Maternity Final Exam Study Guide😭🤓🫃

Postpartum Care

Vital signs

• <100.4 F temp during first 24 hrs is normal

• slight bradycardia

  • tachycardia can indicate infection/blood loss

• BP should return to normal but watch for s/s preeclampsia/PPH

  • orthostatic HoTN during two days postpartum is normal

Physical Assessment

• breasts

  • soft on day 1-2

  • filling on day 2-3

  • full, softened for breastfeeding on days 3-5

  • nipples intact skin with no soreness

• uterus

  • normal findings

    • firm, midline in first 24 hrs

• perineum

  • monitor for healing if episiotomy or laceration

  • use ice packs/sitz bath

• lochia

  • rubra

    • first 3-4 days

    • red, bloody

  • serosa

    • 4-10 days

    • pink/brown and contains less blood

  • alba

    • up to six weeks

    • white/yellow with mucus

Gestational Diabetes

Risk factors

• overweight

• >25 years old

• family hx type 2 DM

• hx GDM

• polycystic ovarian syndrome

• hx given birth to baby >9 lbs

• if no risk factors, test for GDM at 24-28 weeks using one/two-step approach

Maternal risks

• short term

  • glycosuria

    • high level of glucose in urine increases UTI and vaginitis

    • polyhydramnios

      • abdominal discomfort

      • back pain

      • swelling of lower extremities

      • SOB

      • increased risk for prolapse

    • potential for arrested labor, lacerations, c-section

• long-term

  • cardiovascular disease

  • metabolic syndrome

  • type 2 DM

  • GDM in future

Fetal risks

• short-term

  • increase risk for fetal complications from hyperglycemia

    • c-section

    • shoulder dystocia

    • stillbirth

    • preterm birth

    • newborn birth trauma

    • neonatal metabolic/respiratory complications

    • congenital anomalies

    • stillbirth

    • hypoglycemia

    • jaundice

    • fetal growth restriction

    • macrosomia

      • fetus weighs >4000 g

      • extra glucose from blood to fetus, increases insulin response

      • risk for polycythemia, hypoglycemia, respiratory problems, congenital abnormalities

• long-term

  • fetal neuro/congenital heart defect greater in people dxed with type 1 or 2 DM prior to conception

    • ventricular/atrial septal defect

    • tetralogy of fallot

    • narrow aorta

    • spina bifida

    • microcephaly

  • increased risk for complications later in life

    • obesity

    • HTN

    • metabolic syndrome

    • insulin resistance

Diagnosis

• fasting blood glucose >126 mg/dl

• hemoglobin A1C >6.5%

• random blood glucose >200 mg/dl

• 2 hr plasma glucose ≥ 200 mg/dl

Treatment

• 15-15 rule

  • consume 15 grams of simple carbs

  • check blood sugar 15 min later

  • repeat until blood glucose is >70 mg/dl

• adopt healthy lifestyle, exercise

  • 30 min moderate exercise a day

  • exercise after meals when blood glucose is highest

    • glucose of <140 is optimal after having a meal

• use artificial sweeteners

  • DO NOT offer saccharin (sweet ‘n low), crosses placenta and shoud be avoided during pregnancy

• non-starchy veggies, plant protein, lean protein

• DO NOT take metform/glyburide during pregnancy

• AVOID

  • hot yoga

  • bouncing/jolting movements

  • pressure on abdomen

  • contact sports

Lifelong monitoring

• GDM increases risk of DM2 after delivery

• screen for prediabetes 4-12 weeks postpartum

• every three years

Physiologic Changes of Pregnancy and Postpartum

Cardiac system

• increased blood volume and cardiac output

  • will return to pre-pregnancy levels within 2-4 weeks

• HR increases 10-15bpm

• decreased BP d/t vasodilation

Respiratory system

• increased tidal volume by 30-40%

• growing uterus can cause SOB and increased RR

• nasal congestion

Integumentary system

• linea nigra (dark line down abdomen)

• melasma

• striae distensae (stretch marks)

