Maternity test 2- Chapter 19, 20, 21,22,23
Chapter 19- Conditions existing before Conception
Asthma
- Complicates 3% to 5% of pregnancies
- Some women experience worsening of their symptoms while others see improvements
- Complications from asthma include:
o Antepartum & postpartum hemorrhage
o Pulmonary embolism (blood clot breaks off and goes into lungs)
 Causes SOB and wheezing
o Miscarriage
- Treatment goals: optimize control & limit exacerbations or asthma attacks
o Minimize hospital time
- Education: encourage women to take their asthma medications, stop smoking, and
evaluate asthma exacerbations with continuous pulse oximetry (concern <95%)
o Encourage smoke cessation
- While dyspnea is common in pregnancy, an asthma exacerbation may be recognized by
dyspnea with wheezing or cough
Question 1
- A pregnant woman with an asthma exacerbation tells the nurse she stopped taking her
medication because she didn’t want it to affect her baby. What is the best response by
the nurse?
A. “You are right to stop taking any medications while you are pregnant.”
B. “You should still take your asthma medication while you are pregnant to help control
your asthma.”
C. “You should only take your asthma medications when you have an exacerbation.”
D. “You probably won’t need your medication because asthma always improves with
pregnancy.”
Epilepsy
- 1-2% of people have epilepsy
- Children of mothers with epilepsy are at increased risk for developing a seizure
disorder
- Complications due to epilepsy include preeclampsia, preterm labor, & fetal death
o Oxygen to fetus is cut off when mother has a seizure
- Increased risk of congenital anomalies in women who take antiseizure medications
during pregnancy
- Education:
o Teach patients to take antiseizure medications despite risks to fetus and avoid
seizure triggers
- Women on antiseizures meds should take 4 mg of folic acid daily, beginning 3 months
before conception
o Anemia, sickle-cell diseases should increase folic acid, or foods high in folic acid
- Infants of mothers on antiseizure meds are at increased risk for bleeding
Thyroid conditions
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Hypothyroidism (0.3% to 0.5% of pregnancies) can cause preeclampsia, postpartum
hemorrhage, and early pregnancy loss
o Mothers with hypothyroidism experience: fatigue, weight gain,
constipation…body slows down
Treatment:
o levothyroxine (a T4 replacement), adjusted based on TSH levels every 4 weeks
to 3 months
o Medication dose adjustments are typically required more frequently in early
pregnancy than in later pregnancy
Education: be taught to take levothyroxine first thing in the morning and on an empty
stomach with no further oral intake for one hour
Hyperthyroidism (0.1% to 0.4% of pregnancies) may cause pregnancy loss, low birth
weight, (mother may lose weight) and maternal heart failure
Woman with Hyperthyroidism experience: Weight loss, irritability, bulging eyes
Treatment: suppression of thyroid hormone synthesis with a class of medications called
thioamides
o Thioamides cross the placenta, suppress fetal thyroid hormone synthesis, and
have been associated with fetal anomalies
Goals: control hyperthyroidism and avoid hypothyroidism.
Education: encourage consistent medication use
Pregestational Diabetes
- Women with pregestational diabetes should receive preconception care and achieve
excellent glycemic control PRIOR to attempting pregnancy
- Pregestational diabetes risks include:
- Preeclampsia
- Perinatal death
- Macrosomic fetus
- Congenital anomalies
- Polyhydramnios
- Fetal loss
- Preterm birth
- First trimester assessments:
o Hemoglobin A1C (glycemic control over time)
 Women can be noncompliant or don’t record levels
 Level should be less than 7
o Women with diabetes will have an evaluation of baseline kidney function with a
24-hour urine collection
o She may also have a screening of her thyroid, heart, and eyes during the first
trimester
- Second and third trimester assessments:
o Vasculopathy may be evidenced by fetal growth restriction.
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o Antepartum testing for fetal well-being usually begins between 32 & 34 weeks
gestation and may include:
o Nonstress test
 If abnormal, they would get biophysical profile
o Biophysical profiles
 Will be induced if biophysical is not normal
o Contraction stress tests (not common)
 See if baby can survive in a stressful environment
 Hook woman up to FHR, drip of oxytocin
Delivery considerations:
o Vaginal delivery is not contraindicated, although some providers recommend a
cesarean section for fetal macrosomia diagnosed by ultrasound.
 Macrosomia more than 4000g
o Labor often induced between 39 and 40 weeks
Care considerations
o Diet, exercise, and medications are important care components that should be
closely monitored
Question #2
- Which of the following recommendations should the nurse make to the patient with
diabetes who is interested in becoming pregnant?
A. “Achieving excellent glycemic control now will help ensure positive pregnancy
outcomes.”
B.“Because of your diabetes, you will not be able to deliver vaginally.”
C.“Pregnancy risks for diabetic mothers are caused by macrosomic infants.”
D.“You will need to make sure to have good control of your blood sugars as soon as you find
out you are pregnant.”
Fasting glucose= below 105
Normal glucose- 70-140
Multiple Sclerosis (MS)
- Chronic immune-modulated demyelinating disease of the central nervous system that
often includes relapses and remissions
- Pregnancy is often a time of disease remission, while postpartum is a significant time
for relapse
- In pregnancy, MS may slightly increase the risk for a cesarean birth and a decrease in
neonatal birth weight
- Some medications for MS are teratogenic and contraindicated. Others have limited
information available
- Breastfeeding is not contraindicated for women with MS, but the medications used to
treat MS may not be safe for a breastfeeding infant. Women may choose not to take
MS medications while breastfeeding
Cardiovascular Disease
- Cardiac disease only complicates a small number of pregnancies but is a significant
cause of maternal morbidity and mortality in pregnancy.
- increases 50% during pregnancy and may exacerbate any underlying cardiac conditions
- Fetal testing of women with cardiac disease may include nonstress tests, biophysical
profiles, or contraction stress tests
- Management:
o Depends on the disease type, severity, and complications, and often involves
collaborations between several disciplines, including obstetrics, cardiology, and
neonatology
Chronic Hypertension:
- Associated with higher rate of poor pregnancy outcomes including intrauterine growth
restriction, stillbirth, preeclampsia, and stroke
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Defined as blood pressure greater than 140/90 mm Hg that predates the pregnancy or
appears before the 20th week of the pregnancy
- Diagnosed after 20 weeks it is gestational diabetes
- Mild to moderate hypertension: is a systolic BP between 140 & 159 mm Hg and/or a
diastolic between 90 and 109 mm Hg
o No clear benefit of treating women with mild to moderate hypertension during
pregnancy
- Severe hypertension:
o systolic blood pressure greater than 160 mm Hg and diastolic blood pressure
greater than 110 mm Hg
o Women with severe hypertension should be treated
o Goal: maintain a systolic blood pressure of 140 to 150 mm Hg and a diastolic of
90 to 100 mm Hg (may be lower if she has evidence of organ damage).
