Mortality - death.
Fetal Death: intrauterine death of a fetus of at least 20 weeks
gestation with absence of any signs of life after birth.
Neonatal death: death of an infant born with signs of life up to
28 days after birth.
Perinatal death : sum of fetal & neonatal deaths per 1000
live births.
** BEST indicator of perinatal care
INFANT MORTALITY: the number of deaths per 1000 that occur
in the first year of life.
*** This the the statistic used by most countries. This is what is
most seen in the Literature ALTHOUGH is not the best indicator
of Perinatal care.
Maternal Death: death of mothers per 100,000 due to
complications of pregnancy, labor , delivery or postpartum.
Maternal Mortality (per 100,000 births)
1915 1940 1950 1960 1983 1997 2002
All Women
608 376 83.3 37
8
7.2 7.6
White Women
61
26
5.9
5.5 6
Nonwhite Women
221.6 97.9 18.3 18-20 18
Adequate prenatal care
3
Poor prenatal care
5
No Prenatal Care
23
Leading Causes Pregnancy Related Death:
hemorrhage, embolism, hypertension, infection,
anesthesia related complications
Maternal Mortality Rate : approximately 7.5 per 100,000 in 1998
When compared to white women ; Black women have 4 times the risk for
dying from complications of pregnancy and childbirth.
One half of all deaths could be prevented with early detection.
No significant changes since 1982 - fluctuated between 7 & 8 %.
Hemorrhage, PIH, infection, and ectopic pregnancies account for most
of the deaths.
Fetal mortality rate in 1998 was 6.7% improved from 6.8%
White = 5.7%
Black = 12.3%
Perinatal Mortality = 7.2% ; Whites = 6.2% , Blacks = 12.9%
Neonatal mortality = 4 .8% ; Whites = 4.0% , Blacks = 9.4% . | In 1990 was 5.7% |
Postneonatal Mortality = 2.4% ; Whites = 2.0% , Blacks = 4.4 %
Taken from the last CDC statistics 1998
Regionalization
Level 1 :
Level 2 : IVCH, CHO
Level 3 : St. Francis
Small group of women is high risk
with good prenatal care almost 2/3 of ALL HIGH risk
problems can be identified early and high possibility of
preventing further complications
Only 23%-25% of High Risk delivered are surprises
KEY = Identification Prenatal care
Obstetrical – uterine malformations
Bicornate uterus
Sepate uterus
Double uterus
Didelphys or
Complete
Double uterus
Relationship between
maternal and fetal
malnutrition
Loss and Grief - outline
Types of losses arising in perinatal period and their causes
Loss of “real vs ideal” (pregnancy)
Loss of Physical Control
-maternal or fetal demise
-inability to push or inability to withstand
-need for hospitalization or transport to
distant site
-diagnosis of fetal anomalies
-intrauterine fetal demise
Loss of “normal” labor experience
-development of complications
-need for intervention (IV’s, oxytocin, oxygen)
-need for FHM
-fetal distress
-need to remain in bed or analgesia or
anesthesia
Loss of emotional control
-screaming, crying
-verbalization of anger, fear, discouragement
-use of expletives
involuntary urge to push
-involuntary vocalizations, defecation,
or urination during delivery
-inability to maintain breathing or
relaxation techniques
-vomiting
-slapping or hitting coach or med staff
-throwing objects
Loss of Natural Birth Experience
-preterm birth
-need for analgesia or anesthesia
-need for forceps or vacuum extraction
-need for cesarean delivery
Types of losses arising in perinatal period and their causes continued:
Loss of shared experiences
-absence of father, partner, or
other significant friend
Loss of body image
-incompetent cervix
-severe edema with preeclampsia
-incision from cesarean birth
Loss of “real vs. ideal (postpartum exper.)
