NURS 4341 OB Exam 2 Study Guide -

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HYPERTENSIVE DISORDERS 2nd leading cause of maternal death and is r/t to other HTN complications  Stroke, Placental Abruption (Complete or Partial Detachment from Uterine Wall), Hepatic Failure/Rupture, Eclampsia & AKI  Blood Pressure > 140/90 RISK FACTORS Primigravida (6-8x the risk) Very Young <17yrs or AMA >40 Diabetes | obesity Pre-existing hypertensive, vascular, collagen vascular or renal disease Multiple gestation Hydatiform Mole  egg and sperm unite but have no genetic material Preeclampsia in previous pregnancy, family history  if dad’s siters or mom had any hypertensive disorders with their pregnancies, then mom has risk for HTN during her pregnancy First pregnancy with current partner  Can be associated with a new father PREECLAMPSIA Blood Pressure > 140/90 after 20wks gestation  If BP is 160/110 or more = severe preeclampsia (mom admitted) On 2 separate occasions at least 6 hours apart Proteinuria: 300mg or more on 24-hour urine (or 1+ on dipstick)  Severe= 500mg & 3+ on dipstick Hallmark Signs  Edema: face & hands, sacral area across lower back.

PREECLAMPSIA PATHO Vasospasms and hypoperfusion of organs (causing the increased BP) Pulmonary Edema – Listen to the lungs often Oliguria (decreased renal perfusion possibly leading to renal failure) Thrombocytopenia (RBC’s get damaged in the vessels with high pressure) CNS becomes more involved: Brain more stimulated and hypoxic (seizure risk)  HA, blurred vision, hyperreflexia (HALLMARK SIGN), seizures, CVA, stroke for mom RUQ pain = liver damage or liver rupture.

Poor placental perfusion – FHR late decelerations and increased variability  Leads to IUGR, Fetal Hypoxia, Oligohydramnios (decreases lung development, no cushion around the cord, no room for muscle development) ECLAMPSIA Preeclampsia w/ seizures of unknown Etiology Signs of impending seizure  Increased CNS involvement (visual changes, HA)  Leads to cerebral edema  RUQ pain.  Increasing DTR’s Life threatening (coma/death) Risk for aspiration | Pulmonary edema | Anoxia Keep mom safe and deliver baby ASAP to prevent fetal hypoxia or placental abruption from tremors HELLP EMERGENT - Fast exacerbation of hypertensive disorders which CAN occur without any of the other conditions Vessels begin to spasm and burst  Widespread formation of clots in the microcirculation

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CHRONIC HYPERTENSION Hypertension that is diagnosed before the 20th week of pregnancy or persists greater than 6-12 weeks PP NO proteinuria or Edema Ages placenta, risks for infarct/abruption.

Watch BP, for edema, kick counts, NST’s, antihypertensive meds. IUGR GESTATIONAL HYPERTENSION Elevated B/P in pregnancy or 1st 24 hours PP without signs of Preeclampsia Elevation to 140/90 on 2 occasions 6 hours apart No previous history of HTN – BP returns to normal within 6 -12wks PP  If hypertension persists for longer than 12 weeks PP = chronic HTN NO proteinuria or edema HYPERTENSIVE DISORDERS DIFFERENTIATION Chronic hypertension with superimposed preeclampsia (proteinuria and edema) o Intracranial bleed and abruption Recognize S&S such as Increased BP and Increase/Decrease of DTR’s PREECLAMPSIA NURSING MANAGEMENT Bedrest, drink something, Lie in Lateral position (LLD), quiet environment Teach how to monitor B/P, urine dipstick for protein if at home Teach Fetal kick counts (10 movements every hour | check once a day) – check at night when baby is very active, monitoring for contractions, monitor for edema EFM, seizure precautions, NST’s, low stimulation & stress (away from RN station) Possibly give glucocorticoids to increase surfactant production aiding in fetal lung maturity  Lessens respiratory distress at birth Monitor to prevent progression to more severe form Strict I&O/Foley, Fluid restriction to 125mL/hr  calculate EVERY HOUR (IV meds too) MgSO4 (Initially 4-6 G over 5-30 min then maintenance dose to 2-4 G/hr)

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ECLAMPTIC SEIZURES – NURSING INTERVENTIONS Begins with the same management as Preeclampsia Stay with the patient and prevent injury!!!  Call for Help Maintain a patent airway as much as possible – side lying + suction equipment Give supplemental oxygen Establish or maintain IV site Administer Magnesium Sulfate if not already running to decrease CNS excitability and relax smooth muscles. (Watch for Hypotension) Ensure adequate fetal monitoring Prepare for delivery – get mom to L&D ASAP, notify NICU, notify OR if needed.

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MAGNESIUM SULFATE Decreases seizure potential | Initiate Seizure precautions | Most seizures occur PP  increases bleeding (smooth muscle relaxant) 4-6 grams loading dose over 5-30 minutes, then 2-4 g/hr Use with caution if there is renal impairment.

