It is a reviewer for our prelims., Summaries of Medicine

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ANTEPARTUM

COMPLICATIONS

RISK FACTORS DURING

PREGNANCY

HYPERTENSION

Classification:

Chronic HPN Present before pregnancy / < 20 weeks Gestational HPN > 20 weeks Preeclampsia > 20 weeks, proteinuria, edema

Increases the risk of:

A. Fetal growth constriction (decreased uteroplacental blood flow) B. Preeclampsia or Eclampsia C. Adverse fetal and maternal outcomes

DIABETES

1. Pre-existing diabetes mellitus occurs in ≥ 6% of pregnancies
2. Gestational diabetes occurs in about 8.5% of pregnancies.

Increases the risk of: ( Pre-existing insulin-dependent diabetes ) A. Pyelonephritis B. Ketoacidosis C. Preeclampsia D. Fetal death

Increases the risk of: ( Gestational diabetes )

A. Hypertensive disorders

B. Fetal macrosomia

C. The need for cesarean delivery

Diagnosis: o Oral glucose tolerance test (OGTT)

Treatment:  Dietary modification, exercise, close monitoring of blood glucose levels and insulin

SEXUALLY TRANSMITTED INFECTIONS

Screening should be done during pregnancy

Routine prenatal care:  Screening test

Fetal syphilis in utero can cause fetal death.

Increases the risk of: A. Preterm labor B. PROM

PYELONEPHRITIS

 A kidney infection cause by bacteriuria.  The most common nonobstetric cause of hospitalization during pregnancy

Increase the risk of:  PROM  Preterm labor  Infant respiratory distress syndrome

Treatment:  Antibiotics

ACUTE SURGICAL PROBLEMS

Most common:

1. Appendicitis
2. Biliary disorders

Higher among women who:  Are overweight  Are older  Are multigravida  Smoke

Increase the risk of: A. Preterm labor B. Fetal death

GENITAL TRACT ABNORMALITIES

Increase the risk of: A. Spontaneous Abortion at 2nd^ trim B. Fetal malpresentation C. Preterm labor/delivery D. Dysfunctional labor E. CS

MATERNAL AGE

Increase the risk of: ( Adolescents ) A. Preeclampsia B. Preterm labor C. Anemia

Increase the risk of: ( Women ≥ 35 ) A. Preeclampsia B. Gestational diabetes C. Abruption placenta and Placenta previa D. Stillbirth E. Autosomal trisomy (most common chromosomal abnormality)

MATERNAL WEIGHT

Underweight (BM1 < 18.5)  Low births in neonate

Overweight (BMI > 25-29.9) or Obese (BMI ≥ 30)  HPN  Diabetes  Postterm pregnancy  Fetal macrosomia  CS

MATERNAL HEIGHT

Short women: (< 152 cm)  Small pelvis = dystocia – a abnormal fetal position leading to difficulty  Preterm labor

SIGNS INDICATING POSSIBLE

COMPLICATIONS

Danger Signs of Pregnancy

1. Vaginal Bleeding 1 st^ Trimester A. Abortion – the most common cause B. Ectopic pregnancy C. Hydatidiform Mole

2 nd^ – 3 rd^ Trimester D. Placenta Previa E. Placenta Previa

2. Persistent Vomiting A. Hyperemesis gravidarum – extends at third month of pregnancy **3. Chills and fever or pain on urination

4. Sudden escape of clear fluid** A. PROM B. Preterm PROM (PPROM) 5. Abdominal or chest pain A. Impending convulsion (Abdominal pain) B. Heart disease (Chest pain) 6. Gestational hypertension A. PIH

Symptoms that signal development of gestational hypertension: o Rapid weight gain  2 nd^ trimester = 2lb/week  3 rd^ trimester = 1lb/week

o Swelling of the dace or fingers (edema) o Flashes of light or dots before the eyes (aura of convulsion) o Dimness or blurring of vision o Severe, continuous headache o Decreased urine output (<30 ml/hour)  Glomerular Filtration Rate = 1ml per minute  1 hour = 60 ml  Lower limit: 30 ml/hour

o RUQ pain unrelated to fetal position o BP increased above 140/90 mmHg

7. Increase or decrease fetal movement A. Fetal crushing B. Should have 10 fetal movements/day (minimum) 8. Uterine contractions before 37 weeks of pregnancy A. Preterm Labor (PTL)

Self-Care Needs

o Bathing o Breast care o Dental care – for calcium deficiency o Perineal care – prevents UTI o Clothing – should be loose, comfortable

Sexual Activity

 Coitus on the EDD does not initiate labor  Coitus does not cause ROM  Orgasm does no initiate PTL  SEX is allowed during labor, with limitations.