- NSAIDs such as ibuprofen should be used cautiously for these patients postpartum as
they are associated with increased blood pressure readings
- Preferred antihypertensives in pregnancy include labetalol, methyldopa, and
nifedipine
- Women with chronic hypertension should be carefully monitored for preeclampsia and
HELLP syndrome
Obesity
- 35% of women between the ages of 20 and 39 are classified as obese
- Fat has endocrine function and can have a detrimental effect on inflammatory
pathways, vasculature, and metabolism
- Complications:
o Higher risk for gestational diabetes
o Preeclampsia
o Labor induction and induction failure
o Slower first stage of labor
o Macrosomic infants
o Postpartum thromboembolism
- Weight loss can improve outcomes (dieting, nutrition prior to getting pregnant)
- Nurses should encourage healthy behaviors
- Patients with BMI greater than 30 will receive anticoagulant therapy prior (lovanox)
Eating disorders
- Associated with poor health and psychologic outcomes
- Pregnancy may be challenging for a woman with an eating disorder because of normal
body changes
- Pregnancy should be planned for a time of disease remission
- Although women with an eating disorder may not menstruate, nurses should inform
them that they may ovulate
Iron deficiency Anemia
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16% to 29% of women will become anemic during pregnancy
Severe anemia is associated with nonreassuring fetal heart rate, prematurity, fetal
loss, and maternal death. (Rare in developed countries.)
o below 10.4 is pathological anemia
Physiologic anemia is an expected finding during pregnancy. A normal hemoglobin
level in pregnancy is 11 to 14 g/dL
Supplementing with iron improves maternal hemoglobin and hematocrit levels
Supplemental iron can cause pruritus, rash, and gastrointestinal symptoms.
Nurses should inform patients that iron is best absorbed if taken on an empty stomach
but this may lead to gastrointestinal distress.
Intimate Partner Violence (IPV)
- 7% to 20% of pregnancies are complicated by physical abuse
- Women experience psychologic and sexual abuse during pregnancy, which often goes
underreported
- 5% of women report their partners tried to get them pregnant when they did not want
to be
- Women should be screened for IPV during prenatal visits, hospitalizations, and during
postpartum appointments
o Asking about IPV can be intimidating; using a standardized screening tool can
help with questioning
o Nurses should question patients about IPV when they are alone with the patient.
o Be prepared to make appropriate referrals in the event of a positive screen.
Substance abuse
- 15.4% of pregnant women smoke, 9.4% drink alcohol, and 5.4% use illegal drugs
- Women with substance abuse may not seek prenatal care because they feel ashamed
or they are worried about the involvement of social services
- Complications:
o Infants exposed to opioids and opioid replacement drugs are at a high risk for
neonatal abstinence syndrome.
o Alcohol is a teratogen that can cause fetal alcohol syndrome. There is no known
safe amount of alcohol that can be consumed in pregnancy.
o Smoking can cause preterm birth, intrauterine growth restriction, and stillbirth.
- All women should be screened for substance abuse during pregnancy
- Counseling about the negative impact of substance abuse in pregnancy followed by a
referral for treatment should be included in care
- Stopping consumption of alcohol or drugs at any point during pregnancy can improve
outcomes
- Women with substance abuse often have comorbid conditions and psycho social
challenges, such as homelessness that will need to be addressed
Depression
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Major depression is not treated in pregnancy in up to half of women diagnosed
because of cost, stigma
Untreated depression can lead to substance abuse, poor adherence to care, less
prenatal care, and suicide risk
Treatment: selective serotonin reuptake inhibitors (SSR
o No known teratogenic effects but may lead to lower Apgar scores
o Antidepressants are not contraindicated in breastfeeding.
Stigma is common to all mental illness, and a woman may feel shame and an
unwillingness to discuss the problem
Anxiety
- General anxiety affects 12% of people
- People report fatigue, tension, irritability, and a pervasive sense of apprehension.
- Assessed with a seven-item scale (GAD-7)
- Treatment: antidepressants (particularly SSRIs), counseling, and, occasionally,
benzodiazepines
- Benzodiazepines may cause withdrawal in the neonate and a higher risk of fetal loss
and preterm birth
- Nurses can empower patients with realistic education about therapies and self-care
measures such as mindfulness, exercise, and good nutrition
Question #3
Is the following statement true or false?
Often preconception care involves assessing and treating preexisting conditions and can
have a positive impact on pregnancy outcomes
TRUE
Ch. 20-Conditions occurring during pregnancy
Fetal Surveillance
- Non stress test
o Monitor FHR for 20 Mins
o Results: Reactive or NONreactive
o Reactive:
 Normal FHR
 2 accelerations in 20 minutes
o Nonreactive:
 absence of 2 accelerations in 20 minutes
- Contraction stress test
o Monitor FHR reaction to contractions (at least 3 in 10 min)
o Interpreted by presence/absence of late decelerations
o Positive (ABNORMAL)
 FHR shows late decelerations w/ 50% or more of ctx
o Negative:
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 no late or significant variable decelerations
o Equivocal-suspicious:
 intermittent late decels or significant variable decels
Biophysical Profile (BPP)
o Non-stress Test (NST)
o Fetal breathing
o Fetal activity
o Fetal muscle tone
o Amniotic fluid volume (AFI)
Multiple Pregnancy- The basics
- Amnion
o thin, tough sac of membrane that covers the embryo
o protective, filled with amniotic fluid – inner membrane
- Chorion
o outer membrane that surrounds the amnion
o support platform for fetus and amnion
o provides nutrient exchange from mother to fetus + foundation for embryonic
development
o chorionic villi – barrier between maternal & fetal blood
- Multizygotic
o 2 or more eggs are fertilized at same time
o 2 eggs fertilized= dizygotic or fraternal twins (70% of twins)
o Risk factors
 artificial reproductive technology (ART)
 ethnicity (particularly African descent)
 family history
 advanced maternal age (↑FSH can cause release of >1 egg as menopause
approaches)
o Each fetus has a separate amnion & chorion
- Monozygotic
o All fetuses came from the same ovum – identical twins/triplets/etc
o Time of ovum split determines # of amnions, chorions, placentas
o Random/spontaneous event
o Not associated w/ genetically inherited trait or ethnic group
o Monochorionic twins have an increased obstetric risk of complications such as
Twin-to-Twin Transfusion Syndrome (TTS).
