Exam 2 Study Guide 🤢💩🤰🫄🫃🤱

Labor Complications

Risk factors

• biophysical

  • may affect development/functioning

  • originates with pregnant women/fetus

• psychosocial

  • maternal behavior/adverse lifestyle have negative effect on health

  • risks include emotional distress, hx depression, intimate partner violence, substance use

• sociodemographic

  • lack of prenatal care, low income, single marital status, ethnicity

• environmental

  • hazards in workplace/general environment

  • include environmental chemicals, anesthetic gases, radiation

Antepartum assessment

• ultrasonography during pregnancy

  • first trimester

    • confirm pregnancy and viability

    • determine gestational age

    • rule out ectopic pregnancy

    • detect vaginal bleeding, maternal abnormalities

    • determine multiple gestation

  • second trimester

    • establish/confirm dates

    • confirm viability

    • detect poly/oligohydramnios

    • detect congenital anomalies/IUGR

    • detect placental location

    • evaluate for preterm labor

  • third trimester

    • confirm gestational age/viability

    • detect macrosomia, IUGR, congenital anomalies, placental abruption

    • determine fetal position

    • AFI assessment

    • detect placental maturity/preterm birth

    • BPP

      • at least one episode of fetal breathing movement of at least 30 sec in a 30 min observation

      • at least 3 trunk/limb movements in 30 min

      • at least one episode of active extension and flexion/opening and closing of hand

      • deepest vertical pocket >2 cm

      • reactive NST

Fetal Positioning

• lie

  • the position of the long axis of the fetus

  • described as longitudinal, transverse or oblique

• presentation

  • part of fetus that lies closest to/has entered the pelvis

  • described as cephalic, breech, shoulder

  • breech can cause lack of engagement of the cervix, umbilical cord can come out before baby

• position

  • relationship of presenting part to maternal pelvis

  • described as anterior, posterior, transverse, right, left

• attitude

  • relationship of fetal parts to each other

    • described as flexion or extension

Preterm labor and birth

• spontaneous

  • 75% of PTB

  • definitive factor=infection

  • congenital structural abnormalities of uterus

  • placental cause

  • maternal/fetal stress

  • decreased progesterone

• indicated

  • 25% of PTB

  • preeclampsia

  • multiple gestation

  • placental cause

  • maternal code blue

• fetal fibronectin test (fFN)

  • used to predict who will not go into preterm labor

  • negative test shows less than 1% chance of giving birth within two weeks

  • cannot have anything in vagina for 24 hours

• cervical insufficiency

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

  • can be caused by abnormally short cervix

  • risk factors include collagen disorder, uterine anomalies, hx cervical trauma, prior cervical surgery

  • tx with cervical cerclage placement

  • teach pelvic rest (nothing goes in the vagina)

  • monitor for any types of contractions

  • restrict activity but no bedrest

  • give tocolytic meds or nifedipine to suppress uterine activity

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

• Prelabor rupture of membranes (PROM)

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

  • often preceded by infection (chorioamnionitis)

    • bacterial infection of amniotic cavity

    • maternal fever, tachycardia, uterine tenderness, foul odor

  • administer magnesium sulfate for 24 hrs for fetal neuroprotection

Post term pregnancy

• ≥42 weeks of gestation

• risk for perineal injury, maternal morbidity, macrosomia, meconium aspiration, shoulder dystocia

• more frequent fetal assessment needed (NST or BPP)

Dystocia

• lack of progress in labor

• long, difficult, abnormal

• may need c-section

• causes

  • pelvic dystocia

    • contracture of pelvic diameter than reduce capacity of bony pelvis, inlet, midpelvis, oulet

  • soft-tissue dystocia

    • obstruction of birth passage by anatomic abnormality

  • fetal causes

    • anomaly

    • cephalopelvic disproportion

    • malposition/malpresentation

      • fix with external cephalic version

        • turn fetus from breech/shoulder presentation to vertex before birth

      • contraindications

        • uterine anomaly

          third trimester bleeding

        • multiple gestation

        • oligohydramnios

        • previous c-section/uterine surgery

        • obvious CPD

    • multifetal pregnancy

Obstetric vaginal birth

• increases risk for subgaleal hemorrhage in neonate

  • scalp pulled away from bony calvaria, vessels torn and blood collects in subgaleal space

