Final 2310

• Postpartum Hemorrhage (PPH)


  • Causes: uterine atony - marked hypotonia of uterus - leading cause of PPH
  • Associated with: high parity, hydramnios, macrosomic fetus, multifetal gestation
  • Uterine atony - greatest risk within first 4 hours of birth - uterus contracts to prevent contracting - if it doesn't contract - uterine atony (hypotonia - lack of tone)
  • First sign is profuse bleeding, palpate uterus (boggy)
• Retained Placenta


  • Placenta doesn't come out - nonadherent - doesn't deliver, can go in and remove
  • Adherent is a physical adherence, placenta growing into uterus
• Lacerations of genital tract


  • Occur in cervix, labia
  • Steady trickle of bright red blood
• Hematomas


  • Collection of blood, trauma
• You have 30 mins to deliver placenta, after 30 mins - some kind of intervention (manual removal - pull placenta off of uterus) can cause hemorrhage, infection, and pieces left behind
• Can be given prophylactic IV antibiotic
• Also at risk to need D&C (surgical scrape of placenta off uterus)
• Placenta Accrete Syndrome


  • Accrete, increte, percreta
  • Abnormal adherence - risk > hysterectomy
• Term Placenta


  • Fetal side - smooth
  • Maternal side - rough
• Uterine Inversion


  • Potentially life threatening, occurs in 1 out of 2500 births
  • Prevent inversion - use other hand to support
  • Signs and symptoms can include hemorrhage, shock, and pain
• Care Management of PPH


  1. Early recognition and treatment of PPH are critical

  2. Initial intervention is firm massage of the uterine fundus

  3. Expression of any clots in the uterus

  4. Elimination of bladder distention

  5. Continuous IV infusion of 10-40 units of oxytocin added to 1000mL of IV fluid

  6. Additional uterotonic meds

  7. Surgical management: D&C (surgical scrape of placenta off uterus)

  8. One hand remains cupped against the uterus at the level of symphysis pubis to support the uterus and the other hand cupped to massage and gently compress the fundus toward the lower uterine segment

  9. Bakri Balloon
• Hemorrhagic (Hypovolemic) Shock


  • Results from hemorrhage
  • Emergency situation which perfusion of organs may become severely compromised, death may occur
  • Medical management - restore circulating blood volume
  • Nursing Interventions - monitor pulse and BP
  • Fluid/blood replacement therapy
  • Decreased urine output can be a sign of shock (<30mL/hr)
• Coagulopathies


  • ITP - Idiopathic thrombocytopenic purpura: Autoimmune disorder in which antiplatelet antibodies decrease the lifespan of platelets
  • Von Willebrand Disease: A type of hemophilia, deficiency or defect in blood clotting protein
  • Platelets normal range: 150,000-400,000
  • At risk for shock - hematomas
• Venous Thromboembolism (VTE)


  • Results from formation of blood clot or clots inside a blood vessel, caused by inflammation or partial obstruction of vessel
  • Superficial venous thrombosis - involvement of the superficial saphenous system
  • DVT - occurs most often in the lower extremities; involvement varies but can extend from the foot to the iliofemoral region
  • PE - complication of DVT occurring when part of a blood clot dislodges and is carried to the pulmonary artery, where it occludes the vessel and obstructs blood flow to the lungs
  • To diagnose - labs, doppler US, VQ scan, MRI
• Incidence and etiology of VTE


  • 1 per 1000 pregnancies
  • Major causes - venous stasis and hypercoagulation
• Clinical manifestations of VTE


  • Superficial venous thrombosis (most common form) is characterized by pain and tenderness in the lower extremity
• Medical management and nursing interventions for VTE
• High Risk Newborn


