COMPLICATIONS OF THE CHILDBEARING EXPERIENCE

TRIVIA:
The Greek goddess of Midwives and Childbirth is:

ARTEMIS
Apollos Twin Sister

COMPLICATIONS IN THE INTRAPARTUM PERIOD

Abortion
Termination of pregnancy at any time before

the fetus has attained viability (20 weeks gestation or 500g>) Causes
Idiopathic but associated with chromosomal

anomalies Exposure to teratogens Poor maternal nutrition Viral infections DM, thyroid disease, SLE

 Smoking

Drug abuse
Hematologic incompatibilities Post mature or imperfect ovum/sperm

Incompetent cervix
Radiation

Trauma

 TYPES:
Threatened
Inevitable Habitual Habitual Incomplete Missed

 Assessment:
Cramping Low back pain

Vaginal bleeding (dark spotting to frank bleeding)

Serum beta hCG may be elevated up to 2 weeks of

embyonic demise

CRITICAL QUESTION 1:
Why would there be low back pain in abortion?
HINT: Concept applies to all types of bleeding.

 Diagnostics
Ultrasonic view of sac and embryo Visualization of the cervix (dilatation)

Complications
Hemorrhage Infection Septicemia DIC

 Medical and Collaborative Management

Bed rest Oxytocin infusion RhoGam may be given Dilatation and curettage with evacuation Blood works (blood typing and screens) Shirodkars procedure Fluid replacement

Nursing Intervention
Monitor for: Amount and color of bleeding Maternal vital signs Clot tissues for presence of fetal membranes, placenta or the fetus itself

Report signs of shock Maintain fluid replacement Assist in the surgical procedures to be done Offer self Acknowledge the loss and allow grieving Provide time alone for the couple to grieve Encourage ventilation of feelings If the fetus is intact, provide for an opportunity to view if desired Proper hygiene Explain the need to wait at least 3 - 6 months before attempting another pregnancy Teach to observe signs of infection Provide information on genetic testing of products if necessary

ECTOPIC PREGNANCY
Pregnancy outside the uterine cavity. Also known as tubal pregnancy because 96% of

cases occur in the ampulla of the fallopian tube Some are located at the cervix or ovaries Rarely, it may occur extrauterinely (e.g. intestines)

pic

 Causes

Adhesions of the tube Salphingitis Anomalies of the tube Previous ectopic pregnancy IUD use Multiple induced abortions Decreased tubal motility Menstrual reflux PID Endometriosis Previous tubal surgery Uterine curettage Maternal age

 Assessment
Amenorrhea in most cases Scanty and dark irregular bleeding Uterine size is like that of a normal pregnancy Abdominal tenderness Shoulder pain Increase PR and anxiety Nausea and vomiting, agitation, syncope, or vertigo

may occur Pelvic exam reveals a pelvic mass, posterior or lateral to the uterus Cervical pain upon VE

CRITICAL QUESTION 2:
Why would there be pain in the shoulder in a case of a ruptured ectopic pregnancy?

 Diagnostics

Serum progesterone of 25ng/ml> Transvaginal ultrasound Culdocentesis may show blood Blood works Laparoscopy Laparotomy if there is question of the diagnosis

Medical or Collaborative Interventions

IV fluids Blood transfusions Methotrexate with leucovorin Tubal resections (salphingostomy, salphingectomy, salphingo-oophorectomy)

 Nursing Interventions
Monitor for: Maternal VS Urine output Presence, amount, and character of bleeding Exacerbation of pain and abdominal distention Maintain fluid replacement

Offer self and encourage vent of feelings

Teach about signs of infection Educate that recurrence is possible and educate to

determine signs and symptoms of recurrence Discuss contraception

CRITICAL QUESTION 3:
Is hydatidiform mole really a pregnancy?

HYDATIDIFORM MOLE
Gestational trophoblastic disease
Abnormal pregnancy resulting from the

malformation of the placenta and the conversion of the chorionic villi into clear vesicles There may be no fetus or a dead fetus may be present Fetal issue rather than a maternal thing

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 Causes

Chromosomal anomalies Malnutrition Hormonal imbalance Extremes of ages Low economic status Possible Rh incompatibities

Assessment

1st trimester bleeding Absence of FHT and fetal structures Rapid enlargement of the uterus hCG titers higher than gestational age Expulsion of vesicles Hyperemesis Signs of preeclampsia before 24 weeks

 Diagnostics:

Elevated hCG levels Ultrasound Urinalysis for CHON Blood works (CBC, Rh type)

