Threatened Abortion manifested by vaginal bleeding, usually bright red in color and moderate in HIGH RISK PREGNANCY  One

in which the mother or fetus has a significantly increased chance of morbidity, mortality or both before, during or amount. There are no associated symptoms such as cramping, backache and no cervical dilatation until 29 days after birth or an increased chance of subsequent disability  Treatment  Complete bed rest, restriction of activities Psychosocial Factors  Restrict coitus for 2 weeks following bleeding  Emotional aspects Imminent Abortion - Products of conceptions will be expelled if uterine contraction & cervical dilatation  Race black mother have smaller newborns  Occupation and income occurs, the loss of the products of conception is inevitable, cramping, backache and vaginal bleeding  Teenage mothers  Treatment  Save and bring to the hospital any tissue fragments Paternal Factors DM, Rho O immunization  D/C, IVF, replace blood loss High Risk Factors that Contribute to Perinatal Morbidity & Mortality  Hereditary abnormality  Small for dates  Congenital anomaly, anemia, blood dyscracias, pre-eclampsia  Severe social problem (teenage pregnancy, drug addiction)  No antenatal care  Younger than 18 years old and older than 35 years old  Teratogenic viral disease  Fifth subsequent pregnancy  Prolonged infertility  Significant stressful or dangerous events (critical accident, excessive exposure to addiction)  Heavy cigarette smoking  Conception within 2 months of a previous delivery Neonatal Factors  Prolonged rupture of membranes  Abnormal presentation and delivery  Prolonged difficult labor  Prolapse cord  Birth asphyxia  Fetal heart rate fluctuation  Meconium staining  Fetal acidosis  APGAR score less than 7  Preterm labor  Post term labor  Small for dates infants  Large for dates infants  Any respiratory distress or apnea  Obvious congenital anomalies  Convulsions, limpness, difficulty in sucking or swallowing  Distention and vomiting  Anemia  Jaundice in first 24 hours Fetal Factors  Congenital anomalies  Short cord  Cord compression  Hydramnios  Abnormal presentation of position  Immaturity  Prematurity  Fetal infection Complete Abortion the entire content of conception are expelled, fetus, membranes and placenta Incomplete Abortion part of the coneptus is expelled but the membranes or placenta is retained Missed Abortion the fetus dies in utero but is not expelled  Causes:  Weight loss, decrease in breast size  Painless vaginal bleeding  Complication is DIC Habitual Abortion loss of three or more successive pregnancies  Causes  Defective ova and spermatozoa  Hormonal (decreased thyroid function)  Decreased nutrition  Deviations of the uterus  Listeriosis gram + rod, L. monocytogenes Causes of Early Spontaneous Abortion  Abnormal fetal formation due to a teratogenic factor on a chromosomal aberration  Implantation abnormality due to maternal diseases, endocrine imbalances, inadequate endometrial formation or from an inappropriate site of implantation. With inadequate implantation, the placental circulation will not be well established and fetal formation will be inadequate  Abortion may occur if the corpus luteum fails to produce enough progesterone to maintain the decidua basalis  Trauma resulting in placental detachment  Severe fright or stress increases maternal epinephrine which leads to extensive vasoconstriction and to necrosis of decidua basalis  Infection rubella, toxoplasmosis, influenza, polio cross the placenta  Endocrine disorders decreased estrogen and progesterone  Uterine tumors  Sepsis  Cervical incompetence  Drug ingestion and irradiation  Chromosomal abnormalities (defective genes)  Poor nutritional status  Deviations of the uterus  Psychological factors

HEMORRHAGIC DISORDERS ABORTION termination of pregnancy before viability (is reached at about the 28th week of gestation when the fetus weighs more than 600 g or more) of the fetus Spontaneous Abortion abortion that occurs from natural causes  Duration  Intensity  Description  Frequency  Associated symptoms  Action