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NOT a primary disease, but a secondary event  Hemolysis of RBCs  Elevated  Liver enzymes (LDH, ALT & AST) – Portal hypertension from blood pooling where the vessels are bursting.  Low  Platelets (PT, PTT, fibrinogen and bleeding time)  Platelets will look low because they are being consumed by the lesions in the vessels  Also look at uric acid, 24-hour urine for protein Can have DIC with HELLP = poor prognosis.

Can have liver rupture (watch for ^ RUQ pain), CVA, cardiac arrest, ARDS, renal damage HYDRALAZINE Reduces BP via smooth muscle relaxation, may cause hypotension, Increased HR & CO Caution: heart disease Side effects: tachycardia, hypotension, HA, sodium retention, U/P insufficiency

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LABETALOL Antihypertensive without decrease in maternal HR and CO Side Effects: Hypotension, dizziness, N/V, bradycardia, rash, increased airway resistance CONTRAINDICATED IN WOMEN WITH ASTHMA!!!

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NIFEDIPINE (PROCARDIA) Dilates coronary arteries and decreases systemic vascular resistance Side Effects: Hypotension, HA, Dizziness

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HEMORRHAGIC DISORDERS Any bleeding in pregnancy = medical emergency!!! (maternal & fetal death) Women in pregnancy increase their blood volume by 40-50% 15% of maternal cardiac output (1 L/min) flows through the placental bed at term Blood loss may reach 40% before hypovolemic shock occurs.  Body’s compensation for blood loss = vasoconstriction to conserve blood volume.  BP and Pulse stay the same.

Unchecked bleeding can result in complete exsanguination in 8-10 minutes Most bleeding in 1st trimester is related to spontaneous abortion, gestational trophoblastic disease and cervical insufficiency (Incompetency) Most hemorrhagic deaths are related to ectopic rupture – pregnancy in the fallopian tube.

Most bleeding in 2nd & 3rd trimester related to placenta previa OBSTETRICAL HEMORRHAGE Hemorrhage: a 10% decrease in hematocrit OR a need for a transfusion Hemoglobin will decrease 1-1.5 g/dl & Hematocrit will decrease 2-4% for each 450-500 cc of blood loss Hemorrhage in Vaginal deliveries = 3.9% Cesarean deliveries = 6.4%

PLACENTA PREVIA

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Side Effect - Hypotension ALWAYS ON A PUMP!!

Strict I&O Assess vital signs every 5-15 minutes during loading dose then every 30-60 minutes.

Watch for magnesium toxicity  4-6mEq/l: therapeutic  10mEq/l: loss of DTRs (Check hourly)  15mEq/l: respiratory depression (Watch RR’s)  25mEq/l: cardiac arrest Antidote: CALCIUM GLUCONATE 5-10mEq IV over 5-10 minutes Use Pitocin (to help clamp the uterus down), AVOID Methergine = increases B/P METHYDOPA (ALDOMET) Can be used to tx chronic HTN, to improve uterine blood flow and fetal growth LASIX Diuretics not recommended in pregnancy unless there is pulmonary edema (pulls fluid away from the baby) Hyperpermeability associated with low serum albumin (protein in the urine) – causing the edema  related to the endothelial dysfunction, no fluid volume overload. The vessels are spasmatic causing nicking and fluid leaks out, protein leaks out When all other treatments fail, delivery is the only cure Regardless of the gestational age the choice may be neonatal morbidity to prevent maternal mortality Pt @ 36wks gestation presents to L&D c/o constant HA for past 2 days, face “seems more swollen than usual” – have the patient in bed, relaxed, place her on the monitor, take her blood pressure, get a urine sample to check for protein, then notify HCP OTHER HEMORRHAGIC DISORDERS Miscarriage  SAB Spontaneous- all tissue passed; threatened-bleeding/cramping may or may not result in loss of pregnancy  Inevitable: bleeding/cramping with dilated cervix  Incomplete: some but not all tissue lost – need sx to remove retained part.  Missed: fetus there, no FHR  Habitual: 3 or more with unexplained reason) Can’t cause or prevent a miscarriage Ectopic- Pregnancy in wrong place 3rd most common pregnancy related death in US Cervical Insufficiency (cervical incompetence) painless cervical dilation, cervical weakness  TX: Cervical Cerclage (sutures to tie it close) – can’t do this in a miscarriage (cervix has the problem)  After cerclage place in slight Trendelenburg to decrease pressure of the uterus on the cervix  May need to help prepare her for procedures, give RhoGAM - if indicated Gestational Trophoblastic Disease (Hydatidiform Mole and Choriocarcinoma)  No fetal tissue – from fertilization of empty egg, there is no fetal tissue  Proliferation of rapid dividing cells that invade wall of uterus = forming cancer  TX: evacuate uterus, Methotrexate (Chemo therapeutic treatment)  follow with serial hCG levels (don’t want hCG levels to rise)  Teach: avoid pregnancy X’s 1 year PLACENTAL ABRUPTION

