NCM 220 Care of Mother and Child at Risk (PDF)

NCM 220 CARE OF MOTHER AND CHILD AT RISK OR WITH PROBLEMS (ACUTE AND CHRONIC) UNIT 1| 2ND SEMESTER | ACADEMIC YEAR 2022-2023 LESSON 1: HIGH-RISK PREGNANCY Behavioral Factors...

NCM 220 CARE OF MOTHER AND CHILD AT RISK OR WITH PROBLEMS (ACUTE AND CHRONIC) UNIT 1| 2ND SEMESTER | ACADEMIC YEAR 2022-2023 LESSON 1: HIGH-RISK PREGNANCY Behavioral Factors smoking ASSESSMENT OF RISK FACTORS alcohol intake substance abuse nutritional status Predisposing Factors - are not modifiable; dental hygiene Precipitating Factors - are modifiable; Demographic Factors SCREENING PROCEDURES Age Weight Amniocentesis Height - a medical procedure used primarily in the prenatal diagnosis of Parity - The number of previous pregnancies is a risk factor genetic conditions associated with age and includes all first pregnancies, especially a - has other uses such as in the assessment of infection and fetal lung first pregnancy at either end of the childbearing age continuum. maturity. Marital status Residence Chorionic Villus Sampling (CVS) Ethnicity - sometimes called “chorionic villous sampling” Income - a form of prenatal diagnosis done to determine chromosomal or Occupation genetic disorders in the fetus Socioeconomic Status Fetal Monitoring Inadequate finances - used to check the rate & rhythm of heartbeat Overcrowding, poor standards of housing, poor housing - looks for any increases or decreases in heartbeat Nutritional deprivation Severe social problems Glucose Tolerance Test (GTT) Unplanned and unprepared pregnancy - also known as “oral glucose tolerance test” - measures your body’s response to sugar (glucose) Biophysical Factors Genetic - may interfere with normal fetal or neonatal Group B Streptococcus Culture (GBS) development, result in congenital anomalies, or create difficulties - type of bacteria found in the lower genital tract for about 25% of for the mother. These factors include defective genes, all women transmissible inherited disorders and chromosomal anomalies, - this infection usually causes no problems in women before multiple pregnancy, large fetal size, and ABO incompatibility. pregnancy, but can cause serious illness in the mother during Medical - complications of current and past pregnancies, pregnancy obstetric-related illnesses, and pregnancy losses put the woman at risk Ultrasonography - diagnostic ultrasound; also called sonography or diagnostic Obstetric History medical sonography History of infertility or multiple gestation - an imaging method that uses sound waves to produce images of Grand Multiparity structures within your body. Previous abortion or ectopic pregnancy - the images can provide valuable information for diagnosing and Previous loses directing treatment for a variety of diseases and conditions Previous operative OB Previous abnormal labor Genetic Screening Previous high risk infant - a blood test that examines fetal DNA in maternal bloodstream to Previous hydatidiform mole screen for the increased chance for specific chromosome problems Dystocia - can also provide information about the baby’s sex and Rh blood type Current OB Status Late or no prenatal care Non-Stress Test Maternal anemia - used in pregnancy to assess fetal status by means of the fetal heart Rh sensitization rate and its responsiveness Antepartal bleeding Cardiotocograph - used to monitor the fetal heart rate and presence or absence Pregnancy Induced Hypertension (PIH) of uterine contractions; this test is typically termed “reactive” or Multiple gestation “nonreactive” Premature/postmature labor Polyhydramnios Oxytocin Challenge Test (OCT) Premature Rupture of Membrane (PROM) - a diagnostic tool that can be used in case of suspected placental Fetus appropriately large or small insufficiency to evaluate the fetal tolerance of uterine contractions Maternal Medical History/Status Contraction Stress Test Cardiac or pulmonary disease - measures the fetal heart rate after the mother’s uterus is stimulated Metabolic disease to contract. Endocrine disease - is done to make sure the fetus can handle contractions during labor Chronic Renal disease and get the oxygen needed from the placenta. Chronic Hypertension Venereal and other infectious diseases Nipple Stimulation Contraction Test Major congenital anomalies of reproductive tract - an effective way to induce labor. Hemoglobinopathies - releases the hormone oxytocin in the body Seizure disorders - helps initiate labor and makes contractions longer and stronger. Malignancy Major emotional disorder and mental retardation Biophysical Profile (BPP) NCM 220 Lecture SBSRuaya 1  NCM 220 CARE OF MOTHER AND CHILD AT RISK OR WITH PROBLEMS (ACUTE AND CHRONIC) UNIT 1| 2ND SEMESTER | ACADEMIC YEAR 2022-2023 - measures the health of the baby during pregnancy Administer oxygen if women with extreme heart - checks the baby’s heart rate, muscle tone, movement, and disease breathing. Anesthetic choice - epidural - measures the amount of amniotic fluid around the baby - looking at these areas helps the doctor know how well the baby is A Pregnant Woman with Iron-Deficiency Anemia doing. - most common anemia of pregnancy - many women enter pregnancy with deficiency of iron stores X-RAY: Lateral Pelvimetry resulting from a diet low in iron, heavy menstrual periods, or - a radiological investigation that involves the measurement of unwise weight reduction programs different anthropometric dimensions of the pelvis. - associated with low birth weight and preterm birth - the pelvic inlet and outlet play important roles in labor outcome Assessment: Hematocrit - < 33% Serial Estriol Determination Hemoglobin - < 12 mg/dl Estriol - one of the 3 estrogen hormones a woman experiences extreme fatigue and poor exercise tolerance - estriol levels rise throughout pregnancy, helping to keep uterus and Nursing Interventions: unborn baby healthy. woman should take prenatal vitamins containing an iron - levels are at their highest right before childbirth supplement of 60 mg - help prepare the body for labor and delivery woman should eat a diet high in iron and vitamins advise woman to take iron supplements with orange juice or a Percutaneous Umbilical Blood Sampling vitamin C supplement which supplies ascorbic acid - a quick test also called as cordocentesis, fetal blood sampling or ferrous sulfate turns stools black so caution women about this to umbilical vein sampling prevent them worrying that they are bleeding internally - takes fetal blood directly from the umbilical cord abdominal aortic aneurysms