Labour and process of labour and stages

 Labour process-

NOTES ON OBSTETRICS 

 

NORMAL LABOR (THEORIES OF LABOR ONSET)

1. Oxytocin Stimulation Theory​

2 .Uterine Stretch Theory

3. Progesterone Deprivation Theory

4. Prostaglandin Theory

5. Theory of the Aging Placenta

6 .Fetal Adrenal Response Theory

 

SIGNS OF LABOR  (WRISLIR)

• Weight Loss – 2-3 pounds (progesterone)

• Ripening of the Cervix – “soft”

• Increased Braxton Hicks – “irregular, painless”

• Show – “ruptured capillaries + operculum = pinkish color”

• Lightening – “the baby dropped”

​-  2 weeks (primi) and before or during (multi)

● Relief of respiratory discomfort

● Increased frequency of urination

● Leg pains

● Muscle spasms

● Increased vaginal discharge

● Decreased fundal height

• Increased Level of Activity – large amount of epinephrine (AG)

• Rupture of Membranes – gush or steady trickle of clear fluid

 

FALSE LABOR

CANDAC

✓ Contraction disappear with ambulation

✓ Absence of cervical dilation

✓ No ↑ DIF (duration, intensity, frequency)

✓ Discomfort @ abdomen

✓ Absence of show

✓ Contraction stops when sedated

 

TRUE LABOR

CUPPAD

✓ Contraction persists when sedated

✓ Uterine contraction ↑ DIF (duration, intensity, frequency)

✓ Progressive cervical dilation

✓ Presence of show

✓ Ambulation increase contractions

✓ Discomfort radiates to lumbosacral area

✓  

LENGTH OF LABOR

STAGE OF LABOR

PRIMI (VIRGIN)

MULTI (DIS-VIRGIN)

1ST STAGE

10 – 12 HOURS

6 – 8 HOURS

2ND STAGE

30 MINS – 2 HOURS

Ave: 50 mins

20 – 90 MINS

Ave: 20 mins

3RD STAGE

5 – 20 MINS

5 – 20 MINS

4TH STAGE

2 – 4 HOURS

2 – 4 HOURS

 

ESSENTIAL FACTORS OF LABOR (5Ps)

1. Passages

2. Power

3. Passenger

4. Person

5. Position

 

PASSAGES

FUNCTIONS (Sit Sit)

○ Serves as birthcanal

○ It proves attachment to muscles, fascia and ligaments

○ Supports uterus during pregnancy

○ It provides protection to the organs found within the pelvic cavity

TYPES (GAPA)

○ Gynecoid – normal female type of pelvis

​-  most ideal for childbirth

​- round shape, found in 50% of women

○ Android – male pelvis

​- presents the most difficulty during childbirth

​- found in 20% of women

○ Platypelloid – flat pelvis, rarest, occurs to 5% of women

○ Anthropoid – apelike pelvis, deepest type of pelvis found in 25% of women

DIVISION OF PELVIS

1. False Pelvis – “provide and direct”

2. True Pelvis – “the tunnel” IPO

○ Inlet or Pelvic Brim – entrance to true pelvis

ANTEROPOSTERIOR DIAMETER DOT

1. Diagonal Conjugate – midpoint of sacral promontory to the lower margin of symphysis pubis (12.5 cm)

2. Obstetric Conjugate – midpoint of sacral promontory to the midline of symphysis pubis (11 cm)

3. True Conjugate – midpoint of sacral promontory to the upper margin of symphysis pubis (11.5 cm)

○ Pelvic Canal – situated between inlet and outlet

​- designed to control the speed of descent of the fetal head

○ Outlet – most important diameter of the outlet.

POWERS  3I’s

⦿ Involuntary – not within the control of the parturient

⦿ Intermittent – alternating contraction and relaxation

⦿ Involves discomfort (compression, stretching and hypoxia)

⦿ PHASES OF UTERINE CONTRACTIONS

​1. Increment/Crescendo – “ready, get set”

​2. Acme/Apex – “go”

​3. Decrement/Decrescendo – “stop”

⦿ INTENSITY - strength of uterine contraction

○ Mild – slightly tensed fundus

○ Moderate – firm fundus

○ Strong – rigid, board like fundus

⦿ FREQUENCY – rate of uterine contraction

​- measured from the beginning of a contraction to the beginning of the next contraction

⦿ DURATION – length of uterine contraction

​- measured from the beginning of a contraction to the end of the same contraction

⦿ INTERVAL – measured from the end of contraction to the beginning of the next contraction

 

PASSENGER

⦿ HEAD ​(BOTu)

​- Biggest part of the fetal body

​- Olways the presenting part

​- Turn to present smallest diameter

 

⦿ CRANIAL BONES ​1 FOSE, 2 PaTe

​1 frontal bone​2 parietal bone

​1 occipital bone​2 temporal bone

​1 sphenoid bone

​1 ethmoid bone

⦿ SUTURE LINES – allow skull bones to overlap (molding) and for further brain development (SFC La)

● Sagittal Suture – between 2 parietal bones

● Frontal Suture – between 2 frontal bones

● Coronal Suture – between frontal and parietal

● Lamdiodal Suture – between parietal and occipital

⦿ FONTANELS – intersection of suture lines

● Anterior Fontanel or Bregma – intersection of SFC

​- diamond shaped, closes b/n 12 – 18 months

​- 3 x 4 cm

● Posterior Fontanel or Lambda – intersection of Sla​- triangular shaped, closes b/n 2 – 3 months

⦿ DIAMETERS OF THE FETAL HEAD

AP > T (fetal head)

1.Tranverse Diameters  BBB

● Biparietal – most important TD

​- greatest diameter presented to the pelvic inlet’s AP and at the outlet’s TD

​- average measurement is 9.5 cm

● Bitemporal – average measurement is 8 cm

● Bimastoid – average measurement is 7 cm

2. Anteroposterior Diameters   SOO

● Suboccipitobregmatic – smallest APD

​- fully flexed (presenting part)

​- measured from the inferior aspect of occiput to the ​anterior fontanel

​- average measurement is 9.5 cm

● Occipitofrontal – head partially extended and presenting part is the anterior fontanel

​- average size is 12. 5 cm

● Occipitomental – head is extended and the presenting part is the face

​- measured from the chin to the posterior fontanel

​- average size is 13.5 cm

⦿ FETAL LIE – relationship of the long axis of the fetus to the long axis of the mother

● Longitudinal Lie – “parallel”

● Transverse Lie – “right angle/lying crosswise”

● Oblique Lie – “slanting”

⦿ Attitude or Habitus – degree of flexion or relationship of the fetal parts to each other.