-maternal trauma or disease
-postpartum depression
-neonate unable to breastfeed due to prematurity
illness, or anomalies
Loss of Self Image
-maternal disease process
-preterm labor or birth
Loss of “real versus ideal” (Neonate-fetal or neonatal death
-neonatal anomalies
-birth injuries or asphyxia
Loss of relationships
-preterm infant
-maternal hospitalization or transport to distant
-need for transport to distant site
site
-stillbirth/neonate death
-neonatal transport
-fetal or neonatal death
Loss of self-image
-partner withdrawn during grief process
-maternal disease process
-with fetal or neonatal death, avoidance behaiors
-postpartum depression
by family or friends
DEFINATION OF HYPERTENSION IN PREGNANCY
1. Systolic blood pressure > or = 140 mm Hg
or
2. Diastolic blood pressure > or = 90 mm Hg
3. Increase of > or = 30 mm Hg in systolic pressure
4. Increase of > or = 15 mm Hg in diastolic pressure
NOTE # 3 & 4, most of our women have lower BP to start with!
PEGNANCY – INDUCED HYPERTENSION
A. Preeclampsia : Development of hypertension with proteinuria, edema or
both, induced by pregnancy after the 20th week of gestation
1. Mild:
Preeclampsia is considered mild unless any criteria for severe
is met
2. Severe: One or more of the following signs defines severe preeclampsia
Blood pressure with resting > or = 160 mm Hg (systolic) or
110 mm Hg (diastolic) on two occasions at least 6 hours apart
Proteinuria > or = 5 g in 24 hours, + 3
Oliguria > 400 ml in 24 hours, 30cc/hr
Cerebral / vision disturbances (e.g. altered consciousness,
headache, blurred vision)
Pulmonary edema / cyanosis
Epigastric / right upper quadrant pain (can occasionally
precede hepatic rupture
Impaired liver function of unknown etilology
Thrombocytopenia
3. Eclampsia: The occurrence of convulsions in a woman who meets criteria
for preeclampsia
Preeclampsia
Most women in Mild preeclampsia are not immediately hospitalized,
but will keep close monitoring on maternal & fetal well being.
ks
agement
oring
tion
ns change
If below 37 weeks, betamethosone – IM to mom, helps surfactant development
Checking Reflexes
A = Biceps
B = Patellar reflex
with legs hanging
freely
C = Patellar reflex with
client supint
D = Checking for
ankle clonus
Checking for pitting edema
A=+1
B=+2
C=+3
D=+4
Watch for symptoms even in someone who is below 140/90
or liver
Enzymes
Renal function
What is MAP ? Talking about blood pressure
Mean arterial pressure
MAP = DBP + 1/3 of pulse pressure
A person with a BP or 120/60 has a MAP of 80. Often used this in hypertensive crises, more accurate in gaging medications &/or end-organ damage
Pulse pressure = the difference between the systolic & diastolic pressure.
It is normally about 1/3 of the systolic pressure. If BP is 120/80, the pulse
pressure is 40. See increased with arteriosclerosis of the larger arteries or
during exercise. See decreased with hypovolemia.
Severe Preeclampsia
-Admit to labor and delivery area
-Maternal and fetal evaluation x 24 hours
No
- Maternal Distress
-Severe IUGR
-Fetal Distress
-Labor
->34 weeks gestation
< 28 weeks
-maternal
counseling
-intensive
management
Yes
----Delivery
28-32 weeks
33-34 weeks
-steriods, betamethosone
-amniocentesis
-conservative
management
immature or mature
Pathophysiology of PIH
Severe Preeclampsia
HE LLP
H = hemolysis
E = elevated
L = liver function tests
L = low
P = platelet count
Postpartum Resolution:
- brisk diruesis (150 – 300 ml / hour
-IV MgSO4 until diruesis observed or usually 24 hrs
-keep BP < 140/100 mm Hg
-discharge with weekly follow up until BP is normal
Therapeutic levels of MgSo4 are 4 to 7, toxic levels 8-10
blood levels will be drawn, check DTR, resp. rate
REMEMBER whenever MgSO4 is in use what drug has to be
near by
Calcium gluconate
Uterine relaxation
What should you watch for in mom PP ?
What might happen in newborn ?
