Complications
Antepartum
Intrapartum
Postpartum
Maternal Mortality
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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
Maternal Mortality
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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
Causes of Maternal Mortality
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Hemorrhage, Embolism, Hypertensive
Disorders and Infection are in the top
five causes of maternal mortality
Antepartum Bleeding
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Multiple Etiologies
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Placenta Previa
Abruption
Pre-term Labor
Ectopic pregnancy
Infections
Cervical Polyp/Erosion
Cancer/Molar pregnancy
Trauma
Ruptured Uterus
Physiologic (implantation bleed, show)
Bleeding-Ectopic Pregnancy
Bleeding-Ectopic Pregnancy
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Blastocyst implants outside the
endometrial lining of the uterus
Fallopian tube (95%)
 Ovaries, Cervix, Abdomen
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Rare, but possible to have ectopic and
intrauterine pregnancy simultaneously
Bleeding-Ectopic Pregnancy
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Defining Characteristics
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Any bleeding early in pregnancy
• Ectopic is a possibility until proved otherwise
• Often brownish bleeding, but may be any color or
even absent
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May or may not have pain until rupture
Abnormally low hCG levels
Confirmed by ultrasound or laparoscopy
Bleeding-Ectopic Pregnancy
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Ruptured ectopic pregnancy
Sudden, sharp, severe lower
abdominal pain
 Hypotension/shock
 Abdominal tenderness
 Marked cervical motion tenderness
 Neck/shoulder pain w/ inspiration
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This is a life-threatening situation
Bleeding - Abortion
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Abortion
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medical term for all pregnancy loss prior to
20 weeks
Types
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Spontaneous (Miscarriage)
Missed (embryo/fetus dies, not passed)
Threatened (bleeding, cervical os closed)
Inevitable (bleeding, cervical os open)
Therapeutic (pregnancy termination)
Bleeding - Abortion
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Spontaneous Abortion
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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
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>9 weeks likely to need D&E
Bleeding - Abortion
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Spontaneous Abortion
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Nursing Interventions
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Vital signs
S/Sx of infection
Pad Count
Pain assessment/management
Grief counseling
• Talk about difference for men and women
• Anticipatory Guidance
Bleeding - Placenta Previa
Bleeding - Placenta Previa
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Placenta implants low in the uterus
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Marginal Previa/Low Lying Placenta
• Next to, but not covering the cervical os
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Partial Previa
• Covers part of the internal cervical os
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Complete Previa
• Covers all of the internal cervical os
Bleeding - Placenta Previa
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Bleeding - Placenta Previa
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Malpresentation
• Transverse position
• Breech presentations
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Placenta takes up the space where
the fetal head should be
Bleeding - Placenta Previa
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Cesarean section likely
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Definite if complete previa
• Vessels will tear with dilation/effacement
• Gross maternal & fetal hemorrhage
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Possible vaginal birth if partial previa
• Fetal head may tamponade the blood
vessels enough to allow vaginal birth
• Unlikely in current practice environment
Bleeding - Placenta Previa
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Classic defining characteristics
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Digital vaginal exam contraindicated
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Painless bright red vaginal bleeding
Risk of perforating the placenta
Gross hemorrhage
Cesarean section scheduled prior to onset
of labor
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May need to assess for fetal lung maturity
Bleeding - Placenta Previa
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Essential points to teach patients
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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
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Bleeding - Placenta Previa
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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
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• The more C/S the higher the risk
Bleeding - Abruption
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Also called Abruptio Placenta
Bleeding - Abruption
Premature separation of the normally
implanted placenta
 Serious hemorrhage in the late
second and the third trimesters
 Bleeding may be
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Concealed
 Obvious
 Both
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Bleeding - Abruption
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Bleeding - Abruption
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Associated with
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Sudden deceleration forces
• MVA
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Severe abdominal trauma
• Battery
• Difficult external version
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Sudden ↓ in uterine volume/size
• SROM in polyhydramnios
• Between birth of babies in multiple gestation
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Maternal Hypertension
• Chronic, pre-eclampsia, Cocaine related
Bleeding - Abruption
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Defining Characteristics
Pain is out of proportion to palpated or
monitored uterine activity
 Board-like abdomen (+/-)
 Uterine rigidity (+/-)
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• Both may be absent if posterior placenta
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Back pain (from extravasating blood)
Bleeding - Abruption
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Defining Characteristics
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Bleeding (maybe concealed)
Pain
Colicky uterine contractions
Violent/decreased/absent FM
FHT changes
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Tachycardia
Loss of variability
Variable and Late decelerations
Sinusoidal pattern
Bleeding - Abruption
Defining characteristics will depend on
the extent of abruption
 Partial separation
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May be able to stabilize and deliver
vaginally (often delivery is fast)
Complete separation
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Requires immediate delivery to save
the life of the mother and fetus
Bleeding - Abruption