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Asymptomatic/Painless uterine bleeding in 2nd or 3rd trimester (BRIGHT RED/FRANK BLEEDING)  1st significant episode usually between 29-30 wks EGA  Clots indicate normal coagulation process  Pain usually indicates combined abruption Abnormal implantation of the placenta in the lower uterine segment  placenta should be implanted on the fundus/anterior uterine wall Classified by degree to which cervical os is covered by placenta Theoretical causes: uterine scarring, late development & implantation of ovum MANIFESTATIONS Pallor Fetal malpresentation, High station (placenta taking up room in low uterus) Air Hunger (very late sign) RISK FACTORS Increased parity & short intervals between pregnancies AMA (>35, 1/100; >40, 1/40) Minority race (Asian women 85% higher) Large placenta (multiple gestation, diabetes) TREATMENT Ultrasound to confirm Symptomatic approach (AVOID speculum and vaginal exams) IV (Non-Dextrose crystalloids  RL or NS) O2, LLD Type & crossmatch blood in case blood transfusion needed.

Strict I&O (blood loss: 1g = 1ml/1oz = 29-30ML) Anticipate C-section if complete or significant bleeding COMPLICATIONS Blood loss  Maternal shock, Hypoxic organ damage | renal failure, thrombocytopenia &/or death UTERINE RUPTURE Separation of the uterine myometrium or previous scar, with rupture of the membranes and extrusion of the fetus or fetal parts into the peritoneal cavity Can occur over hours – Increased abdominal tenderness to vomiting, syncope, vaginal bleeding, tachycardia, pallor and FHR pattern changes Suspect abdominal bleeding if woman has tense abdomen with shoulder pain!!!!

Can result in complete cardiovascular collapse RISK FACTORS Previous Cesarean delivery Oxytocin use Epidural anesthesia  mom numb and unable to report abnormalities  “Feels like something has ripped or given way” Abruptio placenta  trauma from the abruption.

Breech version and extraction  turning baby from the outside PREVENTION STRATEGIES Waiting for spontaneous labor (no cervical ripening or Pitocin!!)

Misoprostol should never be used when attempting VBAC (Vaginal Birth After Cesarean) UTERINE DEHISCENCE Dehiscence: separation of the old scar, but the fetus generally remains inside the uterus.

Generally no membrane rupture here.

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Sudden onset, intense, localized uterine pain with or without vaginal bleeding Enlarging uterus | firm & tender | Contractions difficult to palpate  Low amplitude, high frequency contractions (20-30 seconds apart)  uterine irritability – abdomen and uterus filling with blood c/o low back pain External blood loss  Revealed Internal Bleeding  Concealed (mostly where the pain comes in) Separation  normally implanted placenta separates from the uterine wall before delivery of the fetus Signs/symptoms of blood loss – late sign RISKS Hypertension Rapid decompression of the uterus (2nd twin or hydramnios)  1 twin is delivered, uterus can decompress quickly causing it to sheer away from the uterus Abdominal trauma (blunt, amniocentesis) Increased parity Uterine fibroids   TREATMENT SAME AS PLACENTA PREVIA COMPLICATIONS Couvelaire Uterus – SO much blood it flows out of the fallopian tubes into the abdominal cavity.

Prematurity Maternal shock  increased HR, decreasing BP Hypoxic damage to organs | Renal failure | thrombocytopenia | Death |

INVERSION OF THE UTERUS The uterus is turned inside out.  May be d/t type/amount of fundal pressure during massage or from pulling on the cord to help separate the placenta.

Massive bleeding | Life Threatening MULTI-GESTATION 1+ egg fertilized  d/t IVF, AMA, reproductive technologies Maternal: increased risk of preterm labor, hydramnios, anemia, preeclampsia, and antepartum hemorrhage Fetal: Increased risk for RDS, congenital anomalies, prematurity, birth asphyxia, twin to twin transfusion (one baby getting preferential blood flow over the other), IUGR,  Monozygotic: from single egg= identical twins  may have same or different placenta/membranes  Dizygotic: 2 eggs/2 sperm =fraternal twins  always different placentas/membranes MANAGEMENT Nutritional counseling to meet needs of fetuses EFM starting early (28 weeks) to monitor health of all fetuses Teaching signs of preterm labor and preeclampsia Increased risk for PPH – overdistended uterus.

