Final Mchn Slides2

Maternal and Child Health Nursing

PART II

Maternal and Child Health Nursing

Promoting Fetal and Maternal Health Mary Lourdes Nacel G.

Nursing Process 

Nursing Diagnosis  Health-seeking behaviors  Anxiety  Risk for deficit fluid  Constipation  Disturbed body image  Risk for altered sexuality patterns  Disturbed sleep pattern  Fatigue  Risk for fetal injury MARY LOURDES NACEL G. CELESTE, RN, MD

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Health Promotion During Pregnancy 

Self-care needs  Bathing  Breast care  Dental care  Perineal hygiene  Sexual activity

Exercise Sleep Employment Travel MARY LOURDES NACEL G. CELESTE, RN, MD

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Health Promotion During Pregnancy

First-Trimester Discomforts  Breast tenderness  Palmar erythema  Constipation  Nausea, vomiting and pyrosis  Fatigue  Muscle cramps

 Hypotension  Varicosities  Hemorrhoids  Heart palpitations  Frequent urination  Abdominal discomfort  Leukorrhea

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Health Promotion During Pregnancy 

Middle to Late Pregnancy Discomforts Backache Headache Dyspnea Ankle edema Braxton Hicks contractions

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Discomforts associated with pregnancy 1. First trimester 

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Nausea and vomiting (“morning sickness”) related to altered hormone levels and metabolic changes; advise small snacks of dry crackers before arising, small feedings of bland food, milk Urinary frequency and urgency without dysuria; fluid intake should not be restricted Increased vaginal discharge; manage with good hygiene (but no douching) and loose-fitting cotton underwear; report signs or symptoms of vaginitis MARY LOURDES NACEL G. CELESTE, RN, MD

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Breast soreness due to hormonal changes; suggest wearing a wellfitting, supportive brassiere Headache due to tension from emotional and physical stresses at any time during pregnancy; provide reassurance, suggest relaxation techniques; inform patient to report persistent and/or severe episodes MARY LOURDES NACEL G. CELESTE, RN, MD

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Second and third trimester 

Heartburn may be related to tension and vomiting in early pregnancy, progesterone-induced decreased motility and relaxation of the cardiac sphincter; displacement of the stomach by the growing uterus; encourage small, frequent meals and discourage overeating, ingesting fried/fatty foods, lying down soon after eating, use of sodium bicarbonate (would interfere with sodium balance) MARY LOURDES NACEL G. CELESTE, RN, MD

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Constipation related to progesterone-induced hypoperistalsis, compression/displacement of the bowel by the enlarging uterus, poor food choices, lack of fluids, and/or iron supplementation; advise bulk foods, fruits and vegetables, exercise, and generous fluid intake; avoid laxatives

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Hemorrhoids due to pelvic congestion related to pressure from enlarged uterus; suggest regulation of bowel habits, gentle reinsertion into rectum with use of lubricant, relief measures, e.g., ice packs, topical ointments, sitz baths, lying down with legs elevated MARY LOURDES NACEL G. CELESTE, RN, MD

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Uterine contractions (Braxton-Hicks) due to tension on the round ligaments as a result of displacement of the uterus; instruct patient to rest, change position or activity

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Backache due to increased spinal curvature; educate the patient on the importance good posture

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Faintness related to vasomotor lability or postural hypotension; instruct the patient to use slow, deliberate movements when rising, avoid prolonged standing and warm, stuffy environments; elastic hose may be needed MARY LOURDES NACEL G. CELESTE, RN, MD

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Leg cramps related to pressure on the nerves supplying the lower extremities aggravated by poor peripheral circulation or fatigue; instruct the patient to increase calcium and decrease phosphorus intake; encourage dorsiflexion of feet

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Ankle edema related to decreased venous return from lower extremities, instruct the patient to avoid wearing anything that constricts blood flow, elevate legs when sitting or resting, and dorsiflex feet when sitting or standing for any length of time; medical management if edema persists in AM, is pitting, involves the face, or MARY LOURDES NACEL G. CELESTE, RN, MD associated with elevated BP, proteinuria, persistent headaches

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Varicosities of extremities or vulva related to uterine compression of venous return, increased vein wall distensibility from progesteroneinitiated relaxation, or inherited tendency; suggest elevating legs frequently, avoid sitting with legs crossed, standing/sitting for long periods of time, or wearing constrictive clothing; support/elastic stockings may be helpful. MARY LOURDES NACEL G. CELESTE, RN, MD

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DISCOMFORTS OF PREGNANCY Assessment Nursing Considerations May occur any time of day Nausea and vomiting (morning Eat dry crackers on arising sickness) Eat small, frequent meals Bulk foods, fiber Constipation, hemorrhoids Generous fluid intake Increase calcium intake Leg cramps Flex feet, local heat Well-fitting bra Breast soreness Bra may be worn at night Emphasize posture Careful lifting Backache Good shoes Small, frequent meals Antacids – avoid those containing phosphorous Heartburn Decrease amount of fatty and salty foods Dizziness Vertigo, light-headedness Urinary frequency

Slow, deliberate movements Support stockings Vena cava or supine hypotensive syndrome Turn on left side Kegel exercises Decrease fluids before bed Report signs of infection MARY LOURDES NACEL G. CELESTE, RN, MD

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*Fetal heart rate (FHR) *Fetal movements (FM) *Leopold’s Maneuver Health Teachings Schedule of clinic visits Exercises Dental hygiene Clothing Traveling Bathing Employment Sexual relation Immunization MARY LOURDES NACEL G. CELESTE, RN, MD

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Tetanus toxoid     

T1 – anytime during pregnancy T2 – one month after T1 (3) T3 – six months after T2 (5) T4 - one year after T3 (10) T5 – One year after T4 (lifetime)

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DANGER SIGNS OF PREGNANCY SIGN

POSSIBLE CAUSE

Swelling of face. fingers; legs Headache, continuous and severe

Hypertension of pregnancy, thrombophlebitis (for leg swelling) Hypertension of pregnancy

Blurring of vision

Hypertension of pregnancy

Abdominal/ chest pain

Ectopic pregnancy, uterine rupture, pulmonary embolism

Vaginal bleeding

Placental problems (previa, abruption, premature separation)

Vomiting, persistent

Infection (also with fever and chills), hyperemesis Gravidarum

Visual changes

Hypertension of pregnancy

Escape of vaginal fluids

Premature rupture of membrane

Others: change or decrease in movements; dysuria fetal MARY LOURDES NACEL G. CELESTE, RN, MD

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Danger Signs of Pregnancy 

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Abdominal or chest pain Pregnancyinduced hypertension Increase or decrease in fetal movement

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Vaginal bleeding Persistent vomiting Chills and fever Ruptured membranes

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Teratogens Any factor that adversely affects fertilized ovum, embryo or fetus

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Teratogenic Fetal Exposure      

Maternal infections Toxoplasmosis Rubella Cytomegalovirus Herpes simplex virus Syphilis

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Teratogenic Fetal Exposure      

Lyme disease Infections Vaccines Drugs Alcohol Cigarettes

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Teratogenic Fetal Exposure     

Environmental Metal and chemical Radiation Hyperthermia and hypothermia Maternal stress

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Preparing for Labor

Lightening  Show  Rupture of membranes  Excess energy  Uterine contractions 

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Promoting Nutritional Health During Pregnancy Mary Lourdes Nacel G. Celeste, R.N., M.D.

THE FOOD PYRAMID MARY LOURDES NACEL G. CELESTE, RN, MD

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Maternal Diet and Infant Health Recommended weight gain  Components of healthy nutrition Calorie needs Protein needs Fat needs Vitamin needs 

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Total desirable weight gain in pregnancy (for average woman) •about 23-28 lb (11-13 kg) •3-4 lb (1.36-1.81 kg) during the first trimester, followed by an average of slightly less than one pound per week for the rest of the pregnancy 1st trimester: 3-4 lbs 2nd trimester: 12-14 lbs 3rd trimester: 8-12 lbs

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Maternal Diet and Infant Health  Components

nutrition

of healthy

Mineral needs  Calcium  Iodine

and phosphorus

 Iron

 Fluoride  Sodium  Zinc

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Maternal Diet and Infant Health  Components

of healthy nutrition

Fluid needs Fiber needs Foods to avoid  Alcohol

 Caffeine  Artificial

sweeteners  Weight loss diets MARY LOURDES NACEL G. CELESTE, RN, MD

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Nutritional status 1. Weight gain should be within expected parameters 2. increased nutrient requirements a. Calories – 300 kcal/d; may need adjustment for prepregnant under/overweight b. There should be no attempt at weight reduction during pregnancy c. Carbohydrates – needed to prevent unsuitable use of fats/proteins for added energy needs; important to avoid “empty” calorie sources d. Proteins to 60 g/d; additional increase for adolescent/multiple pregnancies; efficient use of requires complete protein (contains all essential amino acids; animal sources) or complemented with other protein sources, e.g., legumes, grains, nuts MARY LOURDES NACEL G. CELESTE, RN, MD

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e. Iron – to a total of 30 mg/d of elemental iron; usually requires supplement f. Calcium to 1,200/d; best obtained from dairy products; if milk is disliked or poorly tolerated, calcium supplement may be necessary g.Sodium – should not be restricted without serious indication; excess should be discouraged 3. 24-h recall/diet diaries may be used to evaluate high-risk woman

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Assessment: Nutritional Health

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Assessment: Nutritional Health

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Preparation for Childbirth and Parenting Mary Lourdes Nacel G.