PLACENTA PREVIA Low implantation of the placenta  Low Implantation implantation in the lower rather than in the upper portion of the uterus  Partial Placenta Previa implantation that occludes a portion of the cervical OS  Total Placenta Previa implantation that totally obstructs the cervical OS  Repeated D&C and CS Complications hemorrhage, infection, isoimmunization  Reduced vascularity of the upper segment due to scarring or tumor necessitating lower implantation Illegal Abortion is an abortion performed in an uncontrolled setting usually by a person other than a physicin and performed  Bleeding may be due to retraction of the lower segments and concomitant without illegal sanction separation of placenta Causes  It is the result of the placenta s inability to stretch to accommodate the differing ECTOPIC PREGNANCY one in which implantation occurs outside the uterine cavity shape of the lower uterine segment  Increases parity and increased gestation  PID caused by IUD  Smoking  Adhesions of fallopian tube from previous infection  Residing in high altitude  Endometriosis Causes  Congenital formations  Kleihauer-Betke Test to detect whether blood is fetal or maternal in origin  Scars from tubal surgery  Bleeding occurs on the 7th month of gestation  Uterine tumors dressing in the proximal end of the tube  Bleeding is usually abrupt & painless and it is not associated with increased Symptoms th activity  6 to 12 week of pregnancy 4 to 10 weeks following a missed menstrual period the growing zygote ruptures the slender tube or the growing  Prone to post partum hemorrhage because the placental site is in the lower uterine segment trophoblast cells break through the narrow base of the fallopian tube with resultant invasion and destruction of the blood vessel  The woman usually experience a sharp, stabbing pain in one of the lower ABRUPTIO PLACENTA Premature separation of the placenta; this occurs after the 20th 28th week of abdominal quadrants and notes a little vaginal spotting pregnancy Symptoms  Light headedness, amenorrhea, VS indicative of shock  Chronic hypertensive disease  Rapid pulse, rapid respiration, falling blood pressure  Pre-eclampsia  Umbilicus may have a purplish tinge (CULBU S SIGN)  Direct trauma as in automobile accident  Extensive vaginal and abdominal pain  High multiparity 5 above  Movement of the cervix on pelvic exam causes excoriating pain  Previous abruption placenta  Leukocytosis  Rapid decrease in uterine volume caused for instance by a sudden release of excessive amniotic fluid ND 2 TRIMESTER BLEEDING Causes  Increasing pressure in the intervillus spaces which may result in hemorrhage & HYDATIDIFORM MOLE proliferation and degeneration of the trophoblast villi as the cells degenerate they become filled with placental separation fluid appearing as a fluid filled, grape-sized vesicles and the embryo fails to develop  Pressure exerted in the vena cava by the enlarging uterus  Complication choriocarsinoma  Deficiencies of folic acid and vitamin C  Symptoms  Vascular engorgement during the vena caval syndrome and sudden  (+) HCG hyperemesis increased uterine fundal height in advance of length of gestation uteropacental vasodilation  Increased BP, edema, proteinuria (appears before the 24th week of pregnancy, No FHB, no fetal movement)  Cocaine use  Vaginal bleeding with clear fluid filled vesicles  Rapid decrease in uterine volume with sudden release of amniotic fluid  External bleeding if the placenta separates that at the edges and blood escapes INCOMPETENT CERVIX one that dilates prematurely and therefore can t hold the fetus until term freely from the cervix. If the center of the placenta separates first, blood will  Causes endocrine, trauma to cervix (D&C), congenital developmental factors, habitual abortion pool under the placenta & be hidden from view. Blood may infiltrate the uterine  Treatment cervical circlage, McDonald s or Shiordkar s Barter procedure Symptoms musculature (convelaire uterus or uteroplacental apoplexy) forming a hard  Symptoms board-like uterus with no apparent or minimally apparent bleeding.  Dilation is usually painless  Shock usually follows  Presence of show followed by rupture of the membranes and discharges of the amniotic fluid  Sharp stabbing pain high in the fundus, DIC  Uterine contractions began  Decreased plasma fibrinogen Maternal  This occurs in the fifth month of pregnancy  Convelaine uterus Complications  Renal failure THIRD TRIMESTER BLEEDING     Blood incompatibilities Immunologic factors Rejection theory Maternal lupus anticoagulant factors

 Shock Differential Diagnosis PLACENTA PREVIA Painless bleeding Bright red blood First episode of bleeding is slight Signs of blood loss comparable to extent of bleeding Uterus soft and non-tender Fetal parts palpable FHR countable Placenta palpable Blood clotting defect absent

ABRUPTIO PLACENTA Bleeding accompanied by pain Dark red blood First episode of bleeding is profuse Signs of blood loss out of proportion to amount of visible blood Uterus painful to touch Fetal parts difficult to palpate FHR irregular or absent Placenta not palpable Blood clotting defect present

   

Maternal absorption of toxins from the placenta Diet increased carbohydrates, decreased protein Deleterious substances in the blood Autoimmune disease which implies that placental antigens cross-react with kidney antigens

PLACENTA ACCRETA When the placenta is deeply embedded in the uterine wall GENERAL PRINCIPLES OF NURSING INTERVENTION: BLEEDING DISORDERS  Constant monitoring of vital signs; blood pressure and pulse is imperative  Observe patient for behaviors indicative of shock such as pallor, clammy skin, perspiration, dyspnea and restlessness  Count pads to assess amount of bleeding. Any tissue or clots expelled should be saved  Prepare for IVF  Prepare equipment for exam  Have O2 available  Collect and organize all data including history, lab and studies  Lateral position not supine to prevent pressure on the vena cava  Assess coping mechanism of patient in crisis  Give emotional support  Sustained presence  Clear explanation of procedures  Communicating her status to her family  Prepare patient for possible fetal loss  Assess her expression of anger, denial, silence, guilt, depression or self blame  Encourage to verbalize feelings  Inform regarding causes of abortion to eliminate guilt  CBR TOXEMIA OF PREGNANCY  Occurs on the 24th week of gestation rd  3 most frequent cause of maternal mortality  Due to poor nutrition and deficiency in pyridoxine (vitamin b6)  Hypertensive disease of pregnancy Etiology  Impairment of uroplacental circulation secondary to uterine distention  Operation of the hormonal mechanism (increase amount of estrogen & progesterone secreted by the placenta may affect kidney function and produce edema)  Stress  Increased maternal fetal corticosteroids