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If risk for abruption (fall, MVA, etc)
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Observation x 4 – 6 hours
• External fetal monitoring
• Uterine irritability
• FHT changes
• Physical s/sx
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Abruption will usually present by 4 hrs
Bleeding – Previa &
Abruption
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Nursing interventions
Get help/notify MD
 Obtain IV access (16 g x 2)
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• fluids
• blood products
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Obtain blood for
• Type and cross-match for ≥ 3 units
• CBC with platelets/PT/PTT/Fibrinogen
• Plain tube for clotting time
Bleeding – Previa &
Abruption
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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
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Pre-term (Premature) Labor
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Labor from 20 – 36 weeks
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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
Pre-term (Premature) Labor
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Defining characteristics
Cramping
 Change in backache
 Change in discharge
 Bleeding or spotting
 Change in pressure/heaviness
 Diarrhea
 SROM
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Pre-term (Premature) Labor
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In absence of infection, attempts to stop
PTL (PML) are made
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Bedrest (no research to support)
PO or IV fluids  medications
• Dehydration associated with contractions
• Medications to stop contractions
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If delivery is inevitable, attempts made to
speed fetal lung maturity
• Betamethasone IM given up to 34 weeks
• Gluteal injection
• Thick, oily, painful
Pre-term (Premature) Labor
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Magnesium Sulfate (MgSO4) (IV)
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Terbutaline (SQ, PO)
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Risk for pulmonary edema
Nifedipine (SL, PO)
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Hourly assessments for magnesium toxicity
and efficacy of medication
Ca++ channel blocker
Indomethacin (PO, PR)
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Prostaglandin synthetase inhibitor
May cause premature closure of ductus and
oligohydramnios
Diabetes in Pregnancy
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Pre-Gestational Diabetes
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Type 1 – usually insulin dependent
Type 2 – may or may not require insulin
Gestational Diabetes
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Onset after 20 weeks of pregnancy
Resolves by six weeks postpartum
• Emphasize f/u due to  lifetime risk of DM
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Usually controlled by
• Diet
• Exercise
• Blood glucose monitoring
Diabetes in Pregnancy
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Universal screen at 28 weeks
1 hour glucose tolerance test (GTT)
 LOTS of false positives
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• Diagnostic 3 hour GTT
• 2 abnormal values = GDM
At risk women screened earlier
 Known diabetics not screened
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Diabetes in Pregnancy
 insulin resistance during pregnancy
 If pancreas cannot produce more
insulin to compensate for resistance
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’d circulating glucose
 Crosses placenta
 ’d fetal insulin
 Insulin acts as growth hormone
 Macrosomia
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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
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Cord cut  glucose levels fall rapidly
 Neonate still has circulating insulin
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Diabetes in Pregnancy
Tight glycemic control can reduce the
risk of pregnancy complications
 Usually aim for
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Fasting ≤ 95
 2 hour postprandial ≤ 120
 Usually checking QID
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• Fasting, 2h post meals, hs
Hypertensive Disorders of
Pregnancy
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Chronic Hypertension
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Predates the pregnancy
• Risk for IUGR, risk for abruption
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Gestational Hypertension
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Pre-eclampsia (“Toxemia”)
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 BP without other symptoms
Mild, Severe
Eclampsia
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Seizures
Hypertensive Disorders of
Pregnancy
Cause of Pre-eclampsia unknown
 Many theories of etiology
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Inappropriate response to
angiontension II
 Inappropriate ratio of prostaglandins
 Disordered placentation
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Hypertensive Disorders of
Pregnancy
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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
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Hypertensive Disorders of
Pregnancy
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Defining Characteristics of
Pre-eclampsia
Onset after 20 weeks gestation
 Classic Triad
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• Edema, Proteinuria, Hypertension
Headache
 Epigastric Pain
 Visual ∆’s (scotoma – flashing lights)
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Hypertensive Disorders of
Pregnancy
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Mild Pre-eclampsia
140/90 or +15/+30 BP
 Classic Triad, some edema
 +1 proteinuria on a single dip
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• (300mg/L in 24 hour urine collection)
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May see other lab abnormalities
Hypertensive Disorders of
Pregnancy
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Severe Pre-eclampsia
≥ 150/100 BP
 3 – 4+ proteinuria on a single dip
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• (5g/L in 24 hr collection)
Classic triad, marked edema
 Other lab abnormalities common
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Hypertensive Disorders of
Pregnancy
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Care is supportive
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Promote excellent nutrition
Lateral lie
• promotes diuresis and placental perfusion
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Magnesium Sulfate
• Quiets neurologic system
• Decreases vasospasm
• Monitor for s/sx of toxicity
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Seizure Precautions
Hourly vital signs
Prepare for delivery
Hypertensive Disorders of
Pregnancy
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If progresses to eclampsia
Magnesium Sulfate (MgSO4)
 Protect airway
 Intrauterine stabilization of fetus
 Protect from excess stimuli
 May proceed to cesarean when stable
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Likely transfer to intensive care unit
for postpartum stabilization
Hypertensive Disorders of
Pregnancy
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HELLP syndrome
Hemolysis, Elevated Liver Enzymes,
Low Platelets
 Atypical Pre-eclampsia presentation
 May be complicated further by