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Childbirth Education  Childbirth

educators and teaching methods  Childbirth education classes  Cultural and socioeconomic factors MARY LOURDES NACEL G. CELESTE, RN, MD

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Childbirth Education  Expectant

parent classes

Sibling education classes

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Childbirth Education  Preparation

Perineal and abdominal exercises  Tailor

sitting  Squatting  Kegel exercises  Abdominal muscle contractions  Pelvic rocking MARY LOURDES NACEL G. CELESTE, RN, MD

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CHILDBIRTH PREPARATION CLASSES Bradley Dick-Read

Lamaze Method Leboyer Method

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CHILDBIRTH PREPARATION CLASSES 1. Bradley (Partner-Coached) Method 

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stresses the important role of the husband during pregnancy, labor and early newborn period woman uses muscle toning exercises limits or omits food that contain preservatives, animal fat and high salt content abdominal breathing exercise woman is encouraged to walk during labor use of dissociation technique MARY LOURDES NACEL G. CELESTE, RN, MD

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2. Dick-Read Method  

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tension (psychic and muscular) is aroused by fear and anticipation of pain sympathetic stimulation brought about by fears causes contraction of the circular muscle of the cervix prenatal courses and training reduce fear, educate and boost self-confidence Covers: fetal development and childbirth; pain relief methods; muscle strengthening exercises; breathing techniques; physical and emotional health for children; mother gets emphatic understanding from partner, nurse, physician fear >>> tension >>> pain abdominal breathing contraction MARY LOURDES NACEL G. CELESTE, RN, MD

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3. Lamaze Method (Psychoprophylactic method) 

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based on stimulus – response conditioning (Pavlov Theory of Classical Conditioning) where unfavorable responses are replaced by favorable conditioned responses high level of activity can excite higher brain centers to inhibit other stimuli as pain woman is taught to replace responses of anxiety, fear and loss of control with more useful activity

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Conscious relaxation Cleansing breath Conscious controlled breathing Effleurage Focusing Second-stage breathing MARY LOURDES NACEL G. CELESTE, RN, MD

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Covers: practice of breathing techniques during labor; controlled perception; relaxation of involved muscles; mouthing silently words or songs with rhythmical tapping of fingers; supportive person nearby in a calm environment Use 3 Gate Control Method of pain relief  education and relaxation  use of imagery and focusing (breathing patterns)  conditioned reflex MARY LOURDES NACEL G. CELESTE, RN, MD

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4. Leboyer Method 

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The contrast of intrauterine environment and the external world causes infant to suffer psychological shock at the time of delivery Gentle controlled delivery Covers: Relaxing the craniosacral axis by supporting the head, neck and sacrum Restoring body heat loss by warm bath Allowing infant to breathe spontaneously Delaving cutting of cord to permit placental blood flow Bonding mother and infant by skin to skin contact MARY LOURDES NACEL G. CELESTE, RN, MD

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Conscious Relaxation – learning to relax muscles deliberately Cleansing Breath – woman breathes in deeply and exhales deeply Consciously Controlled Breathing (Set breathing Patterns) Level 1 – full respiration, 6 – 12cpm, early contraction Level 2 – lighter, 40cpm, 4-6cm dilated Level 3 – more shallow, 50 - 70cpm, transition contraction Level 4 – pant blow pattern, 3-4 quick breaths then forceful expiration Level 5 – continuous chest panting (60cpm), strong contraction and 2nd stageMARY LOURDES NACEL G. CELESTE, RN, MD of labor 48

Leboyer method Birthing room is darkened Soft music Infant placed immediately into a warm-water bath  Hydrotherapy and water birth 

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The Birth Setting  Appropriate

setting  Birth attendant and support person  Hospital births Postpartal birth MARY LOURDES NACEL G. CELESTE, RN, MD

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The Birth Setting  Alternative

birthing centers

 Home

birth  Children attending the birth

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MARY LOURDES NACEL G. CELESTE, RN, MD

Mary Lourdes Nacel G.

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Caring for a Woman During Vaginal Birth

Mary Lourdes Nacel G. Celeste, R.N., M.D.

LABOR AND DELIVERY 

Labor is a process is a process whereby with time regular uterine contractions brings about progressive effacement and dilatation of the cervix, resulting in the delivery of the fetus and expulsion of the placenta.

Critical factors affecting the process of labor:  Passage  Passenger  Power MARY LOURDES NACEL G. CELESTE, RN, MD

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THEORIES OF LABOR ONSET 1. Uterine Stretch Theory – Any hollow muscular organ when stretched to the capacity will contract and empty 2. Oxytocin Theory – Increased production of oxytocin by the anterior pituitary increases as pregnancy nears term while production of oxytinase by the placenta decreases MARY LOURDES NACEL G. CELESTE, RN, MD

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3. Progesterone Deprivation Theory – as pregnancy nears term, progesterone level drops, hence uterine contraction occurs 4. Prostaglandin Theory – when pregnancy reaches term, the fetal membranes produces high levels of arachidonic acid 5. Theory of the aging Placenta – as the placenta ages it becomes less efficient MARY LOURDES NACEL G. CELESTE, RN, MD

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Components of Labor  Passage

 Passenger  Power

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I. Passage (maternal) – size and type of pelvis, ability of the cervix to efface and dilate, and distensibility of vagina and introitus 

Pelvis – the bony ring through which the fetus passes during labor and delivery; consists of four united bones (two hip or innominate bones, the sacrum, and the coccyx) between the trunk and thighs

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Measurements – may be obtained by internal and external pelvic examination (using pelvimeter), x-ray pelvimetry (used rarely in pregnancy and late in third trimester or 61 MARY only LOURDES NACEL G. CELESTE, RN, MD in labor), and ultrasound

Pelvic types:   

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a. Gynecoid – classic female pelvis inlet, well rounded (oval); ideal for delivery - most ideal for childbirth (50% of women) b. Android – resembling a male pelvis, narrow and heart-shaped; usually requires cesarean section or difficult forceps delivery (20% of women) c. Platypelloid – flat, broad pelvis; usually not adequate for vaginal delivery (5% of women) d. Anthropoid – similar to pelvis of anthropoid ape; long, deep, and narrow; MARY LOURDES G. CELESTE,delivery RN, MD usually adequate for NACEL vaginal (25% of 62 women)

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II. Passenger (fetal)      

Size – primarily related to fetal skull Fetopelvic relationships Lie – relationship of spine of fetus of spine of mother; longitudinal (parallel) transverse (right angles) oblique (slight angle off a true transverse lie) MARY LOURDES NACEL G. CELESTE, RN, MD

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Presentation part of fetus that presents to (enters) maternal pelvic inlet

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Cephalic/vertex – head presentation (>95% of labors)

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Breech presentation 

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Complete – flexion of hips and knees Frank (most common) – flexion of hips and extension of knees Footling/incomplete – extension of hips and knees

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Attitude/ habitus 

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relationship of fetal parts to each other; usually flexion of head and extremities on chest and abdomen to accommodate to shape of uterine cavity Vertex – head is maximally flexed Military – head is partially flexed Brow – head is maximally extended Face – head is partially extended MARY LOURDES NACEL G. CELESTE, RN, MD

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Position 

relationship of fetal reference point to mother’s pelvis

Fetal reference point  Vertex presentation – dependent upon degree of flexion of fetal head on chest; full flexion–occiput (O); full extension–chin (M); moderate extension–brow (B)  Breech presentation – sacrum (S)  Shoulder presentation – scapula (SC)

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Position Relation of the presenting part to a specific quadrant of a woman’s pelvis  Right anterior  Left anterior  Right posterior  Left posterior

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Maternal pelvis is designated per her right/left and anterior/posterior – Expressed as standard three letter abbreviation; e.g., LOA = left occiput anterior, indicating vertex presentation with fetal occiput on mother’s left side toward the front of her pelvis

– Fetal position reflects the orientation of the fetal head or butt within the birth canal. MARY LOURDES NACEL G. CELESTE, RN, MD

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Anterior Fontanel The bones of the fetal scalp are soft and meet at "suture lines." Over the forehead, where the bones meet, is a gap, called the "anterior fontanel," or "soft spot." This will close as the baby grows during the 1st year of life, but at birth, it is open. The anterior fontanel is an obstetrical landmark because of its' distinctive diamond shape. Feeling this fontanel on pelvic exam tells you that the forehead is just beneath your fingers. Early in labor, it is usually difficult (if not impossible) to feel the anterior fontanel. After the patient is nearly completely dilated, it becomes easier to feel the fontanel. When attaching a fetal scalp electrode, it is better to not attach it to the area of the MARY LOURDES NACEL G. CELESTE, RN, MD 75 fontanel.