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PREMATURE RUPTURE OF MEMBRANES GESTATIONAL DIABETES PROM  rupture of membranes an hour or more prior to the onset  Obesity of pregnant women increases risk of GDM of labor.  Well controlled blood sugars during pregnancy have the same outcomes as pregnancies not If PROM occurs before 37wks gestation = preterm PROM, or complicated by diabetes PPROM (not SROM)  not in labor after membranes rupture.  Pregestational Diabetes  diabetes occurring prior to pregnancy The gestational age of the fetus at time of rupture has significant  Risk of teratogenicity d/t uncontrolled sugars and microvascular disease– fetal loss in 1st implications. trimester Management is dictated by the presence of overt intrauterine  Congenital anomalies (cardiac, skeletal, GU, NTD, renal, CNS, jaundice) infection, advanced labor or fetal compromise. Also depends on  Fetal asphyxia  respiratory distress syndrome (decreased surfactant production due to gestational age. If mom is @ term – move to delivery/induction hyperinsulinemia) ETIOLOGY/RISKS  Gestational Diabetes  developed during the pregnancy or first recognized during pregnancy Intrauterine infection (STI’s)  Placental hormones cause increased insulin resistance – the larger the placenta = greater insulin  The longer the rupture, the greater risk of infection resistance. (endometritis, chorioamnionitis, sepsis, and neonatal  Insulin production should increase in response to this to maintain normal glucose levels. infections)  If not = gestational diabetes  If infection, get baby out, don’t treat mom with antibiotics  biggest risk is macrosomia (baby larger that 4000 grams), – increased birth trauma, until after newborn hypoglycemia.

Uterine distention (hydramnios, twins)  Increased risk for Pre-eclampsia, preterm birth, operative delivery, infections (ketoacidosis) and Complication from cervical cerclage mortality Preterm labor  if mom is preterm (Bedrest, EFM, Steroids for fetal  DKA occurs at lower sugars than in non-pregnant patient lung maturity)  Requires more frequent follow up (Meds, OB appointments, echocardiograms, NST’s, Labs, U/S, prior preterm delivery (esp. due to PROM) BPP, EFM= $$$$) vaginal bleeding  no vaginal exams until labor onset  Multi-disciplinary management team In many cases, PROM occurs in the absence of recognized risk factors.

SCREENING FOR DIABETES ANTENATAL CARE Usually done at 1st prenatal visit  Maintain pre-prandial glucose <92 mg/dl  Fasting > 126mg/dL or higher  Postprandial 180mg/dl @ 1 hour (ACOG recommends < 130mg/dL)  HbA1C > 7%  Maintain BG by insulin, or Glyburide (not 1st line – more studies needed)  Random > 200 mg/dL  Insulin usually given 2-3 X’s/d Screening Test at 24-28 Weeks (Not dependent on time of day or time since  Nutritional consult | Diet | Exercise last meal)  Teaching self-monitoring/finger sticks | How to administer injections  Give 75 grams oral glucose  Teach signs/symptoms of hyper and hypoglycemia  Draw blood 1 hour after glucose finished  Early fetal testing (EFM), fetal echocardiogram (cardiac anomalies  If 1 hour level above 140mg/dl – 3-hour glucose tolerance test ordered.  Ultrasound (fetal growth, Amniotic fluid, placenta) 3-hour GTT (Diagnostic) POST-PARTUM  75 gm glucose after 3-day high carb diet at least 150 g/d  Insulin needs significantly decrease or none at all in the immediate PP  Should be:  Remember pre-eclampsia/eclampsia can occur in the PP timeframe  Fasting < 92  At risk for post-partum hemorrhage (macrosomic infant and polyhydramnios) and  One-hour < 180 infection  Two-hour < 153  Teach mom that she is at high risk for diabetes later in life  Three-hour < 140  Breastfeeding Encouraged  If 1 or more above = Gestational Diabetes  Breastfeeding has antidiabetogenic effect (children have a 70% chance of Type II diabetes &/or obesity later in life.)  Remember- infant may be kept in NBN longer to be monitored for hypoglycemia PREGNANCY & SURGERY APPENDICITIS If planned procedure 2nd trimester is the safest  Perforation of the appy – moms pass off pain Aspiration precautions d/t pressure/displacement of abdominal contents and  PTL incidence 83% with perforation or if the appendix actually ruptures. relaxed lower esophageal sphincter – suction at the bedside.  S&S  Pain in right flank vs RLQ In the case of twins/triplets – ensure there is a nurse available for EACH  Rebound tenderness/guarding - less reliable sign in pregnancy infant  Surgery should be laparoscopic if mom is prior to 20wks  Laparoscopy safe at 26-28 wks, if later, risk for uterine puncture PREGNANCY CHANGES THAT INCREASE SURGICAL RISKS  Laparoscopy Advantages: less OR time, smaller incision, decreased recovery, Bladder up in the abdominal cavity earlier ambulation decreased thromboembolic disease

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Slight decrease in number of platelets Increased clotting factors hypercoagulable state Increased pelvic venous congestion GDM – stress of surgery altering blood sugar levels

SIGNS PRECEDING LABOR (DOES NOT IMPLY LABOR HAS STARTED!) Lightening Urinary Frequency Backache Braxton Hicks contractions – short usually not painful, tightening or contractions of uterus. Should have less than 6 in an hour – goes away with change in activity Flu-like symptoms or fatigue Surge of energy (nesting) Slight weight loss Bloody show – cervix is getting softer and some bleeding might show Cervical ripening Loss of mucous plug  FETAL FIBRONECTIN  Normally seen in cervical secretions up to 22 weeks and again at about 34 weeks  If present btn 22-34 may indicate she is at risk for PTL  More predictive that she WILL NOT deliver within next 2 week if FFN test is negative ROM (note date/time, color, amount, odor) bag of waters (or membranes) intact (BOWI or I) or ruptured and if ruptured for how long = can indicate risk factors.