Disseminated Intravascular
Coagulation
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Cesarean Section
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Problem with the 3 P’s of labor
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Powers
• Inadequate, too strong, uncoordinated
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Passenger
• Not tolerating labor, malpresentation, size or
congenital anomalies
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Passage
• Mismatch with passenger, unsafe for mother to
labor
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C/S in the absence of a medical indication
Current C/S rate ~ 30%
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anecdotal reports approaching 50%
Cesarean Section
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Types
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Low Transverse
• Horizontal uterine incision
• Also called low cervical, low segment
• Most common, VBAC OK
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Classical
• Vertical incision on uterus
• Uncommon, VBAC contraindicated
• Emergency, preterm, malpresentation
Cesarean Section
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Planned
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Unexpected, but not emergent
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Labor contraindicated
Maternal choice (highly controversial)
Problem with 3 P’s, mother & baby stable
Urgent
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Need to proceed to protect life or health
“Decision to incision” time <30 minutes
• With suspected uterine rupture <18 minutes
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Nursing care depends on circumstances
Cesarean Section
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Support person present in the OR
Remind not to touch sterile areas
 Provide a stool to sit on behind drape
 Keep on eye on them
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Anesthesiologist/Nurse- Anesthetist
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Excellent at communicating with client
Labor nurse usually becomes
circulating nurse in the OR
Cesarean Section
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Post-operative recovery usually on L&D in
special PACU area
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if both mother & newborn stable
• Kept together in PACU area
• Take care to promote thermoregulation
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Assist to breastfeed in PACU if able
All postpartum assessments
All post-operative assessments
Client and/or support person may need to
verbalize about c/s
Amniotic Fluid Embolism
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Amniotic Fluid enters systemic circulation
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Unexplained
Hypertonic contractions
Sudden onset of
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Respiratory distress
Bleeding/oozing (DIC)
Cyanosis
Pain  Shock coma
Amniotic Fluid Embolism
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Life threatening emergency
ABCs
 Blood products
 Intensive care, central monitoring
 Often fatal to mother and baby
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I have only seen this once
>40 units of PRBCs and FFPs
 Near death experience reported
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Shoulder Dystocia
Anterior shoulder stuck behind
maternal symphysis pubis
 Unpredictable
 Increased risk with
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Prolonged labor
 Macrosomic fetus
 Poorly controlled maternal diabetes
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Shoulder Dystocia
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Defining Characteristics
Unexpectedly slow crowning
 Turtle sign with birth of fetal head
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• No restitution or external rotation
Have 4 – 6 minutes to get the baby
out before brain damage ensues
 Shoulder Dystocia drills
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Shoulder Dystocia
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Nursing Interventions
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Note time of birth of the head
Note all interventions used to relieve
Note which fetal shoulder impacted
Call for help
Provide suprapubic pressure when asked
• NOT fundal pressure
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Sharply flex and abduct maternal legs onto
abdomen (McRoberts maneuver)
Anticipate neonatal resuscitation and
maternal postpartum hemorrhage
Postpartum Hemorrhage
Any blood loss significant enough to
cause signs and symptoms
 Traditionally >500 cc for vaginal birth
and >1000 cc for cesarean section
 May be resolved surgically if
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Laceration repair
 Retained placenta (late hemorrhage)
 Placenta accreta
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Thrombophlebitis
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Pregnancy is a prime example of Virchow's
triad of increased risk for VTE
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venous wall damage/irritation
change in flow
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Immobility
Local pressure
Varicose veins
Venous obstruction
Hydration, hypovolemia
blood hypercoagulability
• adaptations for hemostatsis in labor
Thrombophlebitis
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Defining Characteristics
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Pain in area of clot
• if peripheral, +/- erythema
• If peripheral, +/- edema
• If peripheral, +/- cord palpable
• Do NOT massage
• If peripheral, +/- homan’s sign
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Possibly fever, chills
Thrombophlebitis
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Nursing Interventions
Moist heat as ordered
 Pain assessment/management
 Observe for s/sx of PE
 Administer anticoagulant therapy as
ordered – usually Lovenox/heparin
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• Large molecule, does not cross placenta
and not secreted in breast milk
• Coumadin contraindicated in pregnancy
Endometritis
Postpartum infection of the
endometrium
 Predisposing factors
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Prolonged labor
 Prolonged rupture of membranes
 Cesarean birth
 Trauma
 Retained products of conception
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Endometritis
May spread and become a systemic
infection leading to sepsis
 A major cause of morbidity and
mortality
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Endometritis
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Defining Characteristics
Temperature >100.4
 Alteration in VS
 Fundal tenderness
 Foul smelling vaginal discharge
 Rigors, Malaise
 + blood cultures
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Endometritis
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Administer antibiotics as ordered
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May be on triple antibiotics
Promote adequate hydration
 Promote adequate nutrition
 Protect mother-baby bonding and
interaction
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Baby may also have infection
Promote activity as appropriate
REMEMBER!
Despite this depressing and
frightening lecture
 The overwhelming majority of births
are straightforward
 The human race has been around a
long time . . .
 Birth works and babies come out or
we wouldn’t be here today!
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