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Posterior Fontanel The occiput of the baby has a similar obstetric landmark, the "posterior fontanel." This  junction of suture lines in a Y shape that is very different from the anterior fontanel. In cases of fetal scalp swelling or significant molding, these landmarks may become obscured, but in most cases, they can identify the fetal head position as it is engaged in the birth canal. MARY LOURDES NACEL G. CELESTE, RN, MD

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Left occiput anterior (LOA)

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Right occiput anterior (ROA)

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Left occiput transverse (LOT)

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Right occiput transverse (ROT)

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Occiput posterior (OP)

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Occiput Anterior (OA)

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Left occiput posterior (LOP)

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Right occiput posterior (ROP)

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FETAL POSITION

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Station 

level of presenting part of fetus in relation to imaginary line between ischial spines (zero station) in midpelvis of mother –

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–5 to –1 indicates a presenting part above zero station (floating); +1 to +5, a presenting part below zero station Engagement – when the presenting part is at station zero MARY LOURDES NACEL G. CELESTE, RN, MD

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STATION or DEGREE OF ENGAGEMENT

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III. Power – force expelling the fetus and placenta 1. Primary – involuntary uterine contractions  Three phases  Increment – steep crescent slope from beginning of a contraction until its peak  Acme/peak – strongest intensity  Decrement – diminishing intensity MARY LOURDES NACEL G. CELESTE, RN, MD

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Characteristics of contractions  1. Frequency – time frame in minutes from

1. Frequency – time frame in minutes from the beginning of one contraction to the beginning of the next one; frequency of less than every 2 min should be reported

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2. Duration – time frame in seconds from the beginning of a contraction to its completion; more than 90 s should be reported because of potential risk of uterine rupture or fetal distress

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3.Intensity – the strength of a contraction at acme; may be assessed by subjective description from the woman, palpation (mild contraction would feel like the tip of the nose, moderate like the chin, strong like the forehead), or electronic intrauterine pressure catheter (IUPC) MARY LOURDES NACEL G. CELESTE, RN, MD 91

2. Secondary – voluntary bearing-down efforts 

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Psychological state of the woman – fear and anxiety may lead to increased perception of pain and impede progress of labor; preparation and support for childbirth may enhance coping efforts Preparation for childbirth education about the birthing process and methods to decrease discomfort and tension Relaxation of voluntary muscles Distraction, focal point, imagery Breathing techniques with each contraction MARY LOURDES NACEL G. CELESTE, RN, MD

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a.Always begin and end with “cleansing” or “relaxing” breath (inhale deeply through nose and exhale passively through relaxed, pursed lips) b.Hyperventilation – may cause maternal respiratory alkalosis and compromise fetal oxygenation; characterized by lightheadedness, dizziness, tingling of fingers and/or circum-oral numbness; managed by having woman breathe into her cupped hands or a paper bag Support person/”coach” should be involved in the formal preparation MARY LOURDES NACEL G. CELESTE, RN, MD

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Position (maternal) Side-lying enhances blood flow to the utero-feto-placental unit and maternal kidneys Upright (standing, walking, squatting) enlists gravity to aid in fetal descent through the birth canal Frequent changes relieve fatigue and improve circulation MARY LOURDES NACEL G. CELESTE, RN, MD

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Cardinal mechanisms/ movements of labor in vertex presentation

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usually flow smoothly and often overlap; failure to accomplish one or more usually requires obstetrical intervention

(ED FIrE ErE) MARY LOURDES NACEL G. CELESTE, RN, MD

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Cardinal mechanisms/ movements of labor in vertex presentation       

Engagement Descent Flexion Internal rotation Extension Restitution and external rotation Expulsion MARY LOURDES NACEL G. CELESTE, RN, MD

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Engagement - movement of the presenting part below the plane of the pelvic inlet Descent – progress through the maternal pelvis; continuous throughout labor Flexion – as a result of resistance from maternal pelvis and musculature, the head flexes so that a smaller diameter enters pelvis Internal rotation – head rotates from occiput transverse or oblique position (usual position as it enters the pelvis) to anterior/posterior at pelvic outlet; head is under symphysis pubis and neck is twisted MARY LOURDES NACEL G. CELESTE, RN, MD

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Extension – the head is moved backward as it proceeds under the symphysis pubis and baby is born by extension over the perineum Restitution and external rotation – movement of head to align itself with face and shoulders (restitution) and then rotation bringing shoulders into anteroposterior diameter appears as one movement Expulsion – first the anterior shoulder under the symphysis pubis, then the posterior shoulder over the perineum, followed rapidly by the rest of the body; time of birth is recorded at this time MARY LOURDES NACEL G. CELESTE, RN, MD

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MECHANISM OF LABOR & CARDINAL MOVEMENTS OF A FETUS

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Signs of Labor  Preliminary

signs of labor

Lightening Increase in level of activity Braxton Hicks contractions Ripening of the cervix

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Signs of Labor  Signs

of true labor

Uterine contractions Show Rupture of membranes

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Signs and symptoms of labor:        

1. Impending – may begin several weeks prior to labor Lightening “the baby dropped” settling of uterus and fetal presenting part into pelvis sensation of decreased abdominal distention Increase Braxton-Hicks contractions mild, intermittent, irregular, abdominal contractions  decrease/disappear with activity MARY LOURDES NACEL G. CELESTE, RN, MD

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May be heightened anxiety, and anticipation, fatigue Weight loss of about 2-3 lb 3-4 d before onset of labor; related to changes in estrogen and progesterone levels Increased vaginal mucus discharge Fetal movements may appear less active May be episodes of false labor MARY LOURDES NACEL G. CELESTE, RN, MD

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2. Onset     

Expulsion of mucous plug; pink/brown-tinged discharge (bloody show) Regular contraction increasing in frequency, duration, and intensity Spontaneous rupture of membranes (SROM) may occur before or during Check FHR by auscultation for 1 min and with next contraction May be a gush or trickle; report strong/foul odor (infection), meconium-stained (in vertex presentation, may indicate fetal anoxia) or winecolored (indicative of premature separation of MARY LOURDES NACEL G. CELESTE, RN, MD 104 placenta)

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Questionable leakage of amniotic fluids should be tested for alkalinity to differentiate from urine: –

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Nitrazine tape turns blue/gray/green (alkaline); urine (acidic) does not change the yellow color A mixture of cervical mucus and amniotic fluid dried on a slide looks like crystallized ferns by microscopic examination MARY LOURDES NACEL G. CELESTE, RN, MD

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Cervical changes 

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Effacement – thinning and shortening of the cervix during late pregnancy and/or labor; measured in percentages (100% is fully effaced) Dilation – opening and enlargement of the cervical canal; measured in centimeters 0-10 cm (10 cm is fully dilated) MARY LOURDES NACEL G. CELESTE, RN, MD

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EFFACEMENT AND DILATION OF CERVIX

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TRUE VERSUS FALSE LABOR True False Contractions – Contractions – regular with irregular with increasing usually no change frequency in frequency, (shortened duration, or intervals), intensity duration, and intensity Discomfort Discomfort is radiates from usually back around the abdominal abdomen Contractions do Contractions may not decrease lessen with with rest activity or rest Cervix Cervical changes progressively do not occur effaced and MARY LOURDES NACEL G. CELESTE, RN, MD

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DIVISIONS OF LABOR/ FRIEDMAN’S CURVE

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Stages of Labor  First

stage

Latent phase Active phase Transition phase

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Stages of Labor Second stage Period from full dilatation and cervical effacement to birth of the infant  Third stage Placental separation Placental expulsion 

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Friedman’s Division of Labor     

 

Stages of Labor: First stage (dilating/ Cervical stage) – from onset of regular contraction to full cervical dilation AVE: 13-18 h for nulliparas 8-9 h for multiparas A. Latent phase (0-4 cm) – the cervix begins effacing and dilating and contractions become increasingly stronger and more frequent DURATION: nulliparas 7-10 h multiparas 5-6 h MARY LOURDES NACEL G. CELESTE, RN, MD

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B. Active phase (5-7 cm) – more rapid dilation of cervix and descent of presenting part  DURATION: approximately 3-4 h for both C. Transition (8-10 cm) – contractions may be every 1.5 to 2 min and last 60-90sec  DURATION: should not > 3 h for nulliparas  1 h for multiparas MARY LOURDES NACEL G. CELESTE, RN, MD

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



May be accompanied by irritability and restlessness, hyperventilation, and dark heavy show, as well as leg cramps, nausea/vomiting, hiccups, belching Possible rectal pressure creating a desire to push; should discourage before full dilation because it may cause maternal exhaustion and cervical and fetal trauma MARY LOURDES NACEL G. CELESTE, RN, MD

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 



* Monitor vital signs and FHR *Provide comfort measures (ambulate if tolerated and if BOW is not ruptured yet; side lying is usually most comfortable, sacral pressures, back rubs) *Breathing technique during transition phase: Take a deep breath and exhale slowly and completely. At beginning of contraction, take a fairly deep breath. Then engage in shallow breathing. If there is an urge to push, puff out every 3rd, 4th, or 5th breath. Take deep breath at the end of contraction. MARY LOURDES NACEL G. CELESTE, RN, MD

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

  

2. Second stage (stage of expulsion) – from complete dilation of cervix to delivery of the baby AVE: 2 h for nulliparas 20 min for multiparas Contractions are now severe, lasting 60-90sec at 1.5 to 3 min intervals MARY LOURDES NACEL G. CELESTE, RN, MD

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

 



Bearing down/pushing increases intraabdominal pressure from voluntary contraction of maternal abdominal muscles and pushes the presenting part against the pelvic floor, causing a stretching, burning sensation and bulging of the perineum; “crowning” occurs when the presenting part appears at the vaginal orifice, distending the vulva Timing of transfer to delivery room Nulliparas – during second stage when the presenting part begins to distend the perineum Multiparas – at the end of first stage when the cervix is dilated 8-9 cm MARY LOURDES NACEL G. CELESTE, RN, MD

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

 



Third stage (placental stage) – from delivery of the baby to delivery of the placenta; if more than 30 min, placenta is considered retained AVE: < 30mins Separation of placenta from the uterine wall evidenced by a change in the fundus from discoid to globular shape as it becomes firm and rises in the abdomen, a sudden gush/trickle of blood and lengthening of the umbilical cord Expulsion of the placenta through the vagina by uterine contractions and pushing by mother or by gentle traction on the umbilical cord MARY LOURDES NACEL G. CELESTE, RN, MD