- Typical discomforts (amplified)
- Maternal/fetal risks
o gestational diabetes
o hypertensive d/o, including preeclampsia
o pulmonary embolism
o preterm birth (50%)
o perinatal mortality (3x more for twins, 4x more for triplets)
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o placenta previa
o fetal anomalies
o cord entanglement
o twin-to-twin transfusion syndrome (50% higher mortality rate)
Assessment
Interventions
Hyperemesis gravidarum
- unusually acute nausea and vomiting
- usually from weeks 11-20
- Risks:
o Weight loss
o Malnutrition
o Dehydration
o Ketonuria
o Electrolyte imbalances
o HX of hyperemesis gravidarum
o Multiple pregnancy
o Hyperthyroidism
o Female fetus
- Treatment:
o Rest
o Possible anti-emetics
o IV fluids
o Parenteral nutrition
Bleeding in Pregnancy
- Implantation bleeding
o around 6-11 days after fertilization
o , bright red or dark brown, lasting ~1 day
- Spotting
o infection
o sex
o increased blood flow to cervix – usually brief & painless
- Miscarriage (spontaneous abortion)
o Occurs before 20 weeks gestation (5-8 wks)
o Likely due to chromosomal abnormalities
o Risks
 Advanced parental age
 Drug/alcohol use
 Poor maternal nutrition
 Use of teratogenic meds
 Certain maternal health conditions (e.g., diabetes, lupus, uterine
abnormalities)
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o Nursing assessment
o Interventions
 Client education
 Report all episodes of heavy bleeding, fever, smelling discharge,
abdominal tenderness
 Refer to counseling
Ectopic pregnancy
o A pregnancy that occurs outside of the uterus, often occurs in the fallopian tube
o Life threatening
o Signs & evaluation
 Severe pelvic pain that may be unilateral (may refer to one shoulder)
 Bleeding
 Slow rise of Beta hCG levels (Beta hCG should at least double in 72 hrs)
 Can also be asymptomatic
 Should be able to see gestational sac via transvaginal ultrasound by week
5 of pregnancy
o Risk factors (Hx of)
 Ectopic pregnancy
 Pelvic infection
 Pelvic surgery
 Advanced maternal age (AMA)
 Cigarette smoking
 IUD (intrauterine device)
 STI – gonorrhea and/or chlamydia
o Treatment
 Methotrexate
 Inhibits cell reproduction and DNA synthesis = stops cell growth &
ends pregnancy
 Surgical:
 Removal of ovum only if possible OR more structures depending
on pregnancy progression (e.g., salpingectomy = removal of one
or both fallopian tubes)
 Administration of blood products if necessary
 Rhogam for women Rh –
 Support
o Client education
 Report signs of heavy bleeding, dizziness, tachycardia
Gestational Trophoblastic disease
- AKA Molar pregnancy
o nonviable mass of trophoblastic tissue
- Failure of a fertilized egg to develop properly- can be due to:
o Fertilization of egg with no genetic material
o 2 sperm simultaneously fertilize 1 egg w/ normal genetic material
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Can grow beyond uterus & become carcinogenic
Assessment
o Abnormally rapid growth
o Abnormally ↑ beta hCG
o Ultrasound – “snowstorm” (no expected fetal structures)
o Often experience VB
Treatment
o Dilation & curettage (D&C) to remove products of conception if not passed
spontaneously
Pregnancy should be avoided for 6-12 months after end of Molar preg
Clinical signs
o Brownish vaginal bleeding
o Uterine size large for dates
o Nausea
Treatment
o D&C
o Rhogam if Rh negative
o Support
Client education
o Report s&S of Heavy bleeding, fever, abdominal pain, smelling discharge
Gestational Hypertension
- Systolic blood pressure ≥140 mm Hg &/or diastolic blood pressure ≥90 mm Hg without
protein in the urine or signs of end-organ dysfunction after 20 weeks of pregnancy
- Can go on to develop preeclampsia
- Complications
o preterm birth
o small for gestational age (SGA) infants
o placental abruption
- Chronic Hypertension
o hypertension before pregnancy or before 20 weeks of gestation
Preeclampsia
- Patient with hypertension (≥ 140/90 mm Hg) on two occasions at least 4 hours apart
AND has proteinuria
- May be associated w/
o abnormal attachment of placenta
o abnormal pregestational maternal inflammation or epithelial cell functioning
- Risks
o Poor circulation assoc. w/ preeclampsia may contribute to
o Oligohydramnios (low vol. amniotic fluid)
o Placental abruption (premature detachment of placenta from uterine wall)
o Intrauterine growth restriction (IUGR)
- Patient has hypertension with or without proteinuria AND:
o a platelet count <100,000
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o serum creatine liver >1.1 mg/dL
o elevated liver enzymes
o pulmonary edema –oro new-onset visual or cerebral symptoms
Develops after 20 wks
Proteinuria of at least +1
Treatment:
o High risk: aspirin and calcium supplementation
o Mild preeclampsia and gestational-HTN may be monitored on an outpatient
basis and not require medication
o Severe preeclampsia- may need to be induced
o Magnesium sulfate by IV to prevent seizures
Home management
o Bedrest lying on side
o Blood pressure monitoring
o Monitoring weight gain
o Monitor symptoms
o Monitor fetal activity
o Normal diet- no restrictions, increase protein intake
Nursing Assessment
o BP
o Deep Tendon Reflexes
o Epigastric pain (RUQ)
o Headache
o Visual disturbances
o Oliguria (↓ urine output)
o Peripheral edema
o 24-hour urine test
o Laboratory tests (CBC w/ platelets, liver enzymes, serum creatinine)
Fetal assessment
o NST
o BPP
o Ultrasound to monitor placental degradation
o Doppler flow studies to measure umbilical blood flow
o Determination of fetal lung maturity for delivery
Hospital management
o Magnesium sulfate
o Antihypertensive meds for severe (labetalol, hydralazine, methyldopa,
nifedipine)
o BP monitoring
o Minimize stimulation
o NST & BPP
o Prevention of injury from seizures
o Corticosteroids IM for fetal lung maturity
Superimposed preeclampsia
- Development of preeclampsia in women with chronic hypertension
Magnesium sulfate administration
- Administered IV as secondary infusion
- Loading dose of 4 to 6 g over 15 to 30 minutes. Then a maintenance dose of 1 to 3
g/hour to maintain a serum Mg level of 4 to 7 mEq/L
- Signs of magnesium toxicity
o Respiratory depression
o Maternal bradycardia
o Oliguria
o Absent deep tendon reflexes
o Lethargy
o Slurred speech
o Loss of consciousness
o Muscle weakness
- Interventions
o Stop the infusion immediately.