Pathology  Renal lesion has been described consisting of cloudy swelling of the capillary endothelial cell and the deposit of amorphous material between these cells and the basement membrane. The vascular lumen is thus diminished.  Presence of small thrombi the lungs.  Enlarged blanched kidneys are seen. There are ischemic glomerular capillaries adherent to the thickened basement membrane  Degeneration of the endothelial cells is apparent. The tubular cells show hyaline degeneration. The dilated tubules contain protein and casts together with occasional red blood cells and WBC  Arteriolar spasm is present resulting to hypertension  BUN and Creatinine is increased   A-G ratio,  CO2   glomerular filtration rate,  urine output   secretion of ADH, ACTH  Tissue hypoxemia may result in the maternal vital organs, poor placental perfusion may reduce the fetus nutrients & O2 supply  The degeneration changes that develop in kidney glomerulus due to the vasospasm lead to permeability of the glomerular membrane. This in turn allows the serum proteins, albumins and globin to cross into the urine (proteinuria a result of  resistance in the glomerular arterioles & narrowing of the lumina of the glomerular capillaries.)  The degenerative changes also lead to  glomerular filtration.  Tubular reabsorption of Na occur leading to edema. Edema is further increased as more protein is lost, the hydrostatic pressure of the circulating blood decreases and fluid diffuse from the circulatory system into the intracellular spaces to equalize the pressure (edema) General spasm of arteries  Degenerative changes in glomeruli  Decreased glomerular filtration   Tubular reabsorption of Na  Edema Hypertension  Hemorrhages into brain, liver and kidneys  Increased permeability of glomerular membrane  Proteinuria  Loss of serum protein via the urine

Complication known to predispose women to development of toxemia  Diabetes with vascular or renal involvement  Acute hydramnios  Hydatidiform mole  Obesity  (+) family history  Essential hypertension 140/90 or more than 30 mmHg above baseline  Age and parity below 18 and above 35  Race greater among non-white

 Multiple gestations  Socioeconomic level  Stress

 Pernicious vomiting  Vomiting that is prolonged past the third month of pregnancy or is so severe that dehydration, ketonuria and significant weight loss occurs within the first three months

Treatment Causes  Bed rest sodium tends to be excreted at a more rapid rate during rest than activity. This results in lowered levels of  High level of HCG hormone produced by the trophoblasts plasma sodium and diuresis occurs  Because the degenerative products resulting from the functioning of trophoblasts as they invade the  Diet moderate salt restriction. Stringent restriction of slat may activate the Angiotensin system and result in increase BP, endormetrium are foreign to the maternal system, they contribute to the development of this increase CHO, increase CHON, decrease fat and salt extreme physiologic response  Diuretics (IVF) to evaluate the fluid and decrease edema. It is effective in decreasing the reabsorption of Na. This results  Rejection Theory common in woman carrying unwanted children than those carrying wanted in decreased levels of sodium in the plasma. Fluids then shift from the intracellular space into the circulatory system and children edema is decreased. If therapy continues, however, the physiological reserves of Na are depleted, the body s homeostatic mechanisms are disturbed and the body attempts to conserve fluid loss. Symptoms  Also stimulate the release of rennin which increased the permeability of glomerular vessels which leads to increased  Concentration of Na, K, Cl and bicarbonate may be decreased proteinuria and activates angiotension which increases BP  Hypokalemic alkalosis may result  Monitor the BP, FHB and signs of labor  Weight loss, severe protein and vitamin deficiency  Insert urethral catheter  Depletion of CHO leads to ketosis  Weigh daily the patient  Jaundice and hemorrhage due to deficiencies of vitamin C and B complex  Monitor blood concentration  Convulsion precautions Treatment Objectives of Nursing Management  Measure intake and output hourly  Fluid replacement  Control of vomiting  Give magnesium sulfate a cathartic  I and O recording  Correction of dehydration  It reduces edema by causing a shift in fluid from the extracellular spaces into the intestine. It also has a CNS  Give sedatives and  Restoration of electrolyte imbalance depressant action that lessens the possibility of convulsions and a vasodilating effect that lowers BP. antiemetics  Maintenance of adequate nutrition  It depresses the myoneural junction thus decreasing hyperreflexia and resulting in vasodilatation  Psychologic support  It relieves cerebral vasospasm  It increases cerebral blood flow The principle cause of fetal death in utero of SGA infants is uteroplacental insufficiency which causes a decrease in blood supply. The woman is hospitalized and  Placed on strict bed rest  Hypotensive drugs and sedatives may be utilized  Encouraged to lie on her side to increase renal and uterine blood flow which may encourage diuresis and return her blood pressure to within normal limits  Monitor FHB  VS, monitor intake and output regularly DIABETES MELITTUS AND PREGNANCY  Inability to metabolize glucose properly because of insulin deficiency ECLAMPSIA Cerebral irritation which results from the increasing cerebral edema  Glomerular filtration of glucose is increased, causing glycosuria, rate of insulin secretion is increased Signs and Symptoms and the fasting blood sugar is lowered. The woman appears to have a decreased insulin  Increased temperature  Sensation of constriction of the thorax  Insulin does not seem normally effective during pregnancy, a phenomenon that is probably cause by  Increased blood pressure  Twitching of facial muscles the absence of hormone human placental lactogen (chorionic somatomammotropin).  Hyperactive reflexes  Brief sharp cry  This resistance to insulin prevents the blood sugar in a normal pregnancy from falling to dangerous  Epigastric pain and nausea is a  Fixed expression of the eyes limits, despite the increased insulin secretion result of vascular congestion  Blurring of vision of the liver  Severe headache Effects of Pregnancy on the Diabetes  Decreased urinary output  Insulin requirement increase especially in third trimester HYPEREMESIS GRAVIDARUM  Aggravated excessive physiologic nausea and vomiting  Decreased renal threshold  Hypoglycemia is likely to occur during the first half of pregnancy