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Placental delivery make take 5-10 minutes (maximum 30 minutes) Either by  Duncan – margin of the placenta separates first and the dull, red, rough maternal surface emerges from from the vagina first (dirty presentation)  Schultze – center portion of the placenta separates first and the shiny and glistening fetal surface emerges from the vagina MARY LOURDES NACEL G. CELESTE, RN, MD

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

*Crede’s maneuver – gentle pressure on the contracted uterine fundus (never on a noncontracted uterus; uterus may evert and lead to hemorrhage)



Contraction of the uterus following delivery controls uterine hemorrhage and produces placental separation: if necessary, Pitocin (oxytocin) or Methergine (methylergonovine maleate) may be administered to help contract the uterus MARY LOURDES NACEL G. CELESTE, RN, MD

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Fourth stage – immediate recovery period from delivery of placenta to stabilization of maternal systemic responses and contraction of the uterus DURATION: from 1 to 4 h





– –

Mother begins to readjust to nonpregnant state Areas of concern include discomfort due to contraction of uterus 9after pain) and/or episiotomy, fatigue or exhaustion, hunger, thirst, excessive bleeding, bladder distention, parent-infant interaction MARY LOURDES NACEL G. CELESTE, RN, MD

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STAGES OF LABOR STAGE PHASE Dilatation Duration/Interval Intensity First Stage

Second Stage

3rd Stage 4th Stage

Phase10-4 cm 10-30 sec/ 5-30 Mild to Latent min moderate Phase 2- 5-7 cm 30-40 sec/ 3-5 Moderate Active min to strong Phase 3- 8-10 cm 45-90sec/ 2-3 min strong Transition From full cervical dilatation (10 cm) up to the expulsion of the fetus -in the later phase of this stage, station becomes (+); +4 to birth -contraction becomes 1-2 minutes apart; fetal head visible; increased urgency to bear down Placental Delivery- sudden gush of blood, lengthening of the cord, rising of the fundus, globular uterus First 4 hours after delivery of the placenta (monitor VS, fundus and lochia until stable) MARY LOURDES NACEL G. CELESTE, RN, MD

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Maternal and Fetal Responses to Labor  Danger

fetal

signs of labor -

 Heart

rate  Meconium staining  Hyperactivity  Fetal

acidosis MARY LOURDES NACEL G. CELESTE, RN, MD

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Maternal and Fetal Responses  Danger

signs of labor maternal  Blood

pressure  Abnormal pulse  Inadequate or prolonged contractions  Pathologic retraction ring  Abnormal lower abdominal contour  Apprehension MARY LOURDES NACEL G. CELESTE, RN, MD

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Maternal and Fetal Assessment  Assessment

of stage one

History Physical exam Leopold’s maneuvers Rupture of membranes Vaginal exam Pelvic adequacy MARY LOURDES NACEL G. CELESTE, RN, MD

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Assessment  Laboratory

Blood Urine

 Uterine

analysis

contractions

Length Intensity Frequency

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LOCATING FETAL HEART SOUNDS BY FETAL POSITION

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Electronic Monitoring External and Internal Monitoring 

Telemetry FHR and uterine contractions FHR patterns Baseline FHR Periodic changes

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Assessment Techniques  Scalp

stimulation  Fetal blood sampling  Acoustic stimulation

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Fetal Heart Monitoring 





Labor is stressful for the fetus; therefore, continual assessment of fetal well- being through fetal heart rate monitoring is essential. Fetal well-being is determined by the response of the fetal heart rate to uterine contractions. Fetal anoxia resulting from stressful labor must be avoided to prevent intrauterine death or neurological damage. MARY LOURDES NACEL G. CELESTE, RN, MD

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NORMAL FHR: 120 – 160 bpm 

Fetal monitoring during labor and delivery



Methods 1. Periodic auscultation of the fetal heart by fetoscope (stethoscope adapted to amplify sound or Doptone (ultrasound stethoscope) during contractions and for 30sec beyond; best heard over fetal back Electronic fetal monitoring (EFM) – continuous monitoring providing audio and visual recordings as well as tracing strips External – indirect, noninvasive method using a lubricated (water-soluble gel) ultrasound transducer attached to the abdomen Internal – small electrode attached to the fetal scalp; indicated for high-risk maternity patient, problematic labor, or with oxytocin use; requires ROM, cervical dilation of at least 2 cm, and presenting part can be reached









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a.

Alterations in fetal heart rate



a. Normal – 120-160 BPM b. Tachycardia (>160 BPM) – associated with prematurity, maternal fever, fetal activity, or fetal hypoxia/infection, drugs; if continued for an hour or more, or accompanied by late deceleration, indicates fetal distress c. Bradycardia (<120 BPM) – associated with fetal hypoxia, maternal drugs/hypotension, prolonged cord compression, congenital heart lesions; persistent bradycardia or persistent drop of 20 beats per min below baseline mayMARY indicate or 133 LOURDES NACELcord G. CELESTE,compression RN, MD separation of the placenta





Variability – beat-to-beat fluctuations; measured by internal EFM only  

 

a. Normal (6-25 BPM) – significant indicator of fetal well-being b. Absent (0-2 BPM) or decreased (3-5 BPM) may be associated with fetal sleep state, fetal prematurity, reaction to drugs, congenital anomalies, hypoxia, acidosis; if persists for more than 30 min is indicator of fetal distress c. Increased (>25 BPM) – significance is not known d. Loss of the baseline (beat-to-beat variation) or “smoothing out” of the baseline is often prelude to infant death 134 MARY LOURDES NACEL G. CELESTE, RN, MD

Periodic changes 

 





1.Accelerations – rise above baseline followed by a return; usually in response to fetal movement or contractions 2.Decelerations – fall below baseline followed by a return Early – occurs before peak contraction; most often uniform mirror image of contraction on tracing; associated with head compression, commonly in second stage with pushing Late – onset after the peak with slow return to baseline; indicative of fetal hypoxia because of deficient placental perfusion Variable deceleration – transient U/V/M-shaped reduction occurring at any time before, during, or after contraction; indicative of cord compression, which may be relieved by change in mother’s position; ominous if repetitive, severe, or MARY LOURDES NACEL G. CELESTE,prolonged, RN, MD 135 has slow return to baseline



– –

Nursing interventions

None for early decelerations For late decelerations (at the first sign of abnormal tracing) – position mother left side-lying (if no change, move to other side, Trendelenburg or knee/chest position); administer oxygen by mask, start IV or increase flow rate, stop oxytocin if appropriate; if the pattern persists, fetal scalp blood sampling for acidosis (pH >7.25 is normal, 7.20-7.24 is considered preacidotic – repeat in 1015 min; 7.2 or less indicates serious acidosis; prepare for cesarean section) MARY LOURDES NACEL G. CELESTE, RN, MD 136

Fetal Heart Rate Patterns

Indicative of…

Intervention

Tachycardia (>160 bpm)

Maternal

Depends on the cause

Bradycardia (<120 bpm)

or fetal infection Fetal hypoxia (ominous sign) Fetal hypoxia or stress

Early deceleration (deceleration begins and ends with uterine contraction) Late deceleration (HR decreases after peak of contraction and recovers after contraction ends)

Head

client on her left side Increase fluids to counteract hypotension Stop oxytocin (Pitocin) if in use None required

Fetal

Change

Variable deceleration (transient decrease in HR anytime during contraction

Cord

Decreased variability

Fetal

Maternal

hypotension after epidural initiation compression :not ominous Vagal stimulation stress and hypoxia Deficient placental perfusion Supine position Maternal hypotension Uterine hyperstimulation compression Hypoxia or hypercarbia sleep cycle Depressant drugs Hypoxia CNS anomalies

Place

maternal position Correct hypotention Increase IV fluid rate as ordered Discontinue oxytocin Administer oxygen as ordered Change maternal position Administer

Oxygen

Depends on the cause

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Nursing Care: First Stage  Respect

contraction time  Change positions  Voiding and bladder care  Support  Pain management MARY LOURDES NACEL G. CELESTE, RN, MD

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Nursing Care: Second Stage  Preparing

for birth  Positioning for birth  Pushing  Perineal cleaning  Episiotomy  Birth  Cutting and clamping the cord MARY LOURDES NACEL G. CELESTE, RN, MD

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Perineal cleaning

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EPISIOTOMY

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RITGEN’S MANEUVER

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A child is considered born when the whole body is delivered.

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UMBILICAL CORD CLAMP APPLIED TO CORD

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Providing Comfort During Labor and Birth Mary Lourdes Nacel G. Celeste, R.N., M.D.

Intapartal nursing management  

Stage 1 Maternal 



Monitor vital signs, fluid and electrolyte balance, frequency, duration, and intensity of uterine contractions and degree of discomfort (hourly, at minimum); urine protein and glucose with every voiding; laboratory results; preparedness; ROM Provide comfort measures – e.g., positioning, back massage/effleurage (light abdominal stroking in rhythm with breathing during a contraction to ease mild/moderate discomfort), warm/cold compresses, ice chips MARY LOURDES NACEL G. CELESTE, RN, MD

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Support coping measures – reassure, explain procedures, reinforce/teach breathing techniques, relaxation, focal point 2. Assist support person Fetal – monitor status 1.