o Administer calcium gluconate as ordered (typically 1 g by slow IV push over 3
minutes)
Eclampsia
- Preeclampsia with tonic-clonic seizure activity (or coma)
- 60% antepartum
- 20% during labor
- 20% postpartum
- Treatment
o Magnesium sulfate slow IV push in 4-6 g bolus + maintenance dose
o Oxygen Therapy
o Maintain a safe environment
o Hypertensive medications
Control of BP
- Antihypertensives typically not given for gest Hypertension or mild preeclampsia
- Treatment for severely hypertensive pts
o BP 160/110 or greater
o IV hydralazine or Labetolol
o Correct blood pressure only to 140/90
Gestational Diabetes mellitus
- insulin resistance and results in high BG levels
- Routine screening b/t 24-28 wks
o Nonfasting 50 g oral glucose tolerance test (OGTT) (1-hour GTT)
o If blood glucose is >140, diagnostic testing indicated
- Diagnostic testing
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o Fasting 100 g GTT
o Blood sugar evaluated @ fasting 1, 2, and 3 hours after ingesting glucose
solution
o If two or more values elevated, the patient has gestational diabetes
o Fasting ≥95 mg/dL
o One hour ≥180 g/dL
o Two hours ≥155 mg/dL
o Three hours ≥140 mg/dL
Maternal risks
o Hydramnios
o Infection
o Ketoacidosis
o Spontaneous Abortion
o Preeclampsia
Fetal risks
o Stillbirth
o Congenital Anomalies
o Macrosomia
o Intrauterine Growth Restriction (IUGR)
o Respiratory Distress Syndrome (RDS)
o Fetal Hyperinsulinism
Medications
o Glyburide – stimulates pancreas to release more insulin
 Can cause hypoglycemia
 Teach pts s/s
o Metformin – increases sensitivity of cells to insulin & decreases release of
glucose from liver
 Requires supplemental insulin
 Associated w/ lower birth weight
o Insulin
 More challenging to manage
 Patient teaching is key
o Remember – start with least invasive management and escalate as needed…
1st, diet & exercise… then oral meds… then insulin
Check BG 4-6x/day
o Fasting blood glucose should remain <95 mg/dL.
o 1-hour postprandial levels should be <140 mg/dL.
o 2-hour postprandial levels should be <120 mg/dL.
Patient teaching
o Follow weight gain according to BMI
o Monitor carb intake
o Eliminate simple sugars
o Eat 3 meals & 2-3 snacks/day
o Eat snack with carbs before bed
o Don’t go >10 hrs w/out eating
o exercise
Infections in pregnancy
- Chlamydia & gonorrhea
o may cause preterm labor, preterm rupture of membranes (PROM), or
postpartum endometritis
- Gonorrhea
o cause IUGR, postpartum sepsis & chorioamnionitis (infx of membranes
surrounding fetus)
o Infants may be born with conjunctivitis, arthritis, pharyngitis
- Treatment
o Antibiotics followed by retesting 3 mths later
- HIV
o Women with HIV are often delivered by cesarean to reduce risk of transmission
to fetus
o Newborn treated with antiretroviral meds for 4-6 wks
o Breastfeeding increases risk of transmission – *contraindicated in US
- Hep B
o newborns who contract Hep B from mother will develop chronic liver disease
o Newborns of Hep B + women should be given the hepatitis B vaccine and the
hepatitis B immune globulin within 12 hours of birth.
- TORCH infections
o Group of infections commonly implicated in congenital anomalies
o T = Toxoplasmosis
o O = Other (syphilis, varicella, mumps, etc.)
o R = Rubella
o C = Cytomegalovirus (CMV)
o H = Herpes (genital: HSV-1 & HSV-2)
o Toxoplasmosis
 Transmitted through exposure to litter of infected cat, gardening w/out
gloves, eating raw/rare meat
 Greatest risk to fetus during 1st trimester – damage to CNS, skin, ears;
hydrocephalus, IUGR
o Rubella
 Vaccination contraindicated in pregnancy – give PP if needed
 Maternal symptoms: rash, fever, flu-like symptoms
 Fetal anomalies: CNS, cardiac, ocular, endocrine…
o Cytomegalovirus (CMV)
 Most common cause of congenital, nonhereditary hearing loss
 Can also cause vision impairment & cerebral palsy
 60% of women infected w/ CMV by age 44 – transmitted through blood,
saliva, urine, semen, breastmilk
o Herpes Simplev virus (HSV)
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cause severe infection and death to fetus
vaginal birth if active lesions present
UTIs
o Asymptomatic & treated with ABX
Cystitis (bladder infection)
o : frequent urination, sensation of incomplete emptying, pain w/ urination, lower
abdominal or pelvic pain
Pyelonephritis – kidney infection & inflamma
o Same symptoms as cystitis + fever, chills, N&V, lower back pain
o Associated w/ preterm birth – can also progress to sepsis, kidney failure,
respiratory failure
Cervical insufficiency
- Painless, premature dilation of the cervix in the second trimester of pregnancy
- Caused by
o congenital or acquired cervical/uterine defects
- High risk for miscarriage or premature birth
- Diagnosed with history of second-trimester pregnancy losses and/or measurement of
cervical length by ultrasound
- Treatment
o Progesterone: IM or vaginally from ~16-20 weeks GA through 36 wks GA
o Cerclage: cervix stitched closed – reinforces cervix, helps prevent premature
dilation, help protect fetal membranes
o Transvaginal (removed at 36 wks) or transabdominal placement (indication for
c/s)
Conditions in 3rd trimester
- Trauma (MVAs, falls, gun/stab wounds, partner violence)
- Care considerations
o Place a wedge under the woman’s hip to minimize supine hypotension
o Chest compressions may be more challenging and ineffective in a pregnant
woman
o Oxygen consumption is increased - women should be monitored closely for
hypoxia
o Abdominal trauma may result in placental abruption
o Trauma may be an indication for the administration of Rho (D) immune globulin
to an Rh-negative woman
o The nurse should carefully assess the woman (ABCs, VB, ctx, abd pain) and the
fetus (FHR, u/s) for complications related to trauma.
