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Complications Antepartum Intrapartum Postpartum. Maternal Mortality According to official US vital statistics, the risk of death from complications of.

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Presentation on theme: "Complications Antepartum Intrapartum Postpartum. Maternal Mortality According to official US vital statistics, the risk of death from complications of."— Presentation transcript:

1 Complications Antepartum Intrapartum Postpartum

2 Maternal Mortality According to official US vital statistics, the risk of death from complications of pregnancy decreased approximately 99% during the 20th century. However, this progress halted in 1982, and since then, there has been no improvement in the maternal mortality ratio for the US. In the most recent global figures from the World Health Organization, the US ranked 20th in maternal mortality, behind most countries of Western Europe as well as Canada, Australia, Israel, and Singapore. September 2001, the first National Summit on Safe Motherhood

3 Maternal Mortality Many consider a maternal death to be a sentinel event, reflecting a breakdown in the health care system in its broadest sense. Mortality caused by pregnancy and its complications remains an important issue for…the health care system, and as a public health indicator. There continues to be striking racial disparity in maternal mortality. September 2001, the first National Summit on Safe Motherhood

4 Causes of Maternal Mortality 01/issue2/images/large/og jpeg Hemorrhage, Embolism, Hypertensive Disorders and Infection are in the top five causes of maternal mortality

5 Antepartum Bleeding Multiple Etiologies Placenta Previa Abruption Pre-term Labor Ectopic pregnancy Infections Cervical Polyp/Erosion Cancer/Molar pregnancy Trauma Ruptured Uterus Physiologic (implantation bleed, show)

6 Bleeding-Ectopic Pregnancy

7 Blastocyst implants outside the endometrial lining of the uterus Fallopian tube (95%) Ovaries, Cervix, Abdomen Rare, but possible to have ectopic and intrauterine pregnancy simultaneously

8 Bleeding-Ectopic Pregnancy Defining Characteristics Any bleeding early in pregnancy Ectopic is a possibility until proved otherwise Often brownish bleeding, but may be any color or even absent May or may not have pain until rupture Abnormally low hCG levels Confirmed by ultrasound or laparoscopy

9 Bleeding-Ectopic Pregnancy Ruptured ectopic pregnancy Sudden, sharp, severe lower abdominal pain Hypotension/shock Abdominal tenderness Marked cervical motion tenderness Neck/shoulder pain w/ inspiration This is a life-threatening situation

10 Bleeding - Abortion Abortion medical term for all pregnancy loss prior to 20 weeks Types Spontaneous (Miscarriage) Missed (embryo/fetus dies, not passed) Threatened (bleeding, cervical os closed) Inevitable (bleeding, cervical os open) Therapeutic (pregnancy termination)

11 Bleeding - Abortion Spontaneous Abortion Defining Characteristics Bleeding (pink, red or brown) Cramping Starts light, then crescendos Becomes light again after tissue passed Passage of tissue or clots All passed tissue is saved Sent for chromosomes/pathology >9 weeks likely to need D&E

12 Bleeding - Abortion Spontaneous Abortion Nursing Interventions Vital signs S/Sx of infection Pad Count Pain assessment/management Grief counseling Talk about difference for men and women Anticipatory Guidance

13 Bleeding - Placenta Previa

14 Placenta implants low in the uterus Marginal Previa/Low Lying Placenta Next to, but not covering the cervical os Partial Previa Covers part of the internal cervical os Complete Previa Covers all of the internal cervical os

15 Bleeding - Placenta Previa yessentials/Ch02/jpg/02_002.jpg

16 Bleeding - Placenta Previa Malpresentation Transverse position Breech presentations Placenta takes up the space where the fetal head should be

17 Bleeding - Placenta Previa Cesarean section likely Definite if complete previa Vessels will tear with dilation/effacement Gross maternal & fetal hemorrhage Possible vaginal birth if partial previa Fetal head may tamponade the blood vessels enough to allow vaginal birth Unlikely in current practice environment