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 

Stage 2 Maternal

– Monitor physical status; assess progress of labor, perineal and rectal bulging, increased vaginal show – Assist in techniques to foster expulsion – encourage bearing down focus on vaginal orifice (discourage breath holding for more than 5sec), position squatting, side-lying, Fowler’s as appropriate – Provide comfort measures; support coping measures; assist support person MARY LOURDES NACEL G. CELESTE, RN, MD

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  

Fetus/neonate Monitor fetal heart rate and regularity Provide immediate neonatal care

– Assist M.D./nurse/midwife; neonate may be held at above or below level of vagina until cord pulsations cease, then cord is clamped and cut; mucus, is removed by bulb syringe immediately after the head is delivered (mouth before nose to avoid aspiration) – Record time of birth – Hold neonate with head slightly lowered to expedite drainage of amniotic fluid, mucus, and blood – Inspect cord for two arteries and one vein – Dry and wrap neonate to prevent heat loss MARY LOURDES NACEL G. CELESTE, RN, MD

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 

 

Stage 3 Maternal – observe for signs and symptoms of placental separation; assess amount of blood loss; monitor blood pressure, pulse, and fundus frequently Neonate Apgar scores at 1 and 5 min to evaluate condition at birth – Based on five signs: heartbeat, respiratory effort, muscle tone, reflex irritability, color – Each sign rated 0-2 2 is top score); all the scores are added for total score – 7-10 (good condition) should do well in normal neonatal nursery; 4-6 (fair condition) may require close observation; 0-3 (extremely poor condition) resuscitation and intensive care are acquired

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Assessment for Well-Being  Apgar

scoring

Heart rate Respiratory effort Muscle tone Reflex irritability Color MARY LOURDES NACEL G. CELESTE, RN, MD

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APGAR SCORE 0 Cardiac tone Respiration Muscle tone Reflexes Color

Absent Absent Flaccid No response Blue, pale

1 Slow (<100 BPM) Slow, irregular Some flexion Cry Body pink, extremities blue

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2 Normal (>100 BPM) Good cry Active Vigorous cry Completely pink

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

 



Maintain temperature – minimize exposure to environmental heat loss (evaporation, radiation, conduction, convection); skin-to-skin with mother or at 36.4°C skin temperature Weigh and measure infant Place identification band on infant; footprint infant and fingerprint mother Record time of first void and stool (meconium) after delivery; monitor physical status MARY LOURDES NACEL G. CELESTE, RN, MD

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 



Initiate parent-child interaction Instill prophylactic eye drops/ointment – legally required to prevent conjunctival gonococcal infection that could lead to blindness in the neonate; 1% silver nitrate or 0.5% erythromycin Administer intramuscular vitamin K – for first 34 d of life the neonate is unable to synthesize vitamin K, which is necessary for blood clotting and coagulation MARY LOURDES NACEL G. CELESTE, RN, MD

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 

  

Stage 4 Monitor maternal blood pressure and pulse; uterine contractility tone and location; amount and color of lochia, presence of clots; condition of episiotomy every 15 min x 4 Monitor bladder function Provide comfort Evaluate parenteral interaction MARY LOURDES NACEL G. CELESTE, RN, MD

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FOURTH STAGE OF LABOR First 1-2 h Vital signs (BP, pulse) q 15 min q 15 min Fundus q 15 min Lochia (color, volume) Urinary Bonding

Measure first void Encouraged interaction

Nursing Considerations Follow protocol until stable Position – even to 1 cm/finger breadth above the umbilicus for the first 12 h, then descends by one finger breadth each succeeding day, pelvic usually by day 10 Lochia (endometrial sloughing) – day 1-3 rubra (bloody with fleshy odor; may be clots); day 4-9 serosa (pink/brown with fleshy odor); day 10+ alba (yellowwhite); at no time should there be a foul odor (indicates infection) May have urethral edema, urine retention Emphasize touch, eye contact

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Delivery 1. Normal spontaneous vaginal delivery 



The mother is encouraged not to push as the head is delivered; the infant cries (or is encouraged to do so to expand the lungs); if the cord is encircling the neck (nuchal cord), it is gently slipped over the head Episiotomy (a surgical incision of the perineum) may be done at the end of the second stage of labor to facilitate delivery and to avoid laceration of the perineum MARY LOURDES NACEL G. CELESTE, RN, MD

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Types of Episiotomy  Median – rare faulty healing, easier to make and repair  Mediolateral – tearing in the anus and rectum is rare

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









Classification of Perineal Laceration First Degree – involves the perineal mucosa Second Degree – involves the muscle of the perineal body but does not involve the rectal sphincter Third Degree – involves the rectal sphincter but not the rectal mucosa Fourth Degree – involves the rectal mucosa MARY LOURDES NACEL G. CELESTE, RN, MD

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MARY LOURDES NACEL G. CELESTE, RN, MD Mary Lourdes Nacel G. Celeste, R.N., M.D.

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Operatives deliveries 2.Forceps delivery forceps - two doubled-curved, spoonlike articulated blades used to extract the fetal head; indicated if mother cannot push fetus out or compromised maternal/fecal status in late second stage; contraindicated in cephalopelvic disproportion (CPD) 

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

Classification: – Outlet – fetal head is on the pelvic floor – Low – fetal head is below station +2 but not reached the pelvic floor – Mid – fetal head is below station 0 but not reached station +2 – High – fetal head is above station 0

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Indications:  Prolonged second stage (most common)  Non reassuring EFM strip  Avoiding maternal pushing  Breech presentation Complications  Maternal – lacerations  fetal – neonatal – soft tissue compression or cranial injury MARY LOURDES NACEL G. CELESTE, RN, MD

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2. Vacuum extractor – delivery with use of suction device that is applied to the fetal scalp for traction; used in prolonged second stage; contraindicated in CPD and face/breech presentation Indications:  Prolonged second stage (most common)  Non reassuring EFM strip  Avoiding maternal pushing  Breech presentation MARY LOURDES NACEL G. CELESTE, RN, MD

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Complications  Maternal – lacerations  fetal – neonatal – cephalhematoma and scalp laceration, subgluteal hematoma and intracranial hemorrhage (>10min) MARY LOURDES NACEL G. CELESTE, RN, MD

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4. Cesarean delivery

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Comfort and Pain Relief Support from doula or coach  Alternative therapies Relaxation Focusing and imagery Breathing Herbal preparations 

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Comfort and Pain Relief 

Pharmacological Measures Goals Preparation Narcotic analgesics  Intrathecal Regional anesthesia

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Nursing Care: Promoting Comfort  Reducing

anxiety  Coping strategies  Comfort measures  Positioning  Childbirth method  Pharmacologic pain relief MARY LOURDES NACEL G. CELESTE, RN, MD

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Pharmacological control of discomfort 

Principles of use – minimize pain without increasing risk to mother or fetus; type of pain relief is influenced by length of gestation, mother’s emotional status, response to pain, previous history with analgesics or anesthesia, and general character of labor process MARY LOURDES NACEL G. CELESTE, RN, MD

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Analgesia – alleviation of the sensation of pain or the elevation of one’s thresshold for perception of pain 

Narcotic analgesics – effective for relief of severe, persistent pain - with no amnesic effect - adverse effects: nausea and vomiting, maternal respiratory depression, neonatal CNS depression (blocking nerve impulses to the brain) requiring stimulation or resuscitation at delivery - cross the placental barrier and affect the neonate EX: Meperidine HCl (Demerol); Morphine sulfate MARY LOURDES NACEL G. CELESTE, RN, MD

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Anesthesia- includes analgesia, amnesia, and relaxation; abolishes pain perception by CNS depression 

epidural block –most common; local anesthetic such as lidocaine or bupivocaine is injected into the epidural space surrounding the spinal cord; a catheter is placed for continuous epidural anesthesia - - if hypotension occurs, woman should be placed on her left side; IV rate should be accelerated as ordered; oxygen support should be administered if ordered and doctor should be notified MARY LOURDES NACEL G. CELESTE, RN, MD

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Regional Anesthesia  Injection

of local anesthesia to block specific nerve pathways Epidural anesthesia  Nursing

care  Administration

Spinal anesthesia MARY LOURDES NACEL G. CELESTE, RN, MD

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Medication for Pain Relief: Birth  Local

anesthesia

Local infiltration Pudendal nerve block  General

anesthesia

Preparation Aspiration of vomitus MARY LOURDES NACEL G. CELESTE, RN, MD

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   



Timing of administration 1. Before 5 cm (latent phase) – may retard or stop labor From 5 to 7 cm (early active phase) – may aid relaxation After 8 cm (transition phase) – may result in respiratory depression requiring resuscitative measures in sedated neonate - Because most medications cross the placental barrier, FHR is taken frequently before and after administration of medication MARY LOURDES NACEL G. CELESTE, RN, MD

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





Obstetrical analgesia – functions through alleviation of sensation of pain or enhancement of threshold for pain Sedatives/hypnotics – used less frequently than previously because of incidence of side effects Narcotics

– Morphine sulfate – used rarely because of adverse reactions – Meperidine hydrochloride (Demerol) – most commonly used; mother and infant interaction may be limited in immediate postpartum period because infant may still be sluggish and less alert – Alphaprodine (Nisentil) – may be given IV/SC but never IM because of unpredictability by this route MARY LOURDES NACEL G. CELESTE, RN, MD

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– Mixed narcotic agonist-antagonist compounds (Stadol [IM/IV/SC], Talwin [IV/IM] but not SC, which can cause severe tissue damage) – analgesia while decreasing side effects but can still produce respiratory depression, nauseas and vomiting, light-headedness – Narcotic antagonist (Narcan) – counteracts respiratory depressant effects; may be administered to mother IM/IV 5-15 min prior to delivery or to neonate IV via umbilical vein immediately after birth 

Note: Narcotic antagonist given to a woman who is addicted to narcotics may cause immediate withdrawal symptoms. MARY LOURDES NACEL G. CELESTE, RN, MD