Exercise

 Average, well-nourished women should exercise during pregnancy = 3 x weekly for 30 consecutive minutes.  Women can continue any sport participated before pregnancy unless it involves body contact (soccer).  The intensity of the exercise program depends on the cardiopulmonary fitness.  Swimming is not contraindicated for pregnant women.

Benefits:  Lowers cholesterol level  Lowers risk of osteoporosis  Lowers risk of heart disease  Maintains health body weight  Increases energy levels  Increases self-esteem and well-being

Sleep

Left-sided Sim’s position with top leg forward o Good resting position. o Puts weight of the fetus on the bed, not on the woman o Allows good circulation in lower extremities.

Minor Discomforts/Body Changers of Pregnancy

Nasal congestion Nausea and vomiting Palpitations Breast tenderness Shortness of breath Abdominal discomfort Ectopic Pregnancy or Abruptio Placenta Backache Braxton-Hicks contraction Painless, irregular contractions Urinary frequency Constipation Leukorrhea Whitish vaginal discharge Hemorrhoids Muscle cramps Varicosities Ankle edema Palmar erythema Reddish, itchy spot on palm of hands Fatigue Hypotension Pyrosis Heartburn Lordosis Inward curve of the lumbar spine Headache Dyspnea SOB

HYPEREMESIS GRAVIDARUM

Definition

Excessive nausea and vomiting during pregnancy which extends beyond the third month of pregnancy.

Risk Factors

o Multipara (>1) o Grand Multipara (>5) o Primigravida

Cause

Hypersensitivity to Human Chorionic Gonadotropin (hCG)

 Placenta produces hCG o For 100 days o Peak: 60 days o hCG orders Corpus Luteum to produce estrogen and progesterone for pregnancy

Signs and Symptoms

o Severe Nausea and Vomiting

Complication

A. Dehydration a) Fluid and Electrolyte Imbalance leading to Coma

S/S: (Adult) o Dry mouth o Thirsty o Light-headedness o Cold, clammy skin o S/S: (Infant) o Sunken anterior fontanelle o Dry mouth and eyes o Slow rebound skin turgor (elastic)  Test on Abdominal skin  90% of infant’s body is water

B. Jaundice (severe complication) o Yellow discoloration of skin and sclera due to liver dysfunction

C. Weight loss D. Malnutrition

Management

1. Managed at the Hospital  Corrects fluid and electrolyte levels
2. Anti-emetics o Plasil ( metoclopramide )
3. Home remedies: Oresol  For dehydration  Distilled water + 1 tbsp od sugar + pinch of salt

Why we need to wait for vomiting to stop, before we give them food or water? o Prevents Aspiration Pneumonia  Where food, water, or vomit, are inhaled in lungs

o Prevents Infection

ABORTION

Definition

Abortion is a medical term for the disruption of a pregnancy before the fetus reaches its viable age of more than 20 to 24 weeks of gestation or weighs at least 500g.

Pathophysiology

 The most common cause of an abortion is abnormal fetal

development, which is either due to a chromosomal aberration or a teratogenic factor.

 Another common cause is the abnormal implantation of the

zygote, where there is inadequate endometrial formation or the zygote was implanted on an inappropriate site.

 This would cause inadequate development of the placental

circulation, leading to poor nutrition of the fetus and eventually, to an abortion.

Risk Factors

There are always precipitating factors for every condition. Here are the risk factors that concerns abortion:

 Congenital Structural Defect. This structural defect may be

due to chromosomal aberration or a serious physical defect.

 Low Progesterone. Progesterone maintains the decidua

basalis. If the corpus luteum fails to produce enough progesterone, it would risk the life of the fetus inside the uterus.

 Rh Incompatibility. The fetus could get rejected from a

mother’s body if they have an incompatible Rh.

 Undernutrition. Lack of nutrients would cause

undernourishment to both the mother and the fetus, leading to abortion.

