Complications of the Childbearing Experience

7/29/2019 Complications of the Childbearing Experience

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COMPLICATIONS OF THE

CHILDBEARING EXPERIENCE



TRIVIA:

The Greek goddess of Midwives and Childbirth is:

ARTEMIS Apollo’s Twin Sister



COMPLICATIONS IN THE INTRAPARTUM

PERIOD



Abortion

Termination of pregnancy at any time beforethe fetus has attained viability (20 weeksgestation or 500g>)

Causes

Idiopathic but associated with chromosomalanomalies

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 inabortion?

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)

Shirodkar’s procedure

Fluid replacement

Nursing Intervention Monitor for:

Amount and color of bleeding

Maternal vital signs

Clot tissues for presence of fetal membranes, placenta or thefetus 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 beforeattempting 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 vertigomay occur

Pelvic exam reveals a pelvic mass, posterior or lateralto the uterus

Cervical pain upon VE




Why would there be pain in the shoulder in acase 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 todetermine signs and symptoms of recurrence

Discuss contraception




Is hydatidiform mole really a pregnancy?



HYDATIDIFORM MOLE

Gestational trophoblastic disease

Abnormal pregnancy resulting from the

malformation of the placenta and theconversion of the chorionic villi into clearvesicles

There may be no fetus or a dead fetus may be

present

Fetal issue rather than a maternal thing



pic



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 andhysterectomy with the doctor

Measure hCG levels every 1 – 2 weeks until normal,

then begin monthly testing for 6 months then every 2months for a total of 1 year



HYPEREMESIS GRAVIDARUM

Exaggerated nausea and vomiting thatpersist during pregnancy.

Can be experienced with or without foodintake.

Occurs during the 1st 16 weeks gestation.



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 fourtimes the normal



Elevated BUN/creatinine

Serum electrolytes Hypokalemia

Hyponatremia or hypernatremia

Loss of hydrogen and chloride

Ketones in urine and blood



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



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 toher 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 thelower 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 theplacenta and the os has yet to be determined; hasthe chance to migrate upward as the uterusstretches and grows.



Causes:

Unknown

Previous myomectomy Endometritis

Previous uterine surgery

Previous abortion

Multiple births

Previous placenta previa

Grand multiparity

Uterine fibroids or tumors Isoimmunization




How will uterine surgeries and tumorscontribute 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 normallyimplanted placenta before birth.

Bleeding may be:

Concealed – central part of placenta separates firstand blood is accumulated underneath theplacenta

Apparent – marginal part of placenta separatesfirst and blood flows under the membranes andthrough the cervix



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

Di i



Diagnostics: Based on presenting S/S

Ultrasonic viewing of the uterus

Kleihauer – Betke test (check for fetal RBCs in thematernal circulation)

Blood works

Complications: Shock

DIC

Anaphylactic syndrome of pregnancy Postpartum hemorrhage

ARDS

Sheehan’s syndrome

l f l



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

l bl d



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 thatis 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 andvisual disturbances, HELLP syndrome

l i



Eclampsia

S/S of preeclampsia + seizures

Preeclampsia/Eclampsia Superimposed onChronic 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

A



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 1month

Altered LOC, visual changes, headache, blurred vision,scotoma

Epigastric pain at RUQ

Hyperreflexia with or without clonus

Seizures and possible coma

HELLP syndrome




Why will HELLP syndrome occur in PIH?

Diagnostics



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:



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 presentingsigns 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



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, andtongue blade ready.

Teach importance of bed rest



POLYHDRAMNIOS

An excessive amount of amniotic fluid in theamniotic sac (500 – 1000mL> or 2000mL>)

At 36 weeks, 1L is present and decreases afterthis time.

AF is controlled by fetal urination andswallowing.

Causes:



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 Leopold’s maneuver

Diagnostics



Diagnostics:

Based on presenting S/S

Ultrasound

AFI: 25cm>

Large pockets of AF between fetus and uterine wall orplacenta

Difficulty assessing fetus Fundal height greater than AOG

Complications of the Childbearing Experience

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