Remember MgSO4 is a CNS
depressant – respiratory distress,
decrease in respiratory effort
Remember 1202
Signs and Symptoms of Shock
Hypovolemic Shock SIGNS:
-tachypnea (deep & rapid)
-tachycardia
-weak, thready pulse
-hypotension – late sign
-narrowed pulse pressure
-increased capillary fill time (>4
sec)
-oligura (less than 20-30 mL/ hr)
-urine sodium = 80 mEq/L
-cool, clammy skin
-pallor and peripheral cyanosis
-hypothermia
SYMPTOMS
-anxiety, restlessness, disorientation
--thirst, dry mouth
--feeling chilled
Septic Shock:
-tachycardia
-hyperdynamic pulse
-thachypnea, respiratory alkalosis
-hypotension
-cerebral oscje,oa
-polyuria, urine sodium 10 mEq/L
-hyperthermia (in early septic
shock)
SYMPTOMS:
-palpitations
-faintness, dizziness
-anxiety, apprehension,
disorientation, stupor
Abortions
A = Threatened
B = Inevitable
C = Incomplete
D = Complete
E = Missed
Incompetent cervix
A = cerclage correction
of recurrent premature
dilation of cervix
B = cross section of closed
cervix
Suture removed around
36-38 wks.
McDonald’s procedure
cerclage suture
Pursestring sutures
Sonograms
HCG levels
Emotional Support
Hydatidform mole or a gestataional trophoblastic neoplasm Rare 1: 1000 to 2000
3 times higher in Asian women, 10% develop Choriocarcinoma
What is treatment?
Often abort spontaneously or D&C
No Pitocin until after deliver
What are S&S?
Nausea Why?
Abnormal uterine growth
What do you have to check?
Why? How often?
HCG levels 1-2 wks until norm, then
1-2 mos for a year.
If do not drop may have to be treated
with chemotherapy
Starts as fertilization, trophoblast
Degenerates & chorion proliferates
Actual Hyditform
MOLE
A&D=
Complete
B&C=
Partial
C&B=
Low lying
or
Marginal
Lower A=
Normal
Placenta Previa NON PAINFUL BLEEDING
What are S&S ?
Pain
Board like abdomen, especially is
concealed.
Who is high risk population ?
History of abruptio
Grand parity
Povery
PIH
Advanced age
Supine hypotension
Short umbilical cord – during labor
Trauma to abdomen
Cocaine or other drug usage
Cigarette – some say
Alcohol abuse – some say
CORD INSERTION & PLACENTAL VARIATIONS: Rare less than 1:3000
May lacerate & bleed, especially
during L& D
A = Vasa praevia or Velamentous
insertion : No wharton jelly
B = Battledore placenta: cord at
end of placenta
C = Succenturiate placenta
blood vessels maybe supported
only by fetal membranes
DIC or Disseminated Intravascular Coagulation
What are S&S?
FIND CAUSE
correct
DIC is secondary
to number of
things:
hemorrhage
septic shock
amniotic fluid
embolism
PIH
infection
diabetes
During PG, clotting factors normally increase and thrombolytic activity decreases
If a condition requires some type of anticoagulant : heparin is choice
Warfarin crosses the placenta & is with fetal malformations
von Willebrand’s disease : an autosomal dominant bleeding disorder in
abnormality of vW factor which affects clotting of blood – hormones
in pregnancy may improve vW factor – but need to monitor
ATP – may improve slightly, but then rebound with more destruction
of the platelets
Maternal infections
1 Syphillis: may pass through placenta may result in abortion, a stillborn, preterm
labor or congenital syphillis (enlarged liver, spleen, skin lesions,
rashes, oseteitis, pneumonia, hepatitis
TX penicillin
2 Chlamydial infection (#1 STD in US) : fetus may be infected during birth
and suffer neonatal conjunctivitis or pneumonitis, which manifests
at 4-6 wks of age PROM , chorioamnionitis, preterm labor
TX erythromycin or amoxicillin (mom)
3 Gonarrhea: fetus may be infected during birth – ophthalmia neonatorium
endocervicitis = PROM and preterm labor
4 Condyloma acuminatum or genital warts (human pailliomavirus): fetus may be
infected during vaginal birth and develop epithelial tumors of the
mucous membranes of the larynx in children. PG can cause proliferation
HPV associated with cervical dysplasia & cancer (see next slide)
5 tichomoniasis basically associated with PROM and postpartum endometritis
Venereal warts or
Condylamata acuminata
Human papillomavirus HPV
Most common viral STD
3 times greater than herpes
Cauliflower like appearance
Maternal vaginal infections
Vaginal candidiasis: fetus may be infected during vaginal birth
oral candidiasis (thrush) TX for infant Mycostatin
TX for mom Monistat, Terazole, Femstat
Most say treat for at least 7 days
PROM, preterm labor, low birth weight, postpartum endometritis
UTI’s , cycstitis, acute pyelonephritis
PROM, preterm labor
Viral infections remember most virus passes placental barrier
Cytomegalovirus: a member of herpesvirus group. Infects most humans
peak ages 15 to 35 yrs. Like most herpes after primary infection, lies latent
with periodic reactivation and shedding of the virus.