 Drugs. There are drugs which are contraindicated for pregnant

women. Ingestion might compromise the fetus and lead to abortion.

 Infection. In infection, the fetus would fail to grow and

estrogen and progesterone production would fall. This would lead to endometrial sloughing, then prostaglandins would be released leading to uterine contractions and cervical dilatation along with expulsion of the products of pregnancy.

Types

Several types of abortion are used to classify every case for a pregnant woman. Once a thorough assessment is done, that would be the time that the type of abortion that occurred could be established.

 Threatened abortion. The embryo is already viable. The

products of conception are still intact and the cervix is closed, but there is vaginal bleeding present.

 Inevitable/Imminent abortion. The embryo is dead with the

products of conception either intact or expelled. The cervix is already dilated and there is presence of vaginal bleeding.

 Complete abortion. All products of conception are expelled

and the embryo is dead. The cervix is dilated, and there is mild bleeding.

 Incomplete abortion. The embryo is dead but some products

of conception are still intact. The cervix is already dilated and there is severe vaginal bleeding.

 Missed abortion. The embryo is already dead while inside the

uterus. The products of conception are still intact and the cervix is closed. There are brown vaginal discharges present.

 Recurrent/Habitual abortion. Abortion becomes recurrent

once the woman has had 3 consecutive miscarriages at the same gestational age.

Signs and Symptoms

As nurses, we are tasked with assessing our patient to provide baseline and accurate information to other caregivers. The signs and symptoms of abortion must be identified first before ruling out any other relative causes.

 Vaginal spotting. Vaginal spotting appears as small brownish

to reddish spots of blood coming out of the woman’s vaginal opening. This usually occurs when the cervix slightly dilates because the woman may have tried to lift heavy objects or mild trauma to the abdomen occurred.

 Vaginal bleeding. Bleeding is a serious occurrence during

pregnancy because it might indicate that the cervix has opened and products of conception might be expelled.

 Cramping/sharp/dull pain in the symphysis pubis. This

could occur on both sides and could be caused by trauma or premature contractions that might cause cervical dilation.

 Uterine contractions felt by the mother. Uterine contractions

can be false or true, but either of the two could be alarming during the early stages of pregnancy because it could expel the contents of the uterus thereby leading to abortion.

Diagnostic Tests

 Pregnancy test. This is to confirm the pregnancy first if

vaginal bleeding occurs. If test turns out negative, then the woman would be subjected to other diagnostic tests that could confirm the nature and cause of the vaginal bleeding. If it is positive, then abortion would be considered and it would be classified according to the presenting signs and symptoms.

 Ultrasound. The safest and confirmatory test for pregnancy,

the ultrasound would be able to confirm if the pregnancy is positive, and also confirm if the products of conception are still intact.

Medical Management

Medical interventions should also be incorporated in the patient’s care plan to reinforce his treatment. These are physician’s orders wherein nurses and other caregivers would assist or take into action, thus ensuring the recovery of the patient.

 Aside from our own nursing management, physicians would

also have to order a series of therapeutic management for the pregnant woman.

 Administration of intravenous fluids. Such as Lactated

Ringer’s, IV therapy should be anticipated by the nurse as well as administration of oxygen regulated at 6-10L/minute by a face mask to replace intravascular fluid loss and provide adequate fetal oxygenation.

 Avoid vaginal examinations. The physician would also avoid

further vaginal examinations to avoid disturbing the products of conception or triggering cervical dilatation.

 The physician might also order an ultrasound examination to

glean more information about the fetal and also maternal well- being.

Surgical Management

Aside from the medical interventions ordered by physician, incidences might occur which would lead to a surgical operation.

 Dilatation and evacuation. This is to make sure that all

products of conception would be removed from the uterus. However, before undergoing this intervention, the physician must be sure that no fetal heart sounds could be heard anymore and the ultrasound must show an empty uterus.

 Dilation and curettage. This is most commonly performed for

incomplete abortions to remove the remainder of the products of conception from the uterus. Since the uterus would not be able to contract effectively, the contents might be trapped inside and could cause serious bleeding and infection.

Nursing Management

Nurses must also have their own independent functions to ensure the safety and well-being of the patient. The following are measures that would allow the nurse to act independently.