PRETERM LABOR Labor occurring prior to the completion of 37 weeks of gestation.

Risks include: Low pregnancy weight, low SES, no prenatal care, multiple gestation, Hx of previous preterm births, 1+ spontaneous & second trimester abortions, uterine anomalies, UTI (Infection), PROM, Placental hemorrhage, AMA or younger than 16yrs old, cervical incompetency The major cause of preterm delivery.  Neonatal death d/t congenital malformations or is delivery happens prior to 24 weeks  Infants born weighing less than 1,500 g are approximately 200 times more likely to die in the first year of life than those weighing more than 2,500 g. –2lbs and a few extra weeks in the uterus are vital  Those surviving are 10 times more likely to be neurologically impaired | developmentally delayed | visual and hearing impairment, chronic lung disease, and cerebral palsy.

Uterine Causes: unicornate and bicornate uterus, DES exposure SIGNS & SYMPTOMS OF PTL Regular uterine contractions (6 or more in an hour) Lower abd cramping (may be mistaken for gas) Low back pain/discomfort – similar to menstrual cramps Change in vaginal discharge/ROM Pelvic pressure

FETAL SURGERY May be required to save life  Infection risk or need for RBC transfusion Risks include PTL, preterm delivery, or uterine rupture - ICU stay for mom CONDITIONS CONSIDERED WORTH THE RISK  Twin to twin transfusion (recipient twin with polyhydramnious and hydrops &/or donor twin has oligohydramnious, growth restrictions)  Spinabifida with hydrocephalus  Obstructive uropathy TRUE LABOR vs. FALSE LABOR True Labor  Contractions get stronger and more regular  Progressive cervical dilatation on vaginal exam  Bloody show?? Mostly just an indicator that cervix is softening.  Rupture of membranes – is this really labor?  Come to the hospital when: o Contractions are q 5 minutes in the nullipara o When they are q 10 minutes in the multipara—usually there is “blood show” o When membranes rupture (pH - > 6.5 means nitrazine paper is blue, while urine is usually around 5– 6) False Labor  Contractions slow or stop with changes in activity No change in cervical dilation after 1-2 hour trial  

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BISHOP SCORE (CERVICAL RIPENING) 

PRETERM LABOR MANAGEMENT HYDRATION & relax on side, palpate abdomen for fetal kick counts.

Watch vital signs, labs, DTR’s, I & O’s Tocolysis Magnesium sulfate – smooth muscle relaxant Beta-mimetic agents  Terbutaline  Side effects: increased HR, nervousness, N/V, increased blood/urine glucose, decreased K+ levels, cardiac arrhythmias, pulmonary edema (black box warning d/t cardiac effects outweighing the benefits of stopping labor) Indomethacin  Maternal side effect: Increased bleeding time, risk to exacerbate hypertensive disorders  Fetal side effects: oligohydramnios, premature closure of ductus arteriosus  Do not give if mom is in the later parts of labor Nifedipine Adjunctive Therapy Corticosteroid Therapy (effects within 48hrs of administration, repeat every 7 days) – stimulating surfactant production Aggressive obstetrical and neonatal interventions have had minimal effects on the survival of infants born at 22-23 weeks gestation.

Criteria for current viability threshold is 24 weeks gestation or 600 g weight.

AUGMENTATION OF LABOR the stimulation of uterine contractions after labor has started spontaneously but

Nulliparas – 9 or more | Multiparas – 5 or more

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THE 5 P’S OF LABOR We don’t know what causes it – but know what affects it.

The Passenger (Fetus and placenta) The Passage (birth canal: soft tissues and boney pelvis) The Powers (contractions) Position (maternal) The Psyche (psychological response)

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progress is unsatisfactory CHEMICAL AGENTS FOR CERVICAL RIPENING Prostaglandin E1 - Cytotec (misoprostol) Prostaglandin E2 – Cervidil, Prepidil (dinoprostone)

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MECHANICAL METHODS OF CERVICAL RIPENING Balloon catheters Hydroscopic dilators – Laminaria, Lamicel Amniotomy Membrane Stripping

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THE PSYCHE “You can do it!”  tell them they are doing well and that they can do it

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  THE PASSENGER SUTURES AND FONTANELLES  Allow molding of the head and serve as landmarks to assess fetal attitude & position o caput succedaneum o cephalohematoma  Vertex: The smallest diameter of the fetal head that moves through the pelvis first - crowning (suboccipitobregmatic) FETO-PELVIC RELATIONSHIPS The part of the fetal body that enters the pelvis first and leads through the birth canal.  Cephalic  Breech  need for external cephalic version to turn baby  Shoulder PASSENGER FETAL ATTITUDE The relationship of fetal parts to each other  Vertex (flexed) (A)  Military (extended) (B)  Brow or Face (extended) (C&D) PASSENGER FETAL LIE The relationship of the fetal spine to the maternal spine  Vertical lie - cephalic or breech  Horizontal or transverse lie

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THE PASSAGEWAY The bony pelvis (4 types: gynecoid, android, anthropoid, platypelloid)

The soft tissues - cervix, vagina, perineum Estradiol, Progesterone, Relaxin, and Prostaglandins increase tissue size and elasticity THE POWERS Uterine contractions cause effacement and dilation You DON’T have to check dilation every hour!!

