NURSING CARE MANAGEMENT 102 (NCM 102 )midterm

BY:

JULIET M. DELA CRUZ, RN,MN,MPA

HEMORRHAGIC ( BLEEDING ) conditions on late part of pregnancy

1. PLACENTA PREVIA

Improperly implanted placenta in lower uterine segment or over internal os

Low implantation of placenta

causes / predisposing factors :

a. History of suction curettage for induced or spontaneous abortion

b. Advance maternal age

c. Smoking/ cocaine

d. Poor vascularity

e. Uterine fibroid tumors

f. Multiple pregnancies

g. Previous uterine surgery

4 TYPES OF PLACENTA PREVIA

1. Low- lying placenta

2. Marginal implantation

3. Partial placenta previa

4. Complete/ total placenta previa

ASSESSMENT FINDINGS:

1. Bleeding

2. FHR

3. Uterus

Complications to the mother/ baby

Life threatening

Presenting part has difficulty entering the pelvis

CS delivery

Placenta accrete

IUGR and congenital anomalies

Diagnostic Tests

Pelvic exam under double set up

Lab studies ( dec in maternal Hgb)

Transvaginal UTZ scanning to determine placental position

Radiologic test

4 TYPES OF PLACENTA PREVIA

1. Low- lying placenta

2. Marginal implantation

3. Partial placenta previa

4. Complete/ total placenta previa

ASSESSMENT FINDINGS:

1. Bleeding

2. FHR

3. Uterus

Medical Treatment

IV fluid therapy

Vaginal birth delivery

Patient remains in the hospital for bed rest

Betamethasone drug

Nursing Interventions:

1. Ensure complete bed rest to avoid premature delivery

2. Place the patient immediately in a side lying/ lateral trendelenberg position to prevent maternal shock and fetal hypoxia

3. Assess the duration of pregnancy and the time bleeding bega

4. Instruct the woman to estimate the amount and color of blood

5. Ready blood for replacement

6. Maintain sterile condition

7. No rectal and vaginal examination

8. Make provision for STAT CS

9. Monitor VS

10. Assess uterine tone

11. Teach client to identify and report signs of bleeding and cramping

12. Have oxygen ready

2. ABRUPTIO PLACENTA – premature separation of the placenta from uterine wall, usually occurs after 20th week of pregnancy manifested by rigid, tender and irritable uterus.

Generally occurs late in pregnancy or during first and second stage of labor

Cause : UNKNOWN

PREDISPOSING FACTORS

1. Cocaine/ cigarette

2. Advance maternal age

3. Thrombophilitic condition

4. Chronic hypertensive disease

5. High parity

6. Short umbilical cord

7. PIH

8. Direct trauma

Assessment findings/ signs & symptoms

1. Bleeding – dark red and painful

2. FHR

Mild- strong and regular

Moderate- barely audible, irregular

Severe- absent

3. uterus/ abdomen – rigid and boardlike, tender, remains firm bet contractions

4. Couvelaire uterus/ uteroplacenta apoplexy- caused by the blood infiltrating the uterine musculature forming hard, boardlike uterus with or without external bleeding

5. Pain –Uterus – agonizing, tearing or irritable ; sharp stabbing pain high in the uterine fundus

Complications

Disseminated intravascular coagulation (DIC) leads to severe bleeding

Shock and circulatory collapse due to severe hemorrhage

Renal failure

Maternal death

Fetal hypoxia/ death

Need for hysterectomy

Diagnostic test

Pelvic examination

CBC and blood typing, may indicate low Hct,hgb &plt ct

Prothrombin time maybe prolonged

Fibrinogen test – maybe low

Abdominal utz

Treatment and management / nursing interventions

Oxygen

Ensure bedrest

Anticipate coagulation problems (DIC)

IVF/BT

Monitor vital signs

MIO

Monitor vaginal bleeding

Sidelying position

Prepare for stat delivery

Keep the woman informed of what is happening

Don’t perform any pelvic or vaginal exam

Provide support

COMPLICATIONS OF LABOR AND DELIVERY

1. DYSTOCIA - abnormal or difficult labor

It results from differences in the normal relationships bet any of the five essential factors of labor

Mechanical dystocia causes

Maternal

1. Contracted pelvis

2. Obstructive tumor

3. Ineffective contractions

4. Excessive analgesia

Fetal causes:

Failure of the vertex to rotate as in occiput posterior

Malpresentation,

Malformation of the fetus

Disproportion of maternal pelvis and fetal presentation

Assessment :

