Complications

1. Complications Antepartum Intrapartum Postpartum

2. Maternal Mortality • According to official US vital statistics, the risk of death from complications of pregnancy decreased approximately 99% during the 20th century. • However, this progress halted in 1982, and since then, there has been no improvement in the maternal mortality ratio for the US. • In the most recent global figures from the World Health Organization, the US ranked 20th in maternal mortality, behind most countries of Western Europe as well as Canada, Australia, Israel, and Singapore. • September 2001, the first National Summit on Safe Motherhood

3. Maternal Mortality • Many consider a maternal death to be a sentinel event, reflecting a breakdown in the health care system in its broadest sense. • Mortality caused by pregnancy and its complications remains an important issue for…the health care system, and as a public health indicator. • There continues to be striking racial disparity in maternal mortality. • September 2001, the first National Summit on Safe Motherhood

4. Causes of Maternal Mortality http://www.greenjournal.org/content/vol101/issue2/images/large/og0133905001.jpeg Hemorrhage, Embolism, Hypertensive Disorders and Infection are in the top five causes of maternal mortality

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

6. Bleeding-Ectopic Pregnancy

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

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

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

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

11. Bleeding - Abortion • Spontaneous Abortion • Defining Characteristics • Bleeding (pink, red or brown) • Cramping • Starts light, then crescendos • Becomes light again after tissue passed • Passage of tissue or clots • All passed tissue is saved • Sent for chromosomes/pathology • >9 weeks likely to need D&E

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

13. Bleeding - Placenta Previa

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

15. Bleeding - Placenta Previa http://connection.lww.com/Products/timbyessentials/Ch02/jpg/02_002.jpg

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

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

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

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

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

21. Bleeding - Abruption • Also called Abruptio Placenta

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

23. Bleeding - Abruption • http://connection.lww.com/Products/timbyessentials/Ch02/jpg/02_003.jpg

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

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

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

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

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

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

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

31. Pre-term (Premature) Labor • Labor from 20 – 36 weeks • 10% of all births in the US • Prematurity is the leading cause of perinatal morbidity and mortality • Prematurity accounts for up to 50% of neurologic problems in infancy • Rates vary by population studied • Modern medicine notoriously unsuccessful at predicting and preventing preterm birth

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

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

34. Pre-term (Premature) Labor • Magnesium Sulfate (MgSO4) (IV) • Hourly assessments for magnesium toxicity and efficacy of medication • Terbutaline (SQ, PO) • Risk for pulmonary edema • Nifedipine (SL, PO) • Ca++ channel blocker • Indomethacin (PO, PR) • Prostaglandin synthetase inhibitor • May cause premature closure of ductus and oligohydramnios

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

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

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

38. Diabetes in Pregnancy • Fat deposition is around the shoulder girdle   risk of shoulder dystocia • Hyperglycemia ’s risk of other congenital anomalies •  risk of neonatal hypoglycemia • Cord cut  glucose levels fall rapidly • Neonate still has circulating insulin

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

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

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

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

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

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

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

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

47. Hypertensive Disorders of Pregnancy • If progresses to eclampsia • Magnesium Sulfate (MgSO4) • Protect airway • Intrauterine stabilization of fetus • Protect from excess stimuli • May proceed to cesarean when stable • Likely transfer to intensive care unit for postpartum stabilization

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

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

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