Hydrostatic force of the membranes & amniotic fluid facilitate effacement and dilation Secondary - bearing down efforts (pushing) in the second stage facilitates expulsion.

THE POSITION Affects maternal and uteroplacental perfusion Affects maternal perception of pain and can promote rest Changing positions facilitates fetal rotation Provide more maternal control + allow for more interaction w/ support persons RECUMBENT POSITION (NOT INDICATED) Aortocaval compression leading to maternal hypotension and fetal distress Narrower birth canal Loss of pelvic mobility Loss of gravity Less efficient contractions Greater discomfort and pain Slower progress of labor LATERAL RECUMBENT POSITION Corrects aortocaval compression Can be used to facilitate rotation of baby Facilitates interventions - Monitoring, regional anesthesia Semi-recumbent, no stirrups Hands and Knees LITHOTOMY POSITION (NOT INDICATED)

PASSENGER FETAL POSITION The relationship of the presenting part to the maternal pelvis  OA: Occiput Anterior - optimal position for labor (baby looking at mom’s spine)  OP: Occiput Posterior - prolongs first and second stage labor; typically causes “back labor” (baby looking at mom’s stomach)  OT: Occiput Transverse - causes arrest of descent at the ischial spines (baby looking at one thigh or the other) PASSENGER FETAL STATION (engagement) – at the Ischial Spines Floating (ballotable) = -4 -3 -2 -1 0 +1 +2 +3 +4 = Crowning o 0 is called “0 station” o Bigger the – number, the further they are from the exit.  Synclitism  Asynclitism STAGES & PHASES OF LABOR 1st STAGE  From onset regular contractions to completely dilated (ends when completely dilated)  Dilation occurs approximately 1 hour per cm in nullipara, faster in multipara  Latent Phase - thick to 100% effaced, 0-3 cm dilated; cervix moves from posterior to anterior; can take hours or days  Active Phase - 3-7 or 8 cm dilated  Transition Phase - 7 or 8 to 10 cm dilated; most rapid and most uncomfortable 2nd STAGE  Pushing and birth of baby – when mom has the sensation, she can push  “Labor down” if mom’s epidural is preventing her from pushing  Latent – rest and calm, passive descent of fetus, “laboring down”  Descent – strong urge to bear down  Transition – presenting part is on the perineum 3rd STAGE  Delivery of the placenta  Usually delivers spontaneously within 10-15 minutes (can be up to one hour).  Pitocin Bolus  Cord blood for fetal blood type or cord gases may be drawn before or after delivery of placenta  Examine placenta for appearance; birth attendant may want to send it to pathology  Family is often interested in the placenta 4th STAGE  Recovery  VS q 15 minutes  Check fundus and lochia q 15 minutes; massage if indicated  Ice pack to perineum if injured or edematous  - REEDA (redness, edema, ecchymosis, drainage, and approximation of edges)  Warm blanket for maternal comfort  Observe for S/S hemorrhage  Promote bonding and initiate breastfeeding  Assess sensation and strength after epidural  Accompany on first ambulation - dangle first and observe for dizziness  Measure first void – should be 150mL  Teach peri care DILATION, EFFACEMENT & STATION  Dilation – how open is the cervix (0-10cm)  Effacement -how thin is the cervix (Long/Thick – 100%)  Station – how high or low the presenting part is

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Causes aortocaval compression Narrows birth canal | Stretches perineum Prolonged or poor positioning in stirrups can cause vascular and nerve damage Most convenient for the obstetrician UPRIGHT POSITIONS Utilize gravity to speed labor progress Facilitate rotation of fetus through the pelvis – basic physics of gravity  Semi-reclining  Sitting (chair or rocking chair)  Standing  Squatting

LABOR & BIRTH COMPLICATIONS Labor Dystocia – long, difficult, or abnormal labor The Powers (hypotonic ctx) The Passage (small pelvic structures) The Passenger (LGA) Position (OP)  abnormal presentation The Psyche (Fighting the process)  Associated with: Epidural analgesia  Multifetal pregnancy - Maternal Exhaustion  Ineffective maternal pushing – may be due to large fetus

LABOR Different for everyone (verbal response, cultural response, support person present)  Closed-Glottis Pushing  Increased intrathoracic pressure  Decreased maternal venous return  Maternal hypotension  Decreased cardiac output  Decreased uterine blood flow  Fetal hypoxia and acidosis  Open Glottis Pushing  Woman-directed  Characterized by sounds - breathing or grunting (not high pitched)  Decreases CV changes  Allows gentle delivery of the head – birth trauma Physiologic Effects of Labor Cardiac - increases workload; increases heartrate; BP may increase during contractions but should remain the same otherwise Respiratory - increased oxygen demand; affected by pain and anxiety GI - slowed bowel motility; prolonged gastric emptying; vomiting common in labor 

