Maternal Care Challenges

Gestational Conditions

• Disorders that did not exist before pregnancy

• Occurrence puts woman and fetus at risk

  • Hypertension in pregnancy

    • Chronic Hypertension

    • Preeclampsia 

    • HELLP Syndrome

    • Eclampsia

  • Gestational diabetes mellitus

  • Hyperemesis gravidarum

  • Hemorrhagic complications (PPH) 

  • Surgery during pregnancy

  • Trauma

  • Infections during pregnancy

Hypertension in Pregnancy

• Systolic blood pressure (BP) >140 mm Hg and diastolic BP > 90 mm Hg

• Severe hypertension: systolic BP >160 mm Hg and diastolic BP >110 mm Hg

Hypertensions in Pregnancy (Significance and Incidence)

• Hypertensive disorders of pregnancy are increasingly common, involving 5 to 10% of pregnancies.

• Women over 40 years of age are at highest risk. 

• Hypertension is the leading cause of maternal and perinatal morbidity and mortality worldwide. 

• SOGC (Society of Obstetricians and Gynecologists of Canada) has recommendations regarding prevention of pre-eclampsia and its associated complications

Hypertensive States of Pregnancy

• Chronic Hypertension

• Superimposed preeclampsia

• Gestational Hypertension

• Preeclampsia

• Severe Preclampsia

• Eclampsia

Chronic hypertension

Hypertension present before pregnancy

Superimposed preeclampsia

Chronic hypertension in association with  pre-eclampsia (after 20 weeks of gestation)

Gestational hypertension

Hypertension develops at or after 20 weeks of gestation in previously normotensive woman without proteinuria.

Preclampsia

Hypertension develops at or after 20 weeks of gestation in previously normotensive woman with proteinuria.

• The main pathogenic factor is not an increase in BP but poor perfusion resulting from vasospasm.

• Pathologic changes caused by disruptions in placental perfusion and endothelial cell dysfunction

• Believed to be an interaction between cardiovascular and uteroplacental responses to pregnancy.

• Arteriolar vasospasm diminishes the diameter of blood vessels, which impedes blood flow to all organs and increases BP. 

Signs and symptoms of preeclampsia

• Swelling of face or hands 

• Fluid retention (decreased urine output)

• Sudden weight gain (>2lbs/week / > 6 lbs/mos)

• Persistent headache 

• Seeing spots or changes in eyesight 

• Pain in the upper abdomen or shoulder 

• Nausea and vomiting (in the second half of pregnancy) 

• Difficulty breathing (dyspnea) 

• Tachycardia

Diagnostic Tests for Preeclampsia

• Hematocrit - >35 & rising

• Kidney involvement – Increased BUN & Uric acid

• Coagulopathy – decreased platelet count

• Bleeding time prolonged – decreased fibrinogen

• Endothelial cell dysfunction – placental ischemia

• Hepatic – decreased liver perfusion 

  • Elevated liver enzymes AST & ALT indicate inflammation

Severe preeclampsia

• Hypertension

• Proteinuria

• Cerebral disturbances

• Epigastric pain

Eclampsia

Seizure activity or coma in woman diagnosed
with preeclampsia (no other reason)

Hematocrit

volume of blood made up of RBC’s

BUN (Blood urea nitrogen)

amount of nitrogen in waste product urea

Uric acid

waste product

Endothelial Cells

 line all blood vessels and regulate exchanges between bloodstream and tissues

Signs of preeclampsia

First Sign - Elevated BP

Second Sign - Proteinuria

3 Questions for preeclampsia

• Do you have a headache?

• Visual disturbance?

• RUQ epigastric pain?

