OB exam 2

PPH risk factors

*Atony* *Trauma* - lacerations - instrumental delivery - large for gestational age infant *Coagulopathy* - hypertensive disorder of pregnancy - intrauterine fetal demise - sepsis - congenital clotting deficiency

Passenger and dystocia

*Cephalopelvic disproportion* (CPD) is a mismatch between the size of the fetal head and the size of the maternal pelvis. The most common fetal malpresentation is the occiput posterior (OP) position. - OP often causes low back pain for women in labor. Breech presentation occurs in 1/33 births - types of breech presentations include frank breech, footling breach, or complete breech.

Preterm Premature Rupture of Membranes (PPROM)

- Preterm premature rupture of membranes (PPROM) is the rupture of membranes prior to 37 weeks gestation - Major concerns for women with PPROM is infection, cord prolapse, fetal malpresentation, and precipitous labor. - Incidence of PPROM is higher in women who smoke, had a previous pregnancy with PPROM, and had any vaginal bleeding during pregnancy

Diagnosis of preterm labor

- cervical dilation of 3cm or more - cervical shortening on ultrasound - postive fetal fibronectin test (evaluation of a protein concentrated between the placenta and the decidua of the uterus) - vaginocervical swab

Group B Streptococcal (GBS) during pregnancy

- common bacteria in healthy women - can be problematic if passed to infant during birth - screen with rectal-vaginal swab between 35-37 weeks gestation GBS treatment indicated if: - GBS disease found in a previous infant - GBS found in maternal urine during current pregnancy - positive GBS screening test - unknown GBS status and membranes ruptured over 18 hours, maternal temperature greater or equal to 100.4 or preterm delivery

Guidelines for supporting the woman and family after a still birth

- communicate warmly and genuinely - avoid medical terminology; use clear lay language - avoid delays in sharing information - validate the emotions of woman and family - provide continuity of care when possible - respect the individual needs of the mourners - treat the stillborn infant with respect - respect womans preferences for seeing and holding baby - collect memorabilia, such as photos and footprints - refer woman to support providers and organizations - provide practical support about issues such as funeral arrangements and lactation

Treatment for PPROM

- corticosteroids if <34 weeks to promote fetal lung maturity (betamethasone) - Antibiotic therapy: PPROM may have been caused by infection - Tocolytics (use of tocolytics for PPROM is controversial) Most women with PPROM deliver within a week Monitor women with PPROM closely for signs of infection

Chorioamnionitis risks to neonate

- early onset sepsis (within first 3 days) - septic shock - pneumonia - meningitis - intraventricular hemorrhage - cerebral palsy death

Indications for cesarean delivery

- failure to progress - nonreassuring fetal heart rate - fetal malpresentation - umbilical cord prolapse - fetal macrosomia

More effective tocolytic agents

- indomethacin - nifedipine - terbutaline Less effective/not recommended - magnesium sulfate

Symptoms of preterm labor

- irregular contractions, often mild - report of "menstrual like" cramping - low back pain - feelings of vagina or pelvic pressure - light bleeding or spotting - bloody show

Preterm labor risk factors

- low maternal education level - low maternal income level - infection - family history of preterm birth - pregnancy with more than one fetus - hypertension in pregnancy - substance abuse - tobacco and alcohol use - short maternal stature - poor weight gain in pregnancy - low or high BMI - short duration between pregnancies - high maternal stress - preexisting medical condition

Postpartum complication early maternal warning signs

- maternal agitation, confusion, or unresponsiveness - report of headache or shortness of breath by a patient with preeclampsia - systolic BP less than 90 or high than 160 - diastolic BP greater than 100 - HR less than 50 or greater than 120 bpm - RR less than 10 or greater than 30 breaths/min - O2 saturation on room air less than 95% - oliguria for 2 or more hours (less than 35 ml/hr)

Uterine rupture

- may occur in women attempting a trial of labor after cesarean - symptoms include the sudden development of category II or category III fetal heart rate pattern, weakening contractions, and abdominal pain - treatment includes cesarean delivery and possible hysterectomy.