o In event of unsuccessful CPR of pregnant woman, goal is to have delivery by
cesarean within 5 minutes
- Intrauterine growth restriction
o The root cause of IUGR may be maternal, placental, or fetal in origin
o Asymmetric IUGR (70%)
 Growth restriction happens mostly or entirely in 3rd trimester
 Normal growth of fetal head, slower growth of fetal body
o Symmetric IUGR
 Both head and body grow at slower rate
 AKA global growth restriction
 Associated with significant neurologic problems in neonate
 Often seen in 2nd trimester
o Risks to infants
 Respiratory distress after birth
 Hypoglycemia
 Problems with thermoregulation
 Necrotizing enterocolitis (NEC)
 Retinopathy of prematurity
 Polycythemia → incr. risk for elevated bilirubin → jaundice
o Long term risks
 HTN
 Type 2 DM
 High cholesterol
 Cardiovascular disease
 PCOS
 Motor &/or cognitive delays
Amniotic fluid volume disorders
- Polyhydramnios (excessive amniotic fluid)
o Mismatch between production & absorption of amniotic fluid, generally b/tw
fetal swallowing & elimination
o Known causes
 congenital anomalies of fetal gut, heart, neural tube
 Diabetes
 Twin pregnancy – suspected cause: twin-to-twin transfusion
o Associated w/ poor maternal &fetal outcomes
 preterm birth, cord prolapse, postpartum hemorrhage, placental
abruption, perinatal death
 Fetal: birth defects, meconium-stained fluid, poor labor tolerance, low
Apgar scores, increased NICU admissions
o Diagnosed by ultrasound to obtain amniotic fluid index
 Afi of 20-25 cm is abnormal
o Monitoring serial BPPS and NSTs weekly
o Treatment
 Amnioreduction
 Administration of indomethacin (prior to 34 weeks) to stabilize amniotic
fluid
 Corticosteroids & fetal lung maturity assessment
 Induction of labor, ideally after 34 wks GA
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Oligohydramnios (decreased amniotic fluid)
o Caused by
 2nd trimester: fetal anomalies or premature rupture of membranes
(PROM)
 3rd trimester: fetal anomalies, PROM, and uteroplacental insufficiency
o Associated w/ poor prognosis
 preterm birth, early induction or c/section related to concerns about fetal
wellbeing
o Diagnosed w/ ultrasound findings of decreased AFI of ≤ 5 cm
o Treatment
 amnioinfusion of Ringer’s lactate into the amniotic sac
Dermatoses of late pregnancy
- Intrahepatic cholestasis:
o Caused by impaired bile flow from liver
o Symptoms include
 pruritis, clay-colored stools, dark urine, and fatigue
o Treatment goals include
 minimizing itching (topical meds), reducing concentration of bile acid (PO
ursodeoxycholic acid), and induced delivery at 36 to 37 weeks
o Resolves with the end of pregnancy
- Pruritic urticarial papules and plaques of pregnancy (PUPPP):
o Highly pruritic papules that may be associated with an inflammatory process
caused by stretching of the skin
o Treatments include
 oral topical corticosteroids and an antihistamine
o Resolves within a few weeks of delivery
Ch. 21- Complications occurring BEFORE labor & delivery
Key terms:
• Chorioamnionitis
• Membrane sweeping
• Premature rupture of membranes (PROM)
• Preterm premature rupture of membranes (PPROM)
• Tocolytics
• Uterine tachysystole
Premature rupture of membranes (PROM)
- Rupture of membranes prior to the start of contractions at or after 37 weeks
- Classic presentation- gush of fluid
o May be a gradual leak
- Increased risk of prolapsed cord, placental abruption, chorioamnionitis, cord
compression, & neonatal ICU admissions
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90% of women with PROM go into labor within 24 hours
Preterm premature rupture of membranes (PPROM)
- Rupture of membranes prior to 37 weeks of gestation (<36.6 weeks GA)
o Increased risk of infection (chorioamnionitis, endometritis, septicemia)
o PPROM earlier in pregnancy w/ oligohydramnios associated w/ fetal
malformation of lungs, bones, face
o Most women with PPROM do not have identifiable risk factors, however, the
incidence is higher in women who smoke, had a previous PPROM, and any
vaginal bleeding during pregnancy
Assessment of PROM/PPROM
- Sterile speculum exam
- Nitrazine pH test
o Normal pH of vagina = 3.8-4.2 --- will show as yellow or light green on nitrazine
paper
o Amniotic fluid pH = 7.0-7.3 ---will show as dark green to blue on nitrazine paper
o False negative may occur if leakage is intermittent
o False positive (rare) if presence of blood, soap, semen & some infections
- Arborization test (ferning)
o sample of fluid from vaginal vault and placed on microscope slide – let it dry for
10 minutes – examine for ferning (+ amniotic fluid)
- Presence/absence of meconium-stained fluid
o Associated w/ higher risk of chorioamnionitis, nonreassuring FHR patterns, fetal
hypoxia, fetal meconium aspiration
o normal function of fetal maturity and is present in 3-14% of births
- GA considerations
o Risk/benefit
- Maternal assessment
o labor assessment (contractions), fetal position, s/s of infection
o bloody show, consistent contractions
- Fetal well-being
PROM treatment
- 90% of women go into labor w/ in 24 hrs of PROM
- Active management
o Induction of labor w/ in 24 hrs of ROM (Pitocin)
 Associated with decrease chorioamnionitis and NICU admissions
- Expectant management
o Delay of induction >24 hrs of ROM
 Spontaneous labor w/in 72 hrs 95% of the time
- GBS + women treated with antibiotics
PPROM treatment
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Corticosteroids in pregnanices under 34 weeks GA to promote fetal lung maturity,
prevent intraventricular hemorrhage, NEC and decrease neonatal death by 30-60%
Antibiotic therapy because PPROM may have been caused by infection OR result in
infection
o Azithromycin, ampicillin/or amoxicillin
Tocolytics used to prevent, suspend, or slow labor
o May be used for 48 hrs to allow time for a full course of corticosteroids to be
administered to the mother
o Use of tocolytics for PPROM is controversial
o Indomenthacin, Nifedipine, Terbutaline, (Magnesium sulfate)
Magnesium sulfate between 24-34 weeks for fetal neuroprotection
o Decrease cerebral palsy
Bed rest
o Not found to improve outcomes, done anyway
Delivery
o Most women w/ PPROM will deliver w/ in a week; risk/benefit assessment
Preterm Labor
- Labor at < 37 weeks GA (spontaneous or induced)
- Higher among African American women
- Leading cause of death for children under the age of 5
- Common reasons for premature induction of labor
o Placental problems
o Hx of uterine scarring
o Fetal growth restriction