      

Ketoacidosis, pre-coma and coma during last trimester Dietary fluctuations due to nausea, vomiting and cravings Pregnancy gen. lowers CHO metabolism Stress of pregnancy may produce abnormal glucose tolerance Pregnancy is a stimulus to the pancreas, the amount of circulating insulin accordingly High estrogen level of pregnancy may predispose to diabetes, because estrogen affects glucose tolerance to the liver Possible acceleration of hypertension, nephropathy and retinopathy

 With vascular involvement  Benign retinopathy  Leg calcification DYSTOCIA may be due to CPD due to macrosomatic of the fetus ANEMIA may be due to vascular involvement and nausea & vomiting INFECTION (UTI) due to poor diabetic control & acidosis, hyaline membrane due to prematurity, lethal congenital anomalies (heart) & neurologic defects MICROSOMATIC (LGA) due to increased maternal levels of blood sugar from which the fetus derives its glucose. These elevated levels provide & relentless stimulus to the fetal Islets of Langherhans to produce insulin. The sustained fetal hyperinsulinism, hyperglycemia lead to excessive growth and deposition of fats HEART DISEASE AND PREGNANCY  Ranks fourth as a cause of maternal mortality  The two most frequent heart conditions that affect pregnancy outcome are rheumatic fever with valvular involvement & uncorrected coarctation of the aorta  Pregnancy taxes the circulatory system of every woman increasing the cardiac output about 30%. Most of this increase occurs in the first 6 months of pregnancy and this increased blood volume & continues to be maintained. Increased heart rate increased cardiac output increased total blood volume.

Effects of Diabetes on Pregnancy  Maternal Complication  Increased rate of toxemia  Hydramnios, dystocia, increased morbidity, infection, ketoacidosis  Fetal Complication  Oversized babies, congenital anomalies, increased fetal mortality  Edema more difficult to control  Increase incidence of abortions  Increase incidence of premature labors  More rapid aging of placenta Management  Evaluation of functioning assessment of fetal maturity and delivery  Glucose tolerance testing fetoplacental  Weight control  Measurement of plasma insulin levels  Blood pressure readings  U/A for albumin and acetone, BUN  U/A for glucose, protein & ketone bodies  Ascertain nutritional status, strict dietary regulation  Oral hypoglycemic agents are contraindicated  Bed rest, control diabetes  Adequate prenatal care

Four Categories of Heart Disease  Patients who have no limitation of physical activity. Ordinary physical activity. Ordinary physical activity causes no discomfort. They do not have symptoms of Class I cardiac insufficiency & do not have anginal pain  Patients have slight limitation of physical activity. Ordinary physical activity Class II causes excessive fatigue, palpitation and dyspnea or anginal pain  Patients have a moderate to marked limitation of physical activity. During less Effects of Diabetes on the Fetus than ordinary activity they experience excessive fatigue, palpitation, dyspnea & Class III  The increase size of the fetus is thought to be related to the hyperactivity of the fetal pancreas, which has been shown to anginal pain contain considerably more insulin than the diabetic mothers because of an increase in number of Islets of Langerhans  Patients are unable to carry on any physical activity without experiencing  Inadequate blood sugar control may contribute to damage of fetal pancreas discomfort. Even at rest they will experience symptoms of cardiac insuffficency Class IV  Mortality rates increases if the fetus is left in utero until term or anginal pain. Women with Class III and IV heart disease are poor candidates for pregnancy Risk of Pregnancy  The cardiac output may become so diminished that the vital organs (including the placenta) are no longer perfused adequately with arterial blood and their O2 and nutritional requirements are thus not met. The left side of the heart may not empty the pulmonary vessels adequately and they become engorged resulting in pulmonary HPN & pulmonary edema. Blood returning to the heart from the venous system may not be handled adequately, so that venous pressure escape the walls of engorged capillaries to form edema or ascites