Common reasons for premature induction of labor

- placental problems - history of uterine scanning - fetal grown restriction - chronic hypertension - preeclampsia - poorly controlled gestational diabetes - pregestational diabetes, poorly controlled or with vascular complications - PPROM

Thromboembolic disease

A *venous thromboembolism* (VTE) is a blood clot or multiple clots that form within a vein Risk factors: - dilated veins leading to slower blood flow and pooling - endothelial injury related to surgical intervention or placental detachment - prenatal increase of coagulation factors to decrease the risk of hemorrhage VTE's may be limited to SUPERFICIAL veins or form in deeper vins of lower extremities (deep vein thrombosis DVT) A *DVT* can break off and travel to the pulmonary artery causing a pulmonary embolism (PE)

Hypotonic uterine dysfunction

A condition where uterine contractions are either too uncoordinated or too weak to effectively dilate the cervix - occurs in the active phase of labor and is related to polyhydramnios, macrosomia, or multiple pregnancies Palpated contractions are soft and occur at a rate of less than three or four every 10 minutes lasting less than 50 seconds. Internal contraction monitoring may be indicated. Treatment may include rest, an amniotomy, or oxytocin

hydatidiform mole (molar pregnancy)

A hydatidiform mole is growth of an abnormal fertilized egg or an overgrowth of tissue from the placenta. Women appear to be pregnant, but the uterus enlarges much more rapidly than in a normal pregnancy. Most women have severe nausea and vomiting, vaginal bleeding, and very high blood pressure. o Aka gestational trophoblastic disease o Not a viable pregnancy and needs to be terminated because that can cause bleeding in early pregnancy § can become cancerous A noncancerous tumor that develops in the uterus as a result of a nonviable pregnancy. There may or may not be an embryo or placental tissue present. If there is an embryo, it unfortunately won't be able to survive. The pregnancy may seem normal at first, but when symptoms develop they include dark brown to bright red vaginal bleeding during the first trimester, along with severe nausea and vomiting. The tumor must be removed to avoid serious complications.

Preciptious labor

A precipitous labor lasts 3 hours or less

HELLP syndrome

A serious complication of high blood pressure during pregnancy. Hemolysis, elevated liver enzymes, low platelet count (HELLP) syndrome usually develops before the 37th week of pregnancy but can occur shortly after delivery. Many women are diagnosed with preeclampsia beforehand. Symptoms include nausea, headache, belly pain, and swelling. Treatment usually requires delivery of the baby, even if the baby is premature.

Shoulder dystocia

A shoulder dystocia is obstruction by the shoulders after the birth of the head. In many cases, no risk factors exist. Macrosomia and maternal diabetes are often associated with shoulder dystocia. Turtle sign is often the first sign of a shoulder dystocia. First interventions to resolve a shoulder dystocia include McRobert's maneuver and the application of suprapubic pressure.

Amniotic fluid embolism

AKA Anaphylactoid syndrome of pregnancy, may occur in pregnancy, labor, delivery, or the immediate postpartum period. It is caused when amniotic fluid enters maternal circulation Associated with maternal mortality rate of 32% Initial symptoms include respiratory failure and cardiac arrest If the patient survives an amniotic fluid embolism, she is at risk for hemorrhagic shock with disseminated intravascular coagulation

Postterm pregnancy - Labor induction

After cervical ripening, oxytocin IV is administered Oxytocin may cause gastrointestinal distress, water retention, tachycardia, hypotension, and uterine tachysystole Uterine tachysystole with oxytocin and a non reassuring fetal heart rate change requires STOPPING the oxytocin infusion and notifying the obstetric provider.

Episiotomy

An episiotomy is a surgical incision of the posterior aspect of the vulva made during the second stage of labor. An episiotomy is used if the patient is at high risk for a third or fourth degree perineal tear or if an expedited delivery is needed because of fetal compromise. Risks include infection, bleeding, and pain.

Chorioamnionitis

An infection of the amnion, chorion, or both that complicates up to 2% of term births and up to 50% of preterm births. - commonly caused by the ascent of bacteria through the cervix. - risk factors for chorioamnionitis include PROM, multiple digital vaginal exams, prolonged labor, and preterm birth. - complications from chorioamnionitis include neonatal sepsis and postpartum hemorrhage - prompt treatment with broad spectrum antibiotics (often ampicillin and gentamicin) indicated.