• varicose veins

• postpartum hairloss

Hematologic system

• increased blood volume leads to anemia

  • RBC do not increase as much as blood volume

• risk of clotting d/t hypercoagulability

• supplement iron postpartum if significant blood loss during pregnancy

GI system

• slow gastric emptying increased progesterone

  • can lead to constipation

• heartburn/acid reflux from pressure on stomach d/t uterus

Reproductive system

• significant expansion of uterus

• cervical, breast changes

GU system

• increased bladder pressure cause frequent urination

  • urinary retention/incontinence

• increased kidney function to accommodate blood volume

Infant Feeding

Breastfeeding

• anatomy and physiology

  • influenced by estrogen, progesterone, prolactin

  • oxytocin ejects milk from glands and through ducts

• benefits

  • contains all vitamins required for infant nutrition (except vitamin D)

  • contains antibodies and immune cells

  • increases bonding

  • lowers risk of SIDS

  • foremilk

    • first milk from breast

    • increased protein and carbs

    • decreased fat and calories

    • watery

  • hindmilk

    • near end of feeding

    • increased fat and calories

  • helps contract uterus, lower risk of breast/ovarian cancer

• starting breastfeeding

  • begin within first hour of life to stimulate bonding and milk production

• frequency

  • 8-12 times in 24 hrs

  • ensure baby is getting enough breastmilk

    • 6-8 wet diapers and 4 dirty diapers every day

• cue-based feeding

  • feed based on hunger cues such as:

    • rooting

    • crying

    • smacking lips

    • sucking on hands

Formula feeding

• contains all vitamins needed d/t supplements

• modified cow’s milk

  • decreased protein content

  • added carbs, essential nutrients, especially iron

Labor Process and Changes

Changes

First stage

• begins with regular uterine contraction, ends with complete cervical effacement and dilation

• latent phase

  • regular, painful uterine contractions that cause cervical change

• active phase

  • period where greatest rate of cervical dilation occurs

• care management

  • determine if patient is in true labor (not prodromal labor)

    • assess contractions, cervix, fetus

Second stage

• begins with full dilation (10 cm)

• complete effacement

• ends with infant birth

• latent phase

  • aka delayed pushing, laboring down, passive descent

• active phase

  • pushing/urge to bear down

  • ferguson reflex activated when presenting part presses on stretch receptors of pelvic floor

• care management

  • monitor FHR and pattern

  • utilize valsalva maneuver

Third stage

• birth of baby until placenta expelled

• shortest stage of labor

• placental separation=lengthening of umbilical cord and gush of blood from vagina

Fourth stage

• begins with expulsion of placenta, lasts until woman stable usually within first hour of birth

• care management

  • assess physiologic changes to pre-pregnancy status

  • assess for excess blood loss and alterations in vitals/consciousness

Coping

• assist with breathing techniques, position changes, hydrotherapy, ambulation

• encourage familial support

Pain control

• risks

  • opioid dependence/side effects

  • sedation

  • further intervention

• benefits

  • improved mobility/healing

  • better bonding d/t decreased stress

  • promote rest/recovery

• preferences

  • respect beliefs and individual pain tolerance

  • may prefer natural methods

  • encouraging asking for pain management

Fetal Monitoring

FHR tracing and uterine activity

• FSE

  • placed on fetal scalp

  • hard surface

  • away from fontanel

  • not on forehead

  • contraindicated

    • communicable disease

    • hemophilia

    • placenta previa

    • intact membranes

• IUPC

  • uterus

  • contraindications

    • non-anticipated vaginal delivery

    • placental abruption

    • intact membranes

  • if not reading accurately:

    • reposition patient

    • flush device with NS

    • replace

Categories

Category 1 (Normal)

• baseline rate of 110-160 bpm

• moderate baseline variability

• no late or variable decelerations

• early decelerations and accelerations may be present or absent

• indicates a well-oxygenated fetus

• interventions

  • no intervention needed

Category 3 (Abnormal):

• absent baseline FHR variability AND any of the following

  • recurrent late decelerations

  • recurrent variable decelerations

  • bradycardia,

  • sinusoidal pattern.

