Gravido Cardia Classification

• Gravido Cardia is a review for the midterm.

Gravido Cardia Classes

• Class I gravido cardia is asymptomatic with very minimal damage and no limitations, managed with normal spontaneous vaginal delivery (NSVD).
• Class II gravido cardia is symptomatic with mild damage and slight limitations (heavy work), managed with normal spontaneous delivery (NSD) or forceps.
• Class III gravido cardia is symptomatic with moderate damage and markedly limited activity, managed with forceps or therapeutic abortion.
• Class IV gravido cardia is symptomatic with severe damage, total/complete limitations and managed with forceps or therapeutic abortion.

Indications for Admission

• Elective admission for cardiovascular issues includes NYHA Class I patients 1-2 weeks before the expected date of delivery (EDD).
• Elective admission includes NYHA Class II patients at 28-30 weeks.
• Elective admission includes NYHA Class III/IV patients irrespective of AOG as soon as they present.
• Elective admission includes changing from oral anticoagulants to heparin early in pregnancy or at 36 weeks in patients on anticoagulants.
• Emergency admission is needed for;
  • Deterioration of functional grade
  • Symptoms and signs of complications like fever, persistent cough, basal crepitations, tachyarrhythmias (P/R >100 min), JVP>2cm, anemia, infections, pre-eclampsia toxemia (PET), abnormal weight gain, or other medical disorders.

Management

• Preconceptional counseling is vital, especially for high-risk cases as maternal mortality correlates with the functional classification at pregnancy onset.
• Pre-pregnancy optimal medical or surgical treatment is essential.
• Counseling should cover maternal and fetal risks, prognosis, and social with cost considerations.
• Hospital delivery is preferable at a tertiary care center.

Health Teachings

• Rest and avoid undue excitement or strain.
• Maintain a balanced diet with iron and vitamins.
• Practice good hygiene and dental care to prevent infections.
• Restrict dietary salt intake to 4-6g/day.
• Avoid smoking and drugs, especially betamimetics.
• Early diagnosis and treatment of PIH (pregnancy-induced hypertension) and infections are crucial.
• Apply therapeutic or prophylactic cardiac interventions.
  • Benzathine Penicillin prevents recurrence of rheumatic fever.
  • Diuretics, Beta Blockers, Digitalis, and Anticoagulants are used as needed.
  • Surgical treatments, such as balloon mitral valvotomy, may be applicable.

Antenatal Care

• Clear counseling of risks and prognosis is important.
• Schedule antenatal care (ANC) every 2 weeks up to 30 weeks, then weekly.
• At each visit, assess pulse rate, BP, cough, dyspnea, weight, anemia, lung bases, and functional grade.
• Ensure treatment compliance.
• Exclude fetal congenital anomalies via level-III ultrasound and fetal ECHO at 20 weeks in maternal congenital heart disease.
• Use fetal monitoring.

Digoxin Administration

• Do not administer Digoxin if the maternal heart rate is below 60 beats per minute.
• Digoxin increases the force of heart contraction, increasing cardiac output.
• Increased urine output of at least 30 ml/hour indicates successful digitalis therapy.

Management During the First Stage of Labor

• Confine to bed in an upright or semi-recumbent position.
• Administer intermittent oxygen inhalation at 5-6 liters per minute.
• Use sedation and analgesia, such as epidural, pethidine, or tramadol.
• Use IV fluids cautiously, not exceeding 75ml/hr except in aortic stenosis and VSD.
• Stop anticoagulants.
• Digitalize if the patient is in CHF, with a pulse rate >110/min and respiration rate >24/min.
• Use diuretics in pulmonary congestion and bronchodilators as needed.
• Prevent infective endocarditis.
• Cardiac monitoring, pulse oximetry, and pulmonary artery catheterization enable continuous hemodynamic monitoring.
• A team of anesthesiologists and cardiologists should evaluate the patient.