Postpartum infections: perineal wounds

Associated with third and fourth degree lacerations Risk factors include: - operative vaginal delivery (forceps, vacuum assisted) - prolonged second stage of labor - third or fourth degree laceration - meconium stained fluid Assessment findings include: - tenderness - redness - swelling - purulent drainage Treatment - removal of sutures and opening of the wound No antibiotics unless evidence of cellulitis

PPH treatment

Call for help Fundal massage of a boggy uterus Assess for lacerations or hematoma if the fundus is firm Bladder catheterization for inability to void Establishing intravenous access Oxytocin administered as first line uterotonic medication

Postpartum infections

Commonly related to: - perineal wounds - cesarean wounds - endometritis - mastitis - UTIs Symptoms can be nonspecific but generally include - a fever (greater than 100.4) - fever that begins 2 to 10 days after birth - elevated white blood cell count that CONTINUES TO RISE rather than fall

Cord prolapse

Condition where umbilical cord precedes the presenting part (fetal head) in the birth canal The first sign of a cord prolapse is often a change in fetal heart rate tracing, typically severe fetal bradycardia and variable decelerations A cord prolapse is an obstetric emergency typically requiring immediate cesarean delivery. The presenting part should be held off of the cord The cord should be handled as little as possible to prevent spasm of the umbilical artery

Postpartum psychosis

Disturbance of a woman's perception of reality as evidenced by: - hallucinations - though disorganization - disorganized behavior - delusions Most common in women who suffer from - depression with schizophrenia - schizoaffective disorder - psychosis Condition may occur within 48 hours of delivery The priority of care is the safety of the patient and the safety of the infant Treatment often requires inpatient psychiatric care

Dystocia of labor

Dystocia of labor is any labor with abnormally fast or slow progression

Bishop score

Evaluates cervical position, consistency, dilation, effacement, and fetal station A Bishop score of 8 or higher is considered favorable for induction and has a greater chance of a successful vaginal delivery Favorable cervix = more likely to dilate and efface Unfavorable cervix = less likely to dilate and efface

Hypovolemic shock treatment

Fluid resuscitation: restoration of circulating blood volume (usually normal saline or lactated Ringer's) Establish 2 large-bore IV lines Monitor urine output using a Foley catheter Monitor vital signs Draw lab work as ordered toe valuate RBC cell count and assess for disseminated intravascular coagulation (DIC) Administer blood transfusions as ordered (massive transfusion protocols)

Complications of cesarean delivery

For mothers: - bowel and/or bladder injury during surgery - hemorrhage - amniotic fluid embolism - infection Major neonatal complication: - respiratory distress

GBS cont

GBS colonization is often asymptomatic for women but can be devastating for infants Signs and symptoms of GBS infections in neonates includes sepsis, pneumonia, or meningitis. Women should be screened for GBS at 35-37 weeks of gestation. GBS positive women are treated in labor with antibiotics that must be started at least 4 hours before delivery Women with preterm labor are treated for GBS without screening

Postterm pregnancy - Cervical ripening

If Bishop score is 6 or less, cervical ripening is indicated prior to induction Pharmaceutical ripening: - prostaglandins often used prior to oxytocin for labor induction - contraindicated for women with pervious cesarean births due to risk of uterine rupture - Misoprostol (common prostaglandin) Mechanical ripening - insertion of a balloon catheter into the cervix - increased risk for infection but decreased risk of uterine tachysystole

Power and dytocia

Ineffective pushing by the mother can also lead to dystocia. Laboring down is a process of allowing the primary powers to facilitate

Types of spontaneous abortion (Miscarriage)

Inevitable - patient experiences vaginal bleeding and cramping; cervix is dilated Threatened - patient experiences vaginal bleeding but cervix is NOT dilated Missed - Pregnancy is no longer viable, but no cervical dilation, cramping, or bleeding is present Septic - any spontaneous abortion that occurs with intrauterine infection Incomplete - patient has experienced vaginal bleeding, cramping, and cervical dilation but not all products of conception expelled

Postpartum infection: endometritis

Infection of the lining of the uterus (27% in c section and 1-3% vaginal deliveries) *Risk factors* - chorioamnionitis - prolonged labor - prolonged rupture of membranes Infection may cause the uterus to become soft and subinvoluted, predisposing the woman to hemorrhage. *Signs and symptoms* - fever - uterine tenderness - flu like symptoms - tachycardia Treated with IV infusion of a broad-spectrum antibiotic