Nursing Assessment

 The presenting symptom of an abortion is always vaginal

spotting, and once this is noticed by the pregnant woman, she should immediately notify her healthcare provider

 As nurses, we are always the first to receive the initial

information so we should be aware of the guidelines in assessing bleeding during pregnancy.

 Ask of the pregnant woman’s actions before the spotting or

bleeding occurred and identifies the measures she did when she first noticed the bleeding.

 Inquire of the duration and intensity of the bleeding or pain felt.

Lastly, identify the client’s blood type for cases of Rh incompatibility.

Nursing Diagnosis

 Risk for deficient fluid volume related to bleeding during

pregnancy

Nursing Interventions

 If bleeding is profuse, place the woman flat in bed on her side

and monitor uterine contractions and fetal heart rate through an external monitor.

 Also measure intake and output to establish renal function and

assess the woman’s vital signs to establish maternal response to blood loss.

 Measure the maternal blood loss by saving and weighing the

used pads.

 Save any tissue found in the pads because this might be a part

of the products of conception.

Evaluation

 The aim for evaluation is inclined towards restoring the

maternal blood volume and stopping the source of the bleeding.

 The client’s blood pressure must be maintained above 100/

mmHg.

 The pulse rate should be below 100 beats per minute and the

fetal heart rate must be at a normal level of 120-160 beats per minute.

 The client’s urine output should be more than 30 mL/hr, and

only minimal bleeding should be apparent for not more than 24 hours.

SEPTIC ABORTION

Definition

Serious uterine infection during or shortly before or after a spontaneous or an induced abortion.

Cause

 Non-sterile technique for uterine evacuation after abortion.  More common on Induced, done by untrained practitioners and without adequate surgical equipment and sterile preparation.

Causative Organisms: o E. coli o Staphylococci o Hemolytic streptococci

Signs and Symptoms

S/S usually appears 24-48 hours after abortion.  Similar to Pelvic Inflammatory Disease (chills, fever)  Similar to Threatened or Incomplete (v. bleeding, dilation, passage of POC)  Severe abdominal pain (due to uterus perforation)  Septic shock (hypothermia, hypotension, oliguria)

Diagnosis

 Vital signs and Abdominal Examination  Blood cultures to guide antibiotic therapy  CBC  USG – check for retained POC

Treatment

1. Antibiotic therapy
2. Uterine evacuation

CERVICAL INSSUFICIENCY

Definition

Formerly known as cervical incompetence. A painless cervical dilation resulting in 2nd-trimester pregnancy loss.

Etiology

 Unknown  Combination of structural abnormalities and biochemical factors (inflammation, infection) o Acquired or Genetic

Risk Factors

o Multiple gestation o Congenital disorders o Trachelectomy o Prior deep cervical lacerations o Women with ≥ 2 prior 2nd-trimester fetal losses (recurrence)

Signs and Symptoms

Often asymptomatic until premature delivery occurs.

Early symptoms:  Vaginal pressure  Vaginal bleeding/spotting  Vaginal discharge  Nonspecific abdominal or lower back pain

Cervix : soft, effaced, or dilated

Diagnosis :

Transvaginal ultrasonography  at ≥ 15 to 16 weeks for women with symptoms or risk factors

Findings:

 Cervical shortening to ≤ 2.5 cm

 Cervical dilation

 Protrusion of fetal membranes into the cervical canal

Treatment

1. Cervical cerclage o Reinforcement of the cervical ring with non - absorbable suture material.

ECTOPIC PREGNANCY

Definition

An ectopic pregnancy results when a pregnancy implants anywhere outside of the uterus. The pregnancy resulting outside of the uterus has no chance of survival. This will result in both physiological and psychological concerns for the mother.

Scarring or tubal deformity may result from

 Hormonal abnormalities  Inflammation  Infection  Adhesions  Congenital defects  Endometriosis

Manifestations

 Lower abdominal pain (classical sign) and light vaginal bleeding  If tube ruptures, sudden:  severe lower abdominal pain  Vaginal bleeding (minimal, on abdomen rather than out)  Signs of hypovolemic shock o Hypotension o Tachycardia o Tachypnea o Cold, clammy skin

 Cullen’s sign – bluish discoloration of the navel

 Shoulder pain may also be felt (due to abdominal bleeding – referred pain)

