Alcohol Abuse and Pregnancy

Alcohol Abuse in Pregnancy

• CNS depressant and a potent teratogen
• Higher incidence of alcohol abuse among women ages 20-40 years and in teenagers
• Causes include folic acid and thiamine deficiencies, bone marrow suppression, and liver disease

Assessment Findings

• H - Hallucination (auditory, tactile, and visual)
• I - Illusions
• N - Nervousness
• D - Disorientation
• I - Insomnia
• Hy - Hyperactivity
• BP - Blood pressure increases
• C - Confusion
• T - Tremors
• T - Tachycardia
• L - Loss of appetite

Alcohol Abuse

• Delirium Tremens (Alcohol Withdrawal Syndrome) is an acute disorder occurring as a symptom following withdrawal from alcoholic intoxication
• Seizures may last from 3-6 days with hallucination

Korsakoff's Psychosis (Korsakoff Syndrome)

• Disorder that produces a symptom of permanent amnesia resulting from alcoholism and thiamine deficiency (Vit. B1) which causes brain damage
• Particularly affects the thalamus which helps in processing sensory information

Wernicke's Encephalopathy

• Brain disease caused by thiamine deficiency

Maternal and Fetal Effects of Alcohol Abuse

• Fetal Alcohol Syndrome (FAS) or growth retardation, failure to thrive, facial anomalies, CNS dysfunction, increased placidity (quietness)
• Low birth weight
• Infant may be alcohol dependent
• Perinatal mortality
• Newborn may suffer withdrawal

Nursing Management for Alcohol Abuse

• Assess intoxication: Normal alcohol level in the blood: 0.08 to 0.10
• Stay with the client and prevent injury
• Monitor both maternal and fetal vital signs
• Encourage pregnant women to keep coming for her prenatal check-up
• Properly observe the medications that will be given which could affect the fetus inside the mother's womb, such as ANTI-ANXIETY: Librium, valium (may cause cleft - lip/palate, and cardiac defects)

Complications of Labor and Delivery

• Premature Rupture of Membrane
• Preterm Labor
• Dystocia
• Prolapsed Umbilical Cord
• Prolonged Labor
• Uterine Inversion
• Uterine Rupture
• Precipitous Labor and Delivery

Premature Rupture of Membranes

• Rupture of the amniotic sac before the onset of labor causes loss of amniotic fluid
• May cause umbilical cord prolapse

Possible Causes of Premature Rupture of Membranes

• Recent sexual intercourse
• Incompetent cervix and Infections like gonorrhea, Chlamydia
• Maternal hormonal changes

PROM Assessment

• (+) presence of vaginal fluid leaking in the mother's vagina
• Sudden drop in intensity frequency of contractions, but still painful

Diagnostic Procedure for PROM

• Nitrazine Paper Test

Nursing Management of PROM

• Take FHT immediately (to monitor for the occurrence of hypoxia)
• Monitor maternal vital signs especially temperature
• Never perform any internal examination once proven that the leakage is the amniotic fluid because it promotes ascending infection
• If (+) fetal distress, mother is subjected for Cesarean Delivery

Preterm Labor

• Labor that usually happens after 20 weeks of gestation, but before 36-37 weeks of gestation

Triad Sign of Preterm Labor

• Premature contraction
• Effacement (60-80%)
• Dilation

Signs and Symptoms of Preterm Labor

• Regular or frequent contractions, may or may not be painful
• Constant low, dull backache
• Belly cramps with or without diarrhea
• Feeling that your baby is pushing down
• Increase in vaginal discharge or more vaginal discharge than usual
• Water breaking

Preterm Labor Management

• Tocolysis Administration offers short term benefit for premature labor.
• Criteria For Administration: (+) for bleeding and cervical dilation of 2-3 cm, FHT is good, this medication may stop the premature contraction
• 15 weeks is the lowest gestational age for tocolysis administration

Contraindications to Tocolysis Administration

• Intrauterine fetal demise
• Fetal anomaly
• Maternal hemorrhage
• Severe preeclampsia or eclampsia

Ritodrine HCL (Yutopar)