Preterm labor treatment

Interventions include suppression of labor, physical activity restriction, progesterone supplements, and, and management of medications - coricosteroids may be administered to women at 23--34 weeks - antibiotics administered because preterm labor may be caused by infection

PPH symptoms

Loss of 500-1000 mL - normal BP - palpations - lightheadedness - minimal increase in heartrate Loss of 1000-1500 mL - lower blood pressure - weakness - diaphoresis - RR of 20-24 breaths per minute - heart rate of 100-120 bpm Loss of 1500-2000 mL - systolic blood pressure less than 90 - restlessness - confusion - pallor - oliguria - delayed cap refill - heart rate of 120-140 bpm Loss of 2,000-3000 mL - BP less than 90 - Pulse pressure less than 25 - delayed cap refill - lethargy - air hunger - no urine production - heart rate greater than 140 bpm

Postpartum depression

Major depression with an onset during pregnancy or in the first 4 weeks after birth Risk factors - history of depression (2x the risk) - depression during pregnancy (5x the risk) Diagnosis - must meet at least five of the nine diagnostic criteria for major depressive disorder during a 2 week period OR one of the symptoms must be a depressed mood or diminished pleasure in all or most activities Warning signs - low mood for at least 2 weeks - negative attitude toward infant - concern about ability to care for the infant - use of alcohol street drugs, drugs prescribed to others, or tobacco Treatment includes medication and therapy

VTE

More common than a DVT Symptoms include: - pain/tenderness and redness along the length of the vein - cord-like vein (palpated) Is often self limiting Supportive measures include: - elevate affected leg - warm/cold compresses for comfort - NSAIDs - compression stockings

Identifying infant with sepsis

Most common signs: - tachycardia - hyperthermia - neonatal respiratory distress Other signs - apnea - bradycardia - hypotension - feeding difficulties - vomiting - jaundice - hepatomegaly (enlarged liver)

Placenta Previa

Occurs when placental tissues overlies the internal cervical os The major complication of placenta previa is maternal hemorrhage Risk factors for a placenta previa include - placenta previa in prior pregnancy - maternal smoking - advanced maternal age Signs of placenta previa include: *PAINLESS VAGINAL BLEEDING* Placenta previa is diagnosed by ultrasound A digital exam is CONTRAINDICATED for a woman with known or suspected placenta previa because palpation is associated with acute bleeding

Cord prolapse

Occurs when the umbilical cord slips between the fetal presenting part and the maternal pelvis - Overt cord prolapse: cord comes out ahead of the presenting part of fetus. An emergency cesarean is needed - Occult cord prolapse: cord alongside the presenting part of fetus. Vaginal delivery may be possible Concern with a cord prolapse is the cord becomes compressed and the baby does not get enough oxygen Greatest risk is when the fetal presenting part is not engaged into the maternal pelvis Often indicated by variable decelerations or bradycardia in fetal heart rate Cord prolapse confirmed during vaginal exam

Postpartum infections: cesarean wounds

Often diagnosed after discharge, from day 4-7 postpartum Signs and symptoms include: - induration (abdominal firmness) - redness - warmth - pain at the incision site - dehiscence (wound edge separation) - purulent discharge and fever may be noted Treated by opening and draining the wound Wound is left open but kept moist and covered

Chorioamnionitis warning signs

One maternal oral temperature greater than 39 C (102 F) OR temp greater than 38 C with one symptom below: - high maternal white blood cell count - maternal tachycardia - fetal tachycardia (160 beats per minute or higher for 10 minutes or more) - cloudy or yellow discharge from the cervix

Pulmonary embolism

PE is a MEDICAL EMERGENCY Anticoagulant treatment should begin prior to confirmation of the diagnosis Anticoagulant therapy continues for approx 6 months Symptoms are often nonspecific and include - dyspnea - cough - swating - pleuritic chest pain Diagnosis confirmed by - ventilation/perfusion scan - computer tomographic pulmonary angiography

Postpartum infection: UTIs

PP women prone to UTIs because frequency of bladder catheterization and genital procedures *Pyelonephritis* is a UTI of the upper urinary tract. Symptoms include: - flank pain - nausea and vomiting - fever Treatment with antibiotics

PROM is confirmed by

PROM is the rupture of membranes before the start of labor. PROM is confirmed by: 1. Nitrazine test - obtain sample of luid using nitrazine paper of cotton swab with nitrazine dye. If paper/swab turns shades of blue, membranes likely ruptured. 2. Ferning test - obtain a sample on a plain cotton swab and wipe on glass slide. If ferning is visible under microscope then membranes likely ruptured.