Complications
Hemorrhage Choriocarcinoma

Medical and Collaborative Management

Suction curettage Possible laparotomy Detection of possible malignancies RhoGam may be given

 Nursing Interventions:
Monitor Maternal VS Type and amount of bleeding and other discharges Fundal height LMP and date of positive pregnancy test Lab results Possible blood replacement
Large bore IV line Prepare patient for surgery Educate on the disease process Allow grieving over the loss of pregnancy Allow ventilation of feelings

 Discuss the possibility of chemotherapy and

hysterectomy with the doctor Measure hCG levels every 1 2 weeks until normal, then begin monthly testing for 6 months then every 2 months for a total of 1 year

HYPEREMESIS GRAVIDARUM
Exaggerated nausea and vomiting that persist during pregnancy.
Can be experienced with or without food

intake. Occurs during the 1st 16 weeks gestation.

 Causes:
Idiopathic High levels of hCG and estrogen Appetite disturbance Altered self concept (neurosis) Molar pregnancies Multiple gestation

Complications:
Fluid and electrolyte imbalances Dehydration Jaundice

 Assessment:
Persistent vomiting Inability to take anything PO Signs of dehydration: Fever or cold clammy skin Dry skin Weight loss (5 10% of body weight)

Diagnostics:
Tests may be done to rule out other causes

(appendicitis, pancreatitis, cholecystitis) Liver function tests elevated ALT/AST up to four times the normal

 Elevated BUN/creatinine Serum electrolytes Hypokalemia Hyponatremia or hypernatremia Loss of hydrogen and chloride Ketones in urine and blood

CRITICAL QUESTION 4:
Why would ketones be present in hyperemesis gravidarum?

 Medical and Collaborative Management:

Bland diet Anti-emetics Phenothiazines (prochlorperazine, chlorpromazine) Droperidol (Inapsine) Metoclopramide (Reglan/Plasil) Meclizine (Antivert) Methylprednisolone more effective than promethazine Dextrose IV loaded with electrolytes and vitamins Bicarbonates may be given

TPN may be indicated

 Complications:
Hypovolemia
Renal insufficiency Liver failure

Nursing Interventions:
Monitor:

Weight gain or loss pattern 24 48H dietary recall Maternal and fetal VS Skin turgor and mucous membranes Serum electrolytes Signs of dehydration

Assess for presence of pica. Provide a quite and peaceful environment. Maintain IV access. Medicate client as needed. NPO until vomiting has stopped and appetite has returned. Small frequent feedings. No spicy, fatty, aromatic foods. Keep emesis pan handy but out of sight Allow ventilation of feelings. Praise the mother as she shows effort in adhering to her regimen. Encourage to move slowly and avoid sudden change of position.

 Tips on how to assist with condition: Eat dry toast or crackers before rising or anytime nausea begins. Get some fresh outdoor air. Lie down in semiprone position. Spearmint, peppermint, raspberries, ginger ale Teach on the right time of taking the antiemetic

PLACENTA PREVIA
Abnormal implantation of the placenta in the lower uterine segment.
Classified as:
Total PP totally covers the os
Partial PP partially covers the os Marginal PP 2 3cm coverage

Low lying placenta exact relationship of the

placenta and the os has yet to be determined; has the chance to migrate upward as the uterus stretches and grows.

 Causes:
Unknown Previous myomectomy Endometritis Previous uterine surgery Previous abortion Multiple births

Previous placenta previa

Grand multiparity Uterine fibroids or tumors

Isoimmunization

CRITICAL QUESTION 5:
How will uterine surgeries and tumors contribute to placenta previa?

 Assessment
Sudden painless vaginal bleeding as early as 7 months Initial episode is rarely fatal.

Soft uterus
Changes in or absence of FHR Fetal position may be on breech or transverse lie

Diagnostics:
Transabdominal ultrasound

Sterile speculum examination

 Management:
Bed rest on left lateral position Sitting position at rest No vaginal examination in any type of bleeding Iron supplementation Blood transfusion IV therapy RhoGam if necessary Prepare for premature birth and cesarian section

ABRUPTIO PLACENTA
Premature separation of a normally implanted placenta before birth.
Bleeding may be:
Concealed central part of placenta separates first

and blood is accumulated underneath the placenta Apparent marginal part of placenta separates first and blood flows under the membranes and through the cervix

 Causes:
Unknown History of abdominal trauma Maternal hypertension Short umbilical cord Presence of a uterine tumor/fibroids Grand multiparity