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

Analgesic potentiator/ataractic (Phenergan, Largon, Vistaril, Sparine) – tranquilizing effect, decreasing apprehension and anxiety as well as the nausea and vomiting associated with many analgesics; fetal and neonatal problems are rare MARY LOURDES NACEL G. CELESTE, RN, MD

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Anesthetics Inhalation

 

–

–

Nitrous oxide and oxygen – used intermittently with each contraction; patient is able to cooperate in bearing down; increased danger of neonatal depression with continued use after 15-20 min Trilline/Penthine – selfadministered by mother with inhaler (under supervision); may cause maternal and fetal narcotic depression MARY LOURDES NACEL G. CELESTE, RN, MD

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

Regional blocks – allow mother to be awake and participate in process; can increase incidence of maternal hypotension and fetal bradycardia; need for forceps delivery, prolonged labor or uterine atony, necessity for catheterization, and sometimes post spinal headache 1. Lumbar epidural block –affects the entire pelvis by blocking impulses at level of T12 through S5; may be administered continuously through tubing left in place; incidence of maternal hypotension may be minimized if 500-1000 ml of IV fluids is infused at a rapid rate prior to administration and mother is maintained in side-lying position 

There must be vigilant monitoring of maternal BP and FHR every 1-2 min x 15 min and every 10-15 min thereafter MARY LOURDES NACEL G. CELESTE, RN, MD

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

Treatment of maternal hypotension includes – Mild/Moderate – place mother in left lateral position, increase the rate of IV fluid; administer oxygen by mask – Severe/prolonged – place mother in Trendelenburg position for 2-3 min 2. Caudal – administered during second stage just before delivery; not commonly used 3. Subarachnoid block/ “saddle block” (nerves from S1 to S4) – anesthetizes perineum, lower pelvis, and upper thighs; diminishes pushing efforts; high incidence of maternal hypotension and potential for fetal hypoxia

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3. Spinal block – now used primarily just prior to cesarean delivery 4. Paracervical block analgesics – injection of an anesthetic solution into region around cervical area to relieve pain caused by cervical dilation; thought to have a depressing effect on infant’s respiratory center 5. Intravenous anesthesia (Pentothal) – rarely used, can cause fetal depression, maternal laryngospasm, vomiting and aspiration, postpartal uterine atony MARY LOURDES NACEL G. CELESTE, RN, MD

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COMMON ANALGESICS AND ANESTHETICS OF LABOR AND DELIVERY Medication Side Effects Nursing Considerations Meperidine hydrochloride Hypotension Increases pain tolerance (Demerol) Respiratory depression Do not administer within 2 h of Gastric irritability expected delivery Constipation Bradycardia Constricted pupils Secobarbitol sodium (Seconal) Drowsiness Sedates Lethargy Anxiety relief Respiratory depression Angioedema Naloxone hydrochloride Tachycardia IV into umbilicus vein for neonates (Narcan) Hypertension (0.01 mg/kg) Tremors Reverses narcotic depression Thiopental sodium (Sodium Respiratory depression Induction anesthesia for cesarean pentothal) secretion Tetraccaine hydrochloride Confusion If subarachnoid space used, keep (Pontocaine; lidocaine) Tremors patient flat for 6-8 h Restlessness Regional nerve block Hypotension Relieves uterine or perineal pain Dysrhythmias Tinnitus Blurred vision

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Cesarean Birth

Mary Lourdes Nacel G. Celeste, R.N., M.D.

Nursing Care: Anticipating a Cesarean Immediate preoperative care 

 Informed consent  Hygiene  GI tract preparation  Baseline intake and output  Hydration  Preoperative medication  Checklist  Transport  Role of support person MARY LOURDES NACEL G. CELESTE, RN, MD

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Nursing Care: Cesarean Birth  Intraoperative

care

Anesthesia Skin preparation Surgical incision  Types

of incisions

Birth MARY LOURDES NACEL G. CELESTE, RN, MD

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Nursing Care: Cesarean Birth  Postpartal

care

Pain control Fluid volume Output Circulation Parenting Infection

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Cesarean Birth 

Birth accomplished through an abdominal incision into the uterus 1970  5.5% of births Currently  26% of births

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Cesarean section – fetus is delivered through an incision in anterior abdominal and uterine wall

Indications:  Cephalopelvic disproportion  Fetal malpresentation  non reassuring EFM strip MARY LOURDES NACEL G. CELESTE, RN, MD

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Complications: hemorrhage  Infection  Visceral injury  Thrombosis 

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Uterine Incisions 2. Low segment Transverse - incision is made in the non contractile portion of the uterus - low chance of uterine rupture, may have trial of labor - fetus must be in longitudinal lie 2. Classical - incision is made in the contractile portion of the uterus - risk uterine rupture - lower segment varicosities and myomas can be bypassed MARY LOURDES NACEL G. CELESTE, RN, MD

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Anesthesia in C/S Most popular:  Regional block  Epidural  Spinal anesthesia • Because the mother is awake and aware of the birth of her infant • When time is of the essence or when an epidural or spinal cannot be used, general anesthetic is used. MARY LOURDES NACEL G. CELESTE, RN, MD

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Scheduled or Unscheduled C/S Scheduled Cesarean Birth - If it is to be a repeat cesarean birth (eg, cephalopelvic disproportion) - If labor is contraindicated (eg, complete placenta previa, hydrocephaly) - If labor cannot be induced and birth is necessary Clients have some time to prepare for the cesarean birth 

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Unscheduled/ Emergency Cesarean Birth Usually a result of some difficulty in the labor process/ failure to progress in labor Placenta previa Abruptio placenta Fetal distress MARY LOURDES NACEL G. CELESTE, RN, MD

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Vaginal Birth after Cesarean (VBAC) When the reason for the initial cesarean is a nonrecurring situation such as placenta previa, prolapsed cord, or breech presentation, the client may be able to have a vaginal birth with the next pregnancy Low transverse uterine incision: trial of labor is recommended Classic uterine incision: trial of labor is CI MARY LOURDES NACEL G. CELESTE, RN, MD

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Complications during Labor and Birth

Mary Lourdes Nacel G.

Risks of Labor and Delivery     

Preterm labor and Birth Premature Rupture of Membranes Dystocia Abnormal duration of labor Prolapsed Cord

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Preterm labor Onset of regular contractions of the uterus that cause cervical changes between 20 and 37 weeks of gestation

Preterm birth - Birth before the end of the 37th week of gestation 

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Factors predisposing to preterm labor and birth History of preterm birth PROM premature rupture of membranes Multiple gestation Bacterial vaginosis Intraamniotic infection Bleeding Uterine/ cervical abnormalities MARY LOURDES NACEL G. CELESTE, RN, MD

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If contractions are continuing and cervical changes are occurring, tocolytic agents may be prescribed. Tocolytic agents – medications that inhibit contractions Ritodrine, Terbutaline, Magnesium sulfate Corticosteroid may also be given to accelerate fetal lung maturation If contractions subside and cervical dilatation and effacement remain the same, client may be discharged with instructions to limit activities and medication to prevent labor. MARY LOURDES NACEL G. CELESTE, RN, MD

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Premature Rupture of Membranes - Spontaneous rupture of membranes before the onset of labor characterized by fluid leak in the cervix and pooling in the posterior fornix of the vagina, (+)nitrazine test, (+)ferning under microscopic exam; possible protrusion of membranes or presenting part, prolapsed cord 

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Prophylactic antibiotic therapy – to decrease the occurrence of chorioamnionitis Tocolysis corticosteroid

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Dystocia long, difficult or abnormal labor caused by any of the 4 major variables that affect labor: Dysfunctional labor: ineffective contractions or maternal pushing efforts (power) Pelvic structure variations (passage) Fetal variations (abnormal presentation or position, very large size or number of fetuses ,anomalies) Mother’s responses related to preparation for childbirth, past experiences, culture and support persons MARY LOURDES NACEL G. CELESTE, RN, MD

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Abnormal duration of labor Prolonged labor labor progress in either the 1st or 2nd stage may be prolonged or arrested (stopped) Hypotonic contractions, CPD, abnormal fetal presentation, or early use of analgesics may cause prolonged labor MARY LOURDES NACEL G. CELESTE, RN, MD

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Precipitate labor - Labor lasting <3 hours from the onset of contractions - Possible maternal complications: loss of coping ability; risk of uterine rupture, laceration of the cervix, vagina and perineum; postpartum hemorrhage - Fetal complications – hypoxia, distress, cerebral trauma  Precipitate birth - Birth occurring suddenly and unexpectedly MARY LOURDES NACEL G. CELESTE, RN, MD

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Prolapsed Cord When the umbilical cord lies below the presenting part of the fetus; may be hidden or visible A cord below the presenting part is compressed between the fetus and the mother’s pelvis resulting in decreased blood flow to the fetus The fetus will have bradycardia with variable decelerations during uterine contractions MARY LOURDES NACEL G. CELESTE, RN, MD

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Occurs in PROM Fetal presentation other than cephalic Placenta previa Intrauterine tumors Small fetus CPD Hydramnios Multiple gestation MARY LOURDES NACEL G. CELESTE, RN, MD

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Relieve pressure on the cord to relieve the compression of the cord and fetal anoxia; done by placing a gloved hand in the vagina and manually elevating the fetal head off the cord - Place the woman in a knee-chest or Trendelenburg position which causes the fetal head to fall back from the cord 

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Other complications Uterine rupture Uterine inversion Amniotic fluid embolism

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Induction/ Augmentation of Labor  

Induction of Labor Augmentation of Labor

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Induction of Labor  Stimulation of uterine contractions before they begin spontaneously  By chemical and mechanical methods 4. Oxytocin 5. Amniotomy May be considered in situations of preexisting maternal disease, PIH, PROM, postterm gestation or fetal demise MARY LOURDES NACEL G. CELESTE, RN, MD