18 Bleeding - Placenta Previa Classic defining characteristics Painless bright red vaginal bleeding Digital vaginal exam contraindicated Risk of perforating the placenta Gross hemorrhage Cesarean section scheduled prior to onset of labor May need to assess for fetal lung maturity

19 Bleeding - Placenta Previa Essential points to teach patients Complete pelvic rest – Huh? Nothing in vagina No nipple stimulation No orgasm Report to the hospital immediately if any vaginal bleeding Report that you have a previa ASAP Some hospitalized for duration

20 Bleeding - Placenta Previa Risk of implantation into muscle instead of decidua (accreta) 5-10% per Varney, 3 rd Ed. No plane of separation Risk of hysterectomy at time of birth Prior C/S increases risk of accreta The more C/S the higher the risk

21 Bleeding - Abruption Also called Abruptio Placenta

22 Bleeding - Abruption Premature separation of the normally implanted placenta Serious hemorrhage in the late second and the third trimesters Bleeding may be Concealed Obvious Both

23 Bleeding - Abruption mbyessentials/Ch02/jpg/02_003.jpg

24 Bleeding - Abruption Associated with Sudden deceleration forces MVA Severe abdominal trauma Battery Difficult external version Sudden ↓ in uterine volume/size SROM in polyhydramnios Between birth of babies in multiple gestation Maternal Hypertension Chronic, pre-eclampsia, Cocaine related

25 Bleeding - Abruption Defining Characteristics Pain is out of proportion to palpated or monitored uterine activity Board-like abdomen (+/-) Uterine rigidity (+/-) Both may be absent if posterior placenta Back pain (from extravasating blood)

26 Bleeding - Abruption Defining Characteristics Bleeding (maybe concealed) Pain Colicky uterine contractions Violent/decreased/absent FM FHT changes Tachycardia Loss of variability Variable and Late decelerations Sinusoidal pattern

27 Bleeding - Abruption Defining characteristics will depend on the extent of abruption Partial separation May be able to stabilize and deliver vaginally (often delivery is fast) Complete separation Requires immediate delivery to save the life of the mother and fetus

28 Bleeding - Abruption If risk for abruption (fall, MVA, etc) Observation x 4 – 6 hours External fetal monitoring Uterine irritability FHT changes Physical s/sx Abruption will usually present by 4 hrs

29 Bleeding – Previa & Abruption Nursing interventions Get help/notify MD Obtain IV access (16 g x 2) fluids blood products Obtain blood for Type and cross-match for ≥ 3 units CBC with platelets/PT/PTT/Fibrinogen Plain tube for clotting time

30 Bleeding – Previa & Abruption Nursing interventions Trendelenburg VS (BP, Pulse) FHT by external monitor Apply oxygen Cover with warm blankets Open OR, set up for stat C/S Insert foley catheter, measure I&O

31 Pre-term (Premature) Labor Labor from 20 – 36 weeks 10% of all births in the US Prematurity is the leading cause of perinatal morbidity and mortality Prematurity accounts for up to 50% of neurologic problems in infancy Rates vary by population studied Modern medicine notoriously unsuccessful at predicting and preventing preterm birth

32 Pre-term (Premature) Labor What is not associated with success? Bedrest Prophylactic oral tocolytic therapy Prophylactic cerclage Home uterine monitors Some controversy about these

33 Pre-term (Premature) Labor Defining characteristics Cramping Change in backache Change in discharge Bleeding or spotting Change in pressure/heaviness Diarrhea SROM

34 Pre-term (Premature) Labor In absence of infection, attempts to stop PTL (PML) are made Bedrest (no research to support) PO or IV fluids  medications Dehydration associated with contractions Medications to stop contractions If delivery is inevitable, attempts made to speed fetal lung maturity Betamethasone IM given up to 34 weeks Gluteal injection Thick, oily, painful

35 Pre-term (Premature) Labor Magnesium Sulfate (MgSO4) (IV) Hourly assessments for magnesium toxicity and efficacy of medication Terbutaline (SQ, PO) Risk for pulmonary edema Nifedipine (SL, PO) Ca++ channel blocker Indomethacin (PO, PR) Prostaglandin synthetase inhibitor May cause premature closure of ductus and oligohydramnios