Advanced maternal age

Cigarette smoking Cocaine use

Amphetamine use

 Assessment:
Painful vaginal bleeding if no bleeding, sudden abdominal pain Hypertonic tetanic uterine contraction

Board like rigidity

Abnormal or absent FHT Bloody amniotic fluid

Signs of shock
Rising fundal height Nausea and vomiting

Preterm labor
Fetal distress

 Diagnostics:
Based on presenting S/S Ultrasonic viewing of the uterus Kleihauer Betke test (check for fetal RBCs in the

maternal circulation) Blood works

Complications:

Shock DIC Anaphylactic syndrome of pregnancy Postpartum hemorrhage ARDS Sheehans syndrome

 Renal failure

Precipitous labor
Maternal and fetal death Prematurity

Pulmonary edema

Management:
Immediate fluid resuscitation Emergent cesarian delivery Vaginal birth may be done

Blood transfusion
Neonatal specialty field Maternal and fetal VS

 Evaluate bleeding

Position to left lateral side

Oxygenation at 8 12L/min Encourage relaxation techniques

Inform the woman about her status

Treat underlying cause

PREGNANCY INDUCED HYPERTENSION

Chronic Hypertension
Present and observable prior to pregnancy or that

is diagnosed before the 20th week of gestation

Preeclampsia
Diagnosis is determined by increased blood

pressure accompanied by proteinuria.

Mild: >/= 140/90 mmHg, proteinuria of >/= 0.3 g/24 hours Severe: >/= 160/110 mmHg, proteinuria >/= 2 g/24 hours, creatinine 1.2mg/dL, persistent headache and visual disturbances, HELLP syndrome

 Eclampsia
S/S of preeclampsia + seizures

Preeclampsia/Eclampsia Superimposed on

Chronic Hypertension
Exacerbation of the chronic condition

Gestational Hypertension
BP elevation for the first time in pregnancy without

proteinuria May not progress to preeclampsia if BP normalizes at 12 weeks

 Assessment:
Clinical signs: Proteinuria : 300 500mg/24H or 1+/2+ in dipstick urine Edema of the hands and face Hypertension: 140/90 mmHg> in 2 occasions at least 6H Oliguria (<400 500ml/24H) Sudden weight gain of 2lb> in 1 week, or 6lb> in 1

month Altered LOC, visual changes, headache, blurred vision, scotoma Epigastric pain at RUQ Hyperreflexia with or without clonus Seizures and possible coma HELLP syndrome

CRITICAL QUESTION 6:
Why will HELLP syndrome occur in PIH?

 Diagnostics:

24H urine for proteinuria Elevated serum BUN and creatinine Elevated liver enzymes and low platelet count Ultrasound Non stress test

Pharmacologic Interventions:
Magnesium sulfate may be given either IV/IM as loading dose and maintenance dose to treat and prevent seizures Antidote: Calcium gluconate Antihypertensive drugs (Hydralazine) Relaxes the arterioles and stimulates cardiac output S/E: tachycardia, palpitations, dizziness, faintness, headaches

 Other drugs include: Labetalol Methyldopa Nifedipine not to be used in hypertensive crisis Sodium nitroprusside not to be used in antepartum (cyanide toxicity) Nitroglycerine Goal of treatment is to treat based on the presenting

signs and symptoms Monitor:

Feto maternal VS QH Intake and output Lab results Deep tendon reflexes Daily weight gain

 Assess breath sounds for wheezes and crackles

IV infusion pump to control IV fluid intake

Evaluate progression of edema Left lateral position

Encourage extra protein in diet

Keep environment quiet and calm as possible Pad side rails

Have oxygen tank, suction catheter, crash cart, and

tongue blade ready. Teach importance of bed rest

POLYHDRAMNIOS
An excessive amount of amniotic fluid in the amniotic sac (500 1000mL> or 2000mL>)
At 36 weeks, 1L is present and decreases after

this time. AF is controlled by fetal urination and swallowing.

 Causes:
Unclear
Maternal DM Multiple gestations

CNS anomalies (spina bifida and anencephaly)

GI anomalies (TEF)

Assessment:
Excessive weight gain
Dyspnea Shiny and tense abdomen

Edema of the vulva, legs, and extremities

Increased uterine size for age Difficulty in performing Leopolds maneuver

 Diagnostics:
Based on presenting S/S Ultrasound AFI: 25cm> Large pockets of AF between fetus and uterine wall or placenta Difficulty assessing fetus

Fundal height greater than AOG