Management During the Second Stage of Labor

• Position the patient upright or in a semi-Fowler's position for delivery.
• Avoid forceful bearing down.
• Provide adequate pain relief with epidural or pudendal block, avoiding spinal or saddle block.
• Cut short the second stage of labor with episiotomy, vacuum, or forceps, but not always.
• Strict Cardiovascular monitoring

Management During the Third Stage of Labor

• Administer 10 U of oxytocin IM.
• Avoid bolus syntocinon/ergometrine.
• Use upright/semi-Fowler's position, oxygen inhalation.
• Administer Furosemide IV 40 mg and Morphine (15mg).
• Watch for signs of CHF & Pulmonary Edema.
• Treat postpartum hemorrhage (PPH).
• In the first hour after delivery:
  • Keep the patient propped up/sitting with oxygen.
  • Watch for signs of pulmonary edema.
  • Sedation may be needed.
  • Administer antibiotics.

Discharge Planning

• Continue medical treatment.
• Avoid infection.
• Schedule reassessment after 6 weeks or earlier if complications arise.
• Provide iron supplementation.
• Refer for cardiological consultation for definitive management of heart disease.
• Contraception options include barrier methods, progesterone-only methods (DMPA, Norplant), IUCD (less preferred), and sterilization (vasectomy-best, tubal ligation). COC is contraindicated.

Gestational Diabetes

• Gestational diabetes is caused by the diabetogenic effect of HPL, which reduces insulin effectiveness.
• Measure serum glucose levels via finger prick.
• Manage gestational diabetes with diet and exercise.
• Risk factors include maternal obesity (BMI > 35) and previous birth of a macrosomic baby.
• Complications of gestational diabetes include the potential to develop type II diabetes after pregnancy.
• Monitor for signs/symptoms of hypo- and hyperglycemia.
• Admit GDM patients if not controlled
• Diagnosis involves OGTT (oral glucose tolerance test)

Insulin

• Insulin types vary in onset, peak, and duration of action.
  • Regular or short-acting insulin has an effect after 30 minutes, peaks in 2-4 hours, and lasts 5-8 hours.
  • Rapid-acting insulin begins working within 5-15 minutes, peaks in 1-3 hours, and lasts 2-5 hours.
  • Intermediate-acting insulin starts in 1-2 hours, peaks in 4-12 hours, and lasts 12-18 hours.
  • Long-acting insulin has an onset of 2-4 hours and lasts 18-24 hours with no peak.
  • Ultra-long-acting insulin takes 6 hrs to have effect and lasts 36-42 hours with no peak.
  • Biphasic/pre-mixed insulins combine rapid and intermediate-acting insulins.
• Insulin is guided by diet.
• A glucose challenge test (GCT) of 50-g is performed if the serum for glucose level is greater than or equal to 140 mg/dL
• OGTT thresholds for diagnosis require increasing CHO intake 2-3 days prior to test.
• Fasting blood sugar in the 100-g test is 95 mg/dL.
• 1 h is 180 mg/dL
• 2 h is 155 mg/dL
• 3 h is 140 mg/dL
• Fasting blood sugar in the 75-g test is 95 mg/dL.
• 1 h is 180 mg/dL
• 2 h is 155 mg/dL

RH Incompatibility

• RH incompatibility is when a mother is Rh (-) and the baby is Rh (+).
• Hyperbilirubinemia is N- 0.1-1mg/dl 1st 24 hours of life after 1-5mg/dl.
• Hyper is 12mg/dl up.
• Direct Coombs test (Fetal) and indirect Coombs test (M) can test for RH SEN.
• The incidence of Rh incompatibility has been greatly reduced by the administration of RhoGAM to all Rh(-) mothers within 72 hours after delivery.

Intrapartal Complications

• Labor complications can arise from issues with:
  • The power (uterine contractions).
  • The passenger (the fetus).
  • The passageway (the birth canal).
  • The psyche (the woman’s and family’s perception of the event).

Labor Induction and Augmentation

• Induction of labor is artificially starting labor
  • Indications include preeclampsia, eclampsia, severe hypertension, diabetes, Rh sensitization, prolonged rupture of membranes, intrauterine growth restriction, and post-maturity.
• Augmentation of labor assists labor that has started spontaneously but is not effective.
  • Indications:
  • Hypotonic contractions
  • Infrequent contractions
• Drugs for cervical ripening:
  • Cytotec 25mg (100mg)
  • Eveprime rose
  • Protaglandin gel
• Drugs or procedures to dilate (buka):
  • Laminaria tent

Cervical Ripening

• Cervical ripening, influenced by estrogen, involves softening the cervix.
• The Bishop score, established in 1964, provides criteria for scoring the cervix.

