maternity exam 3

Common medications used to treat PPH

Oxytocin

Methylergonovine

Misoprostol

Carboprost tromethamine

Tranexamic Acid

post-partum hemorrhage

a cumulative blood loss of 1000 mL or more, or any amount of blood loss associated with manifestations of hypovolemia, regardless of the type of birth

early (or primary) PPH

occurs within the first 24 hours after birth. The client presents with an enlarged, uncontracted uterus that palpates as boggy and is possibly deviated to the side in relation to a distended bladder. However, the uterus may present with a fully contracted fundus with the lower uterine segment demonstrating uterine atony.

secondary PPH (late PPH)

clients will present with heavy vaginal bleeding from 24 hr postbirth up to 12 weeks postpartum. Changes in client vital signs, such as tachycardia, may not occur until the client has experienced a blood loss of greater than 1,000 mL or until the client develops shock.

Signs & symptoms of PPH

- Heavy/excessive vaginal bleeding

- boggy/enlarged uterus with uterine atony

- tachycardia

- hypotension

- pallor

- weakness/restlessness

- decreased urine output

- signs of hypovolemic shock.

- Remember that early changes in VS might not occur until significant blood loss has occurred.

nonpharmacologic treatment for PPH

Bimanual uterine massage

Immune thrombocytopenia (ITP)

the mother's immune system produces antibodies that destroy her platelets, causing low platelets and increased bleeding risk. IgG antiplatelet antibodies can cross the placenta, so the newborn can also develop thrombocytopenia

signs and symptoms of Immune thrombocytopenia (ITP)

bruising, petechiae on the extremities and trunk, and nonurgent bleeding. This bleeding may consist of bleeding gums, epistaxis, and heavy menstrual flow. Pregnancy-induced ITP may present with severe, spontaneous bleeding.

ITP treatment

-long-term course of oral corticosteroids for immune system suppression.

- If the client has experienced a significant bleeding event, such as childbirth, an intravenous immunoglobin may be prescribed in addition to the oral corticosteroids.

- However, if the first-line pharmacological treatments are not effective, the client may undergo a splenectomy.

Preterm Prelabor Rupture of Membranes (PPROM)

the amniotic sac ("water") ruptures before labor begins AND before 37 weeks of pregnancy.

What does PPROM increase the risk of?

Infection, impaired fetal lung development, cesarean birth, hemorrhage, and infant respiratory distress

signs and symptoms of PPROM

- Sudden gush of fluid from the vagina

- Continuous leaking/trickling of watery fluid

- Feeling wetness in the underwear/perineal area

- Fluid is usually clear or pale yellow

- May have uterine contractions if preterm labor begins

What are the risk factors for PPROM?

Low socioeconomic status, low pre-pregnancy BMI, tobacco use, history of PPROM, infection, short cervical length, vaginal bleeding

How is PPROM managed near term?

Expectant management or induction

What medications/treatments may be used for PPROM?

Tocolytics, antibiotics, corticosteroids, magnesium sulfate, activity limitations

What maternal and fetal complications can occur with PPROM

- maternal sepsis

- c-section

- fetal sepsis and fetal respiratory problems

What should the nurse assess with PPROM?

Time of rupture; fluid color, consistency, and odor; maternal VS/history; FHTs and contractions

What should be avoided with PPROM?

vaginal examinations

Group B Streptococcus (GBS)

Bacteria that can colonize the maternal GI/genital tract and can be transmitted to the newborn during birth.

Group B Streptococcus (GBS) treatment

Treated with antibiotics during labor

Group B strep (GBS) testing

- recommended anytime from exactly 36 weeks through 37 weeks and 6 days regardless of the planned mode of birth.

- Clients who test positive for GBS will be treated with antibiotics upon admission to the labor and birth facility and at scheduled intervals until birth.

- Clients admitted to labor and birth prior to the completion of GBS testing or those who have risk factors such as preterm labor, prelabor preterm rupture of membranes, maternal fever or those with membranes ruptured for greater than 18 hr will be treated with antibiotics prophylactically

Chorioamnionitis

- Infection resulting in inflammation of amniotic fluid, placenta, uterus

- Manifestations include fever of 100.4 or greater on 2 different occasions, uterine tenderness, purulent amniotic fluid, maternal/fetal tachycardia, elevated WBC.

- Treatment includes antibiotics

mastitis

- infection in a milk duct of the breast with concurrent flu-like manifestations

- Painful or tender localized hard mass and reddened area, usually on one breast

- Influenza-like manifestations (chills, fever, headache, body ache)

- Fatigue

mastitis treatment

antibiotics

mastitis pt education

- breast hygiene can prevent and manage mastitis.