DIABETES MELLITUS Description  Gestational or chemical diabetes (abnormal glucose tolerance test)  Overt Diabetes (onset after age 20)  Duration less than 10 years  No vascular involvement  Overt Diabetes  Onset before age 20  10-20 years and no vascular involvement  Overt Diabetes  Onset before age 10 duration increased in 20 years

Intrapartal Period during labor and delivery tremendous stress is normally exerted on the unborn fetus. This stress could be fatal to the fetus of a cardiac patient because of the possible decreased O2 and blood supply to it.  Continuous monitoring of labor signs & FHB & contraction. Assess VS to determine if there is Fetal Neonatal Implications tachycardia & hyperventilation  Assessment of pulmonary functions (if dyspnea, rales, cough are present)  Increased infant mortality if maternal cardiac decompensation occurs  Proper positioning to assure cardiac emptying & proper oxygenation (semi-fowler and side lying)  Gives rise to premature labor and delivery  Supportive therapies  Uterine congestion  Use of prophylactic antibiotics  Hypoxia  O2 by mask if dyspnea occurs  Elevation of carbon dioxide content of blood  Diuretics to decrease fluid retention  The respiratory & metabolic acidosis suffered in utero as a result of sub-optional oxygenation of the fetus leads to cellular  Sedatives for rest and reduction of anxiety damage and predisposes the traumatized fetus to intrauterine fetal distress once labor beings and O2 transport and  Analgesics with tranquilizers to potentiate action to reduce pain exchange are further reduced.  Digitalis if signs of cardiac decompensation occur  Assistance during delivery Interventions the primary goal of nursing care is to preserve the cardiac reserve function of pregnant patient. To do this it is  By low forceps necessary to maintain a balance between cardiac reserve and cardiac workload.  Vaginal delivery reduces stress of pushing and decreasing possible trauma to the infant  Minimize the duration of second stage of labor by encouraging & supported relaxation Specific Goals  CS if indicated  Assess the stress of pregnancy on the heart s functional capacity  Psychologic support  Compare the patients vital signs of pulse and respiration to the normal values expected during pregnancy  Establish activity level of patient, including rest, and assess any changes in vital signs Postpartal Period  Identify in order of priority the problems indicating cardiac decompensation  Support the woman s adaptive coping mechanisms to deal with stress  The most significant time for the cardiac patient due to the rapid shift from the physiologic  Allow ample time for the patient to ask questions and encourage her to comment on her pregnancy & its progress readaptation process.  Answer the patient s questions as fully as possible and in terms that she can understand  There is an increase in cardiac output and blood volume as the extravascular fluid is returned to the  Carefully explain all nursing actions to the women bloodstream for excretion  Identify & utilize significant others to give physical and psychological support  After delivery, the intra-abdominal pressure is reduced significantly, venous pressure is reduced,  Identify the severity of the disease process splanchnic vessels engorge and blood flow moves into the blood stream. This mobilization of fluid  Note cardiac classification of patient can place a great strain on the heart if excess interstitial fluid is present. This stress on the heart  Identify problems in order of priority based on nursing diagnosis and patient input could lead to cardiac decompensation, especially during the first 48 hours postpartum. Nursing Care of the Pregnant Woman with Cardiac Disease Nursing Care Antepartal Period  Assessment of post delivery heart status  Adequate nutrition  Proper positioning (semi-fowlers)  Increase protein, increase iron and essential nutrients to meet the increased demands of pregnancy for increased  Gradual & progressive activity program blood volume and oxygen  Progressive performance of activities of daily living  Decrease Na and calorie intake  Progressive ambulation  Promotion of rest  Use of diet administration of stool softeners  Protection from infection it is important to protect the heart from the additional stress of upper respiratory infections,  Psychologic support encourage maternal infant bonding which could lead to cardiac failure due to overload of the heart s reserve capacity  Education and assistance of mother in infant care  Drug therapy drugs that will cross the placenta and are teratogens should not be used  Prepare for discharge  Restriction of activity decrease fatigue, thereby promoting adequate ventilation  Determine whether there are significant others to assist the mother at home in caring for self  Continuous monitoring of pregnancy for assessment of cardiac status and infant

Signs and Symptoms  Rales (auscultated in lung bases)  Peripheral edema  Dyspnea (progressive)  Exhaustion  Frequent cough with or without hemoptysis  Heart murmurs  Palpitations  She will usually wake up at night, anxious and coughing may have cyanosis of the nail beds

 Psychologic support to decrease anxiety  Patients and family regarding their preparation fro childbirth & offer them encouragement to boast their morale th nd The pregnant cardiac patient is most prone to cardiac decomposition between the 28 to 32 weeks of gestation. It is at that time that the cardiac workload is highest.