  • Indicates a poorly oxygenated fetus

  • interventions

    • position change

    • O2

    • stop oxytocin

    • administer IV fluids

    • amnioifusion

Category 2 (Indeterminate):

Any FHR pattern that does not fit into Category 1 or 3:

• moderate variability with recurrent late or variable decelerations

• minimal variability with recurrent variable decelerations

• absent variability without recurrent decelerations

• bradycardia with moderate variability 

• prolonged decelerations

• tachycardia

• indicates fetus that is showing compensatory responses to lack of oxygen

• interventions

  • position change

  • hydration

  • O2

  • discontinue uterotonics

Newborn Assessment and Care

Assessment

Care

• immediately after birth

  • assess general appearance and vital signs

    • observe before touching

    • auscultate before palpation in quiet environment

  • measure weight, head circumference, body length

  • assess newborn reflexes

    • root and suck

      • turns head towards stimulus and opens mouth in search of sucking source

    • moro

      • arms extend, abduct, hands open, arm flexion, hands closing

    • babinski

      • hyperextended toes with dorsiflexion of big toe (should disappear after 1 year)

    • START CHEST COMPRESSIONS heart rate <60bpm after advanced airway is placed

    • warm, dry, and stimulate before starting resuscitation

    • use respirations and HR to assess efficacy of resuscitation

• screenings

  • hyperbilirubinemia (jaundice)

    • newborns should be assessed for jaundice every 8 to 12 hours

    • prevented by adequate feeding

  • universal newborn screening

    • mandated by U.S. law, this screening helps to detect genetic diseases that can cause severe health issues if not treated early.

  • Newborn Hearing Screening is also a part of routine newborn care

Screening for Critical Congenital Heart Disease (CCHD) involves measuring oxygen levels in the right hand and either foot

• hours after birth

  • check HR, SpO2, temp, apply cardiac monitor if baby is tachypneic with respiratory distress

• safe discharge criteria

  • stable vitals

  • sufficient feeding

  • normal reflexes

  • sufficient education on newborn care

OB Complications

Uterine rupture

• manifestations

  • symptomatic disruption and separation of layers of uterus/previous scar

  • mostly occur because of scarred uterus from previous c-section

  • sudden sharp abdominal pain/ripping or tearing sensation

  • bright red vaginal bleeding/signs of hypovolemic shock

  • visible palpation of fetal parts

  • fetal bradycardia

• risk factors

  • c-section

    • classical/T-shaped incision

  • prior uterine rupture

  • trauma

  • abortion

  • multiparity

  • uterine overdistention

  • malpresentation

  • TOLAC patients

• interventions

  • start IV fluids

  • transfuse blood products

  • administer oxygen

  • prepare for immediate surgery

  • support family and provide info about tx during emergency

• maternal effects

  • severe hemorrhage

  • shock

  • hysterectomy

  • infection risk

• fetal effects

  • abnormal FHR tracing

    • abrupt decrease in FHR

    • late/variable decelerations

    • absent baseline variability

    • tachy/bradycardia

  • loss of fetal station/no fetal descent

  • hypoxia

  • acidosis

• post complication care

  • monitor for infection

  • assess for PPH

Shoulder dystocia

• manifestions

  • head is born but anterior shoulder cannot pass under pubic arch

  • cannot be predicted

  • slowing progress of second stage of labor

  • retraction of fetal head (turtle sign)

  • no external rotation

• risk factors

  • hx shoulder dystocia

  • maternal diabetes/obesity

  • prolonged second stage of labor

  • macrosomia >4000 g

  • maternal pelvic abnormality

• interventions

  • assume McRoberts maneuver (pull mother’s knees to ears)

  • Gaskins maneuver (mother on hands and knees)

  • suprapubic pressure

  • clavicle fracture

  • symphsiotomy- incision in cartilage between pubic bones to enlarge pelvic opening