 

PRESENTATION AND PRESENTING PART

LIE

PRESENTATION

ATTITUDE

A. Longitudinal Lie

     1. Cephalic  (head)

 

 

 

 

 

 

 

 

 

 

 

     2. Breech (butt)

 

 

 

 

 

 

 

 

 

B. Transverse Lie

    Causes:

     1. relaxed abdominal wall

     2. placenta previa

 

 

Vertex – most ideal

           - suboccipitobregmatic is presented (9.5 cm)

 

Brow – occipitomental is presented (13.5 cm)

 

Sinciput – occipitofrontal is presented (12.5 cm)

 

Face presentation

 

Chin presentation

 

Complete breech  - feet & legs flexed on the thighs and the thighs are flexed on the abdomen

 

Frank breech -  hips flexed and legs extended (MOST COMMON)

 

Footling Breech – one or both feet are the presenting parts

 

Shoulder Presentation – fetus is lying perpendicular to the long axis of the mother

             - vaginal delivery is NOT POSSIBLE

 

*Compound Presentation – when there is prolapsed of the fetal hand alongside the vertex, breech or shoulder.      

Complete flexion

 

 

 

Moderate flexion

 

Partial flexion (military position)

 

 

Extension

 

Hyperextended

 

Good flexion

 

 

 

Moderate flexion

 

 

Very poor flexion

 

 

Flexion

 

POSITION

⦿ LOA (Left Occipitoanterior) – most favorable & common fetal position

​- fetus in vertex presentation (occiput)

​- fetus usually accommodates itself on the left because the placement of the bladder is at the right

⦿ LOP/ROP – mother will suffer more back pains

⦿ FHT Breech: Upper R or L Quadrant (above Umbilicus)

⦿ FHT Vertex: Lower R or L Quadrant (below Umbilicus)

⦿ STATION - relationship of the presenting part of the fetus to the ischial spine of the mother.

● Minus (-) station – presenting part is above the ischial spine

● Zero (0) station – presenting part is at the level of the ischial spine

● Positive (+) station – presenting part is below the level of the ischial spine

● FLOATING – head is movable above the pelvic inlet

● +1 station – fetus is engaged

● +2  station – fetus is in midpelvis

● +4 station – perineum is bulging

 

⦿ THE PERSON

 

FACTORS affecting labor     PRC PCP

● Perception & meaning of childbirth

● Readiness & preparation for childbirth

● Coping skills

● Past experiences

● Cultural & social background

● Presence of significant others and support system

 

STAGES OF LABOR

⦿ STAGE 1 – DILATATION STAGE

● Starts from first true uterine contraction until the cervix is completely effaced and dilated.

○ Dilatation – widening of cervical os to 10 cm

○ Effacement – thinning to 1- 2 cm

● CAUSES: ​1. Pergusion Reflex

​2. Fetal head and intact BOW serves as a wedge to dilate the cervix

● Maternal Assessment During Labor

​1. PIPIT PEPA HF

​2. Check V/S q 4hrs during the first stage

​- temp q hour if membranes are already ruptured (risk of infection)

​- BP b/n contractions, in left lateral pos, q 15 – 20 mins after giving anesthesia

​- a rapid pulse indicates hemorrhage & dehydration

3. Uterine contraction

Manual: fingers over fundus, you feel it about 5 secs before the client feels it

Techniques:

​1. assess contraction (DIIF)

​2. check contraction q 15 – 30 mins during the first ​stage

​3. refer immediately if:

​- duration more than 90 secs

​- interval less than 30 secs

​- uterus not relaxing completely after each ​contraction

4. Show – slightly blood-tinged mucus discharge

5. Internal Examination – to assess status of amniotic fluid, consistency of cervix, effacement/dilatation, presentation, station and pelvic measurement.

​- do it during relaxation

​- less IE done once membrane have ruptured

​- start with middle finger then index finger

6. Status of Amniotic Fluid (if ruptured)

● Danger of cord prolapse if fetal head is not yet engaged.

● Danger of serious intrauterine infection if delivery does not occur in 24 hours

NITRAZINE PAPER TEST

​- used to assess whether membrane ruptured or not.

● Procedure: “Insert and Touch”

○ Yellow – intact BOW

○ Blue – ruptured

● Normal Color of AF – clear, colorless to straw colored

● Green tinged – meconium stain (fetal distress in non – breech presentation)

● Yellow/Gold – hemolytic disease

● Gray/Cloudy – infection

● Pinkish/Red stained – bleeding

● Brownish/Tea Colored/Coffee Colored – fetal death

OTHER TEST TO DETERMINE STATUS OF AMNIOTIC FLUID

⦿ Ferning pattern of cervical mucus

​ (“swab – dry – view”)

⦿ Nile blue sulfate staining of fetal squammous cells

FETAL ASSESSMENT DURING LABOR    FHT Monitoring

● Latent Phase – every hour

● Active Phase – every 30 minutes

● Second Stage of Labor – every 15 minutes

● FHT is taken more frequently in high – risk cases

⦿ Normal FHT Pattern

● Baseline rate: 120 – 160 bpm

● Early Deceleration –    FHT @ contraction, Normal @ end of contraction (head compression)

● Acceleration -    FHT when fetus moves

⦿ Abnormal FHT Pattern

● Bradycardia – 100 – 119 bpm – moderate

​- below 100 bpm – marked

​CAUSES: ​1. fetal hypoxia (analgesia & ​anesthesia)

​2. maternal hypotension

​3. prolonged cord compression

​MGT: ​1. place mother on left side

​2. assess for cord prolapse

​3. administer oxygen

Tachycardia – 161 – 180 bpm – moderate

​- above 180 bpm – marked

CAUSES:​1. maternal fever, dehydration

​2. drugs (atrophine, terbutaline, ritodrine, etc.

MGT: ​1. D/C oxytocin, position on LLP

​2. give 02 at 8 – 10 lpm

​3. prepare for birth if no improvement

 

● Variable Pattern – deceleration at unpredictable times of uterine contraction

​CAUSE: sign of cord compression

​MGT: release pressure on the cord

● Sinusoidal Pattern – no variability in FHT

​CAUSE: hypoxia, fetal anemia & prematurity

 

CARE OF THE PARTURIENT

1. LATENT PHASE

○ Cervical Dilation: 0 – 4 cm

○ Nature of Contraction: ​Duration: < 30 secs

​Interval:  3 – 5 mins

○ Length of Latent Phase:​Primis – 6 hours

​Multis – 4 – 5 hours

○ Attitude of mother: feel comfortable, walking and sitting at this time

○ Nsg Responsibilties:​TGC

​1. Teach breathing techniques

​2. Give instructions

​3. Conversation is possible (cooperative & focus mother)

2. ACTIVE PHASE

○ Cervical Dilation: 4 – 7 cm

○ Nature of contractions: ​Duration: 30 – 50 secs

​Intensity: moderate to strong

○ Length of Active Phase:​Primis – 3 hours

​Multis – 2 hours

○ Attitude of mother:​prefer to stay in bed, withdraws from her environment and self – focused

○ Nsg Responsibilities:​    CPIC

​1. Coach woman on breathing and relaxation techniques

​2. Prescribed analgesics given during active phase

​3. Instruct woman to remain in bed, minimize noise, raise side rails, NPO

​4. Check BP 30 mins after giving analgesics ​(hypotension)

3. TRANSITION PHASE

○ Cervical Dilatation:  8 – 10 cm

○ Nature of Contractions:​Duration: 50 – 60 secs

​Interval: 2 -3 mins

​Intensity: moderate to strong

○ Length of Transition Phase:

​Primis – 1 hour (baby delivered within 10 contractions or 20 mins)

​Multis – 30 mins (baby delivered within 10 contractions or 20 mins)

○ Attitude of mother: feel discouraged, ask midwife/nurse repeatedly when labor will end, not in control of her emotions and sensations, irritated, may not want to be touched

○ Nsg Responsibilities:   RRE

​1. Reassure woman that labor is nearing end & baby will be born soon

​2. Reinforce breathing and relaxation techniques

​3. Encourage fast-blow breathing to remove the urge to bear down

⦿ CARE OF THE BLADDER – encourage the woman to void q 2 hrs to: DIPC

○ Delay fetal descent

○ Increases the discomfort of labor

○ Predispose to UTI

○ Can be traumatized during labor

⦿ FOODS & FLUIDS – NPO on active phase

○ Clear fluids on latent phase

⦿ POSITIONING – LLP - best position bcoz J RIPES

○ Relieves pressure – IVC

○ Improves urinary function

○ Prevent hypotensive syndrome

○ Encourage anterior rotation of the fetal head

○ Squatting is ideal position – directs presenting part towards the cervix promoting dilatation

⦿ AMBULATION – during the latent phase to shorten the first stage, to decrease the need for analgesia,   FHT abnormalities & to promote comfort​

○ NO WALKING IF BOW IS RUPTURED

⦿ IV FLUIDS – reasons:   PLUA

○ Prevent dehydration/fluid & electrolyte imbalances

○ Life – line for emergencies

○ Usually required before administration of A/A

○ Administration of oxytocin after delivery to prevent atony

⦿ PERINEAL PREP

○ Clean & disinfect the external genitalia

○ Provide better visualization of the perineum

⦿ ENEMA – emptying the colon of fecal matters to:

○ Prevent infection

○ Facilitate descent of fetus

○ Stimulate uterine contractions

○ CONTRAINDICATIONS: NIRVAA

● Not given during active phase

● If premature labor bcoz of danger of cord prolapse

● Rupture of BOW

● Vaginal bleeding

● Abnormal fetal presentation & position

● Abnormal fetal heart rate pattern

SECOND STAGE – EXPULSIVE STAGE

​MECHANISM OF LABOR: EDFIRE ERE

● Engagement

● Descent – entrance of the greatest biparietal diameter of the fetal head to the pelvic inlet

● Flexion – the chin of the fetus touches his chest enabling the smallest diameter (suboccipitobregmatic) to be presented to the pelvis for delivery

● Internal Rotation – when the head reach the level of the ischial spine, it rotates from transverse diameter to AP diameter so that its largest diameter is presented to the largest diameter of the outlet. This movement allows the head to pass through the outlet.

● Extension – the head of the fetus extend towards the vaginal opening.  As the head extend, the chin is lifted up and then it is born.

● External Rotation – when the head comes out, the shoulder which enters the pelvis in transverse position turns to anteroposterior position for it become in line with the anteroposterior diameter of the outlet & pass through the pelvis.

● Expulsion – when the head is born, the shoulder & the rest of the body follows without much difficulties.

● Duration of Second Stage: Primis – 50 mins

​Multis – 20 mins

● Assessment: monitor FHT q 15 mins in normal case and every 5 mins in high risk cases if not yet delivered

● Transfer to the DR: ​Primis – cervix fully dilated

​Multis – cervix is 8 cm dilated

Delivery Position

1. Lithotomy – used when forcep delivery & episiotomy are to be performed.

2. Dorsal Recumbent – head of the bed is 35 – 45˚ elevated, knees are flexed & feet flat on bed. This position facilitates the pushing effort of the mother.

3. Left Lateral Position – indicated for woman with heart disease.

⦿ ASSISTING THE MOTHER IN THE DR

1. Coach the mother to push effectively

2. Instruct the woman to pant

3. Dorsiflex the affected foot and straigthen the leg until the cramps disappear

4. Perform ironing on vaginal orifice if the presenting part moves towards the outlet

5. When the head is crowning, instruct the mother to pant.

6. Perform Ritgen’s Maneuver while delivering the fetal head to:

1. Slows down delivery of the head

2. Lets the smallest diameter of the head to be born

3. Facilitates extension of the head

7. Just after delivery, immediately wipe the nose & mouth of secretions then suction.

8. Take note of the exact time of baby’s birth

9. After the delivery of the baby, place the newborn in dependent position to facilitate drainage of secretions.

10. Place the infant over the mother’s abdomen to help contract the uterus.

11. Clamping the cord:

● After the pulsation stops

● Clamp the cord twice and cut in between 8 – 10 inches from umbilicus

● After cutting the cord, look for 2 arteries & 1 vein

12. Wrap the infant & bring to the nursery

 

THIRD STAGE – PLACENTAL DELIVERY

METHODS OF PLACENTAL SEPARATION:

1. Schultz Mechanism – separation of the placenta starts from the center

​- the shiny & smooth fetal side is delivered first

​- 80% of placental separation

2. Duncan Mechanism – separation begins from the edges of placenta

​- the dirty maternal side is delivered first

​- 20% of placental separation

MANAGEMENT:

1. Watchful waiting.

a) Do not hurry placental delivery.

b) Rest a hand over the fundus to make sure the uterus remains firm

c) Wait for signs of placental delivery

• Calkin’s sign – uterus is firm, globular & rising to the level of umbilicus

• Sudden gush of blood from vagina

• Lengthening of the cord

2. Manage the uterus to keep it contracted.

3. Administer methergin as prescribed.

4. Never leave the client unattended.

5. Oxygen & emergency equipment made available.

 

THE FOURTH STAGE – PUERPERIUM

MANAGEMENT:

1. Repair of lacerations.

​CLASSIFICATION OF PERINEAL  LACERATIONS

​First Degree – fourchette, vaginal mucous membrane, perineal skin

​Second Degree – fourchette, vaginal mucous membrane, perineal skin, muscles of perineal body

Third Degree – fourchette, vaginal mucous membrane, perineal skin, muscles of perineal body & anal sphincter

Fourth Degree - fourchette, vaginal mucous membrane, perineal skin, muscles of perineal body, anal sphincter & mucous membrane of rectum

2. After repair of lacerations & episiotomy, perineum is cleansed, the legs are lowered from stirrups at the same time.

3. Check V/S of the mother every 15 mins for the first hour & every 30 mins for the next 2 hours until stable.

4. Check uterus & bladder q 15 mins.

HYPEREMESIS GRAVIDARUM

Causes:​(UTEP)

​1. Unknown

​2. Thyroid dysfunction

​3. Elevated HCG

​4. Psychological stress

S/Sx:

​1. Excessive N/V – persist beyond 12 weeks

​2. Signs of dehydration (thirst, dry skin, weight loss, concentrated and scanty urine)

Management:

​1. Differential diagnosis (liver & thyroid function studies, urinalysis, Hct/Hgb and WBC)