 An activity schedule that is gradual and progressive and appropriate to patient s needs  Information regarding sexual relationship and contraception COMPLICATIONS DURING LABOR AND DELIVERY DYSTOCIA labors in which contractions deviates from the normal physiologic patterns of uterine activity. The contraction is either abnormally forced or ineffectual. Uterine Inertia sluggish contractions Causes  Inappropriate use of analgesia (excessive or too early administration)  Cephalopelvic disproportion (CPD)  Poor fetal position (POP)  Extension rather than Flexion of the fetal head  Overdistention of the uterus due to multiple pregnancy, multiparity, hydramnious or obesity  Maternal exhaustion  Oversized fetus  Cervical rigidity  Maternal age (above 35)  Full rectum or urinary bladder that impedes fetal descent Primary Uterine Inertia  Hypertonic uterus  Uncoordinated activity  Labor is uncoordinated from the beginning, first stage is long  Cervical dilatation is slow  Patient complains bitterly of continuous pain  Uterus is hypersensitive to palpation  Contraction is not good from the start

Causes  Scar from a previous CS  Hysterectomy  Plastic repair of the uterus  Prolonged labor  Faulty presentation  Multiple pregnancy  Unwise use of oxytocins  Obstructed labor  Traumatic maneuvers such as high forceps extractions, version Signs and Symptoms  Presence of signs of shock  Absence of FHB  Contractions cease  Uterus can be palpated as a separate mass  Abdominal tenderness  Persistent aching pain over the area of the lower segment  Severe stabbing pain during strong labor contraction Pathological Retraction Ring indentation across the abdominal over the uterus; forewarning of uterine rupture; appears as a horizontal indentation across the abdomen AMNIOTIC FLUID EMBOLISM  Amniotic fluid is forced into the maternal blood sinus thru some defect in the membranes or after partial premature separation of the placenta. Solid particles such as vernix caseosa, lanugo, and/or meconium in the amniotic fluid enter the maternal circulation and reach the lungs as small embolism. The woman in strong labor sits up suddenly grasps her chest because of inability to breath and sharp pain. She becomes pale and turns to bluish gray. There is cyanosis, dyspnea, and PP hemorrhage.

Secondary Uterine Inertia  Tone of uterus is hypotonic PRECIPITATE DELIVERY (PPT)  Contractions have been a good quality and proper duration  Labor is completed in less than 3 hours  Effacement and beginning dilatation have occurred, but the contractions gradually become infrequently and of poor  It is apt to occur with multiplicity and may follow induction of the labor by oxytocin an amniotomy quality and dilatation stop  Rapid labor poses risks to the fetus because subdural/intracranial hemorrhage may result from the Maternal Implication (Hyperactive Labor) sudden release of pressure and the woman may sustain lacerations of the birth canal. Forceful  Lacerations of the cervix contractions may lead to premature separation of the placenta and both maternal and fetal risk.  Uterine rupture  Amniotic fluid embolism INVERSION OF THE UTERUS  Post-partal hemorrhage  The fundus is forced through the cervix so the uterus is turned inside out Fetal Neonatal Implications Causes Treatment  Fetal hypoxia  Pulling on the umbilical cord  IVF  Hypercapnia  Insertion of the placenta at the fundus, so that as the  Input and Output monitoring, VS,  Bradycardia fetus is delivered it pulls the fundus down catheter  Release of meconium in utero  Atony of the uterus such that coughing forces the fundus  Manage shock  Suffocation & aspiration due to prolonged labor outward  Never push the uterus  Attempts to deliver the placenta before the uterus has  Never attempt to replace RUPTURE OF THE UTERUS tearing of previously intact uterine musculature or an old uterine scar after the period of fetal contracted inversion viability

 Cord is short Symptoms  Shock  Pallor  Rapid pulse  Falling BP  Hemorrhage

 Never attempt to remove placenta  Never pull on the umbilical cord  Oxygen by mask, prepare for CPR, no oxytocin  Cover the uterus with sterile gauze soaked in saline solution

     

Monitor FHB, labor patterns Assess presentation, position and lie Do amniotomy and allow labor under close supervision CS in fetal distress, CPD and placenta previa Prepare to receive two infants Correctly identify the first to be born infants

PROLAPSE OF THE CORD A loop of the umbilical cord slips down in front of the presenting fetal part Causes  Premature rupture of the membranes  Small fetus, long cord  Fetal position other than cephalic presentation  Placenta previa  Intrauterine tumors that presents the presenting part from engaging  Small fetus  CPD  Hydramnios  Twin gestation

Maternal Implication  Increase incidence in pre-eclampsia  Abortions because of genetic defects or poor placentation and implantation  Maternal anemia because the maternal system is maturing more than one fetus  Placenta previa, hydramnios due to increase renal perfuse from cross-vessel anastomosis of monozygotic twins to due decreased area of choice of implantation  Uterine dysfunction due to overstretched myometrium  Abnormal fetal presentation  Premature labor  Shortness of breath  Dyspnea on exertion  Backache  Pedal edema because of oversized fetus