Fetal health surveillance for preeclampsia

• nonstress test [NST]

• contraction stress test [CST],

• Laboratory tests

contraction stress test [CST],

mild contraction stimulation via IV oxytocin (minimal) or nipple stimulation

Plan of Care for Preeclampsia

ensure maternal safety & healthy baby

Plan of Care for Preeclampsia (Mild)

• Fetal health surveillance

• Activity restriction

• Diet

Plan of Care for Preeclampsia (Severe and HELLP Syndrome)

• Hospital care (O2 for perfusion)

• Magnesium Sulphate (1-1 care)

• Control of BP (< 160/100)

• No NSAIDS (elevate liver enzymes)

Plan of Care for Eclampsia

• Immediate care

• Postpartum nursing care

• Future health care

Magnesium Sulphate

a medication used in pregnancy, primarily to prevent and treat seizures in women with preeclampsia or eclampsia, and for fetal neuroprotection before anticipated early preterm delivery

Magnesium Sulphate: Vital Signs to take for baseline

• BP

• Pulse

• Resp Rate

• Temp

• DTRs (Deep tendon reflexes)

• O2 Sat

• LOC

Minimum Monitoring done for Mom’s on Magnesium Sulphate

• Continuous pulse oximetry

• Q1H: BP, HR, RR

• Q4H: DTRs, LOC, temp

• Foley Catheter

• I&O Q1H

• Max IV intake 80 ml/hr

Magnesium Sulphate Side Effects

• Facial Flushing

• Hypotension

• Metallic Taste

• N&V

• Palpitations

• Sweating

Magnesium Sulphate Toxicity

• Muscle weakness

• Loss of DTRs

• Hypothermia

• Resp. depression

• Altered cardiac condition

• Circulatory collapse

How to fix HDP (hypertensive disorders in pregnancy)

• The only way to fix HDP (hypertensive disorders in pregnancy) is to deliver the baby and remove the placenta. 

• The method of delivery will depend on severity and condition of fetal well-being

Gestational Diabetes Mellitus (GDM)

• Hyperglycemia that is first recognized in pregnancy.

• Prevalence: 3.8 to 6.5% 

• Higher among Aboriginal, Latin American, South Asian, Asian, and African women.

Maternal and Fetal Risks of Gestational Diabetes Mellitus

• 2 times the risk of developing hypertensive disorders

• Uncontrolled GDM can  impact fetus development (LGA infants)

Screening for GDM

• Risk factors: age, hx, obesity, polycystic ovarian syndrome

• Identify hyperglycemia early

GDM Antepartum Interventions

• Diet

• Exercise 

• Monitoring blood glucose levels

• Insulin therapy 

• Fetal surveillance

GDM Intrapartum Interventions

• monitor q1h

• FHR

• no glucose IV bolus

GDM Postpartum Interventions

• returns to N

  • reoccurs = risk of Type 2 later

Nursing Care of Infants of Mother with Diabetes

Critical to stabilize the newborn’s blood glucose

• In the first two hours of life, even a healthy term newborn’s blood glucose falls

• Early skin-to-skin and initiation of BF

• Frequent BF

• Blood sugar levels monitored as per protocol and intervention to maintain blood glucose in target range

• May be a medical indication for supplementation with expressed breast milk or, if EBM not avail., formula

• May need to be admitted for NICU for IV D10W

GDM Symptomatic Infant

• Jittery

• Temp. Instability

• Apnea/Bradycardia

• Sweating

• Irritability

• Tachypnea

• Pallor

• Poor Feeding

• Weak Cry

• Hypotonia

• Seizures

• Loss of Consciousness

Hyperemesis Gravidarum

• Nausea and vomiting during pregnancy is the most common medical condition affecting 50% - 90% of women at some point in their pregnancy.

• HG is protracted vomiting, retching, severe dehydration, and weight loss requiring hospitalization

• Usually begins during the first 10 weeks of pregnancy

Etiology - not well understood, increased levels of Estrogen / hCG, assoc. with transient hypothyroidism

Clinical Manifestations of Hyperemesis Gravidarum

• wt. loss

• dehydration

• low BP

• increased pulse

• poor skin turgor

Assessment for Hyperemesis Gravidum

Severity (freq, duration, diarrhea, wt. fluid/electrolytes, ketonuria – dehydration, CBC, psychosocial

Nursing Care for Hyperemesis Gravidum

• Initial care: Clear fluids to diet with protein, IV, antiemetics, I & O,

• Follow-up care – small freq high protein/bland meals, Mg, K, decrease odors

• compassionate, sympathetic care

Hemorrhagic Disorders

Hemorrhagic disorders in pregnancy are medical emergencies (Hypolvolemia)

• 50% of bleeding in the third trimester is placenta previa or placental abruption.