o Chronic hypertension
o Preeclampsia
o Poorly controlled GB
o Pregestational diabetes, vascular problems
o Preterm premature rupture of membranes
- Risk factors for spontaneous preterm birth
o Low maternal eduction level
o Low maternal income level
o Infection
o Family hx of preterm birth
o Pregnancy with more than 1 fetus
o Pregnancy hypertension
o Substance abuse/ tobacco/alcohol use
o Poor weight gain in pregnancy
o Low/high BMI
PTL assessment & diagnosis
- Symptoms
o Irregular contractions, often mild
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o Report of “menstrual-like” cramping
o Low back pain
o Sensation of vaginal or pelvic pressure
o Light bleeding, spotting, or bloody show
Diagnosis of PTL
o Cervical dilation of 3 cm or more
o Cervical shortening on ultrasound
o Positive fetal fibronectin test (fFN): Evaluation of a protein concentrated
between the placenta and the decidua of the uterus
o Elevated levels associated with birth within 10 days (+ fFN: >50mg/mL)
o Negative result is reassuring
Patient teaching
o Call OB Provider or go to birthing center if:
 Leaking fluid
 Fishy or foul-smelling discharge
 Vaginal bleeding
 Ctx ≤every 10 minutes for an hour
o Drink 2-3 glasses of water
o Empty bladder
o Lie on side for an hour & monitor ctx
Assessment of PTL
o Physical exam for PPROM, VB – speculum exam
o Ultrasound for placental abruption, previa, cervical length
o fFN testing: protein
PTL treatment/interventions
- Suppression of labor
o Tocolytics – indomethacin, nifedipine, terbutaline, magnesium sulfate
o Not used before 24 or after 34 weeks
- Physical activity restriction
o Common recommendation, lacks evidence base
o Sexual activity can stimulate ctx
- Progesterone supplementation
o Shortened cervix (PRE-labor) - progesterone to extend pregnancy
o Not indicated when +fFN test result
- Medical management
o Corticosteroids from ~23 to 34 weeks
o Antibiotics
o Magnesium sulfate for fetal indications (as well as tocolytic indication)
- fFN test
o fFN is a protein produced at the boundary b/tw the amniotic sac and uterine
lining
o Should not be detectable between 22-35 weeks of pregnancy
o IF PRESENT during that time, predicts likelihood of premature delivery within the
next 1-2 weeks
o If NOT present, predicts LOWER likelihood of PTL/PTD
Chorioamnionitis
- Infection of the amnion, chorion, or both
- Complicates up to 2% of term births & 50% of preterm births
- Commonly caused by ascent of bacteria through the cervix
- Risk factors
o PPROM
o PROM
o Multiple digital vaginal exams
o Prolonged labor
o Preterm birth
o HIV
o Invasive fetal/ctx monitoring
o Genital tract infection
- Complications
o Maternal
 prolonged labor, postpartum hemorrhage, wound infection,
endometritis, venous thrombus, sepsis
o Neonatal
 sepsis/septic shock, perinatal death, asphyxia, CP, pneumonia,
meningitis, IVH, neurodevelopmental delay, prematurity-related
problems
o Diagnostic criteria include maternal fever greater than 38˚C (100.4° F) plus at
least two of the following:
 fetal tachycardia
 maternal tachycardia
 uterine tenderness
 foul-smelling discharge
 elevated white blood cell count (over 15,000 cells/mm3)
o Prompt treatment with broad antibiotics (ampicillin & gentamicin)
Post term pregnancy
- >42 weeks
- Risks
o fetal macrosomia
o cord compression (big baby less space to move around)
o prolonged labor (baby too big)
o shoulder dystocia
o birth injury
o infection
o operative delivery (c-section. Vacuum assisted, forceps)
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o postpartum hemorrhage (overdistended uterus)
Post term newborn characteristics
o peeling skin starting on palms/soles, decreased vernix, sparse lanugo, ↑ scalp
hair, longer nails
Dysmaturity
o intrauterine malnutrition d/t aging of placenta
 ↑ risk of perinatal mortality – 2x greater than at term GA
 Characterized by long, thin body, SGA, & may have loose skin w/
prominent creases, oligohydramnios
Treatment
o expectant management or induction of labor
Expectant management
o Close monitoring- 2x weekly NST or BPP beginning at 41 wks
Induction of labor assessment
o Bishop score to assess cervical ripeness (distensible, soft, partly dilated)
o Bishop score evaluates cervical 1) dilation, 2) effacement, 3) station, 4)
consistency, and 5) position (2 points each)
o Score of 8 or higher is considered favorable for a greater chance of a successful
vaginal delivery
o Score of 6 or less = unfavorable → requires cervical ripening
Cervical Ripening
- Pharmaceutical ripening
o Prostaglandins often used prior to oxytocin
 Misoprostol PO or PV – higher doses associated with uterine tachysystole
 Dinoprostone (Cervidil, Prepidil)
o Contraindicated for women with previous cesarean birth or uterine surgery →
risk of uterine rupture
o RN monitoring
- Mechanical ripening
o Insertion of a balloon catheter into the cervix (1cm dilated to insert)
 Blow up with saline, insert water into bag and hang over bed
 Pressure from inside mimics pressure of babys head to dilate cervix
o Increased risk for infection; decreased risk of uterine tachysystole
Labor induction
- Oxytocin (Pitocin) synthetic form
o After cervical ripening, administer IV
o Common dilution: 30 units oxytocin in 500 mL of NSS or LR. At this dilution, 1
mU/min is 1 mL/hour
o Initial dosing of oxytocin: 0.5 to 6 mU/min and increased in doses of 1 to 2
mU/min until regular ctx pattern established
 Goal: 5 ctx in 10 min lasting 40-90 seconds in duration –OR200250 Montevideo units
o SE: GI distress, water retention, tachycardia, hypotension, and uterine
tachysystole
o Stop infusion & notify OB provider if uterine tachysystole or nonreassuring FHR
→ intrauterine resuscitation measures & possible administration of tocolytic
(terbutaline)
Amniotomy
- Artificial rupture of membranes (AROM)
- Fetus must be vertex & engaged
- Risk for cord prolapse & infection
- RN interventions
Placental abruption
- Premature detachment of the placenta from the decidua of the uterus after 20 weeks
GA
o classified as mild/moderate/severe and either acute or chronic
- Causes of placental abruption: often unknown… can be due to blunt force trauma,
smoking, cocaine use, uterine structural abnormalities
- Risk factors: history of previous placental abruption, smoking, HTN
- Prognosis:
o Mild abruption: typically self-limiting & may have little impact on mother/fetu
o Severe abruption: may result in complete detachment of the placenta and risk
the life of the mother and the fetus.