PRE-GESTATIONAL CONDITIONS GESTATIONAL CONDITIONS A Pregnant Woman with Diabetes Mellitus - an endocrine disorder in which the pancreas cannot produce A Pregnant Woman with Hyperemesis Gravidarum adequate insulin to regulate body glucose levels - nausea and vomiting of pregnancy that is prolonged past 12 weeks Classification: of pregnancy that is so severe that severe weight loss occur a. Type 1 - formerly known as IDDM (Insulin Dependent Assessment: Diabetes Mellitus) severe nausea and vomiting b. Type 2 - formerly known as NIDDM (Non-Insulin cannot maintain usual nutrition Dependent Diabetes Mellitus) elevated hematocrit concentration c. Gestational Diabetes - a condition of abnormal glucose weight loss metabolism that arises during pregnancy; a possible Therapeutic Management signal of an increased risk for type 2 diabetes later in need to be hospitalized for about 24 hours to monitor intake and life output and blood chemistries and to restore hydration Risk Factors all oral food and fluids are usually withheld Obesity intravenous fluid may be administered to increase hydration Age over 25 years old antiemetic such as metoclopramide (Reglan) maybe prescribed to History of large babies (10 lbs or more) control vomiting History of unexplained fetal or perinatal loss measure intake and output History of congenital anomalies in previous if there is no vomiting after the first 24 hours of oral restriction- pregnancies small amounts of clear fluid may begun and woman maybe History of polycystic ovary syndrome discharged Family history of Diabetes small quantities of dry toast, crackers or cereal maybe added every Member of a population with high-risk for diabetes 2 or 3 hours if she can continue to take clear fluid Assessment for Gestational Diabetes A fasting plasma glucose of 126 mg/dl or above A Pregnant woman with Hydatidiform Mole Non-fasting plasma glucose of 200 mg/dl or above Gestational Trophoblastic Disease Confirmation is done using a 50g oral glucose - an abnormal proliferation and then degeneration of the challenge test trophoblastic villi Therapeutic Management - they become filled with fluid and appear as clear fluid filled, grape Keeping blood glucose levels near normal helps sized vesicles minimize the risk of maternal and fetal complications Assessment: uterus reach its landmarks before the usual time A Pregnant Woman with Cardiac Disease a serum or urine test for hCG for pregnancy will be strongly Assessment: positive Instruct woman to report coughing during pregnancy hypertension, edema and proteinuria before 20 of pregnancy Assess for edema shows dense growth but no fetal growth in the uterus seen in Record baseline BP, PR, and RR ultrasound Assess for nail bed filing and jugular venous distention no fetal heart sounds is also helpful throughout the pregnancy it will identify as vaginal bleeding approximately at week 20 A woman may need ECG, chest radiograph, Therapeutic Management: echocardiogram suction curettage to evacuate the mole Nursing Interventions during Labor and Birth: baseline pelvic examination, a chest radiograph, serum test for CG Monitor fetal heart rate and uterine contractions during following mole extraction labor a woman should used reliable contraceptive method to be free of Assess for BP, PR, RR risk of a developing malignancy Advise woman to assume a side lying position (left) some physicians give women a prophylactic course of Place woman in semi-fowler’s position to ease the methotrexate the drug of choice for choriocarcinoma work of breathing if woman has pulmonary edema NCM 220 Lecture SBSRuaya 2  NCM 220 CARE OF MOTHER AND CHILD AT RISK OR WITH PROBLEMS (ACUTE AND CHRONIC) UNIT 1| 2ND SEMESTER | ACADEMIC YEAR 2022-2023 A Woman with Ectopic Pregnancy - one in which implantation occurs outside the uterine cavity A woman with Abruptio Placenta - the implantation may occur on the surface of the ovary or in the - premature separation of the placenta cervix; common site is in the fallopian tube. - the separation generally occurs in late pregnancy Assessment predisposing factors: woman usually experiences a sharp, stabbing pain in of her lower - high parity abdominal quadrants at time of rupture followed by scant vaginal - advanced maternal age spotting - short umbilical cord a woman may experience lightheadedness and rapid pulse which - Chronic hypertensive disease are signs of shock if internal bleeding progresses Cervis abdomen becomes rigid from peritoneal irritation - PIH positive Cullen's sign - direct trauma continuing extensive or dull vaginal and abdominal pain - use of recreational drugs and smoking Therapeutic Management Assessment An unruptured ectopic pregnancy can be treated medically by the a sharp, stabbing pain high in the uterine fundus oral administration of methotrexate followed by leucovorin heavy bleeding usually accompanies premature separation of the placenta a hysterosalpingogram or ultrasound is usually performed after the shock may follow quickly chemotherapy to assess whether the tibe is patent uterus becomes tense and feels rigid to touch Mifepristone, an abortifacient is also effective at causing Therapeutic Management sloughing of the tubal implantation site A woman reeds a large gauge intravenous catheter inserted for fluid if an ectopic pregnancy ruptures it is an emergency situation-the replacement and oxygen by mask to limit fetal anoxia woman will undergo laparoscopy to ligate the bleeding vessels and monitor fetal heart sounds to remove or repair the damaged fallopian tube record maternal vital signs every 5-15 minutes to establish baselines and A woman with Placenta Previa observe progress - Is a condition of pregnancy which placenta is implanted keep woman in lateral, not supine abnormally in the uterus do not perform any abdominal, vaginal or pelvic examination - common cause of painless bleeding in the third trimester of if vaginal birth does not seem imminent, cesarean birth is the birth method pregnancy of choice four degrees of implantation: death may occur from massive hemorrhage leading to shock 1. implantation in lower rather than in the upper portion of the uterus A woman with PROM (Premature Rupture of Membrane) 2. marginal implantation - fetal membranes with loss of amniotic fluid during pregnancy 3. Implantation that occludes a portion of the cervical os before 37 weeks 4. implantation that totally obstructs the cervical os - poses major threat to the fetus as after rupture, the seal to the fetus Risk Factors is lost and uterine and fetal infection may occur