  • Classified according to: birth weight, gestational age, predominant pathophysiologic problems
  • Low birth weight infant (LBW) - baby whose birth weight is less than 2.5kg (2500g), regardless of gestational age
  • Very low birth weight (VLBW) - baby whose birth weight is less than 1500g
  • Extremely low birth weight (ELBW) - baby whose birth weight is less than 1000g
  • Appropriate for gestational age (AGA) - infant whose birth weight falls between the 10th and 90th percentiles on intrauterine growth curves
  • Preterm born before 37 weeks & Postterm born after 42 weeks, no matter gestational size
  • Majority of high risk infants are those born in less than 37 weeks - organs are immature and lack adequate reserves of bodily nutrients
• Physiologic Functions of High Risk Newborn


  • Respiratory function
  • Cardio function
  • Maintaining body temp (neutral thermal environment)
  • Central Nervous system function
  • Maintaining adequate nutrition
  • Maintaining renal function
  • Maintaining hematologic status
  • Resisting infection
• Growth and Development Potential of High Risk Newborn


  • Difficult to predict with accuracy
  • Corrected age - age of the preterm infant is corrected by adding gestational age and postnatal age, milestones are corrected until age 2.5
  • VLBW survivors: 15-25% have neurologic or cognitive disability
• Acquired problems of the newborn refer to those conditions resulting from environmental rather than genetic factors
• Acquired problems of the newborn


  • Birth trauma
  • Infant of a mother with diabetes
  • Neonatal infections
  • Effects of maternal substance abuse on the fetus and neonate
  • Effects of maternal use of caffeine and antidepressant meds during pregnancy
• Hemolytic Disease of the Newborn


  • Occurs most frequently with ABO incompatibility - most common, and Rh (D) Incompatibility - second most common
  • Four major blood groups - A, B, AB, O
  • Rh factor: person who is Rh negative means he/she does not have the Rh(D) antigen
  • Rh Incompatibility (Isoimmunization): Rh positive offspring of an Rh negative mother are at risk, mother forms antibodies that then destroy fetal RBCs (hemolysis), results can be mild (fetal jaundice) or severe (erythroblastosis fetalis, hydrops fetalis- most dangerous)
  • ABO Incompatibility: Fetal blood types is A, B, or AB, and the maternal type is O, natural occurring anti A and anti B antibodies are transferred across the placenta to the fetus
• Care Management of Hemolytic Disease of the Newborn


  1. Determine the blood type and Rh factor of every pregnant woman

  2. CDC urges all women of childbearing age consume 400mcg of folic acid each day, in addition to consuming food with folate from a varied diet, to help prevent major birth defects of the baby's brain - neural tube defects
• Perinatal Loss


  • Miscarriage, fetal death - early, late, stillbirth, Death of live born infant - early neonatal, late neonatal, infant death
• Types of Perinatal Losses


  • Miscarriage
  • Serious fetal diagnosis
  • Pregnancy termination - TOPFA (termination of pregnancy for fetal anomalies)
  • Selective reduction
• Perinatal Palliative Care


  Care provided to infants and families experiencing perinatal loss
• Miles Model of Parental Grief Responses


  • Three overlapping phases: Acute distress, Intense grief - guilt, anger, resentment, bitterness, or irritability, Reorganization - better able to function at home and work, experiences a return of self esteem and confidence, can cope with new challenges, and has placed the loss in perspective
• Family Aspects of Grief


  • Grandparents - complicated by emotional pain witnessing and feeling immense grief for their child
  • Siblings - young children respond more to the reactions of parents
• Factors Associated with High Risk Childbearing


  • Biophysical - genetic disorders, nutritional and general health status, and medical or obstetric-related illnesses
  • Psychosocial - maternal behaviors and adverse lifestyles, emotional distress and disturbed interpersonal relationships, inadequate social support, unsafe cultural practices
  • Sociodemographic - lack of prenatal care, low income, marital status, and ethnicity
  • Environmental - hazards in workplace and woman's general environment, chemicals, anesthetic gases, and radiation
• Antepartum Testing: Biophysical Assessment


  1. Daily Fetal Movement count (DFMC) - used to monitor fetus in pregnancies complicated by conditions that may affect oxygenation, a count of fewer than 3 kicks in 1 hour warrants further evaluation by a nonstress test (NST)