Preterm rupture of membranes (PROM)

PROM is the rupture of membranes prior to the start of contractions at or after 37 weeks PROM increases the risk of prolapsed cord, placental abruption, chorioamnionitis, and cord compression. 90% of women with PROM go into labor within 24 hours.

Passageway and dystocia

Passageway complications often occur in conjunction with passenger issues A maternal pelvis that is smaller than normal, or contracted can lead to dystocia. Pelvimetry is associated with higher cesarean risks but not overall improved outcomes. Soft tissue dystocia can be caused by a full bladder or bowel. Scar tissue on the cervix can lead to soft tissue dystocia. Pushing before the cervix is fully dilated can lead to swelling and soft tissue dystocia.

Placental abruption

Placental abruption is the premature detachment of the placenta from the decidua of the uterus and is often classified as mild or severe. Causes of placental abruption include: - often unknown cause - trauma - smoking - cocaine Prognosis: - a mild abruption may have limited impact - a severe abruption may result in complete detachment of the placenta and risk the life of the mother and the fetus.

precipitous labor

Precipitous labor is defined as expulsion of the fetus within less than 3 hours of commencement of regular contractions Precipitate delivery refers to childbirth after an unusually rapid labor and culminates in the rapid, spontaneous expulsion of the infant. Delivery often occurs without the benefit of asepsis.

Role of nursing during a cord prolapse

Remain calm - most of the time an emergency c section is required Requires team for emergent delivery - notify provider of STAT delivery - notify neonatal team of stat delivery - notify anesthesia of stat delivery Keep fetal presenting part off of the pelvis to minimize cord compression (vaginal exam) - do NOT manipulate cord because it can cause vasospasm and impair oxygenation - maintain presenting part elevation off pelvis until delivery Prepare patient for general anesthesia (not spinal or epidural)

Cesarean post operative care considerations

Routine monitoring per protocol - systolic BP should not drop below 90 - heart rate should stay below 120 bpm - RR should stay below 30 breaths per min - o2 stat should be 95% or higher - urine output should remain at or above 30 ml/hr - uterine tone and bleeding from the vagina and incision Breastfeeding to be started in delivery room Bladder catheter removal as soon as possible (as soon as safe ambulation) Ambulation within 6 hours after anesthsia effects are resolved Regular diet as tolerated Would dressing removal from 24-48 hours after delivery Avoidance of heavy lifting and lifting from a squat position for 1-2 weeks

Perinatal loss

Stillbirth occurs in approx 6 of 1,000 pregnancies that reach 20 weeks gestation Risk is higher for - adolescents - women over 35 years old - women of african descent - multifetal gestations - congenital anomalies - maternal disease Prevention of perinatal loss may include - taking folic acid before and during pregnancy - routine syphillis screening and treatment - screening for and treating hypertensive disorders and maternal diabetes - access to emergency obstetric care

DVT

Symptoms include: - swelling - pain/tenderness - localized redness - warmth Diagnosed with ultrasound Treatment includes: - anticoagulation therapy - surgery

Contraindications for Methergine

The following conditions are contraindicated with this drug. Check with your physician if you have any of the following: Conditions: blockage or narrowing of mitral heart valve high blood pressure a heart attack coronary artery disease a stroke a blockage of the arteries called arteriosclerosis obliterans serious numbness or prickling or tingling of fingers and toes liver problems decreased kidney function seizures pregnancy increased cardiovascular event risk sepsis Allergies: Ergot Alkaloids Amine Ergot Alkaloid Hydrogenated Ergot Alkaloid Semi-Synthetic Ergot Alkaloid Dopamine Receptor Agonis