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Augmentation of Labor - Stimulation of uterine contractions after spontaneously beginning but the progress of labor is unsatisfactory - Intravenous oxytocin is used

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Anomalies of the placenta and cord  Placenta  -

Weighs approximately 500 g and is 15 – 20 cm in diameter, 1.5 – 3 cm thick Weight is 1/6 of the fetus Maternal and fetal sides

Umbilical cord length:55 cm at term 1 vein (carries oxygenated blood to the fetus) 2 arteries (carry deoxygenated blood from fetus to placenta) Wharton’s jelly, gelatinous substance Cord extends from the fetal surface of the placenta to the fetal umbilicus MARY LOURDES NACEL G. CELESTE, RN, MD

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Placenta succenturiata 

Placenta has 1 or more accessory lobes connected to the main placenta by blood vessels

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Placenta circumvallata 

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Ordinarily, chorion membrane begins at the edge of the placenta; no chorion covers the fetal side of the placenta This kind- the fetal side of the placenta is covered with chorion

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Battledore placenta 

The cord is inserted marginally rather than centrally

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Placeta increta- invasion of the placenta into the myometrium Placenta percreta – penetration of the placenta through the myometrium to the serosa Vasa previa – placental vessels crossing the cervical os MARY LOURDES NACEL G. CELESTE, RN, MD

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Velamentous insertion of the cord 

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The cord, instead of entering the placenta directly, separates into small vessels that reach the placenta by spreading across a fold of amnion May be found in multiple gestation May be associated with fetal anomalies

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Nursing Care of a Postpartal Woman and Family

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Postpartum FROM STAGE 4 UNTIL 6 WEEKS AFTER DELIVERY 

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Involution – (uterus reduced to prepregnant size) Fundus – midline, firm Position – even to 1 cm/finger breadth above the umbilicus for the first 12 h, then descends by one finger breadth each succeeding day, pelvic organ usually by day 10 If with deviations, check bladder and have 234 MARY LOURDES NACEL G. CELESTE, RN, MD patient void; if deviations continue, massage

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Lochia – (endometrial sloughing) – day 1-3 rubra (bloody with fleshy odor; may be clots) – day 4-9 serosa (pink/brown with fleshy odor) – day 10+ alba (yellow-white); at no time should there be a foul odor (indicates infection) MARY LOURDES NACEL G. CELESTE, RN, MD

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Perineum – possible discomfort, swelling, and/or ecchymosis Managed with analgesics and/or topical anesthetics, ice packs for first 12-24 h and then 20 min sitz baths 3-4 times/d, tightening buttocks before sitting Monitor episiotomy/laceration – teach techniques to prevent infection, e.g., change pads on regular basis, peri care (cleaning from front to back using peri-bottle or surgigator after each voiding and bowel movement), and sitz baths MARY LOURDES NACEL G. CELESTE, RN, MD

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Breasts – progress from soft filling with potential for engorgement (vascular congestion related to increased blood and lymph supply; breasts are larger, firmer, and painful)  Non-nursing woman – suppress lactation  Mechanical methods – tight-fitting brassiere, ice packs, minimize breast stimulation  Nursing woman – successful lactation is dependent on infant sucking and maternal production and delivery of milk (letdown/milk ejection reflex); monitor and teach preventive measures for potential problems MARY LOURDES NACEL G. CELESTE, RN, MD

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Nipple – irritation/cracking  Nipple care – clean with water, no soap, and dry thoroughly; absorbent breast pads if leaking occurs; expose to air  Position nipple so that infant’s mouth covers a large portion of the areola and release infant’s mouth from nipple by inserting finger to break suction  Rotate breastfeeding positions MARY LOURDES NACEL G. CELESTE, RN, MD

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Engorgement  nurse frequently (every ½-3 h) and long enough to empty breasts completely (evidenced by sucking without swallowing)  warm shower or compresses to stimulate letdown  alternate starting breast at each feeding  mild analgesic 20 min before feeding and ice packs between feedings for pronounced discomfort 

Plugged ducts – area of tenderness and lumpiness often associated with engorgement; may be relieved by heat and massage priorMARY toLOURDES feeding NACEL G. CELESTE, RN, MD

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Expression of breast milk  to collect milk for supplemental feedings  to relieve breast fullness or to build milk supply  may be manually expressed or pumped by a device and refrigerated for no more than 48 h or frozen in plastic bottles (to maintain stability of all elements) in refrigerator freezer for 2 wk and deep freezer for 2 mo (do not thaw in microwave or on stove)  Medications – most drugs cross into breast milk; check with physician before taking any medication MARY LOURDES NACEL G. CELESTE, RN, MD

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LACTATION PRINCIPLES Breast Care – Antepartum Initiating Breast Feeding and Postpartum Soap on nipples should be Relaxed position of mother is avoided during bathing to essential – support prevent dryness dependent arm with pillow Nipples can be “prepared” Both breasts should be offered antepartum by exposure to at each feeding sun, air, and by wearing Five minutes on each breast is loose clothing sufficient at first – teach Redness or swelling can proper way to break suction indicate infection and should Most of the areola should be always be investigated infant’s mouth to ensure proper sucking MARY LOURDES NACEL G. CELESTE, RN, MD

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Elimination Urinary – increased output (postpartum diuresis), urethral trauma, decreased bladder sensation, and inability to void in the recumbent position may cause bladder distention, incomplete emptying and/or urinary stasis increasing the risk of uterine relaxation and hemorrhage and/or UTI; monitor I and O encourage voiding every 24 h (early ambulation and pouring warm water over perineum); catheterization may be necessary if no voiding after 8 h MARY LOURDES NACEL G. CELESTE, RN, MD

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GI – bowel sluggishness, decreased abdominal muscle tone, perineal discomfort may lead to constipation; managed by early ambulation, increased dietary fiber and hydration, stool softeners MARY LOURDES NACEL G. CELESTE, RN, MD

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After pains – cramps due to uterine contractions lasting 2-3 d; more common in multipara and with nursing; may be relieved by lying on abdomen with small pillow, heat, ambulation, mild analgesic (if breast feeding, 1 h before nursing) Rubella vaccine – for susceptible woman; RhoGam as appropriate MARY LOURDES NACEL G. CELESTE, RN, MD

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Psychosocial adjustment Attachment/bonding – influenced by maternal psychosocial-cultural factors, infant health status, temperament, and behaviors, circumstances of the prenatal, intrapartal, postpartal, and neonatal course; evidenced initially by touching and cuddling, naming, “en face” positioning for direct eye contact, later by reciprocity and rhythmicity in maternal-infant interaction MARY LOURDES NACEL G. CELESTE, RN, MD

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Psychological Changes  Phases

Talking-in Taking-hold Letting-go

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Phases of adjustment  “Taking in”/dependency (day 1-2 after delivery) – preoccupied with self and own needs (food and sleep); talkative and passive; follows directions and is hesitant about making decisions; retells perceptions of birth experience MARY LOURDES NACEL G. CELESTE, RN, MD

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“Taking hold”/dependencyindependency (by day 3) – performing self-care; expresses concern for self and baby; open to instructions

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“Letting go”/independence (evident by weeks 5-6) – assuming new role responsibilities; may be grief for relinquished roles; adjustment to accommodate for infant in family

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“Postpartum blues” (day 3-7) – normal occurrence of “roller coaster” emotions, weeping, “letdown feeling”; usually relieved with emotional support and rest/sleep; report if prolonged or later onset MARY LOURDES NACEL G. CELESTE, RN, MD

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Sexual activities – abstain from intercourse until episiotomy is healed and lochia has ceased (usually 3-4 wk); may be affected by fatigue, fear of discomfort, leakage of breast milk, concern about another pregnancy; assess and discuss couple’s desire for and understanding about contraceptive methods; breastfeeding does not give adequate protection, and oral contraceptives should not be used during breastfeeding.

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Pregnant Adolescent  Complications

Pregnancy-induced hypertension Iron-deficiency anemia Preterm labor

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Pregnant Adolescent  Complications

and concerns of labor, birth and postpartum Cephalopelvic disproportion Postpartal hemorrhage Inability to adapt Lack of knowledge MARY LOURDES NACEL G. CELESTE, RN, MD

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Over Age 40 

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Complications Pregnancy-induced hypertension Complications and concerns of labor, birth and postpartum Failure to progress Difficulty accepting event Postpartal hemorrhage

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Substance Dependent 

Withdrawal symptoms following discontinuation of the substance Abandonment of important activities Spending increased time in activities related to substance use Using substance for a longer time than planned MARY LOURDES NACEL G. CELESTE, RN, MD

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Substance Dependent Drugs commonly used during pregnancy

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Cocaine Amphetamines Marijuana and hashish Phencyclidine Narcotic agonists Inhalants Alcohol MARY LOURDES NACEL G. CELESTE, RN, MD

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CHILDBEARING – MATERNAL COMPLICATIONS Mary Lourdes Nacel G.