Fetal-Neonatal Implications Treatment  CS if dilatation is incomplete  Prematurity with increased incidence of RDS (hyaline membrane disease)  Pillows under the buttocks (so as not to compress the umbilical cord)  Cytoplasmic mass of organs is diminished & growth rate is decreased. Twins may suffer from  Slipping a chair under the foot of the woman s bed and elevating it intellectual & motor impairment  Assume a knee chest position or turn on her side  Increased incidence of fetal anomalies  Don t attempt to push any exposed cord back into the vagina, this may add to the compression by causing knotting & kinking Superfecundation fertilization of two ova within a short period but not at the same act of intercourse  Cover any exposed portion with a sterile saline compress to prevent drying Superfetation fertilization of ova from two different ovulating cycles  Check FHB Siamese Twins occurs when the division of the embryonic disk is incomplete  Patient should never be left unattended Perinatal mortality is higher after delivery of twins than of single birth due to prematurity, anoxia and COMPLICATIONS INVOLVING THE PASSENGER prolapsed cord MULTIPLE GESTATION When two or more embryo develop in the uterus at the same time OCCIPITOPOSTERIOR POSITION  Monozygote (identical) 2 amnions, 1 chorion  The occiput is directed diagonally and posteriorly, ROP and LOP  Dizygote (fraternal) 3 amnions, 2 chorion  In these positions, in the process of internal rotation. The fetal head must rotate not throwing a 90 degree arc but not through an arc of approximately 135 degrees  Identify a family history of twinning and history of medication taken to enhance fertility  Measure the fundal height  Posterior positions tend to occur in women with android, anthropoid or contracted pelvis  A posteriorly presenting head does not fit the cervix as smugly as one in an anterior position,  2 separate heart beat are auscultated increasing the risk of prolapse of the umbilical cord  During palpation many small parts on all side of the abdomen may be felt  If rotation is incomplete, the head becomes arrested in the transverse position transverse arrest Management and Treatment in Multiple Gestation  If anterior rotation does not take place at all, the occiput usually rotates to the direct occiput posterior position persistent occiput posterior  Counseling about diet and daily activities  300 calories or more over the recommended daily dietary allowance BREECH PRESENTATION  Bed rest for HPN and lateral position to increase uterine and kidney perfusion  Pelvic rocking food posture and good body mechanics for back discomfort Causes Types  IVF for nausea and vomiting  Prematurity  Complete  Small but frequent meals  Placenta previa  Frank

High implantation of the placenta Gestational age under 40 weeks Abnormality in the fetus (hydrocephalus) Hydramnios (it allows free fetal movement) Congenital abnormality of the uterus Contracted pelvis Any space occupying mass prevents engagement Previous breech delivery Pendulous abdomen fetal head lies outside the pelvic rim causing breech presentation  Multiple pregnancy  Unknown factors          SHOULDER, FACE AND BROW PRESENTATION DISPROPORTION Causes  Oversized babies due to maternal diabetes  Hydrocephalus  Contracted pelvis CPD Maternal Implication for Malpresentation  Risks of CPD and prolonged labor chance of infection  Lacerations and fears

 Double footling  Single footling

Placenta Circumvallata no chorion covers the fetal sides of the placenta. The umbilical cord enters the placenta at the usual mid-point and large vessels spread out from there. They end abruptly at the point where the chorion folds back into the surface. Battledore Placenta the cord is inserted marginally rather than centrally. As a result all fetal vessels transverse the placental surface in the direction Velamentous Insertion of the Cord a situation in which the cord instead of entering the placenta directly, separates into small vessel that reach the placenta by spreading across a fold of amnion Vasa Previa umbilical vessels of velamentous cord insertion across the cervical OS so they would deliver before the fetus HEMORRHAGE Loss of over 500 ml of blood during labor Causes  Uterine atony  Ruptured uterus  Cervical lacerations  Retained secundines or placental fragments  Coagulopathy  Folate deficiency UTERINE ATONY Causes  Deep and prolonged inhalation anesthesia that may reduce effectiveness of the contractions  Exhaustion form a prolonged labor  Operative deliveries such as versions  Mismanagement of the third stage of labor  Precipitous labor and delivery  Over distention of the uterus (hydramnios, large baby) LACERATIONS Degrees of Laceration  First Degree Laceration involves the perineal skin and vaginal mucosa  Second Degree Laceration involves perineal skin, vaginal mucosa, muscles and fascia of the perineal body  Third Degree Laceration extends into the anal sphincter  Fourth Degree Laceration extends through the rectal mucosa exposing the rectal lumen

Fetal Neonatal Implications  Hypoxia  Fetal mortality is increased due to injuries and infection  Trauma resulting in tentorial tears, cerebral and neck compression, damage to trachea and larynx  Caput succedaneum may develop  Petechia and ecchymosis because of birth trauma  High possibility of intracranial hemorrhage from a traumatic delivery of the head  Spinal cord injuries caused by stretching and manipulation of the infant s head  Hemorrhage into the fetal viscera  Brachial plexus palsy  Fracture of upper extremities Treatment and Management  Midforceps delivery in +2 station  Manual conversion if there is no CPD  CS  Monitor labor patterns, FHB  Reassure couple, inform them of changes  Adequate resuscitation equipment should be available ANOMALIES OF THE PLACENTA AND CORD Placenta Succenturiata has one or more accessory lobes connected to the main placenta by blood vessels. The placenta will appear torn at the edge.