  2. Ultrasonography - levels: abdominal, transvaginal, indications: fetal heart activity, gestational age, fetal growth, fetal anatomy, fetal genetic disorders/physical anomalies, placental position and function, adjunct to other invasive tests, fetal well-being - doppler blood flow analysis, amniotic fluid volume, biophysical profile (BPP) - modified biophysical profile, placenta graded 1-4

  3. MRI - noninvasive radiologic technique, can evaluate fetal structure, overall growth, placenta, quantity of amniotic fluid, maternal structures, biochemical status of tissues and organs, soft tissue, metabolic, or functional anomalies
• Biochemical Assessment


  1. Procedures used to obtain specimens: amniocentesis, percutaneous umbilical cord blood sampling, chorionic villus sampling, and maternal sampling

  2. Amniocentesis - obtains amniotic fluid, potential complications, indications: genetic concerns, fetal maturity, fetal hemolytic disease

  3. Chorionic Villus Sampling (CVS) - catheter inserted through vagina into uterus to sample villi of placenta, technique for genetic studies, earlier diagnosis, rapid results, performed at 10 weeks gestation

  4. Percutaneous umbilical blood sampling (PUBS) - direct access to the fetal circulation during the second and third trimesters, most widely used method for fetal blood sampling and transfusion, insertion of needle directly into fetal umbilical vessel under ultrasound guidance
• Maternal Assays


  • Maternal serum alpha-fetoprotein (MSAFP) - screening tool for neural tube defects (NTDs) in pregnancy, detects 80% to 85% of all open NTDs and open abdominal wall defects early in pregnancy, screening recommended for all pregnant women between 14-22 weeks gestation
  • Triple and quad screening to detect autosomal trisomy's, multiple marker screens
  • Coombs Test - screening tool for Rh incompatibility, detects other antibodies that may place fetus at risk for incompatibility with maternal antigens
  • Cell Free DNA screening in maternal blood - noninvasive prenatal genetic testing, provides definitive diagnosis noninvasively for fetal Rh status, fetal gender, and certain paternally transmitted single gene disorders, Trisomy 21 - performed as early as 10 weeks of gestation, results are usually available in about 10 business days
• Hypertensive Disorders of Pregnancy


  • Major cause of perinatal morbidity and mortality worldwide due to uteroplacental insufficiency and premature birth
  • Of maternal deaths worldwide, 10-15% can be attributed to preeclampsia and eclampsia
  • Morbidity: renal failure, coagulopathy, cardiac or liver failure, placental abruption, seizures, stroke
  • Mortality: pregnancy-related hypertension accounts for 10-15% of maternal deaths worldwide
• Gestational Hypertension


  Onset of HTN without proteinuria or other systemic findings diagnostic for preeclampsia after week 20 of pregnancy, systolic BP >140, diastolic BP >90
• Preeclampsia


  Pregnancy specific condition in which HTN and proteinuria develop after 20 weeks of gestation in a previously normotensive woman, in the absence of proteinuria, preeclampsia may be defined as HTN along with: thrombocytopenia, impaired liver function, new development of renal insufficiency, pulmonary edema, new onset cerebral or visual disturbances
• Eclampsia


  Onset of seizure activity or coma in a woman with preeclampsia, no history of preexisting pathology, 50% of eclampsic women develop the condition while pregnant, women can develop eclampsia in the immediate postpartum period
• Chronic Hypertension


  HTN present before pregnancy or diagnosed before week 20 of gestation
• Chronic HTN w/superimposed preeclampsia


  Women with chronic HTN may acquire preeclampsia or eclampsia - can be difficult to diagnose
• Preeclampsia Etiology


  • A condition unique to human pregnancy, common risk factors: primigravida in woman <19 or >40 yrs of age, first pregnancy with a new partner, history of preeclampsia, pregnancy onset snoring, cause unknown