1. Evaluate fetal presentation, position and size

2. Nonengagement of fetal head may indicate a contracted pelvic

3. Note any known uterine or fetal anomalies

4. X-ray pelvimetry is used for eval of cephalopelvic disproportion

5. Monitor VS, FHT, contraction

Management/ nursing interventions

1. If occiput posterior position

Relieve back pain as much as posible by sacral pressure, back rubs, frequent change in position from side to side

Observe the character and frequency of contractions and monitor fetal heart rate

IV fluids are used to prevent dehydration and used to provide glucose needed for effective contractions

When cervix is completely dilated, fetal head maybe rotated by physician

Provide encouragement and reassurance to the woman throughout the labor

2. If breech presentation

Labor maybe longer, since in a breech delivery, the soft buttocks do not aid in cervical dilatation as well as the head does in vertex presentation

Analgesia may be limited in order not to interfere with the mother’s ability to push effectively

Amniotomy is not done until breech is well engaged because there is greater danger of prolapsed of the cord with footlong presentation or breech that does not fill the pelvic cavity

Breech presentation maybe delivered spontaneously with strong contractions particularly in multipara

3. Ceasarean birth is performed if there is shoulder presentation, when the size of the fetus is excessive to the size of the pelvis, or when there is persistent occipital posterior presentation in which forcep rotation maybe difficult

Functional Dystocia ( uterine dysfunction or enertia)

Inertia- denote sluggishness of contractions, or the force of labor, has occurred

A condition in which uterine contraction deviates from the normal

Contributing factors:

Uterine anomalies

Over distension such as hydramnios or multiple pregnancy

Cervical scar

Excessive anesthesia

Assessment

Contractions may differ in quality and synchronization of activity

Contractions may also have inadequate intensity

Evaluate contraction quality and pattern

Prolonged labor maybe evident

Monitor and evaluate progress of cervical dilatation, descent and rotation in birth canal

Nursing Interventions according to 2 patterns of ineffective uterine contractions:

1. Hypertonic uterine dysfunction- muscle of the uterus is in a state of greater than normal tension

Provide rest with the aid of sedatives

Provide fluids to maintain hydration and electrolyte balance

Observe for normal contractions when woman awakens

Darkening room lights, and decreasing noise and stimulation

Prepare for CS

2. Hypotonic uterine dysfunction- contractions are inadequate, too weak

Pelvis is reevaluated for size

IV fluids

Oxytocin admin if pelvic size is adequate and fetal position, presentation and station are normal

Rupture of the uterus- immediate laparotomy

Prolapsed cord:

1. Relieve pressure on cord by placing mother in trendelenbrerg or knee chest position

2. Notify AP

3. Do not attempt to replace cord into uterus

4. If cord protrude at vagina cover with saline moistened sterile water

5. Monitor FHT

6. Prepare for CS

7. Oxygen admin

8. Increase IV rate

PRETERM LABOR

Is uterine contraction occuring after 20 weeks gestation and before 37 weeks completed gestation

Risk factors of preterm labor

1. Socio economic risk factor

Low socioeconomic status

More than 2 children

Maternal age

No prenatal care

Poor nutrition

Lack of childbirth experience/ education

2. Medical / obstetric risk factors

Previous preterm delivery

Spontaneous or induced abortion

Uterine anomalies

Less than 1 year bet last birth

Height below 5ft

Multiple birth

Placenta disorders

3. Lifestyle risk factors

Smoking

Excessive fatique

Stressful events

4. Risk factors in current pregnancy

Uterine overdistention

Bleeding

Less wt gain

Fetal/placental malformation

Maternal illness/ dse

Premature rupture of membranes

Management:

1. Prevention of premature delivery

CBR without BRP

Monitor/evaluate uterine contraction

Cervical consistency

Symptoms are monitored

Ivfluids

MIO

2. medications/ tocolytics used in treatment of premature labor are:

Magnesium Sulfate - stops uterine contraction with fewer side effects

Beta adrenergic drugs – decrease effect of calcium on muscle activation to slow or stop uterine contractions

Nefidipine – calcium channel blocker

Indomethacin – prostaglandin synthetase inhibitor

Betamethasone – given to improve fetal lung maturity

3. Health teaching

4. Reducing anxiety

5. Discharge teachings

PREMATURE RUPTURE OF MEMBRANES (PROM)

Is the loss of amniotic fluid or rupture of amniotic sac before the onset of labor

PRETERM PREMATURE RUPTURE OF MEMBRANE

( PPROM)

Is defined as the rupture of membrane before 37th week of gestation

PROLONGED RUPTURE OF MEMBRANE

( PROLONGED ROM)

Occurs when the membranes rupture more than 24 hours before birth/ delivery

Assessment findings

Report from mother of discharge of fluid

PH of vaginal fluid will differentiate between amniotic fluid and urine or purulent discharge