  • c-section

  • 1. call for help

  • 2. lower head of bed

  • 3. footstool next to bed

  • 4. McRoberts

  • 5. suprapubic pressure

  • 6. Rubin II maeuver

  • 7. wood’s corkscrew

  • 8. delivery posterior arm

  • 9. gaskin maneuver

• maternal effects

  • perineal trauma

  • uterine rupture

  • PPH

• fetal effects

  • hypoxia

  • fractured clavicle

  • erb’s palsy

  • asphyxia

• post complication care

  • perform neonatal injury assessment

    • examine clavicle/humerus fracture, brachial plexus injuries, asphyxia

  • maternal perineal care

    • detect s/s hemorrhage

    • trauma to vagina, perineum, rectum

Prolapsed cord

• manifestations

  • cord lies below presenting part of fetus

  • visible/palpable after ROM

  • sudden onset variable/prolonged decels or bradycardia

  • report of feeling cord in vagina

• risk factors

  • long cord

  • malpresentation (breech or transverse lie)

  • preterm labor

  • polyhydramnios

  • external cephalic version procedure

  • induction using balloon catheter

• interventions

  • recognize ASAP as hypoxia from cord compression can cause CNS damage/death

  • relieve pressure off cord

    • hold presenting part off umbilical cord

    • assist into lateral position, trendelenburg, knee-chest

• maternal effects

  • risk for c-section

  • risk for atony/hemorrhage

• fetal effects

  • severe hypoxia

  • distress

  • bradycardia

  • variable decelerations

• post complication care

  • neonatal resuscitation

  • monitor for hypoxic encephalopathy

Preterm labor

• manifestations

  • onset of labor before 37 weeks

  • regular contractions along cervical effacement OR dilation OR both

  • presentation of regular uterine contractions and cervical dilation of at least 2cm

• risk factors

  • spontaneous PTB

    • infection

    • decreased progesterone

    • maternal/fetal stress

  • indicated PTB

    • preeclampsia

    • multiple gestation

    • placental cause

    • maternal code blue

  • cervical insufficiency

  • positive fFN test

  • look for hypothermia and hypoglycemia for late preterm birth

    • hypoglycemia

      • hypothermia

      • poor feeding

      • jitters

      • apnea

      • lethargy

      • seizures

• interventions

  • tocolytics to suppress uterine contractions (nifedipine, terbutaline, mg sulfate)

  • betamethasone for fetal lung maturity

  • cerclage before PTB

• maternal effects

  • risk for anxiety, PPD, PTSD

• fetal effects

  • respiratory distress syndrome

  • necrotizing enterocolitis

• post complication care

  • admit to NICU

Meconium-stained fluid

• manifestations

  • fetal stool in amniotic fluid

  • green, can be thin or thick

• risk factors

  • hypoxia-induced peristalsis and sphincter relaxation

  • cord compression-induced vagal stimulation

  • breech position

• interventions

  • suction fetal airway

  • intubation if thick meconium

• maternal effects

  • chorioamnionitis

  • risk for c-section

  • intrapartum fever

• fetal effects

  • risk for meconium aspiration syndrome

    • cause severe aspiration pneumonia

• post complication care

  • before birth

    • assess amniotic fluid for presence of meconium after ROM

    • gather equipment and supplies for neonatal resuscitation

  • immediately after birth

    • assess newborn respiratory effort, HR, muscle tone

    • suction only mouth and nose if WDL vital signs

    • suction trachea if vitals not WDL

Premature rupture of membranes

• manifestations

  • SROM/leakage of fluid prior to onset of labor at any gestational age

• risk factors

  • often preceded by infection (chorioamnionitis)

    • bacterial infection of amniotic cavity

    • maternal fever, tachycardia, uterine tenderness, foul odor

  • cervical insufficiency

    • passive/painful dilation of cervix leading to recurrent PTB during second trimester

    • tx with cerclage placement

  • multiple gestation

• interventions

  • administer magnesium sulfate for 24 hrs for fetal neuroprotection

  • give tocolytic meds or nifedipine to suppress uterine activity

  • give antenatal glucocorticoids (betamethasone) to reduce respiratory distress syndrome, hemorrhage, necrotizing enterocolitis, death

• maternal effects

  • increased risk of infection

• fetal effects

  • PTB

  • risk for sepsis

• post complication care

  • monitor infection

  • monitor FHR

Hypertensive Disorders of Pregnancy

CONTROLLING BLOOD PRESSURE IS THE OPTIMAL INTERVENTION TO PREVENT DEATH FROM STROKE/PREECLAMPSIA

Gestational HTN management

• defined as systolic BP of >140 or diastolic of >90

• frequent BP and weight measurement

• report promptly if:

  • increase in BP

  • persistent headache

  • visual change

  • rapid weight gain

  • decreased fetal movement

  • uterine contractions

Preeclampsia

• HTN and proteinuria after 20 weeks of gestation who previously had neither condition

• can also develop in postpartum period

• in absence of proteinuria, preeclampsia may be defined as HTN along with:

  • thrombocytopenia

  • renal sufficiency

  • impaired liver function

  • pulmonary edema

  • cerebral/visual symptoms (blinking stars/dots)

• risk factors include:

  • preeclampsia hx

  • multifetal gestation

  • chronic HTN

  • pregestational/gestational diabetes

  • SLE

  • obstructive sleep apnea

  • nulliparity

  • BMI >30

  • AMA

  • thrombophilia

  • assisted reproductive technology

• pathophysiology

  • placenta is root cause

  • begins to resolve after placenta expelled

  • spinal arteries fail to get larger and thicker

    • decreased placental perfusion and endothelial dysfunction= preeclampsia

  • placental ischemia=endothelial cell dysfunction

  • generalized vasospasm=poor tissue perfusion in organ system

• preeclampsia with severe features

  • thrombocytopenia <100

  • renal insufficiency with elevated serum creatinine >1.1 mg/dl/doubling

  • pulmonary edema

  • headache unresponsive to medication

  • visual disturbances

  • right epigastric pain

  • systolic BP ≥160 or diastolic BP ≥110 at least twice 4 hrs apart

• gestational age

  • onset prior to 34 weeks is most often severe

    • manage at facility with resources for management of serious maternal/neonatal complications

  • induction at 37 weeks indicated for preeclampsia without severe features

• management

  • assess BP and edema

  • assess deep tendon reflex/hyperactive reflex (clonus)

  • assess PCR

  • evaluate for these s/s:

    • severe frontal headache

    • epigastric pain (heartburn)

    • right upper quadrant tenderness

    • visual disturbance

  • order CBC, CMP, and PCR labs

Eclampsia

• onset of seizure activity/coma in preeclamptic patient

• no hx of preexisting pathology

• higher in multifetal gestation and women who did not receive prenatal care

• caused by cerebral edema

• watch for headache or visual disturbance

Chronic hypertension w/ superimposed preeclampsia

• dx based on

  • sudden increase in BP that was previously well controlled

  • new-onset/sudden and sustained increase in proteinuria in woman known to have proteinuria before conception/early pregnancy

Signs and symptoms

• persistent BP >140/90

• proteinuria if preeclamptic

• edema

• severe headache

• vision change

Treatment

• turn patient to left lateral position

• protect airway/administer oxygen (8-10 L/min via nonrebreather)

• provide padding around bed

Medications

• labetalol IV

• nifedipine PO

• hydralazine IV

• magnesium sulfate

  • mag sulfate for seizure prophylaxis is indicated for:

    • preeclampsia with severe features

    • severe gestational HTN

    • all cases of severe HTN regardless of classification

  • high Mg levels can causes relaxation of smooth muscle

  • initiate when diagnosed with preeclampsia

  • continue until 24 hrs post delivery or 24 hrs after last seizure if eclamptic

  • dose: 4-6gm loading dose over 20-30 min, then 2gm/hr

  • side effects

    • flushing/warm

    • drowsiness

    • sweating

    • N/V

    • HoTN

    • dizziness

    • headaches

    • slurred speech

    • visual disturbance

    • muscle weakness/decreased DTR

  • toxicity

    • absence/change in DTR

    • decreased LOC

    • SOB

    • decreased respiratory rate

    • persistent HoTN

    • chest pain

    • bradycardia/cardiac arrest

    • Mg greater than 8 mg/dL

  • give 1 g IV calcium gluconate over 3 min for toxicity

  • assessment

    • monitor VS

    • check reflexes

    • monitor I/O (should be >50ml/hr)

