MCN 109 Midterms

• Placenta previa is when the placenta implants abnormally in the lower uterus.
• It is the most frequent cause of painless bleeding during the third trimester.

Associated Factors:

• Increased parity is an associated factor.
• Advanced maternal age can contribute.
• Past cesarean births increase the risk.
• A history of uterine curettage is a factor.
• Multiple gestation pregnancies are associated.
• Presence of a male fetus is noted.

Placenta Previa Degrees

• Low-lying placenta involves implantation in the lower part of the uterus.
• Marginal implantation is when the placenta edge approaches the cervical os.
• Partial placenta previa occludes a part of the cervical os.
• Total placenta previa obstructs the cervical os entirely.

Assessment of Placenta Previa

• Bleeding usually starts when the lower uterine segment differentiates and the cervix dilates.
• The placenta loosens as it cannot stretch, causing damaged blood vessels to bleed.
• Bleeding is generally abrupt, painless, bright red, and sudden.
• Bleeding is often detected during routine sonograms.
• Spotting may linger or be continuous after the initial hemorrhage.

Therapeutic Management

• Placenta previa bleeding poses a risk of hemorrhage since the uterine decidua vessels are open.
• Fetal oxygen and nutrient supply is compromised, which affects the fetus.
• Preterm labor prior to week 37 of gestation can result from placental loosening.
• Place the woman on bed rest in a side-lying position for adequate blood supply to both.
• Inspect the perineum and note the blood loss rate.
• Monitor vital signs for hypovolemic shock symptoms.
• Check the blood pressure every 5-15 minutes.
• NO pelvic/rectal examination should be done due to risk of placental tear and hemorrhage.
• External monitoring equipment should be attached to record fetal heart sounds and uterine contractions.
• Have blood available for placement.
• A vaginal birth is safest when the previa is under 30%; otherwise, a cesarean delivery is needed.
• Betamethasone, a steroid, may be given to encourage fetal lung maturity if the fetus is under 34 weeks.

Premature Separation of the Placenta (Abruptio Placentae)

• Differs from placenta previa in that the placenta appears correctly implanted before separation and bleeding.
• Occurs in about 10% of pregnancies and can lead to death of the the baby.
• This is the most frequent cause of perinatal death.

Assessment

• Assess for sharp, stabbing pain high in the uterine fundus from initial separation.
• Tenderness is also assessed on the uterine palpation.
• Heavy bleeding might be evident.
• Uterus becomes tense.

Therapeutic Management

• Externally monitor fetal heart sounds and record maternal vital signs every 5-15 minutes to establish baselines and monitor progress.
• insert a large-gauge large IV catheter for fluid replacement.
• Administer oxygen to limit fetal anoxia.
• Keep the woman in the lateral position to prevent vena cava pressure.
• Abdominal, vaginal, or pelvic exams should NOT be performed on patients with suspected separation.
• Grade 0 is when no symptoms are apparent, only found after birth with recent clot evidence on the placenta.
• Grade 1 presents minimal separation, causing vaginal bleeding and changes in maternal vital signs, but no fetal distress or shock.
• Grade 2 shows moderate separation with fetal distress, a tense/painful uterus.
• Grade 3 indicates extreme separation potentially leading to maternal shock and fetal death without intervention.

Preterm Labor

• Preterm labor happens prior to the end of week 37 of gestation.
• This occurs in approximately 9-11% of all pregnancies.
• It’s always potentially serious because it could result in an immature infant.

Symptoms

• Persistent, dull low backache is a symotom.
• Feeling of pelvic pressure or abdominal tightening
• Menstrual like cramping can occur.
• Increased vaginal discharge is another sign.
• Uterine contractions and intestinal cramping are common symptoms.