increased parity - causes increased pressure on the umbilical cord from the loss of advanced maternal age amniotic fluid, inhibiting the fetal nutrient supply or cord prolapse past cesarean births Assessment past uterine curettage a sudden gush of clear fluid from her vagina with continued minimal multiple gestation leakage male fetus a woman mistakes urinary incontinence caused by exertion for rupture of Assessment membranes detected on early ultrasound PROM is associated with vaginal infection bleeding that occurs is usually abrupt, painless, bright red and if fetus is mature enough to survive in an extrauterine environment at the sudden enough to frighten a woman time of rupture and labor does not begin within 24 hours labor contractions it may stop abruptly as it began are usually induced by IV administration of oxytocin so infant is born before Therapeutic Management infection occur explain to the woman her condition Therapeutic Management she is cautioned to avoid coitus a woman is placed on bed rest either in the hospital or at home if fetus is not get adequate rest viable call health care provider for any signs of vaginal bleeding (usually administer corticosteroid for fetal lung maturity begins at week 30) prophylactic administration of broad spectrum antibiotics to reduce risk of to ensure adequate blood supply to the woman and fetus, place the infection woman immediately on bed rest in a side lying position a woman with no signs of infection may be administered a tocolytic agent if Assess the following: labor contractions begin - duration of pregnancy - time the bleeding began A woman with PIH (Pregnancy Induced Hypertension) - woman's estimation of the amount of blood - a condition in which vasospasm occurs during pregnancy in both -ask if there was an accompanying pain small and large arteries - color of the blood - signs of hypertension. proteinuria, and edema develop - what she has done for bleeding Risk Factors: - whether there where prior episodes of bleeding - multiple pregnancy - whether she had prior cervical surgery for premature cervical - primiparas younger than 20 years old or older than 40 years old dilatation - women from low socio-economic background inspect perineum for bleeding - those with five or more pregnancies never attempt a pelvic or rectal examination with painless bleeding - those who have hydramnios those with underlying disease late in pregnancy it may initiate massive hemorrhage Gestational Hypertension- develops elevated BP of 140/90 mmHgbut has obtain baseline vital signs no proteinuria or edema assess blood pressure every 5-15 minutes Pre-eclampsia- any status above gestational hypertension and below a point intravenous fluid therapy of seizures monitor input and output Eclampsia- if seizure from PIH occurs monitor fetal heart sounds and uterine contractions Mild pre-eclampsia- when the pregnant mother has proteinuria and blood assess blood components to determine possible clotting disorder pressure rises to 140/90 mmHg NCM 220 Lecture SBSRuaya 3  NCM 220 CARE OF MOTHER AND CHILD AT RISK OR WITH PROBLEMS (ACUTE AND CHRONIC) UNIT 1| 2ND SEMESTER | ACADEMIC YEAR 2022-2023 Severe Pre-eclampsia- when the pregnant mother's blood pressure rises to 160 mmHg systolic and 110mmHg diastolic or above on at least two occasions, marked proteinuria (3+ or 4+) on a random urine sample Eclampsia- most severe classification of PIH, a woman has passed into this stage when cerebral edema is so acute that a grand mal seizure or coma occurs Nursing Interventions for a Woman with mild PIH Monitor antiplatelet therapy Promote bed rest promote good nutrition provide emotional support Nursing Interventions for a Woman with Severe PIH Support bed rest Darken room Monitor Maternal Well-being Monitor Fetal Well-being Administer medications to prevent eclampsia: Hydralazine (Apresoline), nifedipine to prevent hypertension Nursing Interventions for a Woman with Eclampsia maintain patent airway during seizure attacks administer Magnesium Sulfate or diazepam for emergency measure LESSON 2: THE WOMAN WITH AN INTRAPARTUM COMPLICATION Dysfunctional Labor - may result from the problems with: NCM 220 Lecture SBSRuaya 4  NCM 220 CARE OF MOTHER AND CHILD AT RISK OR WITH PROBLEMS (ACUTE AND CHRONIC) UNIT 1| 2ND SEMESTER | ACADEMIC YEAR 2022-2023 The Powers The Passenger Uterine Relaxants: The Passage I - Indomethecin (NSAID) The Psyche N - Nifedipine (CA Channel Blocker) M - Magnesium Sulfate PROBLEMS OF THE POWERS T - Terbutaune (Adrenergic Agonist) Ineffective Contractions Possible causes: Nursing encourage promote uterine Maternal Fatigue Care position blood flow Maternal Inactivity changes promote rest, Fluid and electrolyte imbalance ambulation general comfort, Hypoglycemia emotional ad relaxation Excessive Analgesia or Anesthesia support pain relief Maternal Catecholamines secreted in response to stress emotional or pain support Disproportion between the maternal pelvis and the presenting part Uterine overdistention, such as with: multiple gestation Ineffective Maternal Pushing may result from: or hydramnios use of incorrect pushing techniques or inefficient pushing positions fear of injury because of pain and tearing sensations felt by the Hypotonic Dysfunction Hypertonic Dysfunction mother when she pushes minimal or absent urge to push Definition a labor with uterine pelvic muscles are maternal exhaustion contractions of poor continuously contracting; regional block analgesia that may suppress the woman’s urge to quality that are: symptoms include: pain and push painful difficulty with urination, psychological unreadiness to “let go” of her baby are out of bowel movements and proportion to sexual function. Management: their intensity focus on correcting the causes contributing to ineffective pushing do not cause promote effective pushing cervical oral or IV fluids dilation or effacement PROBLEMS WITH THE PASSENGER are usually uncoordinated and frequent. Fetal problems associated with dysfunctional labor are those related to: fetal size fetal presentation Contractions coordinated but uncoordinated; multifetal pregnancy weak irregular fetal anomalies become less short and poor frequent and intensity but Fetal Size shorter in painful and duration cramp-like. Macrosomia easily indented - infant weighs more than 4000g at birth at peak - Cephalopelvic or Fetopelvic Disproportion - The head or woman may shoulders may not be able to adapt to the pelvis; have minimal - distention of the uterus by the large fetus reduces the strength of