- Thoroughly wash hands prior to breastfeeding.

- Maintain cleanliness of breasts with frequent changes of breast pads.

- Allow nipples to air-dry.

- Proper newborn positioning and latching-on techniques

- include both the nipple and the areola. Release the newborn's grasp on the nipple prior to removing the newborn from the breast.

- Completely empty the breasts with each feeding to prevent milk stasis, which provides a medium for bacterial growth.

- Use ice packs or warm packs on affected breasts for discomfort.

- Continue breastfeeding frequently (at least every 2 to 4 hr), especially on the affected side.

- Manually express breast milk or use a breast pump if breastfeeding is too painful.

- Breastfeed or pump frequently, emptying the affected side.

- Rest, take analgesics, and maintain fluid intake of at least 3,000 mL per day.

- Wear a well-fitting bra for support. The bra should not have an underwire because that increases the risk for infection.

Report redness and fever.

- Complete the entire course of antibiotics as prescribed.

Common signs & complications of shoulder dystocia (mother and baby)

- OB emergency during vaginal birth

- "Turtle sign"

Risk factors for shoulder dystocia

- History of shoulder dystocia

- Obesity

- Macrosomia (r/t diabetes)

- Male gender

- Epidural during labor

- Prolonged 2nd stage

complications for mother with a shoulder dystocia

- Postpartum hemorrhage (PPH) — especially from uterine atony or trauma

- Severe perineal/vaginal lacerations

- Cervical tears

- Pelvic floor injury

Fetal/Newborn complications with a shoulder dystocia

- Brachial plexus injury → weakness/paralysis of the affected arm, such as Erb palsy

- Clavicle or humerus fracture

- Hypoxia/asphyxia from prolonged delivery

- Neurologic/brain injury if severe/prolonged hypoxia occurs

- Death in severe cases

shoulder dystocia treatment

C - Call for help

A - Apply suprapubic pressure (avoiding the uterine fundus) to attempt to free the shoulder

M - Movement of the fetal arm across the head to dislodge shoulder attempted by provider

P - Position the client onto their hands and knees

E - Prepare for an episiotomy

E - Elevate the legs to a knee-chest Position (McRoberts maneuver)

R - Rotation of the fetus manually by provider

Magnesium sulfate

Medication of choice for prophylaxis or treatment to depress the CNS and prevent seizures in the client who has eclampsia and severe preeclampsia.

Magnesium sulfate common side effects

Flushing / feeling warm

Sweating

Nausea/vomiting

Headache

Drowsiness/lethargy

Muscle weakness

Blurred vision

Signs of magnesium toxicity

Absence of patellar deep tendon reflexes

Urine output less than 30 mL/hr

Respirations less than 12/min

Decreased level of consciousness

Cardiac dysrhythmias

If magnesium toxicity is suspected:

Immediately discontinue infusion.

Administer antidote calcium gluconate or calcium chloride.

Prepare for actions to prevent respiratory or cardiac arrest.

Pitocin (oxytocin)

Used to augment labor and strengthen uterine contractions

Pitocin side effects

- Uterine tachysystole — contractions too frequent/strong

- Nausea/vomiting

- Headache

- Hypotension

- Fetal heart rate changes/distress secondary to excessive uterine contractions

- Water intoxication/hyponatremia

Pericare and voiding after birth

Pain Management

Sitz Bath

Medications

Topical Treatments

Cold Therapy

Strengthening Muscles

Pharmacological management of labor and pain

Opioids, Local anesthesia, Spinal block, Epidural analgesia

nonpharmacological management of labor and pain

Relaxation and breathing (yoga, Bradley method, Lamaze) Positioning, Touch/massage (effleurage, counterpressure) Acupuncture, Heat and cold, aromatherapy, Water therapy, Music, Biofeedback, Hypnosis

Nitrous oxide

- Self-administered

- Non-invasive, opioid

- Patient teaching

- Inhale at start of contraction

- Side effects

- Decreased effectiveness as labor progresses

What is a normal vaginal birth?

Delivery of the baby through the vagina, usually with the fetus in a vertex (head-down) presentation.

What stage of labor is the baby delivered?

Second stage: complete cervical dilation (10 cm) → birth of baby.

What stage is the placenta delivered?

Third stage: birth of baby → delivery of placenta.

What should happen after placental delivery?

Placenta is inspected for completeness, and the uterus should become firm and contracted to decrease bleeding.

