Age- Adolescent Mother under 17 versus Mature Mother over age 35
Adolescent Mothers
Less prenatal care- unprepared for labor experience
Increased chance of infection
CPD (cephalopelvic disproportion)
Abruptio placentae
Mature mother
Better psychological preparation but are at risk of more physiologic changes
Gestational Diabetes
Cardiac problems
Hypertension
Chromosomal Abnormalities
Hypoglycemia
Hyperglycemia
Diabetic Ketoacidosis
Fetal Distress
Congenital malformation especially if not well controlled
PIH
Controlled by insulin and possible IV insulin during the delivery- Regular insulin IV
Highest level of risk during labor
VS frequently
A pulse rate faster than 100 or irregular
Respirations greater than 24 or abnormal congested lung sounds
Abnormal lungs
May indicate early cardiac decompensation
ECG’s or EKG’s
Avoid supine position- use left lateral
Elevate shoulders and head
Supplemental oxygen
Epidural anesthesia slows the heart rate and produces peripheral vasodilation and decreases BP- good for this patient

Monitor FHR
Do not elevate legs during delivery- excessive venous return back to weak heart
Use short, open glottis bearing down efforts- no Valsalva
Vacuum assistance
Seizures are more likely to occur during labor and 48-72 hours afterward
Padded side rails
Magnesium Sulfate decreases cerebral edema and slows neuromuscular impulse transmission
Watch for toxicity- deep tendon reflexes and respirations
Watch urinary output
Blood levels of magnesium sulfate assessed- 2.5-7.5 is therapeutic range for MgSO
4
Calcium Gluconate is the antidote
Analgesics and Regional anesthetics are not withheld from suspected substance abusers but must be used with caution!
Track marks
Dilated or constricted pupils
Disorientation/agitation
Inflamed nasal mucosa
Associated with UTI’s and RTI’s
Any delivery that occurs before 37 weeks
Stay at home-no chores-bed rest
Early recognition is important and call doctor
Vaginal bleeding and cramps
Treatment
Bed rest in the left lateral recumbent position
External fetal monitoring only
Encouragement to Mom and family

Suppress Contractions and stop labor
Ritrodine (Yutopar)- causes maternal tachycardia
Terbutaline sulfate (Brethine)- causes maternal tachycardia
Magnesium Sulfate- depresses CNS and relaxes muscles of uterus
ROM- “bag of waters” rupture before labor
Infection- amniochorionitis
Endometritis
Parametritis
Peritonitis
Monitor temperature every 2 hours
Nitrazine test- turns blue
May give antibiotics and use bed rest if only a small amount trickles out
Cord prolapse/gray/bulging/pulsates
FHR- Trendelenburg/Knee chest/ Oxygen-C section
Lifeline that provides oxygen to the fetus
Nuchal Cord
FHR
Loosen if not too tight and unwrap
Clamp and sever the cord before delivery- done by Dr. or Midwife
C-section
Report a temperature that is above 100.4
Avoid sexual intercourse of insertion of anything into vagina
Avoid orgasms
Avoid breast stimulation
Maintain any activity restrictions prescribed
Note any uterine contraction, kick counts

Amnioinfusion
Olighydramnios
Umbilical cord compression
Reduction of recurrent variable decelerations
Dilution of meconium stained amniotic fluid
Replaces the “cushion” for the umbilical cord and relieves the variable decelerations
Hypertonic
Usually occurs during the latent phase of labor
Characterized by contractions that are frequent, cramp like, and poorly coordinated
Painful, but not productive
Excessively strong or longer than expected for a certain stage
Results: precipitous delivery or complete exhaustion of uterus- C section and risk of hemorrhage
Uterus is tense, even between contractions, which leads to reduced blood flow to the placenta
Hypotonic
Weak contractions around 5-9 cm- amniotomy or Pit drip- contractions every 2-3 minutes
Labor begins normally, but diminishes during active phase
More likely to occur if uterus is over-distended
Stretches the muscle fibers and reduces their ability to contract effectively
Dystocia- failure to progress toward delivery
CPD- Cephalopelvic Disproportion
Abnormal uterine contractions
Analgesics or Anesthetics
Maternal Exhaustion