36 Diabetes in Pregnancy Pre-Gestational Diabetes Type 1 – usually insulin dependent Type 2 – may or may not require insulin Gestational Diabetes Onset after 20 weeks of pregnancy Resolves by six weeks postpartum Emphasize f/u due to  lifetime risk of DM Usually controlled by Diet Exercise Blood glucose monitoring

37 Diabetes in Pregnancy Universal screen at 28 weeks 1 hour glucose tolerance test (GTT) LOTS of false positives Diagnostic 3 hour GTT 2 abnormal values = GDM At risk women screened earlier Known diabetics not screened

38 Diabetes in Pregnancy  insulin resistance during pregnancy If pancreas cannot produce more insulin to compensate for resistance  ’d circulating glucose  Crosses placenta  ’d fetal insulin  Insulin acts as growth hormone  Macrosomia

39 Diabetes in Pregnancy Fat deposition is around the shoulder girdle   risk of shoulder dystocia Hyperglycemia ’s risk of other congenital anomalies  risk of neonatal hypoglycemia Cord cut  glucose levels fall rapidly Neonate still has circulating insulin

40 Diabetes in Pregnancy Tight glycemic control can reduce the risk of pregnancy complications Usually aim for Fasting ≤ 95 2 hour postprandial ≤ 120 Usually checking QID Fasting, 2h post meals, hs

41 Hypertensive Disorders of Pregnancy Chronic Hypertension Predates the pregnancy Risk for IUGR, risk for abruption Gestational Hypertension  BP without other symptoms Pre-eclampsia (“Toxemia”) Mild, Severe Eclampsia Seizures

42 Hypertensive Disorders of Pregnancy Cause of Pre-eclampsia unknown Many theories of etiology Inappropriate response to angiontension II Inappropriate ratio of prostaglandins Disordered placentation

43 Hypertensive Disorders of Pregnancy Risk factors for Pre-eclampsia More common in primagravidas Age extremes ( 35 years) Multiple gestations Seems to have genetic component Poor nutrition Chronic hypertension

44 Hypertensive Disorders of Pregnancy Defining Characteristics of Pre-eclampsia Onset after 20 weeks gestation Classic Triad Edema, Proteinuria, Hypertension Headache Epigastric Pain Visual ∆’s (scotoma – flashing lights)

45 Hypertensive Disorders of Pregnancy Mild Pre-eclampsia 140/90 or +15/+30 BP Classic Triad, some edema +1 proteinuria on a single dip (300mg/L in 24 hour urine collection) May see other lab abnormalities

46 Hypertensive Disorders of Pregnancy Severe Pre-eclampsia ≥ 150/100 BP 3 – 4+ proteinuria on a single dip (5g/L in 24 hr collection) Classic triad, marked edema Other lab abnormalities common

47 Hypertensive Disorders of Pregnancy Care is supportive Promote excellent nutrition Lateral lie promotes diuresis and placental perfusion Magnesium Sulfate Quiets neurologic system Decreases vasospasm Monitor for s/sx of toxicity Seizure Precautions Hourly vital signs Prepare for delivery

48 Hypertensive Disorders of Pregnancy If progresses to eclampsia Magnesium Sulfate (MgSO4) Protect airway Intrauterine stabilization of fetus Protect from excess stimuli May proceed to cesarean when stable Likely transfer to intensive care unit for postpartum stabilization

49 Hypertensive Disorders of Pregnancy HELLP syndrome Hemolysis, Elevated Liver Enzymes, Low Platelets Atypical Pre-eclampsia presentation May be complicated further by Disseminated Intravascular Coagulation

50 Cesarean Section Problem with the 3 P’s of labor Powers Inadequate, too strong, uncoordinated Passenger Not tolerating labor, malpresentation, size or congenital anomalies Passage Mismatch with passenger, unsafe for mother to labor C/S in the absence of a medical indication Current C/S rate ~ 30% anecdotal reports approaching 50%