Incidence of Miscarriage - Spontaneous Abortion (Early Pregnancy Bleeding)

15 – 20% 

Clinical Manifestations of Miscarriage - Spontaneous Abortion (Early Pregnancy Bleeding)

• back pain, cramping, bleeding

  • Early Pregnancy 1-6 weeks: heavy menstrual flow

  • Early Pregnancy 6-12 weeks: mod discomfort, blood loss

  • Late Pregnancy 12 – 20 weeks: age, parity, infection, cervical dilation, 

Types of Miscarriage - Spontaneous Abortion (Early Pregnancy Bleeding)

• threatened

• inevitable

• incomplete

• complete

• missed

Assessment of Miscarriage - Spontaneous Abortion (Early Pregnancy Bleeding)

• ultrasound

• lab tests

• infection

• loss

Nursing Care of Miscarriage - Spontaneous Abortion (Early Pregnancy Bleeding)

Medical-surgical management (rest, supportive care, cx dilation, D & C (oxytocin)

Home care – iron supp, bleeding, sexual activity, family planning, support groups, F/U phone call, loss

Premature Dilation of the Cervix

• Incompetent cervix, cervical insufficiency

• Passive and painless dilation of the cervix without contractions or labour

• Etiology – past trauma, D& C (dilation and curettage), short cervix

Nursing Care of Premature Dilation of the Cervix

• Medical-surgical management

  • Conservative management of restricted activity and hydration

  • Prophylactic cerclage (24 weeks)  – removed at 35 – 37 wks.

• Nursing care – monitor for contractions, PROM, infection

• Home Care – decrease activity, bedrest, bleeding, emerg phone numbers

Ectopic Pregnancy

occurs when a fertilized egg implants and grows outside the main cavity of the uterus

Incidence of Ectopic Pregnancy

• (1 in 7,000 pregnancies) with diagnostics     

  • Fertilized ovum implanted outside uterine cavity

  • 95% occur in uterine (fallopian) tube

  • Other sites: Ovary (0.5%),Abdominal cavity (1.5%), Cervix (0.3%)

Clinical manifestations of Ectopic Pregnancy

• Missed menstrual period

• Abdominal pain 

• Mild-to-moderate dark red or brown intermittent vaginal bleeding occurs in up to 80% of women

Nursing Care of Ectopic Pregnancy

• Treatment options: salpingostomy, salpingectomy

• Hospital care – pre-op/post-op, V/S,  discuss future fertility

• Home care – loss & grief / infertility support groups

• Salpingostomy is surgical opening of fallopian tube

• Salpingectomy is removal of fallopian tube

Late Pregnancy Bleeding - Placenta Previa

• Placenta implanted in lower uterine segment near or over cervical os

• Classification based on degree cervical os is covered by placenta

Cervical OS

refers to the openings of the cervix, specifically the internal os (opening into the uterus) and the external os (opening into the vagina). 

Types of placental previa

• Complete placenta previa – covers internal cervical os completely

• Marginal placenta previa – 2.5 cm or closer to the cervical os

• Low-lying placenta – no measurement of edge of placenta to cervical os

Incidence and Risk factors of Placenta Previa

• 0.5% of births

• Risk Factors:

  • previous placenta previa

  • C/S

  • endometrial scarring

Diagnosis of Placenta Previa

•  transabdominal ultrasound examination

• transvaginal ultrasound

Clinical Manifestations of placenta previa

diagnosed by ultrasound,  painless bright red vag. bleeding (2^nd or 3^rd trimester)

Maternal and fetal Outcomes of placenta previa

• Complications: hemorrhage, abnormal placental attachment, poor placental exchange, hysterectomy 

