Definition of terms a. Dystocia and dysfunctional labor difficult labor or failure to progress in labor can arise from any of the three main components of the labor process: (1) the force that propels the fetus (uterine contractions); (2) the passenger (the fetus); or (3) the passageway (the birth canal). b. Abruptio placenta – A normally implanted placenta that separates prematurely (between the 20th week of gestation and birth of the infant). It is painful and associated with dark red vaginal bleeding. c. Placenta previa - the placenta is implanted in the lower portion of the uterus; painless uterine contraction with dark red bleeding; usually occurs on the 24th week of gestation. d. Amniocentesis - is the withdrawal of amniotic fluid through the abdominal wall for analysis at the 14th to 16th week of pregnancy. e. Amniotic fluid embolism -occurs when amniotic fluid is forced into an open maternal uterine blood sinus through some defect in the membranes or after membrane rupture or partial premature separation of the placenta. f. Cerclage - (tracheloplasty), also known as a cervical stitch, purse-string sutures are placed in the cervix usually by a vaginal route although this can be done abdominally. g. Hydramnios - an excessive amount of amniotic fluid (generally over 2,000 ml). The chronic form of the disorder causes discomfort from enlargement of the abdomen; it also causes difficulty in
breathing and collection of fluid (edema) in the legs. Commonly seen in diabetic patients. h. Oligohydramnios - a decreased amount of amniotic fluid. It is typically caused by fetal urinary tract abnormalities such as bilateral renal agenesis, fetal polycystic kidneys or genitourinary obstruction. Uteroplacental insufficiency is another common cause. Complications may include cord compression, musculoskeletal abnormalities such as facial distortion and clubfoot, pulmonary hypoplasia and intrauterine growth restriction. i. Hypertonic labor dysfunction - painful uterine contraction which is more frequent which can lead to maternal exhaustion and fetal distress. j. Hypotonic labor dysfunction - infrequent uterine contraction with poor intensity; low resting tone between contractions which leads to prolong labor. They may occur because more than one pacemaker is stimulating the contractions k. Macrosomia - birth weight above the 90th percentile on an intrauterine growth chart for that gestational age. Associated with poorly controlled maternal diabetes due to excessive production of fetal insulin and hence the increased deposition of glycogen in the fetus. l. Prolonged labor - labor lasting for more than 24 hours. m. Precipitate labor – labor occurring for a very short time, can last for as early as 3 hours. n. Prolapsed cord - a loop of the umbilical cord slips down in front of the presenting fetal part. Prolapsed may occur at any time after the membranes rupture if the presenting part is not fitted firmly into the cervix.
Discussion a. Hemorrhagic Complications during Childbirth Stage/ Bleeding During Early Pregnancy State Abortion 1. Abortion Abortion is the expulsion of the fetus prior to viability, which is considered 20 weeks gestation or weight of less than 500 g. Removal or destructions of an embryo or fetus before birth Either spontaneous, occurring naturally, or induced, occurring as a result of artificial or mechanical interruption. 2. Spontaneous abortion or miscarriage Occurring without medical or other intervention About 25% of all pregnancy results in miscarriages, women older than 35 or younger than 17 years old and couples who have difficulty in achieving pregnancy; women who have had at least miscarriage has a higher chance of experience marriage. About 90% of miscarriage occurs during the first trimester (first three months, or 12 weeks of pregnancy). Some cases of miscarriage happen even before even before a woman realizes that she is pregnant, and she even may not realize that she has aborted. 3. Habitual abortion
Characterized by having 3 or more abortions in one year, approximately every 4 months.
A. Spontaneous abortion Classifications 1. Threatened abortion is a condition of pregnancy, occurring before the 20th week of gestation, the patient usually experience vaginal bleeding with or without cramping, the cervix is closed. Bed rest is usually the only treatment needed. In a few cases the symptoms disappear and the rest of the pregnancy is normal. 2. Inevitable / imminent abortion is when the bleeding continues and becomes heavy; it usually means that the cervix and the contents of the uterus (products of conception) are being expelled. Pregnant woman will experience lower abdominal cramping and bleeding. 3. Incomplete abortion is a name give to the abortion when the uterus retains parts or the entire placenta. Bleeding may occur because part of the placenta may adhere to the uterine wall and the uterus does not contract to seal the large blood vessels that feed the placenta. The usual treatment is a drug that induces labor by stimulating uterine contractions, a surgical procedure called curettage ca also be done to remove the remaining material from the uterus. 4. Complete abortion is when all of the products of conception is expelled. There is no treatment other then rest is usually needed. All of the tissues that come out should be saved for examination by the doctor to make sure hat the abortion is complete. The laboratory examination of the saved tissue may determine the cause of the abortion.