  • increased risk to perineal trauma

• forceps-assisted

  • piper forceps used to assist with delivery of head in breech birth

• vacuum-assisted

  • discouraged for gestational age <34 weeks

  • using forceps after failed vacuum attempt increases newborn complications

Cesarean birth

• birth through transabdominal incision of uterus

• vertical skin incision

  • advantages

    • quicker to perform

    • better uterine visualization

    • can extend upward for more visualization if need (usually for obese woman)

  • disadvantages

    • visible scarring when healed

    • greater chance of dehiscence and hernia formation

• pfannenstiel skin incision

  • advantages

    • less visibility when healed

    • low chance of dehiscence and hernia formation

  • disadvantages

    • less visualization of uterus

    • cannot be done quickly in emergency

    • cannot be extended easily

    • another c-section will take more time

  • low vertical incision

    • advantages

      • can be extended upward to make larger incision

    • disadvantages

      • more likely to rupture

      • tear may extend incision downward

  • low transverse incision

    • advantages

      • unlikely to rupture during subsequent birth

      • VBAC possible for another birth

      • less blood loss

      • easier repair

      • less adhesions

    • disadvantages

      • limited ability to enlarge incision

  • classical incision

    • advantages

      • may be only choice for:

        • placental implantation on lower anterior uterine wall

        • dense adhesions from previous surgery

        • transverse lie of large fetus with impacted shoulder

    • disadvantages

      • likely uterine incision to rupture during another birth

      • no VBAC option for subsequent birth

OB Emergencies

Trial of labor after cesarean (TOLAC)

• TOLAC considered high risk for uterine rupture (highest for previous classical/T-shaped incision, prior uterine rupture, transfundal uterine surgery)

• anxiety increases catecholamine and inhibits oxytocin release

  • delays progress of labor, can lead to repeat c-section

  • encourage VBAC for later pregnancy instead of another c-section

• uterine rupture

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

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

  • can cause ejection of fetal parts/entire fetus into peritoneal cavity

    • risk factors

      • c-section

      • prior uterine rupture

      • trauma

      • abortion

      • multiparity

      • uterine overdistention

      • malpresentation

    • signs

      • abnormal FHR tracing

        • abrupt decrease in FHR

        • late/variable decelerations

        • absent baseline variability

        • tachy/bradycardia

      • loss of fetal station/no fetal descent

      • sudden sharp abdominal pain/ripping or tearing sensation

      • bright red vaginal bleeding/signs of hypovolemic shock

      • palpable fetal parts through abdomen

    • nursing role

      • start IV fluids

      • transfuse blood products

      • administer oxygen

      • prepare for immediate surgery

      • support family and provide info about tx during emergency

  • prognosis determined by whether placental abruption occurs and degree of maternal hemorrhage and hypovolemia

Meconium-stained amniotic fluid

• green, can be thin or thick

• result of:

  • hypoxia-induced peristalsis

  • sphincter relaxation

  • cord compression-induced vagal stimulation

• risk for meconium aspiration syndrome in newborn

  • cause severe aspiration pneumonia

• 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

Shoulder dystocia

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

• r/t excessive fetal size or maternal pelvic abnormality

• cannot be predicted

• risk factors:

  • hx shoulder dystocia

  • maternal diabetes

  • prolonged second stage of labor

• signs

  • slow progress of second stage of labor

  • fetal head retraction following emergence (turtle sign)

  • no external rotation

• interventions

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

  • suprapubic pressure

  • clavicle fracture

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

Prolapsed umbilical cord

• cord lies below presenting part of fetus

• risk factors

  • long cord

  • malpresentation (breech or transverse lie)

  • preterm labor

  • polyhydramnios

  • external cephalic version procedure

  • induction using balloon catheter

• signs

  • visible/palpable after ROM

  • sudden onset variable/prolonged decels or bradycardia

  • report of feeling cord in vagina

• management

  • 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

Breech vaginal delivery

• risks

  • umbilical cord prolapse

  • trapping of fetal head

  • trauma from fetal head extension/fetal arm positioned around neck

• apply suprapubic pressure to keep head flexed until delivery

Uterine inversion

• fundus collapses into uterine cavity after birth (turns inside out)

• caused by:

  • fundal pressure when uterus is not well contracted

  • excessive umbilical cord traction when placenta is high in uterus

• treatment

  • reinsertion of uterus

  • prepare for hemorrhage

  • terbutaline to stop contraction

  • magnesium sulfate, general anesthetic, nitroglycerin to relax smooth muscle

Hypertensive Disorders

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

• fetal changes

  • impaired uteroplacental blood flow can cause:

    • IUGR

    • oligohydramnios

    • placental abruption

    • nonreassuring fetal status

    • preterm labor

• 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

  • 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

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

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

HELLP Syndrome

• can lead to:

  • liver hematoma/rupture

  • ARDS

  • sepsis

  • hypoxic encephalopathy

  • fetal/maternal death

  • preterm delivery

  • recurrent preeclampsia

• treatment

  • induction regardless of gestational age

  • monitor CBC and liver enzymes Q6H

  • magnesium infusion

  • BP control

  • early epidural placement

Long-term Risks after hypertensive disorders of pregnancy

• increased risk for pulmonary edema and cardiomyopathy

• counsel on increased risk of future cardiovascular disease

• evaluate/tx BNP, EKG, cardio echo, for low O2 sat, SOB, dyspnea

Hemorrhagic Disorders

Risk factors

• multiparity

• multiple gestation

• assisted reproductive techniques

• hx uterine surgery

• STIs

• hemorrhagic condition during previous pregnancy

• alcohol

• caffeine

• cigarette smoking

Antepartum hemorrhagic disorders

• antepartum hemorrhage

  • bleeding in pregnancy jeopardizes maternal/fetal well-being

  • blood loss decreases oxygen carrying capacity, increases risk for:

    • hypovolemia

    • anemia

    • infection

    • preterm labor

    • impaired O2 to fetus

    • hypoxemia of fetus

    • hypoxia of fetus

• spontaneous abortion (miscarriage)

  • occurs before 20 weeks

  • loss of fetus weighing ≤500g

  • management

    • assess pregnancy hx, vital signs, pain, bleeding, labs, emotional status

    • administer misoprostol (cytotec)

    • dilation and curettage

    • emphasize rest

• ectopic pregnancy

  • fertilized ovum implants outside uterine cavity

  • manifestations

    • dull, lower quadrant pain on one side

    • delayed menses

    • abnormal vaginal bleeding (spotting)

  • management

    • assess b-hCG level and transvaginal UA exam

    • administer methotrexate

      • refrain from taking folate

    • surgery

• ruptured ectopic pregnancy

  • abdominal discomfort to colicy pain when tube stretches to sharp, stabbing pain

  • referred shoulder pain

  • management

    • pain meds

    • assess for s/s shock (faintness, dizziness)

    • surgery

• hydatidiform mole

• placental trophoblast growth in which chorionic villi develop into edematous, cystic, avascular transparent vesicles that hang in grape-like cluster

• complete

  • no embryonic/fetal parts

  • sperm fertilizes empty egg

• partial

  • often have embryonic/fetal parts and amniotic sac

  • abnormal placenta forms, two sperm fertilize one egg

  • generally can’t survive

• manifestations

  • anemia from blood loss

  • hyperemesis gravidarum

  • abdominal cramps

  • large fundal height

  • preeclampsia

• management

  • transvaginal UA

  • monitor b-hCG levels weekly for 3 weeks then monthly for 6-12 months

  • suction curettage

  • instruct to not get pregnant for 12 months

    • can increase risk for cancer

• placenta previa

  • placenta implanted in lower uterine segment near/over internal cervical os

  • risk factors

    • previous c-section

    • AMA

    • multiparity

    • hx suction curettage

    • maternal cocaine use

    • smoking

  • low-lying

    • placenta in lower segment of uterus

    • does not reach opening of cervix

  • marginal

    • placenta next to cervix but does not cover

  • partial

    • placenta covers part of opening

  • complete

    • placenta covers entire opening

  • manifestations

    • painless bright red vaginal bleeding during second/third trimester

    • soft, relaxed, nontender abdomen

  • outcomes

    • major complication is hemorrhage

    • morbidly adherent placenta

    • surgery-related trauma

    • preterm birth/IUGR

    • late decels, absent/variable variability

  • management

    • no vaginal exams/internal monitors EXCEPT transvaginal ultrasound determining placental location

    • c-section is only option

      • cut right through placenta

    • come to hospital if any bleeding occurs

• placental abruption

  • detachment of all/part of placenta after 20 weeks of gestation

  • risk factors

    • maternal HTN

    • cocaine/methamphetamine use

    • penetrating/blunt external abdominal trauma

    • smoking

    • hx abruption

    • PPROM

  • manifestations

    • painful, tight belly

    • wave-like contractions

• vasa previa

  • fetal vessels lie over cervical os

  • vessels implanted into fetal membranes rather than into placenta

  • velamentous insertion

    • cord vessels branch at membranes and onto placenta

  • succenturiate placenta

    • placenta divided into 2+ lobes

  • battledore insertion of cord increases risk of fetal hemorrhage

Intrapartum hemorrhagic disorders

• disseminated intravascular coagulation (DIC)