Management  Uterine massage  Offer bedpan  Give oxytocin, O2 by mask, methergine  Blood replacement  Manual removal of retained placental fragment

Causes  Precipitous deliveries  Breech deliveries (forceps deliveries)  Large babies  When maternal tissue are fragile (e.g. cancer)

RETAINED PLACENTAL FRAGMENTS Placenta does not deliver, managed through D&C HYDRAMNIOS over 2000 ml amniotic fluid in uterine AMNIOTOMY The artificial rupturing of membranes to shorten labor INDUCTION OF LABOR deliberate initiation of uterine contractions prior to the spontaneous onset

Indications  Pre-eclampsia  Rh incompatibility  Diabetes  Premature rupture of membranes  Post maturity n  Antenatal death

Contraindications  CPD  Previous CS  Previous uterine surgery  Several fetal distress  Placenta previa  Abruptio placenta  Invasive CS of the cervix  Myomas cysts  Lack of patient acceptance  Unfavorable cervix  Fetal weight below 2500 grams  Abnormal presentation  Grand multiparity  Multiple gestation

 Hemorrhage  Infection  Fetal risks  Facial or brachial palsy  Cord compression  Intracranial hemorrhage VERSIONS  Alteration of fetal position by abdominal or intrauterine manipulation to accomplish a more favorable fetal position for delivery  An operative procedure in which the presenting part is maneuvered to another presentation External Podalic Version - Infant is rotated from a breech or transverse position to cephalic position by abdominal manipulation Internal Podalic Version - The OB insert gloved hand and arm inside the uterus

EPISIOTOMY Surgical incision of the perineum Purposes  Easier to repair, heals faster and can be controlled directionally  Trauma to fetal head is decreased  Second stage of labor is shortened  Stretching and tissue necrosis of the vaginal mucosa which can result in a fistula are prevented

Indications  Prolapsed umbilical cord  Transverse lie  Delivery of second twin  Compound presentation

FORCEPS DELIVERY It is used to provide traction, to rotate or both Dangers of Internal Version  Low Forceps when the skull has reached the perineum and is visible during a contraction (+3 station) when progress is  Uterine atony as a result of deep anesthesia slow and when the mother become exhausted  Lacerations of the cervix  Midforceps when the biparietal diameter of the fetal has passed through the inlet and skull has reached the ischial  Abruption placenta spines (station 1 & 2)  Infection  High Forceps the head has entered the pelvis but is unengaged  Fetal anoxia Fetal Indications  Irregular heart rate  Passage of meconium in cephalic presentation  Prolapse of cord  Fetal distress  Premature fetal separation Prerequisite for forceps operation  Fully dilated cervix  Head engaged  Vertex for face presentation  Ruptured membranes  No CPD  Empty bladder and bowel line CESARIAN SECTION An operative procedure by which the fetus is delivered thru an incision in the abdominal wall and the uterus Indications  Rh incompatibility Maternal Implications  Fetal distress  Fetopelvic  Diabetes disproportion or CPD  Prolapse of the cord  Chronic nephritis  Hydrocephalus  Uterine dystocia  Placenta previa or Types abruption placenta  Previous uterine  Classical Section the uterus is incised in the midline. (D) There is surgery more danger of rupture of uterine scar in subsequent pregnancy.  Severe pre-eclampsia  Low Segment Type incision is low cervical segment of the uterus.  Older primi (A) Less danger of infection or hemorrhage, less likelihood of  Pelvic tumors rupture of the uterus, better healing of the wound.  VD/STD  Elective Section  Fractured pelvis  Extra Peritoneal Section the lower segment is approached by  Essential hypertension separating the bladder from the uterus not entering the peritoneal cavity

Maternal Implications  Patient with a rigid perineum  As arrest of the fetus head that requires rotation  Prevention of laceration  Ineffectual contractions of the second stage  Cardiac mother  Complications such as bleeding  Intrapartal infections  Acute pulmonary edema  Exhaustion

Risks involved of application of forceps  Maternal Risks  Injury to bladder on rectum  Lacerations of the vagina and cervix

 CS hysterectomy Effects of Surgery on the Woman  Stress response release epinephrine increase HR, bronchial dilatation, increase glucose level and Norepinephrine peripheral vasoconstriction blood to central circulation increase BP DYSFUNCTION OF THE FIRST STAGE OF LABOR Prolonged Latent Phase (e.g. rigid cervix,  use of analgesia) hypertonicity

uterus is in hypertonic phase, administer morphine to relax

Prolonged Active Phase (CPD & fetal malposition) uterus is in hypotonic phase Prolonged Descent Phase (CPD & poor fetal positioning) Tx amniotomy, IVF (oxytocin), semi-fowler s position, squatting and kneeling position to increase descend DYSFUNCTION OF THE SECOND STAGE OF LABOR  Prolonged deceleration phase  Secondary arrest of dilatation  Arrest of descent  Failure of descent Treatment  IVF, orange juice to provide glucose  Lie on the side to prevent pressure on the vena cava  Breathing techniques  Empty bladder every 2 hours