discomfort contractions both during and after birth. because the contractions Shoulder Dystocia are weak - Delayed or difficult birth of the shoulders that may occur as they become impacted above the maternal symphysis pubis. Uterine not elevated higher than normal - Turtle sign - As soon as the head is born, it retracts against the resting tone perineum, much like a turtle’s head drawing into its shell - unpredictable and can occur in a baby of any weight Phases of Active Latent - requires urgent intervention Labor Abnormal Fetal Presentation or Position Therapeutic Amniotomy correct cause Management Oxytocin can be identified Rotation Abnormalities Augmentation light sedation to - Persistence of the fetus in the occiput posterior (OP) or occiput Cesarean birth promote rest transverse (OT) position if no progress hydration - delay fetal descent and other mechanisms of labor (cardinal Tocolytics - to movements) reduce high - Maternal position changes promote fetal head rotation to an uterine tone and occiput anterior position and fetal descent: promote hands and knees placental side-lying perfusion the lunge squatting NCM 220 Lecture SBSRuaya 5  NCM 220 CARE OF MOTHER AND CHILD AT RISK OR WITH PROBLEMS (ACUTE AND CHRONIC) UNIT 1| 2ND SEMESTER | ACADEMIC YEAR 2022-2023 Breech Presentation - the buttocks or the feet are the first body parts that will contact the cervix - cause a difficult childbirth - Cervical dilation and effacement are often slower - Problems associated with breech birth: Maternal Soft Tissue Obstructions fetal injury - full bladder (common) prolapsed umbilical cord - reduces available space in the pelvis low birth weight - encourage woman to void every 1-2 hours fetal anomalies - catheterization may be needed if she cannot urinate or receives complications related to placenta previa regional block analgesia Multifetal Pregnancy PROBLEMS OF THE PSYCHE - also known as multiple gestation - may result in dysfunctional labor because of uterine overdistention Responses to excessive or prolonged stress interfere with labor in several - potential for fetal hypoxia during labor ways: - risk for postpartum hemorrhage increased glucose consumption - often cesarean reduced maternal blood supply to the placenta less effective labor contractions and maternal pushing efforts Fetal Anomalies increased pain perception; decreased pain tolerance - such as hydrocephalus - may prevent normal descent of the fetus General nursing measures involve: - may be discovered by ultrasound examination before labor establishing a trusting relationship with the woman and her family making the environment comfortable by adjusting temperature and light PROBLEMS OF THE PASSAGE promoting physical comfort such as cleanliness providing accurate information Pelvis implementing non-pharmacologic and pharmacologic pain - A small (contracted) or abnormally shaped pelvis may retard labor management and obstruct fetal passage. - the woman may experience: Abnormal Labor Duration poor contractions slow dilation Prolonged Labor slow fetal descent - type of dysfunctional labor that results from problems with any of long labor the factors in the birth process - the danger of uterine rupture is greater Potential maternal and fetal problems in prolonged labor include: Maternal infection, intrapartum or postpartum Neonatal infection, which may be severe or fatal Types of Pelvis Shape Prognosis for Maternal exhaustion Vaginal birth Higher levels of anxiety and fear during a subsequent labor Nursing measures for the woman: Gynecoid Round, cylindric Good promotion of comfort shape throughout; conservation of energy wide pubic arch (90 emotional support degrees or greater) position changes that favor normal progress assessment for infection Anthropoid Long, narrow oval; More favorable than anteroposterior android or Nursing care for the fetus: observation for the signs of intrauterine infection diameter is longer platypelloid pelvic and compromised fetal oxygenation. than transverse shape diameter; narrow Precipitate Labor pubic arch - rapid birth that occurs within 3 hours of labor onset - priority nursing care: promotion of fetal oxygenation and maternal comfort Android Heart or Poor woman should remain in side-lying position - to enhance placental triangular-shaped blood flow and reduce effects of aortacaval compression; to slow inlet; narrow the rapid fetal descent and minimize perineal tears. diameters throughout; narrow pubic arch; Preterm Labor - begins after the 20th conditions week but before the maternal Platypelloid flattened: wide, short Poor obseity end of 37th week of pregnancy oval; transverse - factors associated: diameter wide, but maternal medical condition anteroposterior maternal obesity diameter short; wide chronic health pregnancy disorders pubic arch conceptions achieved by assisted reproductive technology present and past obstetric conditions fetal conditions social and environmental factors demographic factors - signs and symptoms: uterine contraction NCM 220 Lecture SBSRuaya 6  NCM 220 CARE OF MOTHER AND CHILD AT RISK OR WITH PROBLEMS (ACUTE AND CHRONIC) UNIT 1| 2ND SEMESTER | ACADEMIC YEAR 2022-2023 “balling up” sensation - manifestations: cramps uterus is either absent from the abdomen or a constant low backache depression in the fundal area is present sensation of pelvic pressure interior of the uterus may be seen through the cervix or pain, discomfort, or pressure in the vulva or thighs protruding into the vagina change or increase in vaginal discharge massive hemorrhage, shock and pain “just feeling bad” severe pelvic pain - nursing considerations: Therapeutic Management: assess the uterine fundus for firmness, height and woman is placed on bed rest deviation from midline IV fluid therapy observe for tachycardia and falling BP and falling UO vaginal and cervical cultures indwelling catheters administer Terbutaline, Magnesium Sulfate NPO Prolonged pregnancy - pregnancy that lasts longer than 42 weeks - nursing considerations: teaching about procedures, such as: antepartum testing or induction of labor support for the woman’s psychological and physical fatigue nursing care related to specific procedures, such as induction of labor Placental Abnormalities Placenta Accreta - abnormally adherent placenta - may cause immediate or delayed hemorrhage after birth Placenta Increta - placenta penetrates the uterine muscle itself Placenta Perceta - placenta penetrates all the way through the uterus Prolapsed Umbilical Cord - slips down after the membranes rupture - more likely to happen: a fetus remains at a high station a very small fetus breech presentations transverse lie hydramnios Manifestation: cord visible at the vaginal opening changes in FHR such as bradycardia or viable decelerations Therapeutic Management: Actions to relieve cord compression and increase fetal oxygenation: position the woman’s hips higher than her head vaginal elevation of the presenting part avoid or minimize manual palpation or handling of the cord ultrasound examination give oxygen at 8-10L/min by facemask tocolytic drug warm saline moistened towels Uterine Rupture - tear in the wall of the uterus occurs because the uterus cannot withstand the pressure against it - possible signs and symptoms: abdominal pain and tenderness chest pain hypovolemic shock signs associated with impaired fetal oxygenation absent fetal heart sounds cessation of uterine contractions - Nursing consideration: administer oxytocin cautiously Uterine Inversion - the uterus is completely or partly turns inside out NCM 220 Lecture SBSRuaya 7  NCM 220 CARE OF MOTHER AND CHILD AT RISK OR WITH PROBLEMS (ACUTE AND CHRONIC) UNIT 1| 2ND SEMESTER | ACADEMIC YEAR 2022-2023 LESSON 3: NURSING CARE OF A FAMILY EXPERIENCING A Surgical management: uterine curettage; uterine artery ligation; POSTPARTUM COMPLICATION hysterectomy Bimanual massage for Uterine Atony - placing one hand in the Postpartum complications vagina and pushing against the body of the uterus while the other - are always potentially serious because they can impact so many hand compresses the fundus from above through the abdominal people. A complication may be so serious it could cause a personal wall. the posterior aspect of the uterus is massaged with the injury, leave a woman with her future fertility impaired, or even anterior aspect with the vaginal hand. result in death. - this is to encourage contraction. after a few seconds, the uterus assumes its healthy, grapefruit-like feel. POSTPARTUM HEMORRHAGE - If a woman’s uterus does not remain contracted, you - blood loss of 500ml or more following a vaginal birth need now to contact her primary healthcare provider so - with cesarean, 1000 ml blood loss or a 10% decrease in the that intervention to increase contractions such as hematocrit level administering a bolus or a dilute intravenous or - is one of the primary causes of maternal mortality associated with intravenous infusion can be prescribed to help the childbearing uterus maintain its tone. - is a major threat during pregnancy throughout labor and continuing of the postpartum period. - Although hemorrhage may occur either early (within the first 24 hrs following birth) or late (from 24 hrs to 6 weeks after birth), the greatest danger is in the first 24 hours because of the grossly denuded and unprotected uterine area left after detachment of the placenta. Reasons: 1. Uterine Atony - Tone - a soft and weak uterus after childbirth Oxytocin (Pitocin), when this is given intravenously, its action on - happens when uterine muscles do not contract enough to clamp the the uterus is immediate but we need to be aware that oxytocin has placental blood vessels shut after childbirth only a short duration of action so approx. an hour. - Most common cause of postpartum hemorrhage - Symptoms of uterine atony can recur quickly, so it is administered only in a single dose. - If oxytocin is not effective in maintaining the tone you can give the: Carboprost tromethamine (Hemabate) - may be repeated every 15 minutes to 90 minutes up to 8 doses and Methylergonovine maleate (Methergine) may be repeated every 2 to 4 hours up to 5 doses, both of these are given intramuscularly. These are second possibilities. Signs and Symptoms Misoprostol (Cytotec), would be administered rectally to Excessive blood loss after delivery - can cause a drop in the decrease any postpartum hemorrhage. A second dose of your arterial blood pressure and and consequently increase heart rate Cytotec should not be administered unless a minimum of 2 hours May also experience pain in the lower back has lapsed. Risk factors: uterine over distention secondary to hydramnios 2. Lacerations - trauma multiple gestation - commonly occur when there is a difficult or precipitate use of oxytocin birth in primigravidas. fetal macrosomia - may occur in the cervix, vagina, or perineum after birth high parity or any time the uterus feels firm but bleeding persists. rapid or prolonged labor Types of Lacerations intra-amniotic infection and use of uterine-relaxing agents cervical - are lacerations of the cervix or usually found on the presence of uterine myomas sides of the cervix near the branches of the uterine artery. So if the operative birth artery is torn the blood loss may be so great that blood gushes placenta previa and accreta from the vaginal opening. premature separation of the placenta vaginal - are easier to locate and assess than cervical lacerations retained placental fragments because they are so much easier to view. Measures to combat uterine atony: perineal - occur when a woman is placed specially in a lithotomy elevate woman’s lower extremities position for birth rather than in a supine position. offer a bedpan or assist to the bathroom at least every 4 hours Classification of Perineal Laceration administer oxygen by facemask at a rate of 10-12L/min First degree - tear involves vaginal mucous membrane and skin obtain vital signs frequently Second degree - tear involving vagina, perineal muscles, perineal Treatment: skin, fascia, levator ani muscle, and perineal body Initial treatment: uterine massage; medications Third degree - tear with partial anal sphincter involvement; the Tamponade techniques: gauze packing; bakri balloon; foley entire perineum extends to reach the external sphincter of the catheter; rectum. NCM 220 Lecture SBSRuaya 1  NCM 220 CARE OF MOTHER AND CHILD AT RISK OR WITH PROBLEMS (ACUTE AND CHRONIC) UNIT 1| 2ND SEMESTER | ACADEMIC YEAR 2022-2023 Fourth degree - tear with complete tear of anal sphincter - Most likely to occur after rapid, spontaneous birth, and in women involving bowel lining; includes the entire perineum, rectal who have perineal varicosities. sphincter, and some of the mucous membrane of the rectum. - may occur at the site of the episiotomy or laceration repair if a vein was punctured during suturing or this can cause a woman acute discomfort and concern. Assessment: severe pain in the perineal area feeling pressure between the legs purplish discoloration with obvious swelling in the perineal area Therapeutic