Complications Antepartum Intrapartum Postpartum Maternal Mortality

Complications Antepartum Intrapartum Postpartum

Maternal Mortality ¢ ¢ According to official US vital statistics, the risk of death from complications of pregnancy decreased approximately 99% during the 20 th 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 20 th 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

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

Causes of Maternal Mortality http: //www. greenjournal. org/content/vol 1 01/issue 2/images/large/og 013390500 1. jpeg Hemorrhage, Embolism, Hypertensive Disorders and Infection are in the top five causes of maternal mortality

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

Bleeding-Ectopic Pregnancy

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

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

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

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

Bleeding - Abortion ¢ Spontaneous Abortion l 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 l >9 weeks likely to need D&E

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

Bleeding - Placenta Previa

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

Bleeding - Placenta Previa http: //connection. lww. com/Products/timb yessentials/Ch 02/jpg/02_002. jpg

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

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

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

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

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

Bleeding - Abruption ¢ Also called Abruptio Placenta

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

Bleeding - Abruption ¢ http: //connection. lww. com/Products/ti mbyessentials/Ch 02/jpg/02_003. jpg

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

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

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

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

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

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

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

Pre-term (Premature) Labor ¢ Labor from 20 – 36 weeks l l l 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

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

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

Pre-term (Premature) Labor ¢ Magnesium Sulfate (Mg. SO 4) (IV) l ¢ Terbutaline (SQ, PO) l ¢ Risk for pulmonary edema Nifedipine (SL, PO) l ¢ Hourly assessments for magnesium toxicity and efficacy of medication Ca++ channel blocker Indomethacin (PO, PR) l l Prostaglandin synthetase inhibitor May cause premature closure of ductus and oligohydramnios

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

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

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

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 l Neonate still has circulating insulin l

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

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

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

Hypertensive Disorders of Pregnancy ¢ Risk factors for Pre-eclampsia More common in primagravidas l Age extremes (<17, >35 years) l Multiple gestations l Seems to have genetic component l Poor nutrition l Chronic hypertension l

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

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

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

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

Hypertensive Disorders of Pregnancy ¢ If progresses to eclampsia Magnesium Sulfate (Mg. SO 4) l Protect airway l Intrauterine stabilization of fetus l Protect from excess stimuli l May proceed to cesarean when stable l ¢ Likely transfer to intensive care unit for postpartum stabilization

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

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

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

Cesarean Section ¢ Planned l l ¢ Unexpected, but not emergent l ¢ Labor contraindicated Maternal choice (highly controversial) Problem with 3 P’s, mother & baby stable Urgent l l 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

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

Cesarean Section ¢ Post-operative recovery usually on L&D in special PACU area l if both mother & newborn stable • Kept together in PACU area • Take care to promote thermoregulation l l 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

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

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

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

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

Shoulder Dystocia ¢ Nursing Interventions l l l 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 l l Sharply flex and abduct maternal legs onto abdomen (Mc. Roberts maneuver) Anticipate neonatal resuscitation and maternal postpartum hemorrhage

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 l Retained placenta (late hemorrhage) l Placenta accreta l

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

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

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

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

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

Endometritis ¢ Defining Characteristics Temperature >100. 4 l Alteration in VS l Fundal tenderness l Foul smelling vaginal discharge l Rigors, Malaise l + blood cultures l

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

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! ¢