Gestational Diabetes and Disseminated Intravascular

Gestational Diabetes (GDM)

• GDM screening is done at 24-28 weeks of gestation
• Screening includes a 50g, 1-hour Oral Glucose Tolerance Test (OGTT)
• Ideal glucose levels in pregnancy are 60-105 mg/dL fasting
• Ideal glucose levels in pregnancy are less than 120 mg/dL 2 hours after meals
• Diet and insulin dose require alteration if a woman has pre-gestational diabetes
• Maternal risks and complications of GDM include: macrosomia, hydramnios, ketoacidosis, hyperglycemia, and hypoglycemia
• Fetal risks and complications of GDM include: macrosomia (greatest risk), hypoglycemia (carefully monitored after birth), RDS, congenital malformations, and preterm birth
• Maternal hypoglycemia is more common than hyperglycemia
• The degree of glycemic control is the most important factor affecting pregnancy outcome

Disseminated Intravascular Coagulation (DIC)

• DIC is an acquired syndrome characterized by widespread intravascular activation of coagulation
• DIC results in excessive clot formation and hemorrhage
• DIC is never a primary diagnosis; it results from an event that triggered coagulation
• Addressing the underlying cause is essential in the management of DIC
• Prepare for a blood administration order when caring for a patient with DIC

Iron Deficiency Anemia

• The most common medical complication of pregnancy
• Hemoglobin (Hb) levels below 11 g/dL indicates iron deficiency anemia
• Recommended iron intake during pregnancy is 27 mg/day
• Supplement iron during pregnancy with vitamin C source (OJ), not with a calcium source (milk)

Gestational Hypertension

• The onset of hypertension without proteinuria after the 20th week of pregnancy
• Elevated blood pressure equal to or greater than 140/90, recorded 4 hours apart
• Absence of proteinuria
• Blood pressure returns to baseline by 6 weeks postpartum
• Administer Magnesium Sulfate IV for severe gestational HTN
• Provide dark, quiet environment for severe gestational HTN
• Ensure calcium gluconate is available for severe gestational HTN

Preeclampsia

• A pregnancy-specific syndrome
• Hypertension develops after 20 weeks of gestation in previously normotensive women
• A vasospastic systemic disorder categorized as mild or severe
• Disruptions in placental perfusion and endothelial cell dysfunction cause preeclampsia
• Proteinuria greater than or equal to 1+

Mild Preeclampsia

• Few if any symptoms
• Diagnostic criteria include blood pressure elevated to greater than or equal to 140/90 mmHg or higher
• Proteinuria is 1+ to 2+ on dipstick, or 300 mg in a 24-hour specimen
• Generalized edema may be present

Severe Preeclampsia

• These findings are concerning
• May develop suddenly
• Diagnostic criteria include blood pressure greater than or equal to 160/110 mmHg on two occasions at least 6 hours apart during bed rest
• Dipstick urine protein measurement 3+ or greater on two random samples at least 4 hours apart
• Oliguria with urine output less than or equal to 500 mL in 24 hours
• Signs/symptoms of severe features include headache, visual disturbances, epigastric or RUQ abdominal pain, altered mental status, and shortness of breath

Eclampsia

• Severe preeclampsia plus seizure activity
• Characterized by grand mal convulsion or coma
• May occur before onset of labor, during labor, or early in postpartum period
• Women may have one or more seizures
• Maternal safety and patent airway is a priority intervention

HELLP Syndrome

• Usually associated with preeclampsia
• Platelet count of 90,000, an elevated aspartate transaminase (AST) level, and a falling hematocrit indicate HELLP Syndrome
• Associated with risks for: pulmonary edema, acute renal failure, liver hemorrhage or failure, DIC, placental abruption, acute respiratory distress syndrome, sepsis, stroke, fetal and maternal death

Placenta Previa

• Defined as an abnormal placental attachment (ex: placenta covering vaginal opening)
• Causes excessive bleeding, usually begins as scant and becomes more profuse
• The most accurate diagnostic sign is painless, bright-red vaginal bleeding
• Nursing care and assessment: consider unengaged fetal presenting part, transverse lie is common
• Assess fetal status with continuous external fetal monitoring
• Anticipate need for blood transfusion
• Assess maternal vital signs every 15 minutes if no hemorrhage, every 5 minutes during active hemorrhage
• NO vaginal exams
• ALWAYS necessitates a C-Section