Cord Prolapse

- Obstetric emergency

- Cord may be visible with vaginal exam

- If membranes intact, may prevent presenting part from being observed or felt.

Risk factors

- Maternal

- Fetal

- Iatrogenic (caused by medical intervention or treatment)

Nursing Actions When Prolapsed Cord is Identified:

F- Fetal presenting part elevated with sterile gloved hand

R- Rapid response team notified

R- Reposition client

O- Oxytocin discontinued (if currently infusing)

M- Monitor fetal heart rate

A- Apply oxygen if prescribed

I- Insert IV and indwelling urinary catheter; Instill fluid into bladder as prescribed.

Treatments/therapies for cord prolapse

- Initiate OB rapid response

- Emergent birth

- Keep presenting part off cord using 2 fingers

- Positioning

- Oxygen via face mask

- Sterile fluid infusion into bladder

Clinical presentation of a cord prolapse in fetus

- Fetal heart tracing

- Prolonged decel

- Fetal bradycardia

- Recurrent variable decels

First stage of labor:

- Begins at onset of labor

- Ends in full cervical dilation/effacement

Latent phase of labor

- Irregular contractions

- 0 to 4 cm dilation at onset, may increase to 6 during transition to active

Active phase of labor

- Presenting part of fetus descends

- Full dilation (10 cm)

Second stage of labor:

- Vaginal Birth

- Vertex Position of Fetus

- Crowning

- Birth of the Head

- Birth of the Shoulders

- Birth of the Body and Extremities

- Perineal Lacerations

- Vaginal and Urethral Lacerations

- Cervical Injury

- Episiotomy

Third stage of labor:

- Maternal Assessment

- Passive Management of Placenta Expulsion

- Active Management of the Third Stage of Labor (AMTSL)

- Newborn Assessment

- Apgar Score

- Temperature Regulation

- General Appearance

- Respiratory

- Cardiovascular

- Neurological

- Eyes, Nose, Mouth

- Skin

- Care of the Maternal Client

- Hygiene

Fourth stage of labor

• Maternal Client Assessment

• Vital Signs

• Fundal Position

• Urinary Elimination and Bladder Distention

• Lochia

• Perineum

• Vaginal Birth Post Anesthesia

• Activity

• Respirations

• Blood Pressure

• Level of Consciousness

• Sensation/Movement of Extremities

• Maternal Client Assessment

• Cesarean Birth Post Anesthesia Recovery

• Activity

• Respirations

• Blood Pressure

• Level of Consciousness

• Skin and Surgical Site

• Orientation

• Newborn Assessment

• Posture

• Vital Signs

• Care of the Maternal Client

• Nutrition

• Hydration

• Rest

• Bonding with the Newborn

• Pain Management

• Elimination

• Safety

Lochia rubra

dark red, first 3-4 days postpartum

Lochia serosa

pink to brown, days 4-10 postpartum

Lochia alba

white or yellow, days 10-14 postpartum

The amount of flow on the perineal pad after 1 hour is noted as:

• scant (less than 2.5 cm on pad),

• light (less than 10 cm on the pad),

• moderate (15 cm on the pad),

• heavy (pad saturated in 1 hour)

Category I FHR

Normal FHR, no intervention needed

Category II FHR

Indeterminate FHR, requires observation and potential corrective measures.

Category III FHR

Abnormal FHR, immediate intervention and continuous evaluation necessary.

Variable deceleration

Abrupt decrease (shaped like V, U, W)

Umbilical cord compression

reposition patient

early deceleration

Gradual

Mirror contraction

Compression of fetal head during contraction

Does not warrant intervention

Late deceleration

Decreases after peak of contraction

Associated with some maternal conditions or placental abruption

Emergency: stop stressors, mom on left side, administer oxygen, give tocolytic (terbutaline sub q), intrauterine resuscitation

Prolonged deceleration

- Non-reassuring pattern

- Decrease in FHR of at least 15 beats per min over 2 min to 10 min

- Associated with maternal hypotension, rapid cervical dilation, anesthesia, artificially rupture membranes

- If no recovery to baseline, emergent birth is necessary

Sinusoidal pattern

Emergency, requires intrauterine resuscitation

4th degree laceration/episotomy

Ice packs to perineum initially → ↓ swelling and pain

Give analgesics as ordered

Give stool softeners

Encourage fluids + fiber → prevent constipation/straining

Provide/teach careful perineal hygiene

Assess the repair for redness, edema, bruising, drainage, approximation

Monitor for infection and hematoma

Later, sitz baths may provide comfort and promote healing

Postpartum voiding

Assess for bladder distention and urinary elimination. A distended bladder can displace the uterus and interfere with uterine contraction, increasing bleeding risk.