Fetal & neonatal effects: 2% of all live births may be infected. These
infants shed the virus from the nosopharynx and urine for several yrs.
Most severe effects: deafness, mental retardation, seizures, blindness
& dental bnormalities
TX: gancyclovir for TX of congenitally infected infants
No screening yet available
Rubella: up to 10% of adults remain susceptible
Fetal & neonatal effects: greatest risk is first 3 ms. 1/3 will result in
spontaneous abortion, surviving maybe seriously compromised –
deafness, mental retardaation, cataracts, cardiac defects, IUGR
and mirocephaly. Infants will shed the virus for many months
TX: prevention, A titer of 1.8 or greater provides immunity
Rubella vaccine after delivery – educate no PG for at least 3 mos. WHY?
Varicella – Zoster virus ( herpesvirus) = chickenpox:
Acute infection for mom: r\preterm labor, encephalitis & varicella
pneumonia. 5 –15% of aduls in US are susceptible
Fetal & neonatal effects. Depend upon time of infection. If in the first
20 wks, the fetus may have congenital varicella syndrome (limb hypoplasia, cutaneous scars, chorioretinitis, cataracts, microcephal and
symmetric IUGR. In later pregnancy , transplacental passage of
maternal antibodies usually protect fetus. However, the infant who
is infected 4-6 days or 2 days after birth will not have the benefit
of maternal antibodies, leaving the infant at risk for life-threatening
neonatal varicella
TX: immune testing, varicella-zoster immune globulin should be administered
to women who have been exposed
TX: infants born to mothers infected with varicella during the perinatal
period, immunization with varicella-zoster immuni globulin as soon as possible
but within 96 hrs after birth.
Live attenuated vaccine after 12 mos through adults, avoid PG for 1 mo after
each of the two injections, which are given 4 to 8 wks apart.
Herpesvirus serotypes 1 & 2: one of most common sexually transmissible
disease. Most genital warts are type 2. Lesions form at site, begin at
painful papules that progress to vesicles, shallow ulcers, pustules, crusts.
Virus is shed until completely healed.
lies latent in the sensory ganglion which can be reactivated
Vertical transmission from mom to infant generally occurs: 1 after rupture of
membranes or 2 during vaginal birth or with fetal scalp electrode
Fetal & neonate effects: Primary infection in first 20 weeks : spontaneous
abortion, IUGR and preterm labor.
Neonatal herpes is uncommon but potentially devastating. From skin
lesion to systemic or disseminated. If systemic death rate or serious
sequelae is 50% . Watch for infection S&S temp instability, lethargy,
poor sucking, jaundice, seizure & herpetic lesions.
TX: no known cure although antiviral chemotherapy (acyclovir) Category C
May breast feed if no lesions are on breast
Parvovirus: or erythemia infectiosum or fifth disease.
highly communicable characterized by “slapped cheeks” appearance
followed by a generalized maculopapular rash, fever, malaise
and joint pain.
Titers can be drawn if exposure during PG
Fetal & neonate effects: I/4 to 1/3 of fetuses infected will have transient
adverse effects, fetal death rate is less the 5%. Death usually results form
failure of fetal RBC production, fetal anemia, hydrops (edema)
and heart failure
Hepatitis B : more likely to occur in person with STD, IV drug users & some
population groups, Asians, Native Americans, Eskimos, Southeast
Asian and subSaharan African immigrants. Chronic Hepatitis B
develops in 1 to 6 % of infected adults who are at a greater risk for
chronic liver disease, cirrohosis of the liver, premary hepatocellular
carcinoma
Fetal & neonatal effects: prematurity, low birth weight, and neonatal
death increases. Infants born are chronic carriers of hepatitis B.
Chronic hepatitis develops in about 90% of infected newborns –
likely to have chronic liver disease
TX for Hepatitis B: prevention vaccines of 3 IM injections given during a
6 – 12 mos. period.