Treatment

Sensitive PT For hCG, to determine if woman is pregnant Transvaginal ultrasound

to determine if embryo is growing within uterine cavity Laparoscopic examination

Lighted instrument for viewing internal organs; to view damaged tube Salpingectomy Surgical removal of pregnant fallopian tube

 Priority is to control bleeding

Three actions can be taken

1. No action if the woman’s body is resorbing the pregnancy
2. Treatment with methotrexate to inhibit cell division
3. Surgery to remove (POC) pregnancy from the tube

Signs and Symptoms of Hypovolemic Shock

A chief concern for the woman who is experiencing an ectopic pregnancy is the onset of hypovolemic shock.

o Fetal heart rate changes (increased, decreased, less fluctuation) o Rising, weak pulse (tachycardia) o Rising respiratory rate (tachypnea) o Shallow, irregular respirations; air hunger o Falling blood pressure (hypotension) o Decreased or absent urinary output (usually less than 30 mL/hr) o Pale skin or mucous membranes o Cold, clammy skin o Faintness o Thirst

Nursing Tip

Supporting and encouraging the grieving process in families who suffer a pregnancy loss, such as a spontaneous abortion or ectopic pregnancy, allows them to resolve their grief

Stages of Grief (DABDA)

1. Denial
2. Anger
3. Bargaining
4. Depression
5. Acceptance

HYDATIDIFORM MOLE

Definition

Hydatidiform mole (HM) is a rare mass or growth that forms inside the womb (uterus) at the beginning of a pregnancy. It is a type of gestational trophoblastic disease (GTD).

Other Name

 Hydatid mole  Molar pregnancy  Hyperemesis – molar

Causes

HM, or molar pregnancy, results from abnormal fertilization of the oocyte (egg). It results in an abnormal fetus. The placenta grows normally with little or no growth of the fetal tissue. The placental tissue forms a mass in the uterus. On ultrasound, this mass often has a grape-like appearance, as it contains many small cysts.

Chance of mole formation is higher in older women. A history of mole in earlier years is also a risk factor.

Molar pregnancy can be of two types:

1. Partial molar pregnancy: There is an abnormal placenta and some fetal development.
2. Complete molar pregnancy: There is an abnormal placenta and no fetus.

There is no way to prevent formation of these masses. H-Mole is a precursor to cancer (Choriocarcinoma)

Symptoms

 Abnormal growth of the uterus, either bigger or smaller than

usual

 Severe nausea and vomiting

 Vaginal bleeding during the first 3 months of pregnancy (with

grape-like discharges)

 Symptoms of hyperthyroidism (>20 weeks) , including heat

intolerance, loose stools, rapid heart rate, restlessness or nervousness, warm and moist skin, trembling hands, or unexplained weight loss

 Symptoms similar to preeclampsia (<20 weeks) that occur in

the first trimester or early second trimester, including high blood pressure and swelling in the feet, ankles, and legs (this is almost always a sign of a hydatidiform mole, because preeclampsia is extremely rare this early in a normal pregnancy)

Exams and Tests

Your health care provider will perform a pelvic exam, which may show signs similar to a normal pregnancy. However, the size of the womb may be abnormal and there may be no heart sounds from the baby. Also, there may be some vaginal bleeding. A pregnancy ultrasound will show a snowstorm appearance with an abnormal placenta, with or without some development of a baby.

Tests done may include:

 hCG (quantitative levels) blood test [most significant test]

 Abdominal or vaginal ultrasound of the pelvis

 Chest x-ray

 CT or MRI of the abdomen (imaging tests)

 Complete blood count (CBC)

 Blood clotting tests

 Kidney and liver function tests

Treatment

1. Dilation and Curettage (D&C) – removal of abnormal tissues; evacuation of moles
A. Manual Vacuum Aspiration B. Suction Aspiration – uses suction cup to remove contents from the uterus 2. Anticancer drugs – Methotrexate 3. Hysterectomy – surgery to remove the uterus; may be an option for older women who DO NOT wish to become pregnant in the future.

Very rarely, a partial molar pregnancy can continue. A woman may choose to continue her pregnancy in the hope of having a successful birth and delivery. However, these are very high-risk pregnancies. Risks may include bleeding, problems with blood pressure, and premature delivery (having the baby before it is fully developed). In rare cases, the fetus is genetically normal. Women need to completely discuss the risks with their provider before continuing the pregnancy.