Management: Report a presence of a hematoma Report to the primary healthcare provider the estimated size of a hematoma and the degree of the woman’s discomfort administer a mild analgesic apply ice pack 3. Retained Placental Fragments To identify the complication of a retained placenta, every placenta PUERPERIAL INFECTIONS should be inspected carefully after birth to be certain that the - potentially serious placenta is complete. - potential to spread in the perineum or the circulatory system You can determine that there is a remaining placenta through - organisms commonly culture: group B streptoccoci, staphylococci, ultrasound or you may have a blood serum sample that contains and aerobic gram-negative bacilli the HCG because this hormone will reveal that part of the placenta - management: use of appropriate antibiotic is still present. Therapeutic Management: 3 main types: systemic or topical antibiotic Placenta Adherens - there is failed contraction of the analgesic myometrium behind the placenta sitz bath or warm compresses Trapped Placenta - a detached placenta trapped behind a closed woman should wipe from front to back cervix Partial Accreta - there is a small area of accreta preventing 4. Disseminated Intravascular Coagulation (DIC) Causes: - a rare but serious condition that causes abnormal blood clotting a. contractions are not strong enough to expel it throughout the body’s blood vessels b. placenta is unusually strongly attached to the wall of - may develop DIC when you have an infection or injury that affects the uterus the body’s normal blood clotting process c. you have placenta accreta - a condition in which small blood clots develop throughout the d. the cervix closes and traps the placenta inside the bloodstream, blocking small blood vessels uterus - the increased clotting depletes the platelets and clotting factors Symptoms: needed to control bleeding, causing excessive bleeding; a. fever Symptoms: b. bad smelling discharge from vagina pain c. heavy bleeding redness d. large pieces of tissue coming out of the vagina warmth e. pain swelling in the lower leg Assessment: headaches bleeding speech changes - may be apparent in the immediate postpartum period because the paralysis uterus cannot contract with the fragments in place. dizziness - But if the fragments are small, bleeding may not be detected until trouble speaking and understanding postpartum day 6 - 10. This is when a woman notices an abrupt Treatment: discharge and a large amount of vaginal bleeding. blood transfusions are recommended to bleeding and Therapeutic Management: massive bleeding type removal of retained placental fragment Heparin is recommended for those with Methotrexate - to destroy the retained fragments non-symptomatic type PERINEAL HEMATOMA - a collection of blood that has leaked from a burst of blood vessel in the area around the anus - blood pools up outside the blood vessel below the surface of the skin; although it is possible to see the characteristic dark-blue discoloration - also known as anal thrombosis - can be small or large NCM 220 Lecture SBSRuaya 2  NCM 220 CARE OF MOTHER AND CHILD AT RISK OR WITH PROBLEMS (ACUTE AND CHRONIC) UNIT 2| 2ND SEMESTER | ACADEMIC YEAR 2022-2023 RESPIRATORY DISORDERS - Alteration in Oxygenation - an area of pus-filled tissue at the back of the mouth, next to one of the tonsils. The abscess can be very painful and can make it hard to open the mouth. - can also cause swelling that can push the tonsil toward the uvula (the dangling fleshy object at the back of the mouth). This can block the throat, making it hard to swallow, speak, and sometimes even breathe. Chronic Tonsillitis 1. Chronic Follicular Tonsillitis - tonsillar crypts are full of infected cheesy material which shows on the surface as yellowish spots 2. Chronic Parenchymatous Tonsillitis - there is hyperplasia of lymphoid tissue - tonsils are very much enlarged and may interfere with speech, UPPER RESPIRATORY DISORDERS deglutition and respiration - attacks of sleep apnea may occur TONSILLITIS 3. Chronic Fibroid Tonsillitis - inflammation of the tonsils and especially the palatine tonsils - tonsils are small but infected, with history of repeated sore throats; typically due to viral or bacterial infection - marked by red enlarged tonsils usually with sore throat, fever, difficult swallowing, hoarseness or loss of voice, and tender or Etiology Pathophysiology Clinical Less common swollen lymph nodes Manifestation symptoms s Acute Tonsillitis 1. Catarrhal Tonsillitis Viral As with pharyngitis, Sore throat nausea - usually present with URI and measles; infection - the cause may be Red, swollen stomachache - least severe form includes viral or bacterial tonsils vomiting - manifested as redness or sore throat adenovirus, As a result of Pain when furry tongue 2. Follicular Tonsillitis rhinovirus, inflammation, the swallowing bad breath - involvement of crypts with discrete yellow patches of exudate on influenza, tonsils, palatine or High (halitosis) tonsils and enlargement of regional gland coronavirus faucial, enlarge. temperature voice changes 3. Parenchymatous Tonsillitis Bacterial They may meet in (fever) difficulty infection - the midline and Coughing opening the Group A obstruct the passage Headache mouth B-hemolyti of food and air Tiredness (trismus) c If the adenoids are Chilling streptococc also involved, they A general us may block the sense of feeling posterior nares, unwell resulting in (malaise) mouth-breathing. white The Eustachian pus-filled spots tubes may be on tonsils - there is congestion and swelling blocked resulting in swollen lymph otitis media. nodes (glands) in the neck pain in the ears or neck The diagnosis of GABHS tonsillitis can be confirmed by culture of samples obtained by swabbing both tonsillar surfaces and the posterior pharyngeal wall and plating them on the sheep blood agar medium. 