51 Cesarean Section Types Low Transverse Horizontal uterine incision Also called low cervical, low segment Most common, VBAC OK Classical Vertical incision on uterus Uncommon, VBAC contraindicated Emergency, preterm, malpresentation

52 Cesarean Section Planned Labor contraindicated Maternal choice (highly controversial) Unexpected, but not emergent Problem with 3 P’s, mother & baby stable Urgent Need to proceed to protect life or health “Decision to incision” time <30 minutes With suspected uterine rupture <18 minutes Nursing care depends on circumstances

53 Cesarean Section Support person present in the OR Remind not to touch sterile areas Provide a stool to sit on behind drape Keep on eye on them Anesthesiologist/Nurse- Anesthetist Excellent at communicating with client Labor nurse usually becomes circulating nurse in the OR

54 Cesarean Section Post-operative recovery usually on L&D in special PACU area if both mother & newborn stable Kept together in PACU area Take care to promote thermoregulation Assist to breastfeed in PACU if able All postpartum assessments All post-operative assessments Client and/or support person may need to verbalize about c/s

55 Amniotic Fluid Embolism Amniotic Fluid enters systemic circulation Unexplained Hypertonic contractions Sudden onset of Respiratory distress Bleeding/oozing (DIC) Cyanosis Pain  Shock  coma

56 Amniotic Fluid Embolism Life threatening emergency ABCs Blood products Intensive care, central monitoring Often fatal to mother and baby I have only seen this once >40 units of PRBCs and FFPs Near death experience reported

57 Shoulder Dystocia Anterior shoulder stuck behind maternal symphysis pubis Unpredictable Increased risk with Prolonged labor Macrosomic fetus Poorly controlled maternal diabetes

58 Shoulder Dystocia Defining Characteristics Unexpectedly slow crowning Turtle sign with birth of fetal head No restitution or external rotation Have 4 – 6 minutes to get the baby out before brain damage ensues Shoulder Dystocia drills

59 Shoulder Dystocia Nursing Interventions Note time of birth of the head Note all interventions used to relieve Note which fetal shoulder impacted Call for help Provide suprapubic pressure when asked NOT fundal pressure Sharply flex and abduct maternal legs onto abdomen (McRoberts maneuver) Anticipate neonatal resuscitation and maternal postpartum hemorrhage

60 Postpartum Hemorrhage Any blood loss significant enough to cause signs and symptoms Traditionally >500 cc for vaginal birth and >1000 cc for cesarean section May be resolved surgically if Laceration repair Retained placenta (late hemorrhage) Placenta accreta

61 Thrombophlebitis Pregnancy is a prime example of Virchow's triad of increased risk for VTE venous wall damage/irritation change in flow Immobility Local pressure Varicose veins Venous obstruction Hydration, hypovolemia blood hypercoagulability adaptations for hemostatsis in labor

62 Thrombophlebitis Defining Characteristics Pain in area of clot if peripheral, +/- erythema If peripheral, +/- edema If peripheral, +/- cord palpable Do NOT massage If peripheral, +/- homan’s sign Possibly fever, chills

63 Thrombophlebitis Nursing Interventions Moist heat as ordered Pain assessment/management Observe for s/sx of PE Administer anticoagulant therapy as ordered – usually Lovenox/heparin Large molecule, does not cross placenta and not secreted in breast milk Coumadin contraindicated in pregnancy

64 Endometritis Postpartum infection of the endometrium Predisposing factors Prolonged labor Prolonged rupture of membranes Cesarean birth Trauma Retained products of conception

65 Endometritis May spread and become a systemic infection leading to sepsis A major cause of morbidity and mortality

66 Endometritis Defining Characteristics Temperature >100.4 Alteration in VS Fundal tenderness Foul smelling vaginal discharge Rigors, Malaise + blood cultures

67 Endometritis Administer antibiotics as ordered May be on triple antibiotics Promote adequate hydration Promote adequate nutrition Protect mother-baby bonding and interaction Baby may also have infection Promote activity as appropriate

68 REMEMBER! Despite this depressing and frightening lecture The overwhelming majority of births are straightforward The human race has been around a long time... Birth works and babies come out or we wouldn’t be here today!

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