• Fetal risks: malpresentation, stillbirth, and fetal anemia preterm birth

Late Pregnancy Bleeding: Abruption

Placental abruption: premature separation of placenta

Incidence and Etiology of Abruption

1 in 75 – 226 pregnancies. Hypertension, trauma (MVA), cocaine use, smoking, PROM, twin pregnancies

Grades of Abruption

mild, moderate, severe

Clinical Manifestations of Abruption

•  partial or complete separation

  • Dark, vaginal non-clotting bleeding, 

  • Abdominal back pain,

  • Port-wine stained amniotic fluid

  • Uterine contractions

  • Uterine tenderness

Fetus and Maternal outcomes of abruption

Maternal: hemorrhage, hypovolemic shock, thrombocytopenia (low platelets), renal failure

Fetus: Abnormal FHR patterns, neurological defects, IUGR, death, > incidence of SIDS

Late Pregnancy Bleeding: Placental Variations

• Placenta accrete

• Placenta increta

• Placenta Percreta

• Velamentous insertion of cord/ vasa previa

Cord insertion and placental variations

• Battledore (marginal) insertion of cord 

Placenta accrete

• (placenta previa) trophoblastic invasion extends beyond normal endometrial barrier.

Placenta increta

extends into the myometrium

Placenta percreta

extends beyond the uterine serosa

Velamentous insertion of cord/ vasa previa

• rare anomalies

  • Higher incidence in multiple gestations and pregnancies from assisted reproductive technology

  • Cord vessels branch at membranes and course onto placenta 

  • Rupture of membranes or traction on cord may tear one or more fetal vessels

  • Fetus may rapidly bleed to death as a result

Battledore (marginal) insertion of cord

Increases risk of fetal hemorrhage, especially after marginal separation of placenta

Infections Acquired During Pregnancy

• Sexually transmitted infections

  • Impact morbidity rates, infertility

• Urinary tract infections (common – 20%)

  • Responsible for 10% of hospitalizations

  • Asymptomatic bacteriuria

  • Cystitis (bladder infection)

  • Pyelonephritis

Asymptomatic bacteriuria

• antibiotics

• repeat urine culture

Cystitis (bladder infection)

• dysuria

• urgency

• suprapubic pain

• 3-day course of antibiotics which may stain urine orange

Pyelonephritis

• common, 2^nd trimester

• fever

• chills

• pain in lumbar area

• N & V

• admitted with IV antibiotics (10–14 d)

• monitor for sepsis

• regular urine cultures

Physical trauma during pregnancy

MVA, falls, burns, Violence 

Significance - (6 - 7% of pregnancies) & (80% fetal deaths)

• Effect of trauma on pregnancy is influenced by the following:

  • Length of gestation

  • Type and severity of the trauma 

  • Degree of disruption of uterine and fetal physiological features  - fetal death

  • Special considerations for mother and fetus:

    • Physiological alterations of pregnancy

    • Fetal survival depends on maternal survival.

    • Pregnant woman must receive immediate stabilization and care for optimal fetal outcome 

• Fetal physiological characteristics

  • Careful monitoring of fetal status 

  • Fetal monitor tracing works as an “oximeter” for fetal well-being. 

Perimortem Caesarean Birth

• Poor fetal survival with C/S > 20 minutes after maternal death.

• Consider Caesarean birth after 4 minutes of resusc. with no response in the mother.

• Rarely successful

Postpartum Hemorrhage (PPH)

• Leading cause of maternal death worldwide, preventable

• Postpartum hemorrhage (PPH) traditionally defined as:

  • Loss of >500 mL of blood after vaginal birth

  • Loss of >1000 mL after Caesarean birth

  • Any blood loss that has the potential to cause hemodynamic instability 

• Among leading cause of maternal mortality worldwide

• Life-threatening, with little warning

Stages of PPH

• Early/ Primary – within 24 hrs of birth

• Late/secondary - > 24 hrs – 6 weeks  post birth

  • Due to retained placenta fragments /infection

  • Subinvolution of uterus (retained frag, pelvic infection)

  • Discharge teaching – signs of normal involution, complications

4 T’s of PPH

•  tone

  • Uterine atony

    • Marked hypotonia of uterus

    • Leading cause of early PPH 

• tissue

  • Retained placental fragments

  • Placenta accreta, increta, percreta

• trauma

  • Lacerations of birth canal

  • Uterine inversion

  • Hematomas

• thrombin

  • Various clotting disorders

    • Correction of underlying cause

Assessment for PPH

Evaluation of contractility of uterus.