Postpartum pericare

Clean perineum front to back, change pads frequently, perform hand hygiene, assess lochia/perineum, use cold therapy initially for swelling/pain and sitz baths later for comfort.

Rho-gam administration

- Administer RhO (D) immune globulin IM around 28 weeks of gestation for clients who are Rh-negative.

- All Rh-negative clients who have have newborns who are Rh-positive must be given Rho(D) immune globulin administered IM within 72 hr of the newborn being born to suppress antibody formation in the mother. The nurse should check to see if the client has not been sensitized prior to administering Rho(D) immune globulin. Observe the client for at least 20 minutes post administration for an allergic reaction.

RhoGAM indication

Give to an unsensitized Rh-negative client when there is risk of exposure to Rh-positive fetal blood, including routine antepartum prophylaxis and postpartum after an Rh-positive newborn; sensitizing events such as pregnancy loss, ectopic pregnancy, invasive prenatal procedures, abdominal trauma, or significant pregnancy bleeding can also prompt administration.

Placenta previa

occurs when the placenta abnormally implants in the lower segment of the uterus near or over the cervical os instead of attaching to the fundus. The abnormal implantation results in bleeding during the third trimester of pregnancy as the cervix begins to dilate and efface.

expected findings with placenta previa:

Painless, bright red vaginal bleeding during the second or third trimester

Uterus soft, relaxed, and nontender with normal tone

Fetus in a breech, oblique, or transverse position

Reassuring FHR

Vital signs within normal limits

Decreasing urinary output, which can be a better indicator of blood loss

Disseminated Intravascular Coagulation (DIC)

a coagulopathy in which clotting and anticlotting mechanisms occur at the same time. The client is at risk for both internal and external bleeding, as well as damage to organs resulting from ischemia caused by microclots.

Disseminated Intravascular Coagulation (DIC) expected findings

→ Uncontrolled/oozing bleeding→ Bleeding from IV or injection sites → Petechiae/ecchymosis→ Vaginal bleeding→ Hematuria→ Hypotension/tachycardia if significant blood loss occurs

DIC treatment

Treat the underlying cause, support circulation, and replace blood/clotting components as prescribed (such as PRBCs, FFP, platelets, or cryoprecipitate depending on the deficiency).

placental abruption

Premature separation of the placenta from the uterine wall before birth

placental abruption expected findings

→ Sudden, painful vaginal bleeding → Abdominal/uterine pain and tenderness→ Firm, board-like/rigid abdomen → Frequent contractions/uterine irritability→ Fetal distress may occur

Gestational Diabetes Mellitus (GDM)

- Diabetes first diagnosed during pregnancy, causing maternal hyperglycemia.

- Higher rates among Black and Indigenous clients.

Gestational Diabetes Mellitus (GDM) expected findings

Polyuria → frequent urination

Polydipsia → increased thirst

Polyphagia → increased hunger

Fatigue

Glucose in the urine (glycosuria)

Recurrent infections, such as UTIs or yeast infections

GDM treatment

Blood glucose monitoring, nutrition/diet management, appropriate activity/exercise, and medication such as insulin when needed

Cephalic presentation

Fetal head presents first.

Presentation

Part of the fetus that enters the maternal pelvis first.

Breech presentation

Fetal buttocks, feet, or knees present first.

Denominator

Designated reference point on the presenting part, such as the occiput, sacrum, or mentum.

ROA

Right occiput anterior.

LOA

Left occiput anterior.

ROP

Right occiput posterior.

LOP

Left occiput posterior.

Lie

Position of the fetal spine relative to the maternal spine.

Longitudinal lie

Fetal spine is parallel to the maternal spine

Transverse lie

Fetal spine is horizontal/perpendicular to the maternal spine.

Oblique lie

Fetal spine is at an acute angle to the maternal spine.

Attitude

Relationship between the fetal head and fetal spine.

Vertex

Fetal neck is flexed with chin to chest; smallest head diameter presents.

Face presentation

Fetal neck is extended; a wider head diameter presents.

Compound presentation

Fetal extremity is alongside the primary presenting part.

Shoulder presentation

Shoulder is the lowermost/presenting fetal part.

Leopold maneuvers

Four abdominal palpation maneuvers used to determine fetal position/presentation and assist with fetal monitor placement.

TOCO (tocodynamometer)

External, noninvasive monitor used to assess contraction frequency and duration.