Therapeutic Management

• Analyze changes in vaginal mucus, testing for fetal fibronectin, to predict preterm contractions.
• Absence of the protein indicates labor is not likely to occur within 14 days.
• Take an oral tocolytic agent (drug to stop labor) terbutaline.
• Administer an antibiotic for group B streptococcus prophylaxis and a corticosteroid to the fetus to accelerate lung surfactant formation.
• Administer Betamethasone to the mother if she is under 34 weeks gestation to hasten lung maturity.
• Magnesium sulfate is the drug of choice to stop contractions and has a central nervous system depressant action.
• Ritodrine Hydrochloride (Yutopar) and Terbutaline (Brethine) are beta 2 receptors that cause blood vessels, bronchi, and uterine muscles to relax.

Preterm Rupture of Membrane

• Preterm rupture of membrane is when the fetal membranes rupture with loss of amniotic fluid before 37 weeks.
• Occurs in 5-10% of pregnancies.
• Cause is strongly associated with infection of membranes (chorioamnionitis).
• Pressure on the umbilical cord inhibits fetal nutrition supply.
• Cord prolapse is the extension of the cord out of the uterine cavity past the small fetus; which can interfere with blood circulation.
• Another risk is Potter-like syndrome causes facial features and pulmonary hypoplasia from uterine pressure.
• Test fluid with Nitrazine paper (amniotic fluid shows alkaline reaction appearing blue and urine remains yellow acidic reaction.

Gestational Hypertension

• Condition in which vasospasm occurs in both small and large arteries during pregnancy.
• It causes the sign of increased blood pressure, proteinuria, and edema.
• Old term for the condition was toxemia of pregnancy.
• Symptoms are thought to be caused by women producing a toxin in response to the foreign protein of the growing fetus.
• Occurs in 5% to 7% of pregnancies.

Gestational Hypertension Symptoms

Gestational Hypertension

• BP IS 140/90 mmHg or SP elevated 30 mmHg or DP elevated 15 mmHg above pregnancy level

• No proteinuria or edema

• BP returns to normal after birth

Mild Pre-Eclampsia

• BP is 140/90 mmHg or SP elevated 30 mmHg or DP elevated 15 mmHg above pregnancy level

• Proteinuria of 1+ - 2+ on a random sample.

• Weight gain over 2 lb/wk in 2nd Trim and 1 lb/wk in 3rd Trim

• Mild edema in upper extremities or face

Severe Pre-Eclampsia

• BP is 160/110 mmHg

• Proteinuria on a random sample and .5g on a 24-h sample

• Oliguria (500 ml or less in 24hr or altered renal function tests)

• Elevated serum creatinine more than 1.2 mg/dl

• Cerebral or visual disturbances, pulmonary/cardiac involvement.

• Extensive peripheral edema, etc.

Eclampsia

• Either seizure or coma accompanied by signs & symptoms

• Classic signs include vision changes, hypertension, and proteinuria and edema.
• Mild pre-eclampsia is when a seizure from gestational hypertension occurs, and there is elevated blood pressure and some proteinuria/edema.
• Severe pre-eclampsia is an evolution of mild to severe pre-eclampsia, accompanied by elevated blood pressure that rises to 160mmHg.

Management

• Administer magnesium sulfate (pregnancy Risk Cat B)
• Dosage: Loading dose: 4-6 g, Maintenance dose: 1-2g/h IV for muscle relaxant, prevent seizures.
• Administer Hydralazine (Apresoline) pregnancy Risk Cat C)
• Dosage: 5-10 mg IV for antihypertensive (Peripheral vasodilator), used to decrease hypertension
• Administer Diazepam (Valium) (Pregnancy Risk Cat d)
• Dosage: 5-10 mg IV to halt seizures.
• Administer Calcium Gluconate (Pregnancy Risk Cat C)
• Dosage: 1 g IV (10 Ml of 10% Solution)
• Indication: Antidote for magnesium intoxication)

Edema Risk Factors

• women in color
• Primiparas younger than 20 and older than 40 years of age
• Low socioeconomic backgrounds
• Hydramnios (overproduction of amniotic fluid)
• Underlying disease
• Hypertension develops during the last half of pregnancy in a woman who previously had normal blood pressure.
• Renal involvement may cause proteinuria.
• • Nonpitting - swelling cannot be indented with finger pressure
• • 1+ Pitting Edema - tissue can be indented slightly
• • 2+ Pitting Edema - moderate indentation
• • 3+ Pitting Edema - deep indentation
• 0+ No Pitting Edema
• 1+ Mild Pitting Edema (2mm depression)
• 2+ Moderate Pitting Edema (4mm depression)
• 3+ Moderately Severe Pitting Edema (6mm depression)
• 4+ Severe Pitting Edema (8mm depression)
• Accumulating edema will reduce a women's urine output to approx. 400 to 600 ml/24 hours.