 After treatment, your hCG level will be followed.  Urinalysis will be done regularly in 12 months (no pregnancy on 12 months)  It is important to avoid another pregnancy and to use a reliable contraceptive for 6 to 12 months after treatment for a molar pregnancy.  This time allows for accurate testing to be sure that the abnormal tissue does not grow back.  Women who get pregnant too soon after a molar pregnancy are at high risk of having another molar pregnancy.

Outlook (Prognosis)

Most HMs are noncancerous (benign). Treatment is usually successful. Close follow-up by your provider is important to ensure that signs of the molar pregnancy are gone and pregnancy hormone levels return to normal. About 15% of cases of HM can become invasive. These moles can grow deep into the uterine wall and cause bleeding or other complications. This type of mole most often responds well to medicines. In very few cases of complete HM, moles develop into a choriocarcinoma. This is a fast-growing cancer. It is usually successfully treated with chemotherapy, but can be life threatening.

Possible Complications

Complications of molar pregnancy may include: o Change to invasive molar disease or choriocarcinoma o Preeclampsia o Thyroid problems o Molar pregnancy that continues or comes back

Complications from surgery to remove a molar pregnancy may include: o Excessive bleeding, possibly requiring a blood transfusion o Side effects of anesthesia  Chills  Hypotension

PLACENTA PREVIA VS ABRUPTIO PLACENTA

Bleeding on the 2nd^ or 3rd^ trimester (most common) [4-9/10 months]

Placenta Previa Abruptio Placenta

Description

Implantation of placenta in the lower uterine segment.

Normal site: Upper back of the fundus

Types:

1. Complete
2. Partial
3. Low-lying

Premature separation of abnormally implanted placenta

Causes concealed/covert bleeding.

Types of bleeding:

1. Overt – obvious or apparent
2. Covert – hidden or concealed

Causes Unknown etiology^ Unknown etiology Direct trauma: accidents

Risk Factors

Maternal age (<18 or >35) Multiparity ( >2 pregnancies) Abnormality in the uterine lining Twin pregnancy

Hypertension o Chronic – long-term o Pregnancy Induced Hypertension (PIH)

Previous CS delivery Abdominal trauma Sort umbilical cord Signs and Symptoms

Painless vaginal bleedng Board-like abdomen with or without vaginal bleeding Abdominal tenderness Nursing Management

No internal examination (IE) Oxygen (O2) therapy Bed rest until term

Vital signs, including FHR, F movement Oxygen (O2) therapy Bed rest

Medical Management

Normal spontaneous delivery (NSD), for low lying p. o Blood loss: 300-500 cc

CS delivery, for complete previa o Blood loss: 500-1000 cc

NSD, CS

Blood transfusion (2 units of blood) Need to know for BT: o Blood type o Cross-matching

Normal FHB: 120-160 bpm

Abnormal FHB: <100 OR >180 bpm (fetal distress)

Nursing Management:

1. Turn patient to left side
2. Administer oxygen
3. Report to OB

PREECLAMPSIA &

ECLAMPSIA

Definition

 New onset of hypertension after 20 weeks age of gestation, with proteinuria and edema.  Preeclampsia, formerly known as toxaemia.  Preeclampsia is a Pregnancy Induced Hypertension (PIH)  Preeclampsia, if progressed to Eclampsia “convulsive state” – seizures occurs.

Risk Factors

o Maternal age o Obesity o Kidney Disease o Family History of Preeclampsia o Primigravida o Diabetes mellitus o Chronic Hypertension

Signs and Symptoms

3 Cardinal Signs:

1. Hypertension  >140/  If reading is 130/90, obtain BP again after 10 minutes.  Normally, BP in women is low due to estrogen – makes blood watery. 2. Proteinuria  Presence of protein (albumin) in urine  Diagnosed via Urinalysis – which shows (+) Albumin  Albumin is a protein = Albuminuria

Non-laboratory test:  Heat and Acetic Acid Test – heating of urine while gradually dropping amounts of acetic acid to determine presence of protein. A positive sign shows whitish or turbid (cloudy) urine after heating due to protein coagulation.