5. Missed abortion is a case in which an intrauterine pregnancy is present but is no longer developing normally. Before widespread use of ultrasonography, the term missed abortion was applied to pregnancies with no uterine growth over a prolonged period of time, typically 6 weeks after its (fetus) death. Missed abortion is usually indicated by the disappearance of the signs o pregnancy except for the continual absence of menstrual periods. Missed abortions are usually treated by induction of labor by dilation (or dilatation) and curettage (D&C). 6. Septic abortion is a condition when the products of conception become infected during abortion. There is fever (380C), foul odor, elevated WBC, chills. There may be the presence of retained placental parts.
pregnancy is in the 1st trimester. Beyond 12 weeks gestation, induction of labor by intravenous oxytocin and prostaglandins may be use to expel the dead fetus. Nursing Management: Threatened A woman may be asked to come to the clinic or office to have fetal heart sounds assessed or a sonogram done to evaluate the viability of the fetus. Blood for human chorionic gonadotropin hormone (hCG) may be drawn at the start of bleeding and again in 48 hours (if the placenta is still intact, the level in the bloodstream should double in this time). Avoiding strenuous activity for 24 to 48 hours is the key intervention, assuming the threatened abortion involves a live fetus and presumed placental bleeding. Complete bed rest is usually not indicated. Bed rest may stop the vaginal bleeding, but only because blood is pooling vaginally. When a woman does ambulate again, bleeding will recur. Women are apt to be extremely worried at the sight of bleeding. They need to talk with a sympathetic, supportive person about how distressed they feel. Be certain to convey concerned reassurance that miscarriages happen spontaneously, not because of anything a woman did. Women with threatened miscarriages look for reasons why this could have happened, such as running up a flight of stairs, forgetting to take an iron pill, or getting angry with an older child. Being told that none of these events causes miscarriage can help to minimize the guilt that many women feel. Imminent (Inevitable) Miscarriage
Medical Management: One of the more reliable indicators of potential spontaneous abortion is the presence of pelvic cramping and backache. These symptoms are usually absent in bleeding caused by polyps, ruptured cervical blood vessels, or cervical erosion The therapy prescribed for the pregnant woman with bleeding is abstinence from coitus and perhaps sedation. If bleeding persist and abortion is imminent or incomplete, the woman may hospitalized, IV therapy or blood transfusions may be started to replace fluid, and dilatation and curettage or suction evacuation is performed to remove the remainder of the products of conception. In missed abortions, the products of conception eventually are expelled spontaneously. If this does not occur within 4-6 weeks after fetal death, hospitalization is necessary. Dilatation and curettage or suction evacuation is done if the
o Save any tissue fragments passed in the labor
room, along with any brought from home, so they can be examined for an abnormality such as gestational trophoblastic disease (hydatidiform mole) or for assurance that all the products of conception have been removed from the uterus. After the D&E, a woman should assess vaginal bleeding by recording the number of pads she uses. Saturating more than one pad per hour is abnormally heavy bleeding. Complete Miscarriage After a self-limiting complete miscarriage, a woman needs clear instructions on how much bleeding is abnormal (a rule of thumb is that more than one sanitary pad per hour is excessive) and what color changes she should expect in bleeding (gradually changing to a dark color and then to the color of serous fluid as it does with the postpartum woman). She should know that any unusual odor or passing of large clots is also abnormal. If her physician has prescribed an oral medication such as oral methlergonovine maleate (Methergine) to aid with contraction, be sure she understands why it is being prescribed an the importance of taking it. Incomplete Miscarriage In an incomplete miscarriage, there is a danger of maternal hemorrhage as long as part of the conceptus is retained in the uterus because the uterus cannot contract effectively in this condition. The physician will usually perform a dilation and curettage (D&C) or suction curettage to evacuate the remainder of the pregnancy from the uterus. Be certain a woman knows that pregnancy is already lost and that this procedure is being done only to protect her from hemorrhage and infection, not to end the pregnancy. Missed Abortion
o A sonogram can establish the fetus is dead. Often