​2. Conservative management

​a. dry, low fat, high carbohydrate and bland diet

​- dry crackers

​- small frequent feedings & sips of water (gastric distention – trigger vomiting reflex)

​- avoid very hot or very cold food & beverages

​b. avoid noxious stimuli

​- motion and pressure around the stomach (tight waistbands)

​- temporary cessation of iron supplement (gastric upset)

​- avoid highly seasoned and spicy foods

​- avoid strong odors (perfumes)

​- avoid loud noises, bright and blinking lights

​​c. take vitamin supplement to correct nutritional deficiencies from decreased food intake

​d. have enough relaxation & rest

​e. take prescribed medications

​- Promethazine (Phenergan)

​- Prochlorperazine (Compazine)

​- Ondansentron (Zofran)

​- Droperidol (Inapsine)

​- Metoclorpramide (Reglan)

​- Diphenhydramine (Benadryl)

​- Meclizine (Antivert)

​3. Hospitalization (correct dehydration and F&E imbalances)

​a. IV fluids (lactated ringers)

​b. Vitamin supplementation

​c. NPO for 24 – 48 hours (rest GIT)

​d. Oral fluid intake after hydrated and nausea subside

e. when patient begins oral intake of foods:

​- administer antiemetics before meals

​- see patient is relaxed & comfortable

​- introduce food gradually starting with clear liquids

​- small frequent feedings

​- do not serve odorous, spicy & greasy foods

​- do not force patient to eat

​4. Parenteral or enteral therapies

​5. Complementary therapies

​a. acupressure (pericardium 6 or P6)

​b. herbal remedy (ginger – carminative effect/aroma)

​c. vitamin supplementation

​6. Provide emotional support

​a. show sincere concern for the women’s welfare

​b. empower patient with knowledge & encouragement

​c. provide necessary referrals (counseling)

ABORTION

Definition of Terms:

1. Abortion – most common bleeding d/o of early pregnancy (before 20 weeks/fetus weighs 500 grams)

2. Early Abortion – before 12 weeks pregnancy.

3. Late Abortion – between 12 – 20 weeks

4. Abortus – fetus that is aborted weighing less than 500 grams

5. Occult Pregnancy – zygotes that were aborted before pregnancy is diagnosed or recognized

6. Clinical Pregnancy – pregnancies that were diagnosed

7. Blighted Ovum – small macerated fetus, sometimes there is no fetus, surrounded by a fluid inside an open sac.

8. Carneous Mole – zygote that is surrounded by a capsule of clotted blood

9. Fetus Compressus – fetus compressed upon itself and desiccated with dried amniotic fluid

10. Fetus Papyraceous – fetus that is so dry that it resembles a parchment

11. Lithopedion – a calcified embryo

12. Immature Infant – having a birth weight b/n 500 – 1000 grams

13. Full Term Infant – born between 38 – 42 weeks

 

Types of Abortion:

1. Elective/Therapeutic Abortion – “the deliberate termination of pregnancy”

a. EA – initiated by personal choice

b. TA – recommended by the healthcare provider

2. Spontaneous Abortion – “loss of a fetus due to natural causes”

Causes of Spontaneous Abortion:

A. Fetal Causes (80% – 90%)

1. Developmental anomalies

2. Chromosomal abnormalities (Trisomy 16)

B. Maternal Causes (congenital/acquired conditions)

1. Advanced maternal age (after 35 years of age)

- <35 y/o (15% miscarriage rate)

- b/n 35 – 39 y/o (20 – 25% miscarriage rate)

- b/n 40 – 42 y/o (about 35% miscarriage rate)

- >42 y/o (about 50% miscarriage rate)

2. Structural abnormalities of the reproductive tract

3. Inadequate progesterone production (corpus luteum/placenta)

4. Maternal infections (rubella virus, cytomegalovirus, listeria infection, toxoplasmosis)

5. Chronic and systemic maternal diseases

6. Exogenous factors (tobacco, alcohol, cocaine, caffeine, radiation)

Complications of Abortion:

​1. Hemorrhage

​2. Infection or septic abortion

​3. Disseminated intravascular coagulation (DIC)

Types of Spontaneous Abortion:

1. Threatened Abortion – “possible”

​- (+) bleeding, (-) cervical dilatation

S/Sx:

​​-Light vaginal bleeding (bright red)

​-None to mild uterine cramping

​Management:

​1. Assess for:

​- LMP

​- Save all pads for examination

​- ask for presence of clots

​- abdominal pain

​2. Conservative management

​- bedrest until 3 days after bleeding has stopped

​- no coitus up to 2 weeks after bleeding stopped

​3. Educate mothers.

Management:

​1. Monitor V/S

​2. monitor closely for bleeding or signs of infection

​3. regular diet (high in iron foods)

​4. rest for a few days to 2 weeks (coitus&douching for approx 2 weeks)

​5. may experience intermittent menstrual-like flow and cramps (next menstrual period occurs after 4 – 5 weeks)

​6. Reassure patient that her next pregnancy is likely to last to term if she is young and has no other risk factors.  (no pregnancy for the next 3 months)

​7. determine woman’s Rh factor

​8. Advise patient to return if:

​- profuse vaginal bleeding

​- severe pelvic pain

​- temperature greater than 100˚F

2. Inevitable or Imminent Abortion – “can not be prevented”, (+) complete dilatation

​S/Sx:

​1. Moderate to profuse bleeding

​2. moderate to severe uterine cramping

​3. open cervix or dilatation of cervix

​4. rupture of membranes

​5. no tissue has passed yet

​Management:

​*Avoiding complications of infection or excessive blood loss

​1. Hospitalization

​2. D&C

​3. Oxytocin after D&C

​4. Sympathetic understanding and emotional support

3. Complete Abortion – “spontaneous expulsion”

​S/Sx:

​1. Vaginal bleeding, abdominal pain and passage of tissue

​2. On examination:

​- light bleeding or some blood in the vaginal vault

​- no tenderness in the cervix, uterus or abdomen

​- none to mild uterine cramping

​- closed cervix

​- empty uterus on utrasound

4. Incomplete Abortion – “expulsion of some parts and retention of other parts of conceptus in utero”

​S/Sx:

​1. heavy vaginal bleeding

​2. severe uterine cramping

​3. open cervix

​4. passage of tissue

​5. ultrasound shows some products of conception

​Management:

​1. D&C

​- uterus must kept contracted after D&C

​- inspect fundus frequently

​- a danger of D&C (uterine perforation)

​2. Monitor blood loss

​- inspect perineal pads (60 – 100ml of blood)

​- monitor v/s (BP & PR)

​- monitor the blood studies of patient’s clotting factors

​- monitor I & O (Oliguria – decrease renal perfusion – shock)

​3. Sympathetic understanding and emotional support.