HELLP Syndrome includes:

• • H - Hemolysis
• • EL - Elevated Liver Enzymes
• • LP - Low Platelets
• Maternal mortality rate can be as high as 24% with infant mortality around 35%.

Common Symptoms of HELLP

• Pain in right upper quadrant or lower right chest/mid-epigastric area
• Because of liver distention
• Nausea and Vomiting
• Sudden increase in intraabdominal pressure
• Possibility of Hepatic rupture Monitor and administer the following interventions.
• Monitor/administer Antiplatelet Therapy (aspirin)
• Promote Bed Rest (lateral recumbent position)
• Administer Medication to Prevent Eclampsia (hydralazine, labetalol, nifedipine)

Multiple Pregnancy

• Multiple pregnancies are complications because a woman's body must adjust to the effects of more than one fetus.

MONOZIGOTIC

• Begin with a single ovum and spermatozoon.
• In the process of fusion, or in one of the first cell divisions, the zygote divides into two identical individuals.
• SINGLE OVUM TWINS usually have one placenta, one chorion, two amnions, and two umbilical cords.

DIZYGOTIC

• Non Identical Twins
• The result of fertilization of two separate ova by two separate spermatozoa
• DOUBLE-OVA TWINS have two placentas, two chorions, two amnions, and two umbilical cords.
• Twins are always the same sex

HYDRAMNIOS

• Usually the amniotic fluid volume at term is 800-1200 ml
• Occurs when here is excess fluid of more than 2000 ml or an amniotic fluid index above 24 cm.
• Amniotic fluid is a combination of cells of the amniotic membrane and from fetal urine.
• First sign of hydramnios is unusually rapid enlargement of the uterus

Power

• Inertia is a time-honored term to denote sluggishness of contractions or that force of labor, is less than usual, a more current term is dysfunctional labor
• Primary - occurring onset of labor
• Secondary - occurring later in labor

Hypotonic Contractions

• Hypotonic contractions number of contractions are usually low or infrequent
• Membranes may be artificially ruptured (amniotomy) to further speed labor
• Rise in pressure no more than 10 mmHg

Hypertonic Contractions

• Hypertonic Contractions occur frequently and are most commonly seen in the latent phase of labor
• Occurs because the muscle fibers of the myometrium do not depolarize or relax
• More painful than usual
• High resting pressure (35-40 mmHg)

Uncoordinated Contraction

• Oxytocin may be helpful to stimulate more effective and consistent pattern of contractions.

Dystocia

• A difficult labor, can arise from any of the 4 components of the labor process is called dystocia.
• Each component of the labor process can affect dystocia.
• POWER includes uterine contraction
• PASSENGER includes fetus
• PASSAGEWAY includes birth canal
• PSYCHE includes perception

Stages of Labor

Dysfunction with the first stage

A. Prolonged Latent Phase - Longer than 20 hrs in nullipara - 14 hrs in multipara

• Administration of Morphine Sulfate may relax hypertonicity and allows labor to be more effective and begin to progress

B. Protracted Active Phase – Longer than 12 hrs in primigravida – 6 hrs in multigravida

• If cause is CPD or malposition, CS may be necessary If not CPD, oxytocin to augment labor

C. Prolonged Deceleration Phase – extends beyond 3 hours in a nullipara – 1 hour in a multipara

Abnormal Fetal Head

• Most often results from abnormal fetal head position
• CS is required.
• Occurs when there is no progress in cervical dilatation for longer than 2 hours.
• Oxytocin to assist labor.