the embryo actually died 4 to 6 weeks before the onset of miscarriage symptoms or failure of growth was noted. After the sonogram, a D&E most commonly will be done. If the pregnancy is over 14 weeks, labor may be induced by a prostaglandin, suppository or misoprostol (Cytotec) to dilate the cervix, followed by oxytocin stimulation or administration of mifepristone. If the pregnancy is not actively terminated, miscarriage usually occurs spontaneously within 2 weeks. There is a danger of allowing this normal course to happen, however, because disseminated intravascular coagulation (DIC), a coagulation defect, may develop if the dead (and possibly toxic) fetus remains too long in utero. B. Induced abortion This type of abortion uses drugs or instruments to stop the normal course of pregnancy Induced abortions are done for a number of reasons: to end the pregnancy of a woman whose life is in danger because if the pregnancy (such as woman who have IV heart disease); to prevent the growth of a fetus who has been found on amniocentesis to have a chromosomal defect; to end a pregnancy that is the result of rape or incest; or to terminate the pregnancy of a woman who choose not to have a child at this time in her life. The majority of induced abortions are done for the last reason. Causes 1. Endocrine abnormalities Women suffering from endocrine system dysfunctions like: thyroid dysfunction (imbalance in thyroid-stimulating hormones -
causing hyper or hypothyroidism, thyroxin and triiodothyronine, and calcitonin), and diabetes mellitus (type 1 & 2). 2. Maternal infection TORCH infections during gestations. Toxoplasmosis (a protozoan infection associated with the consumption of infected or poorly cooked meat and poor hand hygiene after handling infected cal litters). Other infections (AIDS, Lyme disease). Rubella (german measles or a 3-day measles. Can lead to congenital defect). Cytomegalovirus herpes virus (transmitted through respiratory droplets and also from the semen, vaginal secretions, breast milk, placental tissue, urine, feces, and blood). Herpes simplex 2. 3. Acquired anatomic abnormalities Disruption in the normal anatomy and physiology of the female reproductive system can pose problems during pregnancy. Uterine fibroids (solid, pedunculated benign tumors found on the muscles layers of the uterus). Endometritis (inflammation of the inner uterine lining). Uterine rupture (rupture of scars from previous CS and hysterectomy repairs). Inversion of the uterus (is a rare occurrence in which the uterus is turned inside out due to increased traction applied on the umbilicus). Amniotic fluid embolism (occurs when amniotic fluid is forced into an open maternal blood sinus through some defect in the membranes or partial premature separation of the placenta). 4. Immunologic factors Rh incompatibility (When carrying an Rh-positive child, the mother will build up
antibodies to the Rh0 factor in about 5 percent of all cases. These antibodies will usually be too weak to harm the first child. But during labor and delivery some of the baby's Rh-positive blood may get into the mother's bloodstream and trigger or sensitize her immune system. Her antibodies will then attack the red blood cells of any subsequent Rh-positive children. This reaction produces erythroblastosis fetalis, or Rh disease, which results in jaundice, anemia, brain damage, and often death, either before or shortly after birth). 5. Environmental factors Heavy Metal and chemical hazards (insecticides, carbon monoxide, Lead, Mercury). Radiation (Fallout, x-rays, CT scans). Hyperthermia and hypothermia in extreme weather conditions (affecting blood flow and F/E imbalances). Manifestations Uterine cramping coupled with vaginal bleeding often indicates spontaneous abortion Cramping is usually absent if the vaginal bleeding is cause by other conditions such as polyps Most reliable indicator of pregnancy with an early abortion: serial serum B-human chorionic gonadotropin hormone (HCG’s) and vaginal examination of the pelvis. Depression Management Bed rest Avoiding vaginal intercourse
If bleeding is excessive – D&C. Woman having induced abortions need the same kind of explanations that women in labor receive. 2. Hydatidiform Mole (H-Mole) / Molar pregnancy / Gestational Trophoblastic Disease From a proliferation and degeneration of the trophoblast villi. As the cell degenerate, they become filled with fluid, appearing as a fluid filled, grape-sized vesicle, in this condition; the embrayo fails to develop beyond a primitive start. They must be identified as they are associated with carcinoma. The incidence of hydatidiform mole is approximately 1 in every 1000 pregnancies. Types: Complete mole is more common than partial moles. It develops from an ovum containing no maternal genetic material that is fertilized by a normal sperm. The embryo dies very early, no circulation is established, the hydropic vesicles are avascular, and no embryonic tissue or membranes are found. Partial mole usually has a triploid karyotype (69 chromosomes), generally because of failure of either the ovum or sperm to undergo the first meiotic division. There may be fetal sack or even a fetus with a heartbeat. The fetus has multiple anomalies because of the triploidy and little chance for survival. The villi are often vascularized and may be hydropic in only portions