​- encourage verbalization of feelings

5. Missed Abortion – “retention after death”

​S/Sx:

​1. Absence of FHT

​2. Signs of pregnancy disappear

​- uterus fails to enlarge

​- no FHT

​- serum or urine test for the subunit of HCG is negative

​- ultrasound showing no cardiac activity

​Management:

​1. Product of conception be removed to prevent DIC

​2. Insert 20mg Dinoprostone (Prostaglandin E) suppository into the vagina q 3 or 4 hours PRN (<28 weeks gestation)

​3. Oxytocin IV infusion (late missed abortion)

 

6. Habitual Abortion – “repeated 3 or more”

​Causes:

​1. incompetent cervix

​2. IUGR

​3. congenital, genetic & chromosomal abnormalities

Management:

​1. Treating the cause

​2. Specific treatment according to cause:

​a. Cervical Cerclage (modified Shirodkar, Mc Donald’s) – suturing ​the cervix

​b. Fertility drugs (Clomiphene, Pergonal, etc.)

​c. Aspirin or Mini – Heparin

​d. Luteal Phase Progesterone Support

​e. correction of defects

​f. treatment of medical illness

7. Infected Abortion – “infection @ POC & MRO”

 

8. Septic Abortion – “dissemination of bacteria in maternal circulatory and organ system

​Causative Organisms:

​1. E. Coli

​2. Enterobacter Aerogenes

​3. Proteus Vulgaris

​4. Hemolytic Streptococci

​5. Staphylococci

S/Sx:

​1. foul smelling vaginal discharges

​2. uterine cramping

​3. fever, chills and peritonitis

​4. leukocytosis – WBC count 16, 000 – 22,000/uL

​5. critically ill patients

​Management:

​1. Treat abortion

​2. high dose IV antibiotic therapy (Penicillin – gram negative, Clindamycin/Tobramycin – gram positive)

​3. D&C if accompanied by incomplete abortion

​4. Infertility may occur

 

ECTOPIC PREGNANCY

Causes:

​1. Mechanical Factors – “delay passage of ovum”

​- salphingitis

​- peritubal adhesions

​- developmental abnormalities

​- previous ectopic pregnancy

​- tumors that distort the tube

​- past induced abortions

​2. Functional Factors

​- external migrations of the ovum

​- menstrual reflux

​- altered tubal motility

​3. Assisted Reproduction

​- ovulation induction(Clomid)

​- gamete intrafallopian transfer

​- in vitro fertilization

​- ovum transfer

​4. Failed contraception

Types of Ectopic Pregnancy:

1. Tubal - >95%

a. Ampulla (most common site, 55%)

​b. Isthmic (25%)

​c. Fimbrial (17%)

​d. Interstitial (2%)

​e. Bilateral (very rare)

2. Ovarian (cystectomy/oophorectomy, 0.5%)

3. Abdominal (1/15,000 pregnancies)

​a. Primary – original implantation outside the tube

​b. Secondary – implantation in the abdomen after rupture and expulsion

4. Cervical (due to in vitro fertilization and embryo transfer

5. Heterotypic Pregnancy (TP accompanied by intrauterine pregnancy)

6. Tubo – Uterine ( partly implanted in the tube and uterus)

7. Tubo – Abdominal ( fimbriated implantation extends into the peritoneal cavity

8. Tubo – Ovarian (partly implanted in the tub and partly in the ovary)​

S/Sx:

​1. missed menstrual period of two weeks duration (68%)

​2. unilateral lower abdominal pain (99%)

​3. irregular vaginal bleeding (75%)

​4. Before rupture

​- brief amenorrhea

​- pelvic and abdominal pain on the side of the affected ​tube

​- “Arias – Stella Reaction”

​5. Ruptured ectopic pregnancy:

​a. pain

​- sudden severe and knife like pain

​- radiating to the neck and shoulder

​- cervical pain during IE

​b. spotting or bleeding – darkbrown

​c. Cullen’s Sign or bluish discoloration of the umbilicus ​due to the presence of blood in the peritoneal cavity

​d. Hard or boardlike abdomen

​e. Signs of shock

​6. Diagnosis

​a. Transvaginal Utrasound (TVUS)

​TVUS + serial HCG det. = most reliable

​b. Serial HCG

​c. Pregnancy Test

​d. Culdocentesis

​e. Serum Progesterone Level

​>25ng/ml –normal viable pregnancy

​<5ng/ml – nonviable pregnancy

​f. Uterine Curettage

​g. Colpotomy

​h. Laparoscopy

​i. CBC

​j. Elevated WBC

 

​Management:

​1. Therapeutic Abortion – unruptured EP

​a. Methotrexate Therapy

​2. Surgical removal – ruptured EP

Nursing Interventions:

​1. Prevent and treat hemorrhage

​- IVF to prevent shock

​- type & cross match blood

​- place flat in bed with legs elevated

​- provide extra blanket to keep warm

​2. Assist in positioning the patient

​3. Post – op interventions:

​- monitor v/s

​- assistance with positioning & ambulation

​- monitor IV fluids therapy

​- If patient is Rh-negative, RhoGAM is given within 72 hours and before discharge

​- provide contraceptive counseling

​4. Meet emotional needs of patient

​5. Prevention

​- safe sex practices

​- importance of gynecological exams

​- S/Sx of STDs

​- possible risks associated with the use of an IUD

 

HYDATIDIFORM MOLE

- benign disorder of the placenta characterized by degeneration of the chorion and death of the embryo.

 

Types:

1. Complete Molar Pregnancy – “only placental parts, no embryo”

2. Partial Molar Pregnancy – “2 fathers, 1 mother”

​- “placenta and fetus formed but incomplete”

Risk Factors/Incidence:

1. Geography

2. High in women below 18 and above 40 years old

3. High in low socioeconomic status (low protein intake)

4. History of molar pregnancy

S/Sx:

1. Excessive N/V due to elevated HCG levels

2. Bleeding from spotting to profuse (brown bleeding)

3. Passage of grape like vesicles around the 4th month

4. Rapid increase in uterine size (out of proportion)

5. Signs of preeclampsia before 24 weeks (HEP)

6. Absence of FHT and fetal skeleton

7. Ultrasound (mass of fluid filled vesicles – “snowflake pattern”)

8. Elevated plasma thyroxine levels

9. Elevated serum gonadotropin level (>100 days)

Management:

1. D&C

2. Methotrexate (Choriocarcinoma)

3. HCG monitoring for 1 year

​- HCG should be negative 2-8 weeks after removal of mole (every 2 weeks)

​- monthly for 6 months

​- every 2 months for another 6 months

​- chest x-ray every 3 months for 6 months

4. Woman advised not to be pregnant for one year

​- contraceptives should not contain estrogen

5. Hysterectomy

​- above 40 years old

​- who have completed child bearing

​- who desire or require sterilization

Complications of H – Mole:

1. Gestational Trophoblastic Tumors – “trophoblastic proliferation”

a. Choriocarcinoma – most severe complication

​- conversion of  chorionic villi into cancer cells that erode blood vessels and uterine muscles.

​- “lungs”

b. Invasive Mole – developed during the first 6 months

​- excessive formation of trophoblastic villi that penetrates the myometrium

c. Placental Site Trophoblastic Tumor – composes of cytotrophoblastic cells arising from the site of the placenta.