Give chance to deliver vaginally
Remarkable to see how head can mold
Vacuums or forceps- watch for damage to facial nerve in baby- asymmetry
Occiput anterior preferred
Occiput posterior- more backache
Watch FHR
Version may be attempted with malpresentations
Use of birthing chairs, bars, overbed tables can sometimes help
Placenta Previa
Abruptio Placentae
C-section- low transverse
Retained placenta- 15 minutes after delivery- detaches and expelled
D&C
Placenta accrete, increta, or percreta
Accreta- most common- 75% of cases- Placenta become part of the Endometrium (D&C)
Increta- 17% of cases- placenta extends into the uterine muscle (hysterectomy)
Percreta- 5-7% of cases- involves the entire uterine wall (hysterectomy)
Placenta succenturiate- satellite placenta tissue (extra placenta)- D&C, possible hysterectomy
Care
Vital Signs
Examination of Placenta
Pitocin
Surgery
Late PP hemorrhage due to retained placental fragments
Infection
Concern with VBAC- vaginal birth after C-section
Prolonged labor
Pitocin administration- stop Pit if occurring every 90 seconds and call doctor
Frequently fatal to fetus
High risk of death to mom

Rh sensitization
Sickle cell anemia
Trauma
Disease
Labor continues for extended time
No labor- 2 weeks and induce
Grieving process
Viewing infant, taking pictures if normal appearance
Should be prepared if infant has anomalies
Move Mom away from maternity unit
Most common: Hemorrhage and Infection
Postpartum Hemorrhage: Defined as loss of more than 500 mls of blood in the 24 hours period following the third stage of labor or 1000 mls following surgical delivery and does not include blood loss during the delivery.
Slow and subtle- more dangerous because may not notice
Sudden and profuse
Pad count- each additional gm of weight of pad= 1 mL of blood lost
Concealed bleeding with hematomas
No relief from pain meds= hematoma
Early: Occurs in the first 24 hours

Causes:

Uterine atony
 Lacerations

Retained placental fragments

Hematomas

Distended bladder
Late: Occurs after first 24 hours
 Causes:

Retained placental fragments

Sub-involution

Infection

Bleeding disorders
Risk factors: episiotomy, lacerations, forceps delivery, multiparity over 5, prolonged labor

Atony is the most common cause of early postpartum hemorrhage
Atony refers to lack of muscle tone
Uterus is difficult to feel, and when found, it feels soft or boggy
Fundal height may be high
Lochia is increased and may contain large clots
Bleeding vessels are not contracting
When the uterus is boggy, the nurse should massage it until it is firm while other nurse calls the doctor
Pitocin
Hysterectomy
Suspect with bright red bleeding in spite of tightly contracted uterus
Cause: Mom pushes before she is dilated complete 10 cm.
Other causes: Forceps delivery, macrosomia, precipitous delivery
First degree: tear of skin and MM of the posterior connection of the labia minora and outer vagina
Second degree: Plus muscles and fascia up to the anal sphincter
Third degree: Plus anal sphincter
Fourth degree: Plus extension through the rectal wall
Trauma during delivery
Excessive pain and pressure in the perineal or rectal area
Cold packs to perineum after delivery
Restless
If epidural is working may go straight into shock
Small or size of baseball containing 250-500 mL of blood

Cystitis- epidural and urinary retention- catheterizations
Watch for signs and symptoms of infection
Mastitis- inflammation or infection of the breast tissue
Inflammation due to blocked milk ducts
Infection from cracks on nipples and bacteria from the mouth of the baby
Swollen engorged breasts
Painful breasts
Reddened and hot to the touch
Fever
Malaise
Goal: get milk flowing freely again
Express milk manually or use a breast pump every 4 hours
Warm heat
Cabbage
Analgesics and antibiotics
Wash nipples and air dry and coat with milk- nurse until abscess