of the placenta. Often partial moles are recognized only after spontaneous abortion, and they may go unnoticed even then. i. Manifestations Clinical features same to that of pregnancy Classis signs: vaginal bleeding (brownish , like prune juice or bright red); uterine enlargement, hyperemesis gravidarum; (-) fatal heart tones and movement PIH prior to 24 weeks gestation strongly suggest a molar pregnancy ii. Signs and symptoms Positive pregnancy (A blood or urine test for pregnancy will strongly positive – 1 to 2 million IU compared to a normal pregnancy level of 400,000 IU- because HCG, the substance tested for pregnancy test, is produced by the trophoblast cells). Abnormal enlargement of abdomen (Because of the rapid proliferation of the trophoblastic cells that occur with complete moles, uterine enlargement may be greater than expected for gestational age). Anemia (At approximately week 16 of pregnancy, it will identify itself with vaginal bleeding). Passage of vesicles (Bleeding may begin as vaginal spotting of dark brown blood or as a profuse fresh flow. As the bleeding progresses, it is accompanied by discharge of the clear fluid-filled vesicles). Absence of fetal movement or parts (no fetal heart sounds will be heard and absence of movement will be noticed because there is no viable fetus).
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Nurses, in providing care for clients with such complications should: Include in the assessment during prenatal visits, observations for signs of molar pregnancy during the first 24 weeks. Provide the woman and her family, information about the disease process, the necessity for a long course of follow- up, and the possible consequences of the disease. Help the woman understand and cope with pregnancy loss and recognize that the pregnancy was abnormal. Encourage the woman and her family to express their feelings and provide information about support groups or counseling resources if needed. Provide explanations about the importance of the need to postpone a subsequent pregnancy and contraceptive counseling to emphasize the importance of consistent and reliable use of the method chosen. b. Bleeding during late pregnancy i. Pregnancy-Induced Hypertension Where the pregnant women experienced high blood pressure; presence of protein in urine and edema. The symptoms usually occur after the 20th week of gestation
b. Mild Preeclampsia (a woman is said to be mildly preeclamptic when her blood pressure rises to 140/90 mmHg, taken in two occasions at least 6 hours apart. Urine output less than 30 ml/hour. May have edema at the face and fingers). c. Severe Preeclampsia (a woman has passed from mild to severe preeclampsia when her blood pressure has risen to 160 mmHg systolic and 110 mmHg diastolic or above on at least two occasions 6 hours apart at bed rest or her diastolic pressure is 30 mmHg above the pregnancy level. May yield a +4 albumin result found in urine). d. Eclampsia (it is the most severe classification of hypertension of pregnancy. A woman has passed into this third stage when cerebral edema is so acute that a seizure or coma occurs). Management a) Promote bed rest. When the body is in a recumbent position, sodium tends to be excreted faster than during activity. Bed rest is the best method in aiding increased evacuation of sodium and encouraging dieresis. Rest should always be in a lateral recumbent position to avoid uterine pressure on the vena cava. b) Promote good nutrition. A woman should continue her usual pregnancy diet but should not have a stringent restriction of salt because it can activate rennin-angiotensin-aldosterone system and result in increased blood pressure, compounding the problem. c) Monitor maternal well-being. Take the blood pressure frequently (at least every 4 hours) or with continuous monitoring device to detect any increase, which is a warning that a woman’s
condition is worsening. Obtain blood studies as ordered. Obtain daily weights as the same time each day to evaluate tissue fluid retention. d) Monitor fetal well-being. Generally, single Doppler auscultation at approximately 4-hour intervals is sufficient at this stage of development. Fetal heart rate may be assessed continuously with an external fetal monitor. e) Administer medications to prevent eclampsia. a hypotensive drugs such as hydralazine (Apresoline) or labetalol (Normodyne) may be prescribed to reduce hypertension. These drugs act to lower blood pressureby peripheral dilatation and thus do not interfere with placental circulation. They can cause tachycardia. Therefore, assess pulse and blood pressure after administration. Diastolic pressure should not be lowered below 80 to 90 mmHg. Despite these new drugs, magnesium sulfate remains the drug of choice to prevent eclampsia.
