia birth injuries

• asphyxia

• brachial plexus damage

• clavicular/brachial fracture

shoulder dystocia maternal risks

• excessive blood loss from uterine atony, rupture, lacterions, episiotomy, or endometritis

shoulder dystocia interprofessional care management

• mcroberts maneuver (knees to chest)

• supraprubic pressure (push shoulder under the pubic arch)

• gaskin maneuver (all fours)

• posterior arm (extend the free arm)

• rubin (twist the head)

prolapsed cord

when the cord lies below the presenting part of the fetus

contributing factors to prolapsed cord

• long cord (100cm +)

• malpresentation

• transverse lie

• unengaged presenting part

• polyhydramnios

prolapsed cord interprofessional care management

• prompt recognition

• pressure off cord

• position change (extreme trendelenburg, side-lying, knee to chest)

• administer O2

• monitor FHR using FSE

• start IV fluids

uterine rupture

disruption and separation of layers of the uterus or previous scar (ex. trauma, surgery, previous C/S)

uterine dehiscence

incomplete uterine rupture or separation of prior scar

amniotic fluid embolus (AFE) or anaphylactoid syndrome of pregnancy (ASP)

sudden onset of hypotension, hypoxia, and hemorrhage caused by coagulopathy amniotic fluid and debris (vernix, hair, skin, mec) entering maternal circulation and obstructive pulmonary vessels