Precipitate Labor

• Precipitate Dilatation - a cervical dilatation that occurs at a rate of 5 cm or more per hour in a primipara or 10 cm or more per hour in a multipara
• precipitate Birth - occurs when uterine contractions are so strong a woman gives birth with only a few, rapidly occurring contractions, often defined as a labor that is completed in fewer than 3 hours.

Induction and Labor

• Induction of Labor - labor started artificially
• Augmentation of Labor - assisting labor that has started spontaneously but is not effective

Umbilical Cord Prolapse

• Umbilical Cord Prolapse is a loop of the umbilical cord slips down in front of the presenting fetal part.
• Prolapse may occur at any time after the membranes rupture if the fetal part is not fitted firmly into the cervix.
• ASSESSMENT
• Cord may be felt as the presenting part on initial vaginal examination.
• Cord may be visible at the vulva.

Fetal Position

• Fetal Position is fetal position is posterior rather than anterior.
• Occiput is directed diagonally and posteriorly, either to the ROP or LOP.
• Head must rotate not through 90 degree arc, but through an arc of approx 135 degree.

Hemorrhage

• Hemorrhage is more likely with cesarean birth.
• Often happens after the placenta is delivered.
• Uterus normally contracts and pushes out the placenta.

TREATMENT

• Put pressure on the bleeding inside the uterus.
• Surgery to open abdomen to find the cause of bleeding.
• Tying off or sealing bleeding blood vessels.

Puerperal Infection

• Puerperal Infection Occurs when bacteria infect the uterus and surrounding areas after a woman gives birth.
• Also known as postpartum infection

TYPES OF POSTPARTUM INFECTIONS

• Endometritis - infection of uterine lining Myometritis - infection of uterine muscle
• Parametritis - infection of areas around the uterus. less common since introduction of penicillin

Treatment

• treated with oral antibiotics is the infection
• Clindamycin (Cleocin) or Gentamicin (Gentasol) are drug of choice

Thromboembolic Disorders (Postpartum Blood Clots)

Blood Clots (Thrombi) forms in blood vessels Embolus - a blood clot that travels through the bloodstream and blocks an artery

Deep Vein Thrombosis

• Deep Vein Thrombosis is the Formation of blood clots (thrombi) in the deep veins

May be injected IV (vein) or SC (under skin) Leg swelling, Pain, Tenderness, during delivery

Depression

Postpartum Depression (PPD) is a complex mix of physical, emotional, and behavioral changes that happen in some women after giving birth. PPD is a form of major depression that begins within 4 weeks after delivery.

• Similar to the baby blues, but stronger For severe cases of depression, an IV of Brexanolone (Zulresso) may be prescribed

Infertility

Haven't been able to get pregnant after a year of trying Woman age 35, haven't been able to get pregnant after 6 months of trying A woman who's never been able to get pregnant will be diagnosed with PRIMARY INFERTILITY Azoospermia - sperm absent in semen Oligospermia - decreased sperm in semen

• Postcoital Test

Prematurity

• live-born infant before the end of 37 weeks of gestation. small for their age because they have experience IUGR or failed to grow at the expected rate in utero.

Cephalohematoma

is collection of blood between the periosteum of a skull bone and the bone itself, is caused by rupture of a periosteal capillary because of the pressure of birth, appears by 24 hours after birth May be discolored (black and blue) because of the presence of coagulated blood underneath the periosteum

Seizures

Seizures associated with high fever

• Due to sudden spike of temperature
• Ibuprofen and Acetaminophen
• Persistent pattern of inattention and/or hyperactivity-impulsiveness revealed before the age of 7 years

REACIVE ATTACHMENT DISORDER

A unique syndrome in which an infant falls below the 5th percentile for weight and height on a standard growth chart or is falling in percentiles on a growth chart.

HIRSHSPRUNG'S DISEASE

Absence of ganglionic innervation to the muscle of a section of the bowel - in most instances, the lower portion of the sigmoid colon just above the anus

Anencephaly and Microcephaly

– absence of the cerebral hemispheres. -fetal brain grows so slowly that it falls more than three standard deviations below normal on a growth chart at birth.