 Abruption of ≥ half of the interface b/tw placenta & decidua assoc. w/
fetal death and DIC
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Acute abruption s/s
o Sudden onset of abdominal pain, vaginal bleeding (possible) & frequent
hypertonic contractions. Uterus rigid on palpation & may be tender
Chronic abruption
o Intermittent light vaginal bleeding may be only maternal sign
o Fetus may be SGA, have IUGR &/or oligohydramnios
Treatment depends on GA and degree of abruption
o May need hospitalization – continuous fetal monitoring & ctx, IV access (for
blood transfusion), maternal hemodynamic monitoring (UO, HR, BP, blood loss)
o Corticosteroids for fetal lung development if less than 34 wks GA
Disseminated intravascular Coagulopathy (DIC)
- Caused by a pathologic activation of the clotting cascade that results simultaneously in
blood clots, platelet and clotting factor depletion, and bleeding
- Can lead to thrombosis, hemorrhage, and multiple organ failure
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DIC is always a complication of another pregnancy condition -- common antecedent
conditions include:
o Placental abruption
o Postpartum hemorrhage
o Preeclampsia/eclampsia/HELLP syndrome
o Prolonged fetal demise
o Maternal sepsis
Treatment of DIC usually happens rapidly and must address DIC and the underlying
cause.
o RN should be sure patient has 2 large bore IVs in anticipation of transfusion…
fluid, blood/blood products, oxygen
Placenta Previa
- Occurs when placental tissues overlie the internal cervical os
- Major maternal complication of placenta previa=hemorrhage
o Fetal complications (prematurity)
- Placenta previa typically presents as painless vaginal bleeding
- Diagnosed by ultrasound
- May resolve as pregnancy progresses (lower uterine segment lengthens and grows
toward fundus & placenta moves away from os)
- Digital vaginal examination is contraindicated with known or suspected placenta previa
- palpation associated with acute bleeding
- Because of bleeding concerns, women are often instructed to avoid exercise & vaginal
intercourse after 20 weeks GA
- What else would the RN tell the pregnant woman?
- Delivery usually indicated at 36-37 weeks (c-section)
Vasa Previa
- Occurs when fetal blood vessels overlie the cervical os.
- Occurs with:
o velamentous cord insertion where blood vessels run along the fetal membrane
over the cervix or
o succenturiate placenta where the placenta is made of different lobes (usually 2)
and blood vessels connect them
- Complications
o fetal hemorrhage and exsanguination with rupture of membranes
- Treatment
o administration of corticosteroids prior to 34 weeks and cesarean delivery
between 34 and 35 weeks, unless an early delivery indicated
Chapter 22- Complications occurring during L&D
Group B streptococcus (GBS)
- GBS colonization is asymptomatic for women, but can be devastating for infants
- Signs & symptoms of GBS infections in neonates
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o Sepsis
o Pneumonia
o Meningitis
Should be screened at 35-37 weeks’ gestation
o Is a culture with a sterile swab from inner vaginal canal to perineum
GBS positive women are treated in labor w/ antibiotics at least 4 hours before delivery
o Treat with penicillin G
o Vancomycin given every 12 hours up to delivery
 If given too fast women can get red man syndrome, slow down infusion
o Women with preterm labor are treated without screening
 Treated as patient is positive
Can also test through urine
5 Ps of Labor
- Dystocia of labor is any labor with abnormally fast or slow progression
- Precipitous labor lasts 3 hours or less
- 5 Ps include
o Powers-refers to uterine contractions and pushing efforts
o Passageway-refers to maternal bony pelvis and soft tissues
o Passenger-refers to fetal factors
o Psyche- refers to maternal state of mind
o Position- refers to maternal position
- Power
o Hypotonic uterine dysfunction is a condition where uterine contractions are
either too uncoordinated or too weak to dilate cervix
o Hypotonic uterine dysfunction occurs in active phase of labor (4-7 cm)
 Related to polyhydramnios, macrosomia, or multiple pregnancy
o Hypotonic contractions palpate soft & occur at a rate of <3 or 4 every 10
minutes lasting <50 seconds
o Internal contraction monitoring may be indicated
 Pt must already be ruptured
o Treatment
 Rest, amniotomy, or oxytocin administration
o Ineffective pushing can lead to dystocia
o Laboring down is process of allowing the primary powers to facilitate fetal
descent in second stage
o Pushing resumes when woman feels urge to bear down
o Used in women w/ epidurals
- Passageway
o complications often occur in conjunction with passenger issues
o A maternal pelvis that is smaller than normal, or contracted can lead to dystocia
o Pelvimetry is associated with higher cesarean risks but not overall improved
outcomes
o Soft tissue dystocia can be caused by a full bladder or bowel
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o Scar tissue on the cervix can lead to soft tissue dystocia
o Pushing before the cervix is fully dilated can lead to swelling and soft tissue
dystocia
Passenger
o Cephalopelvic disproportion (CPD) is a mismatch between the size of the fetal
head and size of maternal pelvis
o Fetal position in relation to maternal pelvic can impact labor progress
o Most common fetal malpresentation is occiput posterior position
 OP position causes low back pain
 Pt has a long second stage of labor
o Breech presentation
 Frank breech, footling breech, or complete breech
 Greater risk for asphyxia or birth trauma, often delivered by cesarean
 Diagnosed by Leopold’s maneuvers or ultrasound
 External cephalic version (ECV) may be attempted after 36 wks to turn
fetus to a head down position
Psyche & position
o Psyche
 Anxiety can have negative impact on labor & fetal outcomes
 Nurse can play role in labor support
o Position
 Upright positions (sitting, kneeling, squatting, or standing) can shorten 1 st
stage of labor by 90 minutes
Shoulder Dystocia
- Impacted shoulder above or behind the symphysis pubis
- Obstruction by the shoulders after the birth of the head
o Shoulders won’t rotate to come out, and head goes back in
- No risk factors exist
o Macrosomia and maternal diabetes often associated
- Turtle sign if first sign of a shoulder dystocia
o Head comes out, then retreats back
- Interventions
o Call for help
o Lower HOB and perform McRoberts maneuver
o application of suprapubic pressure
o Documentation
Intrapartum procedures
- Episiotomy
o Surgical incision of posterior aspect of the vulva during 2nd stage of labor
o Used if PT is at risk of 3rd-4th degree perineal tear
o Risks include infection, bleeding, and pain
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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
Risks
o 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
Cesarean Birth
- Complications
o bowel and bladder injury during surgery, hemorrhage, amniotic fluid embolism,
and infection. A major neonatal complication is respiratory distress
- Indications for c-section
o Failure to progress
o Nonreassuring fetal heart rate
o Fetal malpresentation
o Umbilical cord prolapse
o Fetal macrosomia
- Unplanned cesarean deliveries may cause women a sense of frustration,
disappointment, even failure.