4. Peri-tonsillar abscess The isolation rate can be increased by incubating the cultures - may develop bacterial tonsillitis under anaerobic conditions and using selective growth media. A - may present with trismus and muffled voice with poor oral intake, single throat culture has a sensitivity of 90-95% for the detection severe pain on swallowing and opening of the mouth, high fever, of GABHS. offensive breath, enlarged cervical lymph glands and otalgia. on examination of the throat, unilateral bulge in the soft palate and Preoperative Care peritonsillar region with vulvar deviation to the opposite side are scene Assessment if the patient should be done for the other respiratory functions NCM 220 Lecture SBSRuaya 1  NCM 220 CARE OF MOTHER AND CHILD AT RISK OR WITH PROBLEMS (ACUTE AND CHRONIC) UNIT 2| 2ND SEMESTER | ACADEMIC YEAR 2022-2023 History about the bleeding tendency should be considered Types Examination for bleeding and clotting time are necessary 1. Unilateral choanal atresia Loose teeth should be taken care. - more common, less serious and sometimes appears later in childhood Management - persistent nasal drainage Warm saline gargles, throat lozenges, and analgesics can relieve - recurrent sinus infections discomfort and congestion. Nutrition can be supplied by feeding the children with a soft well 2. Bilateral choanal atresia cooked and non-irritating diet - life-threatening and symptoms appear immediately after birth Antibiotics should be given if needed as for the prescribed period - respiratory distress If a surgery is needed, the children and parents should be prepared - cyanosis psychologically for the operation. Clinical Features Post-operative care difficulty breathing after birth Proper position should be given to avoid aspiration. Children are inability to breathe and feed simultaneously placed in the prone position to help the drainage of secretion. persistent one-sided nasal blockage or discharge When children become alert, they may like the sitting position. retraction of the chest when the child cries Comfort measures are necessary to relieve pain; Analgesics are helpful. Pathophysiology Pulse and respiration are checked for four hours; especially - this condition is congenital obstruction of the posterior nares at the patients should be observed for hemorrhage. entrance to the nasopharynx Patient should be discouraged to cough and clear the throat to - the obstruction is usually caused by a. membranous septum maybe prevent bleeding caused by a bony growth If there are no signs of haemorrhage and if patient becomes fully alert, the clear fluids can be started. Diagnosis Parents should be explained and advised about the care to be medical history and physical exam provided at home. test for nasal airflow Due to sore throat, there may be discomfort in the ear on CT scan swallowing for a few days. Diet should be followed for 8-10 days. Treatment Children should be avoided exposure to infection surgical - Transnasal Endoscopic Surgery a variety of approaches available include: transplatal, transnatal Complications and transseptal techniques peritonsillar abscess drilling may be required to create a new passage for bony atresia parapharyngeal abscess intra tonsillar abscess Nursing Management tonsilloliths directed at keeping the nostrils clean and preventing upper tonsillar cyst respiratory infections infants who have bilateral choanal atresia may need to be gavaged until defect is corrected CHOANAL ATRESIA stents are placed in the nasal passage to prevent restenosis; these - failure of the nasal cavities to open posteriorly into the are left in place for 3-6 weeks and require close nursing care to nasopharynx (choanae) during fetal development prevent blockage Complications aspiration while feeding and attempting to breathe through the mouth respiratory arrest re-narrowing of the area after surgery EPISTAXIS - nosebleeds - can occur easily because of the location of the nose and the close-to-the-surface location of the blood vessels in the lining of the nose Causes: Different kinds a developmental abnormality 1. Anterior nosebleed the anomaly is present at birth an can be associated with other - starts in the front of the nose on the lower part of the wall that developmental abnormalities separates the two sides of the nose (septum). there is no known specific cause - capillaries and small blood vessels in this front area of the nose are most believe that this occurs when the tissue that separates the fragile and can easily break and bleed nose and mouth area during fetal development remains after birth - most common type of nosebleed and is usually not serious NCM 220 Lecture SBSRuaya 2  NCM 220 CARE OF MOTHER AND CHILD AT RISK OR WITH PROBLEMS (ACUTE AND CHRONIC) UNIT 2| 2ND SEMESTER | ACADEMIC YEAR 2022-2023 - are more common in children and are usually able to be treated at home DYSPHAGIA 2. Posterior nosebleed - a condition where children or adults have difficulty swallowing - occurs deep inside the nose food,liquids, or even their own oral secretions. Sometimes - caused by a bleed in larger blood vessels in the back part of the children with dysphagia get food or liquid into their airway and nose near the throat lungs, this is known as aspiration. - can be a more serious than anterior nosebleed - can result in heavy bleeding, which may flow down the back of Clinical Manifestation the throat; may need medical attention right away Atelectasis - more common in adults Bronchiectasis Pulmonary abscess Etiology Choking Gagging Local factors: Other possible factors: Stridor blunt trauma anatomical deformities foreign bodies insufflate drugs Cyanosis inflammatory reaction intranasal tumors low relative humidity of inhaled Treatment nasal cannula O2 Laryngoscopic or bronchoscopy removal of the foreign body may be required.If lodged in the larynx, a tracheostomy may be Pathophysiology necessary to maintain the respiration,until further treatment is caused by external trauma, foreign bodies, forcible blowing or given. picking of the nose Antibiotics may be prescribed to prevent infection. allergic rhinitis or sinusitis may also lead to nosebleed. Patients need observation for a further change in the signs. result strain of emotional excitement or physical exercise may be enough to start nose bleeding Prevention a circulatory renal or emotional conditions that produces elevated Provide only sturdy,well constructed ratties for infants. may be cause nasal hemorrhage Provide only pacifiers that have a one piece, durable construction Removal small parts that could be aspirated or swallowed from Management toys. First Aid: Remove diaper or safety pins, buttons,small whole or broken parts Trotter’s procedure makes the patient sit up, pinch nose, open of toys, and other small objects from areas where infant can reach mouth and breath. Do not permit infants to play with balloons. Ice or cold application on the bridges of the nose. Remove small objects from the floor before the infant is placed Pinching the nose for a minute. there and from the crib when the infant is sleeping. Do not give infants nuts, lozenges, other hard candies, fruits that contain pits or seeds. Two