 IE: 5/30%/-2 ANAPHYLACTOID SYNDROME OF PREGNANCY (AMNIOTIC FLUID EMBOLISM)  Amniotic fluid containing particles of debris enters maternal circulation  Risks- multiparity, abruptio placentae, short tumultuous labors, oxytocin augmentation or induction, macrosomia, IUFD, operative birth.  Maternal complications - acute respiratory distress, cyanosis, cardiovascular collapse, profound shock, coma, DIC, and death  S/S - acute respiratory distress, cyanosis, CV decompensation, bleeding.  Management  Oxygen – ventilation support (CPR)  ABGs - Invasive hemodynamic monitoring  Blood and blood products  Heparin Immediate delivery

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OXYTOCIN INDUCTION/AUGMENTATION Administration – titrated IV drip via pump piggybacked in most proximal port of IV line  Dosage – 1-2 mU/minute, increased by 1-2 mU q 30-40 minutes  Monitor – CTX frequency, duration, intensity, and uterine resting tone; FHR pattern, maternal VS, labor progress  Contraindicated in cases where vaginal delivery is inadvisable  Hazards – uterine hyperstimulation (tachysystole)  Signs – CTX frequency <q 2minutes, duration >90 seconds, uterine resting tone > 20 mmHg; non-reassuring FHR tracing  Interventions – Turn off infusion, turn Mom to side, O2 via face mask, IV fluid bolus, notify primary care provider, may need to give Terbutaline; document responses to actions  Other Hazards: water intoxication, tumultuous labor with tetanic contractions, placental abruption, uterine rupture, cervical lacerations, PP hemorrhage, consequent fetal effects SHOULDER DYSTOCIA UMBILICAL CORD PROLAPSE Failure to deliver the fetal shoulders by the usual cardinal movements after the head has  A loop of the umbilical cord lies beside or below the presenting part of been born the fetus Risks: Increased size of fetus, maternal obesity, excessive maternal weight gain,  Risk factors - long cord, anything that prevents engagement of the contracted pelvic outlet, protracted labor fetal head in the cervix (malpresentation, CPD, multiple gestation, Maternal complications - trauma to pelvis or birth canal polyhydramnios, congenital anomalies) Fetal complications - fractures clavicle, brachial plexus palsy, asphyxia, death  Amniotomy should be delayed until head engages in cervix.

S/S - delay in delivery of shoulders following delivery of the head, “Turtle sign”  Fetal consequences - compression of cord leading to asphyxia or  Retraction of the fetal head immediately on it’s delivery death Intervention: McRobert’s maneuver – have mom move legs back and out and apply  S/S - visualization of the cord at the vaginal introitus, palpation of suprapubic pressure – fist on abdomen and push down NO FUNDAL PRESSURE! pulsing cord on vaginal examination, fetal distress on monitor tracing Generous episiotomy  Intervention: Knee-chest or trendelenburg position, lifting fetal Anticipate resuscitative support of baby presenting part off cord, emergency cesarean delivery Flip mom over onto her hands and knees to try and get the baby moved.

Possible cesarean section PERINATAL LOSS & GRIEF PARENTS NEEDS Help parents and family members actualize loss – don’t act like nothing  Mourning - the process by which an individual reorganizes and adapts following happened. the death of a loved one. The emotion that dominates this process is grief.

Help parents with decision making – sudden chaos, need help knowing what to  Reality of pregnancy (validation) do next.  Recognition that something was wrong – help explain things so they can understand Help bereaved acknowledge and express feelings (siblings & grandparents too) what happens and how it affects further pregnancies.

Normalize grief process and facilitate positive coping  grief is NORMAL and  Appropriate and sensitive medical intervention painful  Concern for the ability to produce a subsequent normal, healthy pregnancy PRINCIPLES OF ATTACHMENT  Give as much control as possible – assist where needed but give them space Maternal attachment precedes paternal attachment  Pictures | Keepsakes (footprints, hand prints) The baby becomes “real” to the mother and family as the pregnancy progresses  “Being a Parent” – bathe them, dress them. (allow them to say hello so they can say Attachment is influenced by many factors, including previous losses goodbye) - The cherished goodbye Divorce rate increases four-fold with NICU admission – parents grieve differently,  Autopsy financial concerns, not sure how to talk about it.  Burial is required if baby is greater than 20 weeks gestation, greater than 350 Moms tend to get more support than fathers. grams, (10-12 ounces) or has life signs at birth “Mothers grieve the first year, fathers grieve the second.” – The differences in  Parents have the right to bury any baby grieving styles and patterns set couples up for conflict. Nurses can offer  Baby may be buried at gravesite of a grandparent anticipatory guidance to prepare them for this. 

