Common Maternal Complications 2024 Student version PDF

Common Maternal Complications Kimberly Rosenbaum, MSN, C-EFM, RNC- OB, IBCLC Assistant Clinical Professor, Texas State University Objectives 1. Differentiate among & discuss the medical and nursing management of gestational hypertension, preeclampsia, ecl...

Common Maternal Complications Kimberly Rosenbaum, MSN, C-EFM, RNC- OB, IBCLC Assistant Clinical Professor, Texas State University Objectives 1. Differentiate among & discuss the medical and nursing management of gestational hypertension, preeclampsia, eclampsia and chronic hypertension. 2. Identify causes, signs and symptoms, possible complications and medical and nursing management of postpartum hemorrhage. 3. Summarize the nurse’s role in assessing potential problems and managing people with postpartum complications. Postpartum Hemorrhage  Effects 4-8% of all births  Top 3 causes of mortality in industrialized nations  American woman x3 more likely to die in perinatal period than in Canada  American women are x6 more likely to die than Scandinavian  In the UK, maternal death is so unlikely, a woman’s partner is more likely to die while pregnant than she is.  Postpartum Hemorrhage  A vaginal delivery normally has less than 500 ml of blood loss.  A c-section may have a slightly higher blood loss  Any amount can be considered a PPH  ACOG definition:  Cumulative blood loss of > 1,000 mL for either vaginal or cesarean birth or less and showing S/S of hypovolemia Advanced Life Support in Obstetrics (ALSO) Program  Risk Factors  Uterine atony  Trauma  Prolonged second stage  Vacuum- or forceps-  assisted birth Prolonged oxytocin use  Cesarean birth (especially  Intrauterine infection urgent/emergent  Magnesium sulfate treatment cesarean)  Overdistended uterus  Uterine inversion  Multifetal pregnancy  Hematoma  >4 vaginal births  Lacerations (possibly from precipitous delivery)  Polyhydramnios  Tissue  Macrosomic infant  Retained placenta  Coagulopathy  Placenta acreta or previa Assessment Findings  Assess lochia   Systemic Blood clots larger than a quarter symptoms  Heavy bleeding  Tachycardia (saturation100, RR 20-30, diaphoretic, weak, urine output 20-30 ml/hr 2000 ml Hypotension, narrowed pulse pressure, HR>120, RR 30-40, pale, extremities cool, restlessness, urine output 5-15 ml/hr >2500 ml Profound hypotension, HR >140, RR>40, slight urine output or anuria From CMQCC Definition, Early Recognition, and Rapid Response Using Triggers https://www.cmqcc.org/resource/ob-hem-definition -early-recognition-and-rapid-response-using-triggers   Delayed return of enlarged puerperal corpus to normal size and function  Common with secondary or late PPH  Causes Subinvolution  Retained products of conception  Infection  Malposition  Myomas  Gestational trophoblastic disease Tone (atony) Symptoms of Subinvolution  Pelvic discomfort or backache  Bleeding from an enlarged, boggy, tender uterus  Lochia does not change from rubra Tone (atony) Medications for Early PPH Methergin Pitocin Hemabate e 10-40 U in Contraindicate Contraindicate 500/1000 ml d in HTN pts d in crystalloid IV, 0.2 mg IM or asthmatics or 10 units IM PO 0.25 mg IM Usually IM q15- 90 min initially, up to 8 doses cannot repeat until at least 2 hours Tone (atony) Medications for Early PPH Cytotec 800-1000 mcg rectally Tranexamic acid (TXA) Helps decrease blood loss by maintaining blood clots and preventing the breakdown of fibrin 1 gm loading dose of IV TXA over 10 minutes (1 mL/min) upon diagnosis of excessive blood loss Medical Device or Surgical management Intra-uterine Balloon Tamponade  Bakri balloon The Jada for PPH Medical Management of PPH  Bimanual compression/massage  Surgical management  Bakri Balloon  Massive transfusion protocol (MTP) Tone (atony)  Example OB Hemorrhage  Cart Quick access to emergency supplies  Refrigerator for meds  Establish necessary items and par levels  Label drawers/compartments  Include checklists  Develop process for checking and restocking  IV pressure bags  Sutures for B-lynch and modified B-lynch techniques  Bakri balloon  500 cc fluid for filling Fridge  Bag for drainage collection  Kerlex roll  Vaginal pack Nursing Management of PPH  Call for help  Assess and massage uterus properly  Ensure 18 G IV, LR with ongoing Pitocin  