Main Types of Choking: 1. Partial Airway Obstruction or Mild Choking 2. Complete Airway Obstruction, or Severe Choking Common Causes of Choking eating or drinking too quickly swallowing food before it has been sufficiently chewed. swallowing small bones or objects. inhaling small objects Nursing Management Details family history and history of illness to be obtained and LOWER RESPIRATORY TRACT DISORDERS necessary investigations to be performed Blood transfusion may be necessary in some children with BRONCHOPNEUMONIA epistaxis - A form of pneumonia that affects the walls of the bronchioles and Continues monitoring of vital signs, bleeding,hypoxia, respiratory the surrounding alveoli difficulty and nasal packing. Teaching the parents and family members about measures to stop epistaxis and immediate medical help are also important. Instructions to be given to the parents apply lubricant to nasal septum twice daily to reduce dryness and to avoid nasal blowing or picking nose after nose bleed Preventive measures of foreign body in the nose, nasal injury and solar radiation to be explained. Need for management of local and systemic causes of epistaxis should be informed and emphasized. NCM 220 Lecture SBSRuaya 3  NCM 220 CARE OF MOTHER AND CHILD AT RISK OR WITH PROBLEMS (ACUTE AND CHRONIC) UNIT 2| 2ND SEMESTER | ACADEMIC YEAR 2022-2023 1. Follow strict precautions to prevent spread of infection. 2. Administer high humidified oxygen. 3. Clear nasal congestion, try a bulb syringe and saline (saltwater) nose drops. 4. Provide adequate Ng. Care of vomiting, fever, & diarrhea 5. Small frequent diet, & increase fluid intake. BRONCHIOLITIS - It is the acute inflammation of the walls of the bronchioles. It is a type of pneumonia characterized by multiple foci of isolated, acute consolidation, affecting one or more pulmonary lobules. Causes Other possible culprits include Etiology Respiratory syncytial virus is implicated in most cases. Most cases of bacterial Staphylococcus aureus pneumonia are caused Other causative organisms include adenovirus, influenza, by the bacterium Haemophilus influenzae parainfluenza, coronavirus and rhinovirus also cause bronchiolitis. Streptococcus Klebsiella pneumoniae pneumonia; however, it Pathophysiology is not uncommon for pneumonia to be caused Clinical features by more than one type of bacteria. Difficulty in breathing Prolonged expiration Persistent dry enough makes children restless and exhausted Pathophysiology Fever and dehydration Due to etiological factors Cyanosis Inadequate intake of food may be due to cough and discomfort while swallowing. Accumulation of mononuclear cells in the submucosa and perivascular space. Investigation X-ray shows over infiltration of lungs. Partial obstruction of the airway. Throat swab may be examined for virology study They clinically manifest as wheezing and crackles. Disease progresses when the alveolar type II cells lose their structural integrity and surfactant production is diminished, a hyaline membrane forms, and pulmonary edema develops. Clinical features Fever Cough that brings up mucus Shortness of breath Treatment Chest pain Antibiotics are prescribed to treat the bacterial infection Rapid breathing Acidosis may be corrected by sodium bicarbonates and the patient Sweating was monitored with the blood gas studies. Chills Humidified oxygen is required to relieved hypoxia Headache Humid atmosphere can be maintained by placing a vessel of Muscle aches boiling water in a room to have a warm and humid atmosphere. Fatigue Maintenance of fluid and electrolyte balance is essential in the cases intravenous fluid is required, to maintain nutrition and Risk Factors hydration. being age 2 or younger A recent Cochrane review on use of bronchodilators in having a lung disease, such as cystic fibrosis,asthma, or chronic bronchiolitis suggests that salbutamol with ipratropium inhalation obstructive pulmonary disease (COPD) may provide some benefit and there may be some beneficial effect having HIV/AIDS of inhaled epinephrine. having a weakened immune system, which may be caused by Continuous positive airway pressure (CPAP) or assisted chemotherapy or use of immunosuppressive drugs ventilation may be required to control respiratory failure. being on a ventilator smoking Nursing care heavy alcohol use NCM 220 Lecture SBSRuaya 4  NCM 220 CARE OF MOTHER AND CHILD AT RISK OR WITH PROBLEMS (ACUTE AND CHRONIC) UNIT 2| 2ND SEMESTER | ACADEMIC YEAR 2022-2023 trouble coughing or swallowing being malnourished ASTHMA - is a condition of the lungs in which there is a airway obstruction Diagnosis due to spasms of the bronchial smooth muscle, edema of the The diagnosis is based on history and physical examination. mucosa and increased mucus secretion in the bronchi and Complete blood count (CBC). An elevated number of white blood cells may indicate a bacterial infection. A chest X-ray is one of the best ways to diagnose this condition. - This helps to locate the areas that are affected by bronchopneumonia. A computed tomography(CT) scan produces a picture similar to an X-ray but in more detail. This will help to locate the location the infection is occurring in the lungs. A sputum culture tests a sample of mucus from your lungs to determine the cause of the infection. bronchioles brought on the various stimuli A bronchoscopy Types of Asthma Treatment 1. Intermittent Specific treatment for pneumonia includes: - This type of asthma comes and goes and feel normal in between Rest asthma flares. Antibiotics for bacterial pneumonia 2. Persistent Inhalers for wheezing - Persistent asthma means you have symptoms most of the time. 1. Albuterol inhaler Symptoms can be mild, moderate or severe. 2. Proventil inhaler 3. Ventolin inhaler Risk Factors Cough medications: A number of factors are thought to increase your chances of developing 1. Dextromethorphan asthma. They include: Decongestant medications: Having a blood relative with asthma, such as a parent or sibling ○ Only for use in older children and adults Having another allergic condition, such as atopic dermatitis-which ○ Pseudoephedrine (Sudafed) causes red, itchy skin- or had fever- which causes a runny nose, ○ Phenylephrine (Neo-Synephrine) congestion and itchy eyes Acetaminophen for pain and fever control Being overweight Nonsteroidal anti-inflammatory medications for pain and fever Being a smoker control Exposure to secondhand smoke ○ Ibuprofen (Motrin, Advil, Nuprin, NeoProfen) Exposure to exhaust fumes or other types of pollution ○ Ketoprofen (Actron, Orud