• Beta sympathomimetic drug that stimulates the beta 2 receptors in the smooth muscles
• The frequency and intensity decreases as the muscles relax
• Dosing: D5W 500cc + 150 mg to be infused at 10-20 ml/hour

Maternal Side Effects of Ritodrine HCL

• Tachycardia, systolic rise and diastolic decrease, chest pain

Fetal Side Effects of Ritodrine HCL

• Fetal tachycardia
• Hyperglycemia

Contraindications for Ritodrine HCL

• Antepartal hemorrhage
• Intrauterine fetal death

Prolonged Labor

• A condition where labor occurs for more than 20 hours for primigravida and more than 14 hours for multigravida
• Not a medical problem for as long as there are no signs of distress to the baby and mother's vital signs are stable

Prolonged Labor; Associated Factor

• Primigravidas ( causes ineffective uterine contraction )
• Malpresentation (face and brow presentation)
• CPD
• Uterine atony
• Maternal exhaustion
• Tight Nuchal or short cord

Nursing Management for Prolonged Labor

• Monitor for both maternal and fetal vital signs and watch out for signs of fetal distress
• Monitor for maternal exhaustion
• Provide chances for maternal rest and relaxation

Dystocia

• Abnormal or difficult labor
• Often an indication of operative delivery with its associated complications
• Shoulder dystocia
• Problem with the presentation, position, or development of the fetus

Mechanical Factors Associated with Dystocia

• Problem with the expulsive forces (power)
• Problem with the presentation, position, or development of the fetus (passenger)
• Problem with the maternal bony pelvis (passageway)
• Problem with the dilatation of the cervix

Dystocia

• Problem with the expulsive forces (power)

Hypertonic Uterine Contraction

• Intensity of the contractions may not be stronger or very active, frequent contractions but ineffective
• Occurs more frequently and commonly seen in latent phase of labor
• The muscle fibers of the uterus (myometrium) do not repolarize

Risk Factors for Hypertonic Uterine Contraction

• Bowel/bladder distention prevents descent/engagement
• Multiple gestation
• Large fetus
• Hydramnios
• Multiparity

Signs and Symptoms of Hypertonic Uterine Contraction

• Painless less frequent contraction

Nursing Management for Hypertonic Uterine Contraction

• Oxytocin administration - to strengthen contractions and increase effectiveness
• Amniotomy (artificial rupture of membranes - to further speed labor
• Palpate the uterus and assess lochia every 15 minutes to prevent postpartum bleeding
• Monitor maternal VS and FHR
• Position changes to relieve discomfort and enhance discomfort

Prolapse of Umbilical Cord

• Descent of the umbilical cord into the vagina ahead of the fetal presenting part with resulting compression of the cord (cord compression)
• "Emergency situation", immediate delivery is attempted to save the baby
• Incidence rate is 0.2-0.6% of births or 1 of 200 pregnancies

Associative Factors with Prolapse of Umbilical Cord

• Premature rupture of membranes (the fetal fluid may rush and carry the cord along toward the birth canal)
• Breech presentation
• Placenta previa
• Intrauterine tumors preventing the presenting part from engagement
• Small fetus
• CPD preventing engagement
• Hydramnios
• Multiple gestation

Signs and Symptoms of Prolapse of Umbilical Cord

• The umbilical cord seen or felt during vaginal exam
• Reports feeling of cord into the vagina

Prolapse of Umbilical Cord Management

• Do not attempt to push any exposed cord back into the vagina (adds to compression and cord kinking)
• Cover any exposed portion of the cord with sterile gauze soaked in NSS around the prolapsed cord
• If the cervix is fully dilated at the time of prolapse (the most emergent delivery route is NSD and encourage mother to push)
• If not fully dilated, mother is delivered via CS (upward pressure on the presenting part to keep pressure off the cord)

Occipito-Posterior Position

• LOA (LEFT OCCIPITO-ANTERIOR) IS THE MOST IDEAL AND COMMON FETAL POSITION
• LOP (left occipito-posterior) is located on left and posterior quadrant pelvis
• ROP (right occipito-posterior-s located at the right and posterior quadrant pelvis
• ROP - in this position, during internal rotation, the fetal head must rotate not through a 90-degree arc but through an arc of approximately 135 degrees