Emergency Cart  Weigh pads; monitor bleeding  Assess lochia for color, amount, and clots  Administer medications/blood/oxygen  Monitor vital signs  Insert Foley  Assign runner, recorder, CRNA, family liaison  Collect lab work as ordered Lacerations/Hematoma Under the “T” of Trauma  Injuries to the labia, perineum, vagina, and cervix  Hematoma  Cardinal sign is pain not relieved by analgesics  Lacerations  Bleeding despite firm uterus Trauma Vaginal Lacerations Trauma Episiotomy & Lacerations Extent of Episiotomies/Lacerations  1st -involves skin & vaginal mucosa  2nd –extends deeper into muscles of perineum  3rd-extends from skin & muscles to anal sphincter  4th -extends into rectum itself & rectal mucosa 21 Episiotomy 22 Vulvar and Vaginal Hematomas  Associated with forcep deliveries  Patients complain of rectal pressure Trauma Uterine Inversion Uterine Inversion  Nursing Actions  Discontinue Pitocin  Call for help  Start IV  Consider what medications you have available to relax uterus.  Fluid Resuscitation  Provider will manually replace uterus Retained Placental Tissue  Normal separation within 15 min  95% separation within 30 min  Retained placenta  Notseparated within 30 min of start of 3rd stage Tissue Abnormal Placental Implantation Placenta Acreta Syndrome Tissue Postpartum Hemorrhage: Algorithm  Most common medical complication Hypertensi in pregnancy. on in Significantly pregnancy contributes to perinatal morbidity and mortality. 29   Chronic Hypertension–CHTN  Gestational Hypertension-GHTN 4 types of  Preeclampsia-(AKA Pre-e or hypertension older slang term was ‘Toxemia’) (specific to  Preeclampsia with severe pregnancy) features  Eclampsia 30 Physiology Of Hypertension In Pregnancy  Narrowed blood vessels  Placental insufficiency/restricted blood flow/poorly oxygenated  Oligohydramnios = low amniotic fluid  IUGR, SGA 31 Chronic hypertension (CHTN) Present BEFORE pregnancy o May or may not be diagnosed already 140s/90s typical If new onset HTN develops prior to 20 weeks, it is CHTN. No protein in the urine Increased BPs remain x12 weeks after birth What fetal condition does the woman with CHTN need to be monitored for? Gestational Hypertension (GHTN) First occurs at 20+ weeks gestation during pregnancy- HTN >140s/90s 2 occasions, 4 hours apart No protein in the urine No systemic symptoms of preeclampsia Resolves following pregnancy 2% to 7% of healthy Preeclampsia nulliparous  HTN that develops >20 weeks pregnant get  Hypertension 140s/90s with: preeclampsi a  Proteinuria in a urine specimen  300+ mg in a 24 hr specimen  Or 0.3+ protein/creatinine ratio spot check  Resolves by 12 weeks postpartum  Common risk factors  Multifetal gestation  History of preeclampsia  Chronic hypertension  Preexisting diabetes and/or thrombophilias  Women with a new partner  Paternal factors Table 27-3 Preeclampsia with Severe Features Hypertension 160+/110+ and Proteinuria with one or more: o Thrombocytopenia o Impaired liver function o New onset renal insufficiency o Pulmonary edema o New onset cerebral disturbance (severe headache) o New onset visual disturbances Increased risk of placental abruption, IUGR, and still birth Resolves by 12 weeks postpartum 3 6 Eclampsia Seizure activity or coma (definitive) No history of preexisting (seizure-related) disorder Eclamptic seizures can occur before, during, or after birth Due to cerebral edema or cerebral hemorrhage Possible placental abruption Occurs in approximately 1 in 2000 to 1 in 3448 births YouTube: Preeclampsia And Eclampsia https://youtu.be/RB5s85xDshA (6.46 min) 3 9 Interprofessional Care  High risk patients can receive low dose aspirin in 1st trimester  Accurate BP’s at Clinic visits  Assess for  HTN  Edema/large sudden weight gain  DTR’s/clonus  Proteinuria  Symptoms of severe features GHTN & Pre-e Care Management  No Maternal and fetal assessment good  NST, BPP weekly evidenc  Fetal Movement Counts (4 or more in 1 hr) e o see Ch 26 for more on fetal testing to o support AFI and EFW bedrest o Labs weekly but it is o BP twice/week still prescrib o Daily weights ed  Regular diet with adequate protein Note: AFI is amniotic fluid index Pre-e with severe features 4 2  Pre-e With Severe Features  Inpatient management  Meds – Mag sulfate, antihypertensives, and betamethasone (if