Postpartum blues

Transient, self limiting mood disorder that starts 2 or 3 days after delivery and resolves within 10 days to 2 weeks

GBS intrapartum period

Treatment for GBS started during labor and delivery when indicated Treatment includes: - Penicillin - Clindamycin for women with penicillin allergy - antibiotic dosing must be started 4 or more hours before delivery to be considered treated

Hypovolemic shock

Triggered when the volume of circulating blood decreases to a degree that the body's organs do not have enough oxygen to function properly. Symptoms of hypovolemic shock include - hypotension - tachycardia - tachypnea - oliguria - mental status changes - cool, pale, and clammy skin - slowed capillary refill

Postpartum Hemorrhage

Typical blood loss is 500 mL for vaginal delivery and 1000 mL for a cesarean delivery. A postpartum hemorrhage (PPH) is bleeding of more than 1000 mL despite uterine massage and first line uterotonics (such as oxytocin) *early PPH* occurs within 24 hours of birth *delay or secondary PPH* may occur 24 hours to 12 weeks after delivery After birth the uterus normally maintains homeostasis and prevents PPH by clotting and contraction of the myometrium of the uterus *PPH is often caused by* uterine atony, blood coagulopathies, or trauma

Postpartum infection: lactational mastitis

Unilateral inflammation of the breast tissue, often associated with infection Most common in the first 3 months of breastfeeding *Factors contributing to mastitis include* - delayed breast emptying - poor drainage of one or more ducts - inconsistent pressure on breasts (poorly fitting bra) - oversupply of milk - nipple trauma *Symptoms* - tender, red area of breast - malaise - high fever - flu like symptoms *Treatment* - cold compresses - NSAIDs - regular and complete emptying of the breast - antibiotics

amniotic fluid embolism interventions

call for help if prior to birth, place the woman in the side lying position to displace the uterus continuously monitor womans oxygen sat level, heart rate, RR, and BP if birth has not occured, perform continuous fetal monitoring

Postterm pregnancy

equal or greater than 42 weeks gestation Risks: fetal macrosomia, prolonged labor, birth injury, postpartum hemorrhage Treatment: expectant management or induction of labor Induction of labor begins with an evaluation of the woman's cervix using a Bishop score

Placenta previa cont

instruct patients to seek care urgently if they experience bleeding or contractions delivery is generally recommended between 36 and 37 weeks Because the likelihood of blood transfusion is high, women may have their blood typed and cross matched at the time of admission Cesarean sectino is almost always indicated for placenta previa

Cesarean section Preoperative care considerations

laboratory testing - hemoglobin - blood type and antibody screen Antibiotics administration - single dose antibiotic given within 60 minutes before incision Thromboembolism prophylaxis Fetal heart rate monitoring Placental incision and fetal position assessment Bladder catheterization Skin preparation Vaginal preparation Draping around surgical site Displacement of the uterus to avoid supine hypotension

Tachysystole

more than 5 contractions in 10 minutes

hyperemesis gravidarum

severe nausea and vomiting in pregnancy that can cause severe dehydration in the mother and fetus This condition can require hospitalization and treatment with IV fluids and anti-nausea medications. In the case of hyperemesis gravidarum, the following are risk factors: - Hyperemesis gravidarum during an earlier pregnancy. - Being overweight. - Having a multiple pregnancy. - Being a first-time mother. - The presence of trophoblastic disease, which involves the abnormal growth of cells inside the uterus.

hypertonic uterine dysfunction

uncoordinated uterine activity. Contractions are frequent and painful but ineffective in promoting dilation and effacement.

Operative vaginal delivery

vaginal birth that is assisted by vacuum extraction or forceps Operative vaginal delivery may be attempted for a prolonged second stage of labor, fetal compromise, or a disorder that limits the mother's ability to push. Risk for operative vaginal delivery include shoulder dystocia and tissue damage to the mother and fetus *Forceps assisted birth* are applied to either side of the fetal head to allow the provider to pull with contractions - Cesarean deliveries are performed if it is difficult to apply forceps safely or delivery does not occur within 15 to 20 minutes *Vacuum assisted birth* is a device that applies suction to the fetal head to aid in extraction - Cesarean deliveries are performed after three sets of pulls (traction) or a total application time of 15 to 30 minutes