    • raise bedrails

    • O2 and suction at bedside

  Meds for chronic HTN during pregnancy	dose
  labetalol	200-2400 mg	first-line in pregnancy, does not reduce uterine blood flow
  nifedipine	30-90 mg daily	use with caution with mg sulfate
  methyldopa	500-2000 mg	not effective when taken less than three times a day
  hydrochlorothiazide	12.5-25mg daily	may be continued if taken before conception but not started as new med in pregnancy risk for thrombocytopenia for newborn

HELLP syndrome

• characterized by:

  • hemolysis

  • elevated liver enzymes

  • low platelet count

• symptoms

  • upper right abdominal pain

  • N/V

  • headache

  • blurry vision

• can lead to:

  • liver hematoma/rupture

  • ARDS

  • sepsis

  • hypoxic encephalopathy

  • fetal/maternal death

  • preterm delivery

  • recurrent preeclampsia

  • DIC

• treatment

  • induction regardless of gestational age

  • monitor CBC and liver enzymes Q6H

  • magnesium infusion

  • BP control

  • early epidural placement

Fetal changes

• impaired uteroplacental blood flow can cause:

  • IUGR

  • oligohydramnios

  • placental abruption

  • nonreassuring fetal status

    • absent varability

    • tachy/bradycardia

  • preterm labor

Hemorrhagic Disorders

Hemorrhage

• diagnosis criteria

  • blood loss ≥ 500ml after vaginal birth OR ≥1000ml after c-section

  • 10% drop in Hct

  • signs of hypovolemia

    • tachycardia, HoTN, pallor, AMS

• treatment

  • fundal massage

  • empty bladder if uterus is displaced

  • IV fluids, blood

  • Bakri balloon

• laboratory findings

  • decreased hct and hgb

  • decreased fibrinogen

  • decreased platelets

DIC

• risk factors

• clinical signs

  • clot formation in microsystem

  • petechiae

  • bleeding from IV site

  • hematuria

  • abnormal bleeding

• treatment

  • administer blood products (FFP, PT, PRBC)

  • heparin for chronic DIC/when thrombosis suspected

• lab findings

  • low fibrinogen <100

  • prolonged PT followed by prolonged aPTT

Postpartum Hemorrhage

• readiness

  • utilize checklist and algorithms

• recognition

  • measure QBLs

• response

  • use MTP protocol

• reporting

  • debrief

Placental Disorders

• placenta previa

  • implantation of placental near or over cervical os

  • painless, bright red vaginal bleeding

• placental abruption

  • premature separation of placenta from uterine wall from ruptured maternal vessels in placental bed and subsequent hemorrhage

    • hard board-like abdomen

    • painful with no rest between contractions

    • bleeding can be concealed

• vasa previa

  • fetal vessels lie over cervical os

  • leads to severe blood loss for fetus

• placenta accreta—slight penetration on myometrium

• placenta increta—deep penetration of myometrium

• placenta percreta—perforation of myometrium and uterine serosa

• management

  • early delivery

  • hysterectomy in severe cases

Obstetrical Procedures

Types

• Vacuum extraction and forceps delivery

  • assisted vaginal delivery for prolonged second stage or fetal distress

• Cesarean section

  • surgical delivery for non-reassuring FHR, fetal malpresentation, maternal complications

• external cephalic version

  • turn fetus from breech/shoulder presentation to vertex

  • DO NOT PERFORM IF:

    • oligohydramnios

    • previous classical/T-shaped incision

    • nonreassuring FHT

    • nonanticipated vaginal delivery

Indications

• active maternal infection (herpes for vaginal birth)

• fetal distress

• risk of uterine rupture

• uterine anomaly

• third trimester bleeding

• multiple gestation

• oligohydramnios

• CPD

• previous uterine surgery

Contraindications

• active maternal infection (herpes for vaginal birth)

• fetal distress

• risk of uterine rupture

Maternal Sepsis

• life-threatening complication from infection that includes organ dysfunction

Prevention

• screening

  • modified early obstetric warning system (MEOWS)

    • identify abnormal criteria within obstetric population

  • triggers include:

    • altered mental status

    • visual disturbances

    • severe headache

    • dyspnea

    • epigastric pain

Diagnosis

• first step

  • assess vital signs (temperature, HR, RR)