  • acquired secondary complication resulting in formation of clots in microsystem

  • clotting occurs throughout entire circulation

  • clotting factors are consumed, unable to keep up with demand

  • fibrinolysis occurs

    • fibrin split product damage RBC, cause hemolysis

    • damage endothelial lining of vessels, capillaries in lungs, platelets

      • leads to ARDS, pulmonary edema

  • lab findings

    • low fibrinogen <100

    • PT prolonged before PTT

  • management

    • administer fresh frozen plasma (FFP)

Postpartum hemorrhagic disorders

• postpartum hemorrhage

  • cumulative blood loss ≥1000 ml OR bleeding associated with s/s of hypovolemia within 24 hrs of birth

  • primary PPH (early/acute)

    • occurs within 24 hrs of birth

    • uterine atony/rupture/inversion

    • coagulopathy

    • genital laceration

    • retained/invasive placenta

  • secondary PPH (late)

    • occurs more than 24 hrs to 12 weeks after birth

    • infection

    • retained placenta

    • coagulopathy

• subinvolution of uterus

  • prolonged lochial discharge

  • irregular/excessive bleeding

  • sometimes hemorrhage

• hemorrhagic (hypovolemic) shock

  • results of hemorrhage, death may occur

  • assessment

    • respirations

    • pulse

    • BP

    • skin

    • UO

    • LOC

  • characteristics

    • cool, pale, clammy

    • rapid, shallow respirations

    • rapid, weak, irregular pulse

    • lethargy, anxiety

  • management

    • fluid/blood replacement therapy

    • O2 delivery/maintain CO

    • restore blood volume

Hemorrhage Safety

• have hemorrhage cart ready at all times

• recognize risk assessment and QBL

  • low risk

    • no hx uterine incision

    • singleton

    • ≤ 4 previous vaginal birth

    • no bleeding disorder

    • no hx PPH

  • medium risk

    • prior c-section/uterine surgery

    • multiple gestation

    • chorioamnionitis

    • >4 previous vaginal birth

    • hx PPH

    • uterine fibroids

  • high risk

    • placenta previa

    • placenta accreta, percreta, increta

    • Hct <30

    • PT <100,000

    • active bleeding

    • coagulopathy

    • overdistended uterus

    • prolonged labor

• know massive transfusion protocol (MTP)

  • stage 1

  • stage 2

  • stage 3

  • 3 units blood in 1 hr/ 10 units over 24 hrs

  • keep puting blood in until blood stops coming out

  • avoid LETHAL TRIAD

    • coagulopathy

    • hypothermia

    • acidosis

  • first priority is to replace PRBC and FFP

• acidosis

  • develops from poor perfusion

  • delayed production of fibrin alters structures and breaks down

• hypothermia

  • affects how platelets work to control bleeding

  • give warm blood/fluids

• management

  • fundal massage

  • pack uterus

  • postpartum balloon

  • arterial embolization

  • hysterectomy

  • assess four Ts

    • tone

      • uterine atony associated with high parity, hydramnios, macrosomia, obesity, multiple gestation

    • tissue

      • retained placenta

      • uterine atony

      • trapped/fragmented placenta

      • placenta accreta—slight penetration on myometrium

      • placenta increta—deep penetration of myometrium

      • placenta percreta—perforation of myometrium and uterine serosa

    • HOW TO REMEMBER: ATTACHMENT SEVERITY BASED ON ALPHABETICAL ORDER

    • trauma

      • vaginal lacerations

        • first degree—limited to vaginal mucosa

        • second degree—involves perineal skin, mucous membranes, underlying fasciae, muscles

        • third degree—

        • fourth degree

      • hematoma

      • surgical complications

    • thrombin

      • DIC

      • idiopathic thrombocytopenia

      • von Willebrand disease

PPH medications

• pitocin (oxytocin)

  • IM or IV

  • 10-30 MU

• misoprostol (cytotec)

  • rectal/vaginal

  • 800-1000 mcg

• methergine (methylergonvine)

  • PO or IM

  • 0.2 mg

  • contraindicated in HTN

• hemabate (carboprost)

  • IM

  • 250 mcg

  • contraindicated in asthma

• tranexamic acid

  • IV

  • 1 gm

  • treat lacerations