Edama (is a general term for the accumulation of excess fluid in any body tissue, cavity, or organ, except bone. Major causes are heart or kidney failure, low blood serum protein after starvation or liver failure, shock, and impaired return of blood from extremities). Types 1. Dependent edema is most likely to occur around the sacrum or heels of the client who sits up in bed or in the feet and lower legs of the client who sits in a chair.
Hypertension Types a. Gestational Edema (Blood pressure is 140/90 or systolic pressure elevated 30 mmHg or diastolic pressure elevated 15 mmHg above prepregnancy level; no proteinuria or edema; blood pressure retuenrs to normal after birth).
2. Pitting Edema is edema that leaves a small depression or pit after finger pressure is applied to the swollen area. The pit is caused by movement of fluid to adjacent tissue, away from the point of pressure. Within 10 to 30 seconds the pit normally disappears. May be shiny and cold. Can be graded as +1 = if indention is 2mm in depth; +2 = 4mm in depth, +3 = 6mm in depth, +4 = 8mm in depth. Protenuria (late stage of preeclampsia) is the presence of protein in the urine. Trace amounts of glucose and protein in the urine are common during pregnancy because of increased glomerular permeability, so proteinuria must be compared to a woman’s individualized prepregnancy level to be meaningful. Theories regarding PIH Increased vasoconstriction – due to an increase sensitivity to circulating pressors such as angiotensin II and possibly imbalance between prostaglandin and prostacylin Endothelial cell activation – due to decreased placental perfusion; endothelial damage; arteriolar vasospasm contribute to the increased capillary permeability. Increased edema – can lead to decrease intravascular volume – which predispose to pulmonary edema Immunologic factor – the presence of foreign protein, the placenta or the fetus may trigger adverse immunologic response
c. Common Pathologic Changes During Intrapartum i. Dystonia / dysfunctional labor “Inertia” is a time-honored term to denote that sluggishness of contractions has occurred. Causes Inappropriate use of analgesia (excessive or too early administration) Pelvic bone contraction that has narrowed the pelvic diameter so that the fetus cannot pass, such as might have occurred in a client with rickets. Poor fetal positioning (posterior rather than anterior position). Extension rater than flexion of the fetal head. Overdistention of the uterus, as with multiple pregnancy, hydramios or an excessive oversized fetus. Cervical rigidity Presence of a full rectum or urinary bladder that impedes fetal descent Mother becoming exhausted from labor Primigravida Types 1. Primary Dysfunctional Labor (occurring at the onset of labor) /Hypertonic Uterine Dysfunction IV.
3. 4. 5.
Management and Nursing responsibilities Oxytocin is not as effective as effective with hypertonic contractions as is rest and possibly sedation. Change the linen and her patient gown; darken room lights, decrease noise and stimulation. If there is late deceleration in the fetus, an abnormally long stage of labor, or lack of progress (“second stage arrest”), the woman will be scheduled for a cesarean delivery. Both the woman and her support person need support to understand why contractions that feel as if they must be effective because they feel strong are in reality ineffective and are nor achieving cervical dilation. 2. Secondary Uterine Inertia (occurring later in labor) /Hypotonic uterine dysfunction Management and Nursing responsibilities An infusion of oxytocin to “assist” labor is usually helpful to strengthen contractions and increase their effectiveness. Membranes may be artificially ruptured (amniotomy). Mark in the woman’s chart that hypotonic contractions occurred. In the first hour post partum, the uterus needs to be palpated every 15 minutes and lochia should be assessed carefully to ensure that postpartal contractions are adequate.