- produce both prolactin and HCG

​- main symptom is “bleeding”

 

**Management of all trophoblastic tumors is HYSTERECTOMY

 

INCOMPETENT CERVIX

Diagnosis:

1. Pelvic examination or IE

2. Ultrasonography – (cervical os is >2.5cm or length is shortened to <20mm)

​- “funneling”

 

Predisposing Factors/Causes:

1. DES exposure in utero

2. Cervical trauma from previous difficult deliveries (forcep deliveries)

3. Hormonal influences

4. Congenitally short cervix

5. Forced D&C

6. Uterine anomalies

S/Sx:

1. Painless vaginal bleeding or pinkish show accompanied by cervical dilatation (first sign)

2. Rupture of membranes and passage of amniotic fluid

Management:

1. Cervical cerclage @ 14 weeks (“earlier the better”)

2. Prerequisites of cervical cerclage:

cervix not dilated beyond 3 cm

​- intact membranes

​- no vaginal bleeding and uterine cramping

3. Types of cervical cerclage:

● Shirodkar Suture – “permanent suture”

● Mc Donald Suture – “temporary suture”

- 38 – 39 weeks removal of suture

4. After suturing the cervix:

​- place woman on bedrest for 24 hours – several days

​- observe for bleeding, contraction and rupture

​- report passage of fluid or signs of PROM

​-  if uterine contracts, RITODRINE may be given

​- restrict activities after application for the next 2 weeks including coitus

 

ABRUPTIO PLACENTA

- “ablation placenta, placental abruption & accidental hemorrhage”

Causes:

1. Maternal hypertension

2. Advanced maternal age (>35y/o)

3. Trauma to the uterus

4. Rapid decompression of an over-distended uterus

5. Grand multiparity (thinning of endometrium)

6. Short umbilical cord

7. Uterine leiomyoma or fibroids

8. Behavioral factors:

​- cigarette smoking, methamphetamine and cocaine abuse

​- maternal alcohol consumption (14 or more drinks)

 

Types of Abruptio Placenta:

A. Classification According to Placental Separation

​1. Covert/Central AP – “bleeding is internal and not obvious”

​2. Overt/Marginal AP – “bleeding is external”

B. Classification According to Signs and Symptoms

​1. Grade 0 – no symptoms

​2. Grade 1 – some external bleeding, uterine tetany and tenderness, absence of fetal distress and shock

​3. Grade 2 – external bleeding, uterine tetany, uterine tenderness and fetal distress

4. Grade 3 – internal bleeding and external bleeding (>1000ccc), uterine tetany, maternal shock, probably fetal death and DIC

 

Classification According to Extent of Separation

​1. Mild​ – <1/6 of the placenta is separated

​- bleeding may or may not be present (<250cc)

​- uterine irritability with no fetal distress

​- some uterine tenderness and vague backache

 

​2. Moderate – approx 1/6 – 2/3 of placenta

​- dark vaginal bleeding may or may not be present (<1000ml)

​- uterine tenderness and tetany is present

​- fetal distress d/t uteroplacental insufficiency

 

​3. Severe - >2/3 of the placenta

​- uterine tenderness and rigidity along with severe pain

​- dark vaginal bleeding (>1000cc)

- fetal distress if not delivered fetal death is imminent

​​- entire placental separation (maternal shock, fetal death, severe pain and possible DIC

S/Sx:

1. Vaginal bleeding occurs in 80% of women

• Dark red vaginal bleeding (CAP)

• Bright red vaginal bleeding (OAP)

2. Abdominal pain

• Uterine irritability and low back pain (2/3 of patient)

• Complain “labor-like pains” (mild AP)

• Gradual or abrupt pain (moderate AP)

• Sudden and knife-sharp pain, localized and diffused over the abdomen (severe AP)

• Sharp pain over the fundus – placental separates

• Escalating abdominal pain – concealed bleed

   3. Board like abdomen – accumulation of blood behind the placenta with fetal parts hard to palpate.

   4. Signs of shock and fetal distress if bleeding are severe.

Management:

1. Hospitalization is a must

2. If fetus is below 36 weeks​

​a. manage @ prolonging pregnancy with the hope of improving fetal maturity if:

​- bleeding is not life threatening

​- FHT are normal

​- mother is not in active labor

​b. manage bleeding episode

​- place in bedrest (sidelying position)

​- IFC to accurately record I&O (at least 30cc/hr)

​- NPO status

- oxygen therapy (NC @ 4 – 6 lpm)

- observe & record bleeding q 30 mins or more (saturated perineal pad can absorb approx 60 – 100ml of blood)

​- assess status of abdomen

​- mark fundus of the uterus (concealed bleeding)

​- monitor V/S

​- assess uterine contractions

​- blood typing and cross matching

​- administer IVF (LRS 125cc/hr)

​- monitor fetal condition by daily nonstress test and ​kick counts

​- administer prescribed medications

• Bethametasone (hasten fetal maturity)

• Tocolytic therapy (MgSO4, Ritodrine or Terbutaline)

- observe for signs of DIC

• Assess bleeding

• “clot test”

• Coagulation studies (fibrinogen level, prothrombin time (PT), partial prothrombin time (PTT), CBC, anticoagulant factor and electrolytes)

- delivery

• CS – distressed fetus or uncontrolled bleeding (30 minutes)

• VD – fetus is dead, maternal bleeding is mild and if the mother is in stable condition

- postpartum (WOF couvelaire uterus)

 

PLACENTA PREVIA

Types of Placenta Previa:

1. Complete/Total PP – covers the internal os

2. Partial PP – partially covers the internal os

3. Marginal PP – edge of the placenta is lying at the margin of the internal os

4. Low Lying PP – implants near the internal os with its margin located about 2cm – 5 cm from the internal os

Frequency:

1. approx 3.5 – 8 pregnancies per 1000 after 20 wks AOG

2. Maternal mortality assoc. with PP is <1%

3. Maternal morbidity is about 5%

Predisposing Factors/Causes:

1. Unknown

2. Decreased blood supply or scarring @ upper segment

​- multiparity

​- previous molar pregnancy

​- endometritis

​- age (above 35 y/o)

​-previous CS

​- abortion

​- repeated D&C

3. Decreased blood supply to the endometrial lining

4. Short umbilical cord

5. Abnormal placentas (placenta increta and accreta)

6. Large placenta

 

Complications:

1. Hemorrhage

2. Infection

3. Prematurity

4. Obstruction of birth canal

5. DIC

6. Abnormal adhesion of placenta

7. Renal failure may occur r/t shock caused from hemorrhage or DIC

8. Anemia

9. More lacerations

10. Fetal effects/neonatal effects

11. Brain damage or neurological abnormalities

 

**Ultrasonography best way to differentiate AP from PP

 

S/Sx:

1. Sudden painless vaginal bleeding (24 – 30 weeks)

2. Bright red bleeding occurs in gushes and is rarely continuous (usually @ night with the patient awakening and finding herself lying in a pool of blood)

3. Fetus assumed transverse position, “no engagement”

4. Decreased urinary output

**Ultrasound is the earliest and safest diagnostic tool for PP

Management:

1. IE by MD only under double set up (done in the OR – patient is prepped and draped)

​Double Setup is Indicated When:

​1. ultrasound is not available

​2. the ultrasound evidence is inconclusive

​3. patient with ongoing but not life-threatening vaginal bleeding in labor

​4. mother has a marginal previa and is well-established labor

2. Assess extent of blood loss

● visual estimates (most often used but the most inaccurate)

● Vital signs

● Tilt Test (woman bleeds profusely but has normal blood pressure and pulse in recumbent position will develop hypotension and tachycardia when placed in sitting position)

● Urine flow​

3. If pregnancy is below 36 weeks

● Watchful waiting/expectant management/conservative management

Nursing Interventions:

a) Monitor:

✓ FHT and activity

✓ Vaginal bleeding

✓ Uterine contractions

✓ Maternal V/S

✓ Maternal I&O

b) Woman in CBR (if no bleeding after 48 hours, mother is allowed bathroom privileges)

c) Manage bleeding episodes

✓ Keep woman on NPO

✓ Monitor V/S, FHR, vaginal bleeding

✓ Maintain on absolute bedrest

✓ Start fluid replacement therapy and blood transfusion

d) If woman is in active labor, tocolytics may be given.

e) Betamethasone (Celestone)is given to hasten fetal lung maturity (12mg IM q 12 hrs for 2 doses)

f) Amniocentesis (lung maturity)

 

4. Outpatient management

​a. live close to the hospital (within 5 – 10 minutes) and 24 hours transportation availability and close supervision by family or friends @ home

​b. restricted activities @ home

​- bed rest most part of the day

​- heavy lifting is strictly prohibited

​- no vacuuming or standing for long periods of time

​- sexual arousal, intercourse or orgasm should be ​avoided

​- avoid enema and douche

​- stop working or employment

​- provide diversional activities

5. Inform patient and family to be observant

​- bleeding, contraction & decreased fetal activity

 

6. Diet

​- foods high in iron

​- prenatal vitamins (Iron + Vitamin C)

​- increase fiber intake

7. Clinic visit is usually once or twice a week

​- ultrasound tests (2-4 weeks interval)

​- regular NST

​- biophysical profile

8. Labor and delivery

​a. delivery is implemented when:

​- fetus is mature

​- persistent hemorrhage

​- intrauterine infection

​- rupture of membranes

​- persistent uterine contractions unresponsive to tocolysis

​- mother develops coagulation defects (DIC)

b. method of delivery

​CS – delivery of choice (profuse maternal hemorrhage and fetal hypoxia)

​VD – for marginal/partial previa

​c. Nursing Care:

➢ Anticipate doctor orders for:

• Ultrasound

• IVF (LRS, gauge needle #16 or #18)

• CBC, blood type and cross match for at least 2 units of whole blood, DIC panel, PTT, PT and electrolytes.  H/H may order every 12 hours.

➢ In case of profuse bleeding:

• CBR s BRP, quiet environment (+ bleeding)

• Keep on NPO

• Administer O2 tight mask @ 6lpm

• Do not perform enemas

• Discourage bearing down

➢ Position

• Semi – Fowler’s Position

• Trendelenburg Position

➢ Examinations & Monitoring

✓ No IE

✓ Place mother on continuous fetal monitoring

✓ Monitor vaginal bleeding q 15 minutes then 30 minutes after bleeding stopped

✓ V/S q 15 minutes then 30 mins if stable and bleeding subsides

✓ Assess I&O

✓ Observe signs of DIC

✓ Observe for shock

➢ Post – partum nursing care:

✓ WOF hemorrhage

● Oxytocin, gentle massage and close monitoring

● Surgical management such as ligation of the hypogastric arteries (internal iliac) or hysterectomy

✓ Puerperal infection

● Observe elevation of temp above 39˚C or 100.4˚F

● Low – grade fever during 24 hours  (dehydration)

● Aseptic technique and handwashing

● Teach proper perineal care and good  handwashing technique

● Front-to-back motion when applying perineal pads

● Reinforce aseptic techniques during bathroom usage

➢ Anemia

✓ Moderate to severe anemia d/t amount of blood lost

✓ Normal hemoglobin 12 – 13 g/dl

✓ Moderate anemia 9 – 11 g/dl

✓ Severe anemia below 9 g/dl

 

PREGNANCY INDUCED HYPERTENSION (PIH)

- anytime after the 24th week gestation – 2 weeks postpartum

TRIAD SYMPTOMS:

​- hypertension (2 successive BP of 140/90 and above taken 4 - 6 hours apart)

​- edema (upper part of the body – hands and face)

​- proteinuria

*specifically albuminuria

​- albumin (water soluble protein)

Predisposing Factors:

1. Age (<20y/o & >35y/o)

2. Gravida – 5 or more pregnancies

3. Low socio-economic status

4. Extra large fetus

5. Familial tendency

2 Types:

1. Preeclampsia – 140/90, develops after 20 weeks gestation accompanied by proteinuria (300mg/24hrs) and edema.

2. Eclampsia – all S and Sx of preeclampsia accompanied by convulsion or coma that is not caused by other conditions.

Causes:

1. Unknown

2. Genetic predisposition

3. Autoimmune reaction and an immune reaction to paternally derived antigens

4. Protein deficiency theory and dietary deficiencies

5. Endothelin theory

 

PREECLAMPSIA

EFFECT

The amount of circulating plasma volume falls

Rise in hemoglobin and hematocrit

Decreased  blood supply to kidney and hemoconcentration stimulates release of aldosterone, ADH and angiotensin

Sodium retention leading to edema (hypernatremia)

Vasospasm and hypertension

Vasospasm cause damage to the endothelium promotes coagulation and increase sensitivity to pressor agents.

Elevated platelets

Patient’s renal perfusion is affected. Decreased blood  supply to kidneys resulting in decreased GFR. Efficiency of the kidney to remove metabolic waste is impaired. Decreased renal perfusion results in damage to kidney structures allowing passage of large molecules

Serum levels of BUN, creatinine and uric acid rise leading to acidosis and decreased urine output.