3. Edema  Accumulation of fluid in the intracellular space  Edema all over the body.

How to check for edema:  Press against a bone.  A positive sign shows pit or indentation (pitting edema)

Signs of edema:  Excessive weight gain  Edema on extremities (fingers)  Moon face structure

Complications

A. Preterm labor B. Intrauterine Growth Restriction (IUGR) C. Intrauterine Fetal Death (IUFD)

Management

1. Antihypertensive drugs: Hydralazine

2. Magnesium Sulfate (MgSO4)  Prevents seizures/convulsion  Prone to magnesium sulfate toxicity

MgSO4 should be administered when these criteria are normal:

o RR: 16-20 bpm o U/O: >30 ml/hr o KJR: (+)

Antidote for MgSO4 Toxicity: Calcium Gluconate

3. Monitor Fetus  Normal FHB = 120-160 bpm  Abnormal FHB = 100< or >180 (Fetal Distress)

INTRAPARTUM

COMPLICATIONS

PRECIPITATE LABOR

Definition

An extremely rapid labor leading to the birth of a baby or the process of going into active labor, birth, and placenta in 3 hours or less than 5 hours. Occurs when uterine contraction are so strong – it is completed in few hours.

Precipitate Dilation

Primipara : >5 cm / hour Multipara : 10 cm / hour

Risk Factors

 Had previous deliveries  Younger maternal age  Lower infant birth weight  Preterm deliveries  With hypertensive disorders  Fertility treatment  Abruption placenta  Prior pregnancy losses

Causes

Small Baby is Well Placed in Vagina

Little baby do not require ^ oxytocin since only small expansion is needed. Wide vagina or Birth Canal

Wide passage means reduced effort for birth. Perfect Alignment or Position of the Canal

Vaginismus is a involuntary tensing of vagina leading to be extremely tilted. Genetic Predisposition Due to genes running in the lineage Efficient Uterine Contractions

Efficient uterine contractions close to labor cause high risk for this. Second or Third Delivery Multifetal pregnancies Drugs (Cocaine) Stimulant drugs enhances physiological processes. Induced Labor By the use of prostaglandins – leads to precipitate labor or CS. PIH Causes more rapid contractions

Diagnosis

A. Pelvic Exam o Evaluate uterine firmness and tenderness o Evaluate fetal size and position o Determine if cervix has dilated, if ROM or Placenta Previa do not occur.

B. Ultrasound C. Uterine Monitoring o Measure duration and spacing of contractions.

D. Vital Signs o Monitors maternal and fetal condition until delivery

• as labor is a very dangerous period in both life and complications can arise with little or no warning.

E. Laboratory Test o Swabbing of vaginal secretions to check for infections and fetal fibronectin. o Urine sample for testing certain bacteria.

Clinical Manifestation Premonitory Signs:

 Rapid widening of cervix  Urge to push (quickly with no warning)  Often with no contractions  Lightening – baby drops lower in abdomen  Loss of mucus plug  ROM  Contractions  Cervical ripening  Rising heartbeat and other distress indication  Absence of recovery phase between contractions

Complications Maternal: o Emotional distress o Abruption placenta o Perineal laceration o Hemorrhage o Infection o Uterine rupture Fetal: o Facial bruising o Intracranial damage o Fetal distress o Hypoxia o Subdural haemorrhage risk

Nursing Diagnosis

Anxiety related to situational crisis of precipitous labor as evidenced by increasing tension, decreased attention span, restlessness, shortness of breath, disorganized thought process, and crying.

Nursing Care Plan

 Assess the anxiety level of the patient, anxiety triggers and symptoms by asking open-ended questions.  Ensure to speak in a calm and non-threatening manner to the patient.  Maintain eye contact when communicating with her.  Provide a comfortable environment by providing sufficient lighting, good ventilation, and reduced noise levels.  Respect the personal space of the client but sit not too far from him/her.  Do not leave the patient when the anxiety levels are high. Re- assure that the healthcare team are here to help her.  Provide factual and honest answer to questions regarding fetal status and contraction pattern.  Provide a supportive approach when the patient has anxiety by giving simple and short directions or information.  Teach the patient to perform relaxation techniques such as deep breathing exercises, guided imagery, meditation, and progressive muscle relaxation.

Treatment

If you see signs of rapid labor, get immediate medical help by contacting your doctor. You can also try to remain calm by:

 Staying in a clean, sterile place until you get to the hospital.  Laying down either on your back or on your side.  Having someone by your side.  Practicing breathing techniques.