Indicators of a Posterior Position

• A dysfunctional labor pattern, like a prolonged active phase
• Arrested descent
• Fetal heart sounds heard best at the lateral sides of the abdomen

Signs and Symptoms of Posterior Position

• Intense lower back pain (lumbosacral pain) - due to compression of sacral nerves during rotation
• Shooting leg pains

Nursing Management for Posterior Position

• Provide back rub
• Change of position (squatting position) may help fetus to rotate
• Encourage voiding every 2 hours to keep bladder empty (because full bladder impedes descent of the fetus)
• Apply hot/cold compress
• Delivered via CS

Face Presentation

• Face (chin, or mentum) presentation is rare
• The head diameter the fetus presents to the pelvis is often too large for birth to proceed

Signs of Face Presentation

• Head that feels more prominent than normal
• Head and back are both felt on the same side of the uterus with Leopold's maneuvers
• FHT heard on the side of the fetus where feet and armis can be palpated
• Confirmed by vaginal examination when the nose, mouth, or chin can be felt as the presenting part

Management of Face Presentation

• An ultrasound is done to confirm it; if indicated, the pelvic diameters are measured.
• If the chin is anterior and the pelvic diameters are within normal limits, it may be possible for the infant to be born without difficulty (perhaps after a long first stage of labor, because the face does not mold well to make a snugly engaging part)
• If the chin is posterior, cesarean birth is usually the method of choice; otherwise, it would be necessary to wait for a long posterior-to- anterior rotation to occur. Such rotation could result in uterine dysfunction or a transverse arrest.
• Babies born after a face presentation have a great deal of facial edema and may be purple from ecchymotic bruising. Observe the infant closely for a patent airway.
• In some infants, lip edema is so severe that they are unable to suck for a day or two.
• Gavage feedings may be necessary to allow them to obtain enough fluid until they can suck effectively.
• They may be transferred to a NICU for 24 hours. Reassure the parents that the edema is transient and will disappear in a few days, with no aftermath.

Brow Presentation

• Rarest of the presentations
• It occurs in a multipara or a woman with relaxed abdominal muscles
• Unless the presentation spontaneously corrects, cesarean birth will be necessary to birth the infant safely
• Brow presentations also leave an infant with extreme ecchymotic bruising on the face
• On seeing this bruising over the same area as the anterior fontanelle, or "soft spot," assure the parents that the child is well after birth.

Transverse Lie

• Occurs in women with pendulous abdomens
• With uterine fibroid tumors that obstruct the lower uterine segment
• With contraction of the pelvic brim
• With congenital abnormalities of the uterus, or with hydramnios
• Occur in infants with hydrocephalus or another abnormality that prevents the head from engaging
• May also occur in prematurity, with room for free movement
• In multiple gestation (particularly in a second twin), or if there is a short umbilical cord
• Mature fetus cannot be delivered vaginally from this presentation; Cesarean birth is necessary
• Membranes rupture at the beginning of labor can cause cord or arm prolapse/shoulder obstruction

Oversized Fetus (Macrosomia)

• 4000 to 4500 g (approximately 9 to 10 lbs); can occur if mother develops gestational DM or in multiparity pregnancies
• Vaginal birth may be impossible and Cesarean birth becomes necessary

Shoulder Dystocia

• Occurs in second stage when fetal head has been delivered but shoulders that are too broad to move through pelvic outlet are stuck
• More common in mother with diabetes, in multiparas, and in post-date pregnancies

Management of Shoulder Dystocia

• McRobert's maneuver, flexing woman's thighs sharply on her abdomen may widen outlet
• Suprapubic pressure applied to help shoulder escape from beneath symphysis pubis

Bandl's Ring

• During labor uterus differentiates into 2 types; the upper contractions portion becomes thicker/shorter as labor progresses while the lower passive portion gradually distends
• This division is called physiologic retraction ring

Management of Bandl's Ring

• Morphine sulfate- relax suterus
• CS (cesarean section)is performed for immediate delivery to prevent mortality

Uterine Rupture

• If developed during the placental stage, a woman is placed on anesthesia and placenta is removed manually