Bishop Score

• The findings include cervical dilatation of 3 cms, effacement of 40%, fetal station at -1, firm cervix located at the middle for a 39-week pregnant.
• To perform Bishop scoring, the nurse must be proficient in; Cervical Ripening.

Umbilical Cord Prolapse

• It is when a loop of umbilical cord slips down in front of the presenting fetal part.
• Causes include: PROM, fetal presentation other than cephalic, placenta previa, intrauterine tumors, a small fetus, CPD, hydramnios, and multiple gestation.
• Clinical Types:
  • Occult cord prolapse
  • Funic (cord) presentation
  • Overt cord prolapse
• Assessment findings:
  • Cord felt as presenting part during initial vaginal exam (rare)
  • Visible cord at vulva
  • Variable deceleration FHR pattern
• Diagnostic: Ultrasound
• Therapeutic Management:
  • Manual elevation of fetal head off the cord
  • Knee-chest or Trendelenburg position
  • Oxygen via facemask (10L/min)
  • Tocolytic agent
  • Amnioinfusion
  • Fetal blood sampling
  • Cover exposed cord with sterile saline compress/gauze
  • Forcep delivery (If fully dilated)

Uterine Rupture

• It involves anticipation of an immediate cesarean birth due to:
  • Sudden, severe pain during a strong labor contractions
  • Complete rupture includes:
  • Uterine contractions immediately stop
  • Two distinct swelling visible on the abdomen (retracted uterus and the extrauterine fetus)
  • Hemorrhage
  • Signs of shock begin
  • Absent Fetal heart sounds
• Incomplete rupture:
  • Localized tenderness and persistent aching pain over the lower uterine segment.
• Diagnostic: ultrasound
• Fluid replacement and IV oxytocin.
• Prepare for possible laparotomy with tubal ligation/ CS hysterectomy.
• Secure Consent.
• Psychological and emotional support

Method of Delivery

• C-section (CS)
• Indications

Shoulder Dystocia

• It occurs in the second stage of labor where after the fetal head is born but the shoulders are too broad to enter and be born through the pelvic outlet
• Maternal DM, multiparity, and post-date pregnancies can be causes.
• Assessment findings:
  • Prolonged 2nd stage of labor
  • Arrest of descent
  • Turtle sign
• Management: McRobert’s maneuver and Suprapubic pressure application
• Complications include:
  • Vaginal or cervical tears
  • Cord compression
  • Fractured clavicle or a brachial plexus injury

Early Decelerations in Labor

• Early decelerations are a decrease in fetal heart rate that begins before or at the same time as a uterine contraction and returns to baseline by the end of the contraction.
• Early decelerations occur early in the contraction, usually before the peak.
• The deceleration is typically uniform and mirror-like, reflecting the shape of the contraction.
• The deceleration usually lasts less than 30 seconds.
• Causes:
  • Head compression and Cord compression.
• Significance:
• It is generally considered a reassuring sign, indicating that the fetus is responding normally to contractions.
• In most cases, no action is needed, and labor can continue as usual.

Differentiation from Other Decelerations

• Late decelerations occur after the peak of the contraction and are often associated with uteroplacental insufficiency or fetal hypoxia.
• Variable decelerations are unpredictable and can occur at any time during the contraction, often due to cord compression.

Monitoring and Management

• Continuous fetal heart rate monitoring can help identify early decelerations and differentiate them from other types of decelerations.
• Women in labor can be reassured that early decelerations are a normal response to contractions.

Late Decelerations in Labor

• Late decelerations are are abnormal fetal heart rate patterns that occur during the second stage of labor.
• Definition: fetal heart rate decreases after the peak of a uterine contraction and returns to baseline after the contraction has ended.
• Late decelerations occur during the second stage of labor, usually during the pushing phase.
• Causes:
  • Uteroplacental insufficiency (inadequate blood flow to the placenta)
  • Fetal hypoxia (lack of oxygen to the fetus)
  • Uterine hyperstimulation (overstimulation of the uterus)
  • Placental abruption (separation of the placenta from the uterus)
• Late decelerations can be a sign of fetal distress and that the fetus is not receiving enough oxygen.
• Management:
  • Administering oxygen to the mother
  • Changing the mother's position
  • Stopping any uterine stimulants
  • Preparing for possible operative delivery (cesarean section or instrumental delivery)