Screen for HBsAg if at high risk screen again in 3rd trimester
If mom is known GBsAg positive usually infection of the newborn can be
prevented by administration of hepatitis B immune globulin followed
by hepatitis B vaccine. Vaccine should be repeated at 1 and 6 mos.
Breastfeeding is considered safe as long as the new born has been vaccinated
HIV – human immunodeficiency virus.
Fetal & neonatal effects: without prophylactic TX (Zidovudine) has a 20-30%
of developing the disease. Typically are asysmptomatic at birth but S&S
during first 12 mos. Enlargement of liver, spleen, lymphadenopathy, failure
to thrive, persistent thrush, extensive seborrheic dermatitis or cradle cap.
TX: prevention prenatal period
intrapartum period (cesarean birth ? )
postpartum period (no breastfeeding)
With Zidovudine throughout PG and L & D. infant TX with zidovudine syrup
may test positive at birth but only 2% will remain positive
If mom contacts HIV virus during PG higher change that infant will be HIV *
Non Viral infections:
Toxoplasmosis: a protozoan infection. Raw or undercooked meat, cat feces
crosses the placental barrier. Flu like symptoms in mom.
Can do serologic test
Fetal and neonatal effects: spontaneous abortion or live birth with congenital
toxoplasmosis - 50% of infants. May be asymptomatic at birth or have
low birth weight, enlarged liver and spleen, jaundice and anemia.
Complications chorioretinitis or signs of neuologic damage may be
several years later.
TX: prevention and education
Group B Streptococcus (GBS): is a leading cause of life threatening perinatal
infections. 10 – 30% of women are colonized with GBS in the vaginal
or rectal area. Most are asymptomatic or may include UTI,
chorioamnionitis
Fetal & neonatal effects: early onset GBS within 7 days of birth, usually 48 hrs.
1 – 2 % will develop early onset GBS, sepsis, pneumonia and meningitis.
late onset is after the first week and meningitis is most common manifestation.
Permanent neurological consequences may be seen in up to 50% of those who
survive
Group B Streptococcus (GBS): is a leading cause of life threatening perinatal
infections. 10 – 30% of women are colonized with GBS in the vaginal
or rectal area. Most are asymptomatic or may include UTI,
Chorioamnionitis
Fetal & neonatal effects: early onset GBS within 7 days of birth, usually 48 hrs.
1–2 % will develop early onset GBS, sepsis, pneumonia and meningitis.
late onset is after the first week and meningitis is most common
manifestation. Permanent neurological consequences may be seen in up to
50% of those who survive
TX: prevention, Cultures early and again at 35-37 wks.
Intrapartum antibiotics, usually IV penicillin G 5 million units initially
and 2.5 million units ever 4 hrs after until birth OR
IV ampicillin, 2 g initially and 1g every 4 hrs until birth
Tuberculosis:
Fetal & neonatal effects: perinatal infection is uncommon, may be acquired
as a result of fetus aspirating amniotic fluid. Signs of congenital TB include
TB failure to thrive, lethargy, respiratory distress, fever and enlargement of
spleen, liver and lymph nodes.
TX: for PG woman isoniazid, pyrazinamide and rifampin every day for 9 mos.
Pyridoxine (vit B 6) should be given with isoniazid to prevent fetal
nuerotoxicity. Some are using short term therapy – 1 to 2 months of
therapy, and then twice weekly therapy
TX for neonates. If mom’s sputum is free of organisms, infant does not need to
be isolated from mom. Education is vital. Skin test of newborn – may
be started on preventive isonaizid therapy. Skin testing again at 3-4 mos.
If positive, receive isoniazid for at least 6 mos. If also have HIV should
receive therapy for 12 mos. Breastfed infants of mothers taking isoniazid
should receive pyridoxine with a multivitamin supplement
Congenital infection: ToRCHS syndrome
T
Toxoplasma
R
Rubella
C
Cytomegalic inclusion disease (CID, CMV)
H
Herpes
S
syphilis
•transplacentally acquired
•congenital infection
•Celery-stalk meaphyses, esp. long bones
•Intracranial calcification
•Decreased growth
•vascular stenosis (aorta, pulm artery)
TORCH
T = toxoplasmosis
O = other
hepatitis A
hepatitis B
R = rubella
C = cytomegalovirus
H = herpes genitalis