• Firm massage of fundus

• Administer intravenous fluids and medication to manage bleeding.

• Active management of 3^rd stage to prevent PPH

  • Oxytocin admin after delivery of fetal shoulder

  • Immediate fundal massage after complete birth

Plan of Care and Implementation for PPH

• Hypotonic uterus – massage, elimination of bladder distention, IV 

• Bleeding with a contracted uterus (manual exploration of uterine cavity for placenta

• Pharmacologic remedies – homeostatic actions or oxytocin age

Puerperal infection (Postpartum Infection)

• any infection of genital canal within 28 days after abortion or birth

• Most common infecting agents are the numerous streptococcal and anaerobic organisms.

• Endometritis

• Wound infections

• Urinary tract infection

• Mastitis

Structural Disorder related to Child-bearing

• Disorders of uterus and vagina related to pelvic relaxation and urinary incontinence are often the result of child-bearing. 

• Uterine displacement and prolapse

  • Posterior displacement, or retroversion

  • Uterine prolapse:

    •  more serious displacement.

Cystocele and rectocele

• Cystocele: protrusion of bladder downward into vagina when support structures are injured

• Rectocele is herniation of the anterior rectal wall through relaxed or ruptured vaginal fascia and rectovaginal septum. 

  • Urinary incontinence

Postpartum psychological complications

• Psychosocial complications in PP period: implications for mother, newborn, and entire family.

  • Interfere with attachment 

  • May threaten safety and well-being of mother, newborn, and other children

Perinatal mood disorders (PMD)

• Up to 80%  - mild depression or “baby blues.”

• 10 to 15%  - more serious depression (PPD)

• Can eventually incapacitate women to point of being unable to care for themselves and their babies

Paternal mood disorder

Predictor is having a partner with PMD

Postpartum anxiety disorder

• Generalized anxiety disorder

• Obsessive-compulsive disorder

• Panic disorder and panic attacks

• Specific phobias

• Social anxiety disorder

• Post-traumatic stress disorder

Postpartum depression without psychotic features

• Characterized by low mood and lack of interest in activities, can be mild to severe

• Treatment options 

  • Antidepressants, antianxiety medications, and electroconvulsive therapy

  • Psychotherapy focuses on fears and concerns of new responsibilities and roles; monitoring for suicidal or homicidal thoughts 

Postpartum psychosis

• Syndrome characterized by depression, hallucinations, delusions, and thoughts of harming either infant or self 

• Psychiatric emergency; may require psychiatric hospitalization

• Antipsychotics and mood stabilizers such as lithium are treatments of choice

Psychological Nursing Care

• Screening for perinatal mood disorder

• On postpartum unit

• In the home and community

• Referral

• Providing safety

• Psychiatric hospitalization

• Psychotropic medications

  • Psychotropic medications and lactation

• Other treatments for perinatal mood disorders

Loss and Grief

• Any perception of loss of control during the birthing experience, hopes and dreams

• Birth of child with complex condition 

• Maternal death

• Fetal or neonatal death

• Grief is a process of recovering from a loss.

• Many emotional, cognitive, behavioural, and physical responses

• Overlapping phases in grief process

  • Acute distress

  • Searching and yearning

  • Disorientation

  • Reorganization and resolution

Family aspects of grief

Grandparents and siblings

Communicating and care techniques

• Help mother, father/partner, and siblings actualize their loss

• Help parents with decision making

• Help bereaved to acknowledge and express their feelings

Communicating and care techniques

• Normalize grief process and facilitate positive coping

• Meet the physical needs of postpartum bereaved mother

• Create memories for parents to take home

Cultural and spiritual needs of parents

• Provide sensitive care at and after discharge

• Provide postmortem care respecting parents’ wishes

• Documentation