Uterine Rupture Sign and Symptoms

• Sudden severe pain during strong contraction
• Reports "tearing sensation"
• Hemorrhage from a torn uterus into abdomen or vagina
• Signs of shock (rapid weak pulse, low blood pressure, cold clammy skin)
• Localized tenderness and aching pain from lower segment
• Fetal distress

Uterine Rapture Causes

• Rupture of scar from previous CS
• Prolonged labor obstructed labor
• Precipitate labor and delivery
• Malpresentation and malposition
• Multiple gestation
• Injudicious use of oxytocin
• Forcep vacuum extraction
• Internal inversion
• Manual removal of placenta
• Over- distention of the uterus
• External trauma sharp blunt
• Placenta increta or accreta

Uterine Inversion

• Uterus turns completely or partially inside out- occurs immediately after placenta delivery
• occurs after the birth if traction is applied to umbilical cord or if pressure is applied before uterus is contracted/placenta attached

Sign and Symptoms of Uterine Inversion

• Sudden gushes of blood from vagina but the fundus is not palpable
• Shows signs of blood loss ( hypotension, dizziness and paleness )
• Bleeding

Management of Uterine Inversion

• Impending inversion and immediately schedule replacement
• Never attempt to replace it because handling may increase bleeding or to remove placenta if still attached
• Steps to limit/prevent hypovolemic shock; use large gauge IV for fluid replacement
• Measure and record VS every 5-15 min
• Administer oxygen by mask
• Prepared for CPR
• Give anesthesia or nitroglycerin or a tocolytic drug IV to immediately relax the uterus Physician/nurse-midwife replaces uterusmanually (push the uterus back inside)

Therapeutic Management of Problems or Potential Problems in Labor and Birth- Induction of Labor

• Performed when contractions are ineffective
• Meant to start labor artificially

Indications of Therapeutic Management of Problems or Potential Problems in Labor and Birth- Induction of Labor

• Pre-eclampsia
• Eclampsia
• Severe hypertension/DM
• Rh sensitization
• Prolonged premature rupture of membranes
• Post-maturity

Requirements for labor induction

• Fetus in longitudinal, cervix must be ripe, presenting part must be engaged
• No CPD
• Fetus matured by date, LS ratio or sonogram (bi-parietal diameter)

Methods of induction labor

Cervical Ripening by Prostaglandin Gel

• Used to speed ripening of the cervix, applied to interior surface
• Applied before labor is induced, may be applied externally
• Every 6 hours, use two to three dosages

Cervical Ripening by Prostaglandin Gel-(Management)

• Place women in a lying down to prevent medication leakage
• Keep the woman on bed rest 1-2 hours and monitor uterine movements
• Check FHT at least 30 minutes during that time
• Have an alternate saline solution if uterine stimulation occurs for over 90 min or over 5 contractions during 10 minutes
• Side affects- vomiting, diarrhea, fever and high blood pressure
• If the previous medication occurred within 6-12 hours, you may begin the labor, but it is all relative
• It's a synthetic form used due to its initiation effects of uterus

Nursing Considerations Related to Induction Labor Oxytocin

• Oxytocin is administered intravenously
• The proportions are 10 IU in 1000 ringers lactic acid
• If discontinuing, keep the main line in, which should also be DSW line
• Check dilatations and keep track of how many centimeters it occurred
• Watch out side effects, you can become nauseous, in peripheral. You may also see a raise in blood pressure
• Keep track of the vaginal signs every fifteen minutes

Anamolies of the Pacenta cord

Place nta Circumatvallata

• Fetal Chorion is covered with chorion
• No abnormalities relate to this

Battledore Placenta

• The cord is inserted, rather than a central
• This is are rare and are insignificant

Velamentous Insertions of the Cord

• The cord does not go into the placenta directly. Instead of separation there small vessels
• This causes folds

Vasa Previa

• Umbilical Vessels are crossed, delivery is needed as fast as possible
• Must identify correct structures during the examination for fetal monitoring, prevents tearing

Paccenta Acereta

• Unusual amount when the pace ta is moved
• Unable to loosen pace ta and must be delivered

Types of placent types of Pacenta

Invasion of the myomentrium

• does not penatrate all membranes. This is the more types
• Placenta extents in the muscle
• Placents Penetraded all membranes. Must touch all external
• Can touch all membranes, touching organs like the bladder