Chorioamnionitis is characterized by maternal fever and uterine tenderness which might cause preterm birth before 34 weeks

Membranes may continue to leak, prolonging the loss of amniotic fluid for the fetus ( oligohydramnios)

Diagnostic test of PROM

Nitrazine paper moisened with vaginal fluid indicates PROM if it turns from yellow to dark blue, means amniotic fluid has alkaline pH

Nursing interventions

1. Take FHT immediately as priority to prevent fetal hypoxia

2. Monitor VS( maternal/ fetal)

3. Calculate AOG

4. Observe for signs of infection

5. Observe color and odor of amniotic fluid

6. Examine for signs of cord prolapsed

7. Prepare for early birth

POSTTERM PREGNANCY ( POST MATURE PREG)

Defined as those pregnancies lasting beyond the end of the 42nd weeks

Assessment findings

Decreased amounts of vernix also allow the drying of the fetal skin, resulting in a dry, parchment like skin condition

Diagnostic test

Measurement of fetal gestational age for fetal maturity

Biophysical profile

Medical / nursing management

Directed toward ascertaining precise fetal gestational age and condition and determining fetal ability to tolerate labor

Induction of labor/ CS

Continual monitoring VS (fetal/ maternal)

Support mother through labor

Assist with amnio- infusion if ordered

PROLAPSED UMBILICAL CORD

Displacement of the cord in a downward direction, near the presenting part or in the vagina

Obstetric emergency: if compression of the cord occur, fetal hypoxia may result in CNS damage / death

Nursing interventions

Check FHT

If cord prolapsed into vagina , exert upward pressure against presenting part to lift part of the cord, reducing pressure on cord

Cover cord with saline

Position mothe rwhere gravity assist in getting presenting part off cord

Oxygen administration

Increase IVF

Notify physician

UTERINE RUPTURE

Is assoc. with previous uterine surgery such as CS, hysterectomy repair tears or other surgeries

Fetal death follows after rupture unless emergency CS is accomplished

Assessment:

Sudden, severe pain during a strong labor contraction called “ tearing sensation”, abdominal pain and tenderness; chest pain

If complete rupture; labor may stop, rapid and weak pulse, cold and clummy skin, air hunger, BP dropped, impaired fetal O2nation and no FHT

If incomplete: only localized tenderness, persistent aching pain over the lower uterine segment

Therapeutic / nursing management

Anticipate the need for CS

Repair of uterus

Hysterectomy

BT if needed

Admin oxytocin to reduce contraction

PRECIPITUS LABOR AND DELIVERY

Labor of less than 3 hours from time of 1st contraction to delivery

Predisposing factors;

Previous same history

Multipara

Large pelvis

Unresistant soft tissue

Small baby in good position

Induction of labor by rupture of membranes and oxytocin

Assessment

Desire to push

Medical management/ nursing interventions

Monitor FHT q 15min

Stay with mother

Don’t prevent birth of baby

Maintain sterile environment if posible

Support baby’s head

Following birth, evaluate infant for signs of trauma

Dry to prevent heat loss

Place baby on mother’s abdomen

Examine mother for cervical, vaginal and perineal lacertions

Check for signs of placental separation

Check mother for bleeding

Cut cord when pulsation ceases

AMNIOTIC FLUID EMBOLISM

Is the escape of amniotic fluid containing debris such as meconium, lanugo and vernix caseosa into the maternal circulation, usually resulting in deposition of fluid in the pulmonary arterioles

Rare but fatal

Predisposing factors:

Marginal placental separation

Uterine rupture

Hysterectomy

Assessment findings

Dyspnea

Cyanosis

Tachycardia

Pulmonary edema

Bleeding

Signs of shock

Hypotension

Death in minutes

Medical / nursing management

Emergency CPR

Establish IV line for BT

Prepare for emergency birth

If cervix is dilated, forcep delivery is used to deliver fetus

Keep patient informed

ANOMALIES OF THE PLACENTA

Placenta succenturiata- has one or more accesory lobes connected to the main placenta by blood vessel

Placenta circumvallata – the fatal side is covered with chorion

Battledore placenta- the cord is inserted marginally rather than centrally

Vasa previa- the umbilical vessels cross the cervical os, they would be delivered first before the fetus

Placenta accreta- ussually deep attachment of the placenta to the uterine myometrium

PROBLEMS WITH POSITION

1. Occipitoposterior

2. Breech presentation

3. Face presentation

4. Brow presentation

5. Shoulder dystocia

6. Macrosomia

7. Transverse lie