 

Proteinuria

Vasospasms decreases blood supply to the brain resulting in cerebral ischemia

Hyperreflexia

Convulsions

Decreased blood supply to the uterus  and placenta

IUGR

Fetal hypoxia and distress

Continuous vasospasm cause diminished blood supply resulting in damage to blood vessels and tissues in the placenta and decidua

Abruptio Placenta

 

Signs/Symptoms

Mild Preeclampsia

Severe Preeclampsia

Blood Pressure

140/90, diastolic BP is more than 100mmHg

Diastolic is 110mmHg or higher

Proteinuria

+1 - +2 by dipsticks

300mg/24 hour urine collection

+2 - +4

5g/24 hour urine collection

Liver enzymes

Slightly elevated

Markedly elevated

Laboratory studies

Normal hematocrit, uric acid, creatinine

Increased Hct, Crea and UA; thrombocytopenia may be present

Fetus

No IUGR

IUGR present

Edema

Digital edema, dependent edema

Pitting edema (4+)

Generalized edema

Weight Gain

1 – 2 lb/week

More rapid weight gain

Urinary Output

Not less than 400ml/24 hours

Less than 400 ml/24 hours

Cerebral Disturbances

Occasional headache

Severe frontal headache, photophobia, blurring, spots before the eyes (scomata), n/v

Reflexes

Normal to 3+

Hyperreflexia, 4+

Epigastric Pain

Absent

RUQ pain (aura to convulsion) d/t swelling of hepatic capsule

 

S/Sx of Eclampsia:

1. All the S/Sx of preeclampsia

2. Convulsion followed by coma

3. Oliguria

4. Pulmonary edema

 

Management:

1. Roll – Over Test (increase of 20mmHg or greater diastolic pressure)

2. Tolerance Hyperbaric Test (portable BP cuff – 48 hours)​

​Ambulatory Management:

​1. Home management is allowed only if:

• BP is 140/90 or below

• Low proteinuria

• No fetal growth retardation and good fetal movement

2. Bed rest (when lying down, assume LLP)

​3. Consult every two weeks

​4. Home management also include phone calls and home visits by the N – M

​5. Diet: high in protein and carbohydrates with moderate sodium restriction

​6. Hospitalization is necessary if condition worsens

​7. Provide detailed instructions about:

a. Dietary modifications

✓ High in protein

✓ Moderate sodium restriction

✓ Eat a balanced diet that include 1200mg calcium

✓ Avoid salty foods, such as canned foods, soda, chips and pickles

✓ Eat foods with roughage

✓ Drink 8 – 10 glasses of water daily

✓ Avoid alcohol

✓ Take daily weight measurement

✓ Measure and record fluid intake and urine output

 

b. Monitor her own health condition and report to health care provider immediately if the following occur:

✓ Take and record her BP twice daily

✓ Count fetal movements per hour (3/h)

✓ Take and record weight daily

✓ Report for increased BP, epigastric pain and visual disturbances

✓ Weight gain more than 1 lb a week

✓ Abnormal fetal movement and abdominal pain

 

​Hospital Management:

a. Hospitalization is necessary if:

• BP is equal or greater than 160/100mmHg

• Proteinuria of 3+ or 4+

• Rapid weight gain

• Oliguria

• Visual disturbances

• Abnormal fetal movement

 

b. Expectant management

● Treatment with Bethamethasone (2 doses)

​c. Fluid therapy

● Crystalloid infusion (LRS & NSS, 100ml/hr – 125ml/hr)

● Close monitoring

d. Medications

● Magnesium Sulfate

✓ Prevent convulsion and seizures

✓ Reduce edema

✓ Reduce BP

Nursing Considerations:

Loading dose: 4gm over 20 mins, followed by 2 – 3gm/hr (ACOG)

Check the ff before giving:

✓ RR above 14cpm

✓ UO at least 100ml/4hr

✓ DTR are present (loss of DTR – first sign of toxicity/hypermagnesemia)

✓ Serum magnesium levels are evaluated periodically

​​7 – 8 mg/dL  (therapeutic level)

10 - 12 mg/dL (developing toxicity)

*If MST develops (1gm (10ml) 10% Calcium Gluconate)

Antihypertensives

Hydralazine (Apresoline)

ID: 5mg IV bolus

RD: 5mg – 10mg q 20 mins if diastole is above 110mmHg

Labetolol (Normodyne) 20mg IV q 10 mins to max of 300mg

Safety measures

✓ Raise padded side rails

✓ Put bed at lowest position

✓ Have emergency equipments available

Care of the woman during convulsion

Stages of Convulsion:

1. Stage of Invasion or Aura – facial twitching, rolling of the eyes to one side, staring fixedly in space, sudden severe headache, screaming and epigastric pain

2. Tonic Phase – rigid body, eyes protrude, arms are flexed with legs inverted, hands are clenched, woman stop breathing lasts for 15 – 20 seconds.

3. Clonic Phase – jaws and eyelids close and open violently, foaming of the mouth, face becomes congested and purple, muscles of the body contract and relaxes alternately last for about 1 minute.

4. Postictal State – contractions cease and woman enters  a semicomatose state.

Nursing Responsibilities:

✓ Always monitor patient for impending signs of convulsions

✓ Two main resp: maintenance of patient airway and protection of patient from self injury

✓ Turn patient on her side to allow drainage of secretions

✓ Never leave an eclamptic patient alone

✓ Do not restrict movement during a convulsion as this could result in fractures

After convulsion:

• WOF signs of AP, vaginal bleeding, abdominal pain, FHT

• Take v/s

• Suction nasopharyngeal secretions and administer oxygen

• Sedatives, Diazepam (Valium) if MgSO4 can not control convulsion

• Do not give anything by mouth unless conscious

 

HEMOLYTIC DISEASE

Incidence:

● About 10% of women are risk for Rh isoimmunization

● 1:1000 births incidence of Rh-related neonatal morbidity

ABO Incompatibility:

● Occurs when maternal blood type is O and fetus is:

Type A – most common

Type B – most serious

Type AB – rare

● Maternal antibodies attack the fetal RBC and destroy it

● Happens during placental separation

Rh Incompatibility:

1. Rh Factor

● Rh factor is a distinct protein antigen found in the covering of RBC

● 85% Rh positive and 15% Rh negative

● If person has the genes ++, the Rh factor is positive

● If person has the genes +-, the Rh factor is positive

● If person has the gene - - , the Rh factor is negative

Rh Sensitization/Isoimmunization:

● Exposure of Rh negative blood to an Rh positive blood

● Occurs during placental separation (0.5 ml fetal Rh positive blood can produce massive production of antibodies during the first 72 hours of life)

● Erythroblastosis Fetalis during pregnancy and Hemolytic Disease after delivery.

• Anemia

• Splenomegaly and hepatomegaly

• Hyperbilirubinemia

• Hydrops fetalis

• Stillbirth

Prevention:

1. Prenatal screening

​a. History

​b. Screening test

Antibody Titer Test (Coomb’s Test)

Indirect Coomb’s Test – maternal serum

Direct Coomb’s Test – fetal cord blood

Antibody titer is negative:

• Repeat: 16 – 20 weeks and 26 – 27 weeks of pregnancy

• Anti-Rho(D) Gamma Globulin (RhoGRAM) @ 28 weeks and within 72 hours after delivery

○ Rho(D) Gamma Globulin be given to all Rh(-) women who:

• Delivered Rh positive fetus

• Untypeable pregnancies

• Received ABO compatible Rh positive blood

• Have invasive diagnostic procedure (amniocentesis)

S/Sx:

1. No signs and symptoms unless the baby dies in the utero and is not born right away.

 

Management:

1. Fetal surveillance (mother’s antibody titer test (+)  >1:16 )

2. Intrauterine Blood Fetal Transfusion (IUFT)

Blood transfusion to the fetus either intraperitoneal or intravascular

3. Labor and delivery

● Do not remove placenta manually to avoid squeezing fetal cells

● Clamp cord immediately after birth

● Kleihauer – Betke Blood Test

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