Hyperemesis Gravidarum

• Signs and symptoms include vomiting, dehydration, weight loss greater than 5%, increased HR and decreased BP, poor skin turgor, decreased urine output, and increased ketones in urine
• Patient education: Eat small, frequent meals, take recommended OTC and prescription antiemetics, report decreased urine output or no voiding in 4 to 6 hours
• Assessments include intake/output, weight, vital signs, FHR, jaundice/bleeding assessment, and emotional state assessment

Hydatidiform Mole (Molar pregnancy)

• Results from chromosomally abnormal fertilization
• Categorized as complete or partial mole
• Complete mole contains no fetus, placenta, amniotic membranes, or fluid
• Partial mole often has embryonic or fetal parts and an amniotic sac
• Clinical manifestations include vaginal bleeding (dark brown or bright red), anemia, excessive uterine enlargement, and preeclampsia
• Diagnosis is via transvaginal ultrasound and serum HCG levels
• Suction curettage is a safe, rapid, and effective method of evacuation
• Contraceptives should be used for 12 months following a molar pregnancy
• HCG levels need to be tested for 12 months to check for choriocarcinoma
• Pregnancy will raise HCG, making cancer diagnosis harder

Labor and Birth

• Four main components of the birth process include power, passage (birth canal), passenger (fetus), psyche
• Four fetal factors affecting labor include presentation, fetal attitude, fetal lie, and fetal position
• Vertex is the ideal way for the baby to be presenting

Fetal Position

• Fetal position is the direction in the pelvis
• To identify: find posterior fontanelle (triangle), on the mom's right or left, determine whether it’s anterior, posterior, or transverse

Fetal Attitude

• Relation of fetal body parts to one another
• Normal attitude is general flexion
• Head flexed, chin on chest
• Arms crossed over chest
• Legs flexed at knee, thighs on abdomen

Fetal Lie

• Relationship of the long axis (spinal column) of the fetus to the long axis of the mother
• Longitudinal (vertical) cephalocaudal axis of the fetus is parallel to the woman's spine
• Transverse lie is associated with shoulder presentation and can lead to complications

Fetal Station

• Ischial spines are zero station
• Presenting part moves from negative to positive (-5 to +3)
• If a baby is at -1 station, they are 1 cm above the ischial spine
• Baby is ready to be delivered when at +3 station

Meds given during labor

• Magnesium sulfate treats preterm labor and prevent eclamptic seizures
• Betamethasone promotes fetal lung maturity

Contractions

• Contractions have phases: increment, acme, and decrement
• Determined with frequency, duration, and intensity

Signs that precede labor

• Lightening
• Braxton Hicks contractions
• Burst of energy
• Bloody show
• Rupture of membranes (ROM)

Stages of Labor

• First stage: Onset of contractions to full dilation of the cervix- 10cm
• Second stage: Full dilation to birth (Focus on pushing when mom feels the urge)
• Third stage: Birth of the fetus until delivery of the placenta
• Fourth stage: 2 hours postdelivery of the placenta, until vital signs return to baseline

True Labor vs False Labor

• True Labor: Contractions occur at regular intervals and intensity, the interval between contractions gradually shortens, pain begins in the back and radiates around to the abdomen, and pain is not relieved by ambulation/resting
• True labor shows progressive dilatation and effacement
• False labor: Contractions are irregular, usually, no change, discomfort is localized to the abdomen, and pain may be relieved by ambulation/resting
• False labor shows lack of change in cervical effacement and dilatation

D/E/S = dilatation/effacement/station

• Example: 50%/6cm/+1 means patient is 50% effaced, 6cm dilated, and +1 station (1cm below ischial spine)

Pain management

• Nursing Role: support decisions, offer nonpharmacological, educate about options, reassure acceptance isn't failure
• If the patient wants a medication free birth, make sure the client understands maternal pain and stress can have a more adverse effect on the fetus then a small amount of analgesia

Natural "no pain meds” fx

• Increased respiratory rate and oxygen consumption
• Metabolic acidosis (bc hyperventilation)
• Blood vessel constriction r/t catecholamines
• Fear and anxiety
• Feelings of being out of control
• Stalled labor progression

Epidural Analgesia

• Nursing care includes vitals, pulse ox, LOC, and FHR monitoring
• Fentanyl is most commonly prescribed narcotic during labor
• Major complication of epidural anesthesia is hypotension
• Maternal hypotension can cause decreased placental perfusion which will lead to decels
• Give bolus of LR or NS prior to epidural placement
• If patient complains of itching on face or neck after epidural infusion, stop the infusion immediately
• Spinal headache is treated with a blood patch, injecting patient's blood into the epidural space