- Types of uterine incisions include classical (vertical), low vertical, or low transverse. It is
safest to attempt a vaginal delivery after cesarean if a low transverse incision was used.
Labor & delivery Complications & interventions
- Uterine rupture
o Tear in the uterine lining secondary to increased pressure
o Occur in women attempting trial of labor after cesarean (TOLAC)
o Avoid VBACs
- Symptoms
o sudden development of a category II or category III fetal heart rate pattern,
weakening contraction, and abdominal pain.
- Treatment
o cesarean delivery and possible hysterectomy
- Nursing considerations
o Increased awareness of risk factors
o Monitor for signs and symptoms
o Use caution with tachysystole tracings
o Stabilize pt and prepare for c-section
Cord prolapse
- umbilical cord precedes fetal head in the birth canal
- Causes
o High station
o Small or preterm fetus
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o Malposition of the fetus
o Polyhydramnios
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1 sign of cord prolapse
o change in fetal heart rate tracing, typically severe fetal bradycardia, and variable
decelerations
Management
o Relieve pressure of the cord to improve blood flow to the fetus and therefore
increase oxygenation
Amniotic fluid embolism
- occur in pregnancy, labor, delivery, and the immediate postpartum period
- caused when amniotic fluid enters maternal circulation and is associated with a
maternal mortality rate of 32%
- symptoms
o respiratory failure and cardiac arrest
Ch.23- After delivery
Postpartum Hemorrhage
- Typical blood loss after vaginal birth is 500 mL and 1,000 mL after a cesarean delivery
- A postpartum hemorrhage (PPH) is bleeding of more than 1,000 mL despite uterine
massage and first-line uterotonics (such as oxytocin)
- Early PPH occurs within 24 hours of birth
- Delayed or secondary PPH may occur 24 hours to 12 weeks after delivery
- After birth the uterus normally maintains hemostasis and prevents PPH by clotting and
contraction of the myometrium of the uterus
- PPH is often caused by uterine atony, blood coagulopathies, or trauma
Uterine Atony
- Clinical manifestations
o Boggy uterus
o Heavy bleeding
o Saturated peripad within 15 to 30 minutes
o Blood clots
o Changes in skin color or turgor
o Disoriented and anxious
o Tachycardia
o Hypotension
- Diagnosis
o Diagnosed clinically
o Confirmed by bimanual exam
- Prevention
o Recognizing risk factors
o Initiating early intervention and treatment
- Nursing Actions & interventions
o Review prenatal and/or intrapartum records
o Monitor vital signs
o Establish intravenous access and draw labs
o Perform fundal checks, assess bleeding, fundal massage
o Assess and monitor patient more frequently
o Administer and/or have uterotonics per orders and protocol
o Reassure patient and provide explanation for nursing action/ interventions
o Provide comfort measures
Lacerations
- Risk Factors
o Instrumented vaginal delivery
o Malpresentation
o Macrosomia
o Episiotomy
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o Precipitous delivery
o Shoulder dystocia
Clinical manifestations
o Steady stream of bleeding despite firm fundus
o Absence of clots
o Origin is often masked
o Pain and hemodynamic instability are often presenting symptoms
o Tachycardia and hypotension
Diagnosis
o Inspection of lower genital tract
Prevention
o Minimal use of instrumentation
o Limited use of an episiotomy
o Offer operative delivery
Nursing Actions & Interventions
o Review prenatal and intrapartum records
o Monitor vital signs
o Perform fundal checks and assess for bleeding
o Monitor blood loss
o Prepare patient for pending pelvic exam
o Administer pain medication as prescribed
o Provide comfort measures and emotional support
Hematoma
- Risk factors
o Episiotomy
o Instrumented vaginal delivery
o Prolonged Second Stage
- Clinical manifestations
o Severe pain in the vaginal or perineal areas
o Pain often uncontrolled by standard analgesia
o Swelling, discoloration, and tenderness
o Vaginal bleeding may or may not be present
- Diagnosis
o Examine affected areas
- Prevention
o Avoid episiotomy and operative deliveries
o Minimize second stage of labor
- Nursing actions
o Review prenatal and intrapartum records
o Monitor vital signs
o Apply ice to perineal area for first 24 hours postpartum
o Assess pain
o Administer pain meds as prescribed
o Review lab results
o Inform physician or APN as indicated
Post Partum Hemorrhage 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 a first-line uterotonic medication.
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
o Hypotension
o Tachycardia
o Tachypnea
o Oliguria
o Mental status changes
o Cool, pale, and clammy skin
o Slowed capillary refill
Thromboembolic disease
- A venous thromboembolism (VTE) is a blood clot or multiple clots that form within a
vein.
- Factors that place a pregnant woman at risk for thromboembolic disease include dilated
veins leading to slower blood flow and pooling, endothelial injury related to surgical
intervention or placental detachment, and the increase of coagulation factors in
pregnancy to decrease the risk of hemorrhage.
- VTEs may be limited to superficial veins or form in deeper veins of the lower extremities
(a deep vein thrombosis [DVT]). A DVT can break off and travel to the pulmonary artery,
which is known as a pulmonary embolism (PE).
- Pulmonary embolisms account for 9.2% of maternal deaths in the United States.
- Symptoms of a DVT include
o swelling, pain, localized redness, warmth, and tenderness
- DVTs are often diagnosed with ultrasound imaging.
- Treatment of a DVT may include anticoagulation therapy or surgery.
- A superficial vein thrombosis is more common than a DVT. Symptoms include
o pain, tenderness, and redness along the length of the vein. The vein may feel
cord-like. A superficial vein thrombosis is often self-limiting.
- Supportive measures for the care of patients with VTEs include:
o Elevating affective leg
o Warm or cold compresses for comfort
o NSAIDs
o Compression stockings
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