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THEORY OF CARING Knowing: Don’t go in with preconceived ideas of what the parent(s) knows, feels or wants to know

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PHYSICAL CARE OF MOM Remember –She is still a post-partum women Provide pain control & discomfort relief

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Being With: No perfect words – just be there; “Don’t just do something, sit there!”

Enabling: Give them the information, teach them, allow her (them) to make the decisions Laying on of Ears: 2 ears 1 mouth = listen twice as much as you talk.

NON-PHARMACOLOGIC COMFORT MEASURES Stay with mom | allow for her support people to be present Allow mom to select position most comfortable for her that will help her fell in control Hydrotherapy Acupressure Aromatherapy Hypnosis | Music | Imagery/Focal points Counterpressure (on the sacrum) Effleurage Touch and massage – in the direction of hair growth (not up and down) Heat/cold Water Therapy TENS (trans electrical nerve stimulation) Breathing techniques  breathe through the contraction, not deep breath before POSITION CHANGES and movement walking/rocking Emotional support/encouragement Updates on progress – physiological support Continuous positive reinforcement | Updates on progress – physiological support NERVE BOCK ANALGESIA & ANESTHESIA Local perineal infiltration anesthesia  Local - local anesthetic (1% Xylocaine) is used to infiltrate the perineal tissue at delivery for episiotomy or perineal repair Pudendal nerve block – numbs the entire perineum to be numb.  Pudendal - local anesthetic is used to infiltrate the pudendal nerve a few minutes prior to delivery to numb the perineum Spinal Anesthesia (block) Epidural  local anesthetic &/or narcotics are infused through a plastic catheter placed in the epidural space during the first stage of labor  Insert IV | Continue EFM  Platelets >100,000  IV bolus of 500-1000mL NS or LRS to prevent Hypotension  S/E  Epidural blood patch  (spinal headache) seen PP  Tx with creating a blood patch by inserting blood to clot Combined Spinal-Epidural  Epidural needle inserted, then smaller spinal needle inserted through that into subarachnoid space. (No local anesthetic used) Spinal  local or narcotic medications are injected into the subdural space through a needle for anesthesia during obstetric surgery Laboring epidural – Numb up to the umbilicus Surgical epidural – numb up to the nipple line Intrathecal – catheter left there and continuous dosing EPIDURAL ADVANTAGES Frequently provide complete pain relief

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Still needs routine post-partum care - Rhogam May be at risk of hemorrhage (still needs Pitocin, fundal massage, vs, taught about breast care, lochia & all the routine PHARMACOLOGIC METHODS Systemic Medications IM or IV (attempt to give <1 hour or >4 hour prior to delivery Opioids  Demerol (Meperidine)  Stadol (Butorphanol)  Nubain (Nalbuphine)  Fentanyl  Morphine ADVANTAGES Provides some relaxation and analgesia Counters the effects of catecholamines in labor Low cost | May be administered by the bedside nurse Mother can still move to assume different positions/ambulation DISADVANTAGES Provides incomplete pain relief May slow labor May cause hypotension if administered too quickly Parenteral medications circulate through the placenta Can cause respiratory suppression in neonates and in mom   Have Antidote: Naloxone (Narcan) - Counteracting Respiratory Suppression  Or to counter side effects of neuraxial opiods (Epidural): pruritus, N/V, urinary retention GENERAL ANESTHESIA The absence of sensation and consciousness induced by various anesthetic agents, primarily by inhalation or injection.

Used only for true EMERGENY deliveries.

ADVANTAGES Rapid induction for emergent deliveries DISADVANTAGES Mom can’t protect her own airway (aspiration, airway injury) Mother cannot participate in delivery, family is usually not allowed into the OR, breastfeeding is often delayed Profound fetal cardiorespiratory suppression - baby must be delivered within a few minutes of induction NURSING SUPPORT Mom and fetal monitoring – basic level Change the syringe or bag of medication if the same medication/dosage with an order Stop infusion if safety a concern May remove catheter after appropriate education Witness informed consent – may not obtain consent PROHIBITED NURSING ACTION DURING GENERAL ANESTHESIA Initiate, insert, bolus/re-bolus infusions Manipulate doses of continuous infusion or manipulate dosage intervals for PCEA Increase/decrease dose of continuous infusions Verify correct placement Prepare or program medication or infusion device

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Pain meds can be given continuously or bolused PRN (Also using EPCA) Does not directly affect the fetus Most indirect effects to the fetus can be prevented or easily corrected Can be used to provide surgical anesthesia (C/S) EPIDURAL DISADVANTAGES Expensive - Requires an anesthesia practitioner Invasive - carries risks of infection, bleeding Limits maternal mobility Slows first and second stage labor Increased rate of operative abdominal and vaginal delivery – using forceps and vacuum for delivery Increased use of oxytocin EPIDURAL COMPLICATIONS Maternal hypotension – how do we help prevent?

Total spinal block – looses respiratory drive if above the nipples

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Reinitiate infusion that has been stopped