Fetal Assessment

• FHR normal range is 110-160 bpm
• Bradycardia- FHR less than 110 bpm
• Tachycardia- FHR greater tham 160 bpm
• The goal of intrapartum FHR monitoring is to identify nonreassuring patterns indicative of fetal compromise

VEAL CHOP

• Variable decelerations: Cord compression
• Early decelerations: Head compression
• Accelerations: Oxygen good
• Late decelerations: Placental insufficiency

Fetal Heart Rate

• Baseline variability: Measures the interplay between the sympathetic and parasympathetic nervous systems over a ten-minute period (the amplitude)
• Absent: Amplitude is undetectable
• Minimal: Amplitude less than5 bpm
• Moderate: Amplitude 6-25 bpm (NORMAL)
• Marked: Amplitude greater than 25 bpm

Accelerations

• Abrupt increase in HR at least 15 BPM over baseline and lasts 15 sec-2 min
• Always reassuring
• Normally caused by movement
• Sign of fetal well-being and good oxygen reserve

Early Decels

• Result from head compression
• Inversely mirrors contraction
• Considered benign
• No nursing interventions required

Late Decels

• Results from uteroplacental insufficiency and considered nonreassuring
• Doesn't always require immediate delivery
• Intervention: notify provider/midwife immediately

Preterm Labor

• Biggest risk factor is cigarette smoking and African American race
• Signs/symptoms: Uterine contractions that occur at least every 10 min, constant or intermittent pelvic pressure, and abd cramping

PROM

• Premature rupture of membranes where infection is the greatest risk
• Nursing care: Monitor for infection, administer antibiotics, assess FHR, and assess the odor of the amniotic fluid

Leopold's maneuver

• Indication: Determines fetal position, presentation, and fundal height
• Is external and noninvasive

VBAC (Vaginal birth after C-Section)

• Indicated when primary cesarean birth indications are nonrecurring
• If mom has a C-section, delivering her next baby vaginally is dependent on what type of incision; vertical incisions cannot ever vaginally deliver
• Uterine rupture is a major complication in moms having a VBAC

Meconium-stained amniotic fluid

• Indicates that the fetus has passed the first stool before birth
• May be a physiologic maturation or related to stress
• Puts the infant at risk for meconium aspiration syndrome (severe form of aspiration pneumonia)
• Requires the team skilled in neonatal resuscitation

Prolapsed Umbilical Cord

• Cord lies below presenting part of fetus
• Contributing factors include long cord, malpresentation, and transverse lie
• Immediate action: Relieve pressure on the cord by placing hand in the vagina and holding baby's head off the cord
• Immediately call for help and prepare for immediate birth

Amniotomy (AROM)

• Can induce labor or augment labor
• Nursing Interventions: Assess FHR prior to AROM, reassure FHR action, assess the color, consistency, and odor of the fluid, and assess temperature q2h

Forcep assisted birth

• Watch for cord compression
• Maternal assessment- vaginal or cervical lacerations, urinary retention, hematoma formation
• Infant assessment- assess for trauma: bruising or abrasions at the sire of blade placement, facial palsy, and subdural hematoma

Tocolytic therapy

• The use of medications in attempt to stop labor
• May delay labor 24-48 hours
• Allows time for betamethasone administration and/or transport to a higher acuity facility
• Most common: Mag. sulfate, indomethacin, nifedipine, terbutaline
• Cannot take mag with nifedipine because both cause hypotension

Magnesium sulfate

• Most effective with fewer side effects
• Loading dose (1-4 g/h titrated to deep tendon reflexes)
• Maternal serum level 5.5–7.5 m g/d L
• Used for 12 hours at the lowest rate to diminish contractions
• Side effects include flushing, feeling of warmth, headache, nystagmus, nausea, dry mouth and dizziness, lethargy, sluggishness, and pulmonary edema
• Nursing interventions: Monitor for mag toxicity and Keep Calcium gluconate at the bedside for toxicity

External Cephalic Version

• Attempt to turn from a breech or shoulder presentation to vertex presentation
• NST, informed consent and tocolytic before procedure
• Main purpose is to change baby's position

Induction of Labor

• Chemical methods: Pitocin and Prostaglandins
• Mechanical methods: Cooks catheter, amniotomy, and stripping amniotic membranes
• Care during IOL: Monitor for uterine tachysystole, watch FHR and patterns, and administer terbutaline for adverse fx
• Bishop Score: Determines readiness for labor