  • parameters adjusted for pregnancy/WBC count

  • obtain within 24 hrs of symptom onset

• second step

  • evaluate for end-organ injury with lab values

  • assess lactic acid levels

    • labor raises lactic acid

• MAP <65 mmHg sustained for 15 min after 30ml/kg fluid load directly defines septic shock

• fetal tachycardia is an early sign of maternal infection

Treatment

• must begin IMMEDIATELY

• alert rapid response team

1. administer broad-spectrum antibiotics without delay

2. rapid admin of 30ml/kg bolus of crystalloid solution for HoTN or lactate ≥4

3. obtain blood cultures before abx if possible

4. give vasopressors for HoTN that persists after fluid resuscitation to maintain MAP ≥65

Lab findings

• bilirubin >2

• lactic acid >2

Causes

• antepartum

  • septic abortion

  • pneumonia/flu

  • pyelonephritis

  • cholecystitis

• intrapartum

  • chorioamnionitis

  • pyelonephritis

  • pneumonia

• postpartum

  • endometritis

    • infection of uterine lining

  • wound infection

    • often develop after discharge

  • mastitis

  • pyelonephritis

  • pneumonia

Hemodynamics

• vasodilation/reduced systemic vascular resistance

• HoTN

• tacycardia

• myocardial depression

Clinical goals

• optimize preload

• maintain MAP ≥65

• maintain urine out put ≥0.5 ml/kg/hr

• support O2 transport via inotropic meds

• abx within 1 hr of sepsis recognition

Birth Injury

Types

• soft tissue injuries (caput succedaneum, cephalhematoma, petechiae)

• clavicle fracture from shoulder dystocia

• brachial plexus (erb’s palsy)

• lacerations from c-section

Assessments

• full head to toe

• check for asymmetry of movement (especially for erb’s palsy)

• assess reflexes

• observe for pain response

Treatments

• surgical intervention

• monitor jaundice

• physical therapy for nerve injuries

Fetal Demise

Risks

• maternal HTN, clotting disorders

• GDM

• preeclampsia

• infection

• placental insufficiency/complications

• smoking/alcohol

Recommendations

• manage chronic conditions

• iduction of labor

• D&C for early losses

• evaluate for maternal clotting factors

• administer Rhogam if mother is Rh-negative

Emotional support

• family

  • allow genuine concern/care

  • allow family to talk about baby

  • reassure that they did everything right

  • use baby’s name

• intrapartum

  • no FHR

  • pain management

  • emotional support

  • pre-birth education

• bereaved mother

  • physical assessment of breasts, uterus, bladder, bowel, lochia, episiotomy (BUBBLE)

  • education of fetal evaluation/autopsy/genetic testing

  • discharge planning

  • edinburgh scale for PPD

• infant

  • comfort measures/palliative care

  • spiritual needs

  • creating memories

• GAD-7 and Edinburgh scale used for perinatal depression and anxiety

Medications

Induction of Labor

Methods

• IV oxytocin

• amniotomy

Indications

• indicated when maternal/fetal risks assoc. with continuing pregnancy are as great as the risks assoc. with delivery

  • postterm pregnancy

  • PROM

  • hypertensive disorders

  • DM

  • fetal growth restriction

  • twins

  • chorioamnionitis

  • placental abruption

  • oligohydramnios

  • cholestasis

  • fetal demise

Contradictions

• active maternal infection (herpes for vaginal birth)

• fetal distress

• risk of uterine rupture

• malpresentation

Risks

• uterine hyperstimulation

• increased c-section risk

• infection

• PPH

• umbilical cord prolapse

monochorionic/monamniotic twins are identical who share both a placenta and amniotic sac

• risk for cord entanglement

• twin to twin transfusion

PPROM risk factors are vaginal bleeding, STI, chorioamnionitis

4 T’s of hemorrhage

tone

tissue

trauma

thrombin

ALWAYS TX BP OF 160/110

nifedipine po

labetalol iv

hydralazine iv

schedule postpartum visit 4-6 weeks for GDM

assess GTT 4-12 weeks postpartum

infants born between 34 weeks and 36s weeks are considered late preterm

• risks for hypothermia and hypoglycemia