Identifying the High-Risk Pregnancy  High-risk

pregnancy

A concurrent disorder, pregnancy-related complication, or external factor jeopardizes the health of the mother, fetus or both MARY LOURDES NACEL G. CELESTE, RN, MD

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Factors associated with increased risk  lack of prenatal care  age less than 18 or older than 35  conception within two months of previous delivery  fifth or subsequent delivery  prepregnant weight 20% more or less than normal and/or minimal or no weight gain  fetal anomaly MARY LOURDES NACEL G. CELESTE, RN, MD

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Adolescence  there may be interference with normal physical growth and maturation  lack of family acceptance or support  isolation from peers  delayed/ no prenatal care  increased medical and obstetrical risks *requires support for feelings, assistance with decision-making, regular monitoring of health status, instruction in nutrition MARY LOURDES NACEL G. CELESTE, RN, MD

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Substance use/abuse Drugs (including alcohol) – may be increased risk of maternal nutritional deficits, sexually transmitted diseases (STDs), AIDS, delayed/no prenatal care, withdrawal symptoms, and fetal intrauterine growth retardation (IUGR), anomalies, spontaneous abortions, death, signs and symptoms of withdrawal or addiction in neonate; educate, reinforce, counsel, and/or refer as necessary; emphasize that a safe level of alcohol has not been identified MARY LOURDES NACEL G. CELESTE, RN, MD

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Cigarettes – increased incidence of intrauterine growth retardation (IURG), preterm births, low Apgar scores, spontaneous abortions, SIDS; as with drugs

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Infections  Urinary tract infections (UTI's) – characterized by urinary frequency and urgency, dysuria, and sometimes hematuria and manifested in upper tract by fever, malaise, anorexia, nausea, abdominal/back pain; confirmed by >100,000/ml bacterial colony count by clean catch urine; sometimes asymptomatic; treated with sulfa-based medications and ampicillin MARY LOURDES NACEL G. CELESTE, RN, MD

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TORCH test series – group of maternal systemic infections that can be transmitted across the placenta or by ascending infection to the fetus; infection early in pregnancy may produce significant and devastating fetal deformities, whereas later infection may result in overwhelming active systemic disease and/or CNS involvement, causing severe neurological impairment or death of newborn MARY LOURDES NACEL G. CELESTE, RN, MD

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TORCH Toxoplasmosis – caused by protozoan Toxoplasma gondii – Caused by eating raw or poorly coked meat or by contact with the feces of infected animals – transplacental to fetus – Asymptomatic or myalgia, malaise, rash, splenomegaly, and posterior cervical lymphadenopathy – Damage to the fetus is worse if acquired early in the pregnancy – Dx: Sabin-Feldman dye test – discourage eating undercooked meat and handling cat litter box – Tx: Sulfadiazine & Pyrimethamine – Incidence of abortion, stillbirths, neonatal death & severe congenital anomalies is MARY LOURDES NACEL G. CELESTE, RN, MD 271 high

Others  

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1. Syphilis – 2. Varicella/ shingles (transplacental to fetus or droplet to newborn) – caution susceptible woman about contact with the disease and zoster immune globulin for exposure 3. Group B beta – hemolytic Streptococcus (direct or indirect to fetus during labor and delivery) – treated with penicillin 4. Hepatitis B (transplacental and contact with secretions during delivery) – screen and immunize maternal carriers; treat newborn with HBIg 5. AIDS (as with hepatitis) – titers in newborn may be passive transfer of maternal MARY LOURDES NACEL G. CELESTE, RN, MD antibodies or active antibody formation

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Rubella (transplacental) – prenatal testing required by law; caution susceptible woman about contact; vaccine is not given during pregnancy  Period of greatest risk for teratogenic effect:  during the 1st trimester; between 3rd – 7th weeks of pregnancy – damage usually results in death  2nd trimester – hearing impairment  Leukemia in childhood noted  Best Tx: PREVENTION!  Live attenuated vaccine given to children ( not given during pregnancy) MARY LOURDES NACEL G. CELESTE, RN, MD

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Cytomegalovirus (CMV) – transmitted in body fluids; detected by antibody/serological testing  Virus found in urine, saliva, cervical mucus, semen & breast milk  Principal organs affected: blood, brain and liver  Anemia, hyperbilirubinemia, thrombocytopenia, (petecchiae, ecchymosis), hepatosplenomegaly  Encephalitis (lethargy, convulsions)  Cerebral palsy may develop MARY LOURDES NACEL G. CELESTE, RN, MD

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Herpes type 2 (transplacental, ascending infection within 4-6 h after ROM or contact during delivery if active lesions)  cesarean delivery if there are active lesions  S/S: genital irritation and itching, vaginal or urethral discharge- may be copious, foulsmelling; enlarged tender lymph nodes; dysuria begins as reddish papules>> itchy pustular vesicles>> break and form painful wet ulcers>> dry and develop crusts  20 – 50% rate of spontaneous abortion if infection occurs during the 1st trimester  Infection after the 20th week leads to incidence of premature birth and not to teratogenic effects  Survivors have permanent visual damage & impaired psychomotor & intellectual 275 development MARY LOURDES NACEL G. CELESTE, RN, MD  Tx: relieve woman’s vulvar pain ;

1st Trimester Bleeding  Spontaneous

miscarriage

Threatened Imminent Complete Missed Recurrent pregnancy loss MARY LOURDES NACEL G. CELESTE, RN, MD

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ABORTION Early (before 20 wks) - Any pregnancy that terminates before the age of viability  Spontaneous abortion characterized by painless (may be cramping) dark-bright red vaginal bleeding 

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CLINICAL CLASSIFICATIONS OF SPONTANEOUS ABORTION Type Assessment Nursing Considerations Threatened Vaginal bleeding and Ultrasound for intrauterine sac, quantitative HCG cramping Decrease activity for 24-48 h, avoid stress, no sexual Soft uterus, cervix closed intercourse for 2 wk after bleeding stops Monitor amount and character of bleeding; report clots, tissue, foul odor Inevitable, if Persistent symptoms, Monitor for hemorrhage (save and count pads) and cervical dilation hemorrhage, moderate to infection; if persistent or increased symptoms, D cannot be severe cramping and C prevented Cervical dilatation and Emotional support for grief and loss (Imminent) effacement Incomplete Persistent symptoms, Administer IV/blood, oxytocin expulsion of part of D and C or suction evacuation products of conception Complete As above, except no retained Possible oxytocin PO; no other treatment if no tissue evidence of hemorrhage or infection Missed – fetus dies May be none/some abating of D and C evacuation within 4-6 wk in utero but is not above symptoms After 12 wk, dilate cervix with several applications of expelled Cervix is closed prostaglandin gel or suppositories of laminaria If retained >6 wk, increased (dried sterilized seaweed that expands with cervical risk of infection, DIC, and secretions) emotional distress Habitual – 3 or May be incompetent cervix, Cerclage (encircling cervix with suture) more infertility MARY LOURDES NACEL G. CELESTE, RN, MD

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1st Trimester Bleeding  Ectopic

pregnancy

Implantation occurs outside of the uterine cavity

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SITES AT WHICH ECTOPIC PREGNANCY CAN OCCUR

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Ectopic pregnancy – implantation outside uterus (commonly in fallopian tube) - potentially life threatening to mother 

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Characterized by: unilateral lower quadrant pain after 4-6 weeks of normal signs and symptoms of pregnancy (amenorrhea, (+) pregnancy test bleeding may be gradual oozing to frank bleeding may be palpable unilateral mass in adnexa low HCG levels rigid and tender abdomen signs and symptoms of hemorrhage MARY LOURDES NACEL G. CELESTE, RN, MD

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– Necessary to be alert for signs and symptoms – investigate risk factors especially PID, multiple sexual partners, recurrent episodes of gonorrhea, infertility Management – prepare for surgery – Shock monitoring and management – postoperatively, monitor for infection and paralytic ileus – Provide support for emotional distress – RhoGam for Rh- negative woman – monitor Hgb and Hct – ultrasound for adnexal mass/ gestational sac in tube – culdocentesis (indicated by nonclotting blood) – laparoscopy and/or laparotomy – adequate blood replacement (type and X LOURDES NACEL G. CELESTE, RN, MD 282 match, IV withMARYlarge-bore needle)

2nd Trimester Bleeding Premature cervical dilatation

Cannot hold the fetus until term Cervical cerclage

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Incompetent Cervix  Painless dilatation of the cervix usually in the 2nd trimester  May lead to infection, premature rupture of membranes, preterm labor

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SHIRODKAR SUTURE FOR CERVICAL CERCLAGE

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2nd Trimester Bleeding 

Gestational trophoblastic disease (hydatidiform mole) Abnormal proliferation and degeneration of the trophoblastic villi

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Hydatidiform mole – degenerative anomaly of the placenta converting the chorionic villi into a mass of clear vesicles *characterized by  elevated HCG levels  uterine size greater than expected for gestational age  no FHR  minimal dark red/brown vaginal bleeding with passage of grapelike clusters  no fetus by ultrasound  possible increased nausea and vomiting and associated pregnancy-induced hypertension  treated with curettage to completely remove all molar tissue, which can become malignant  pregnancy is discouraged for 1 year, and HCG levels are monitored during that time (if it continues to be elevated, may require hysterectomy and chemotherapy) MARY LOURDES NACEL G. CELESTE, RN, MD 287

Gestational trophoblastic disease (hydatidform mole)

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3nd Trimester Bleeding 

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Placenta previa Low implantation of placenta Abruptio Placenta Premature separation of placenta Occurs suddenly

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Late in pregnancy Placenta previa – development of the placenta in the lower uterine segment, partially or completely covering the internal cervical os Characterized by painless vaginal bleeding, which is usually slight at first (spotting – 1st and 2nd trimesters) and increases in subsequent unpredictable episodes; usually soft and non tender abdomen

4 Degrees of Placenta previa 6. Low-lying - in lower segment 7. Marginal - at border of internal cervical os 8. Partial – occludes a portion of the cervical os 9. Total - complete obstruction of the os MARY LOURDES NACEL G. CELESTE, RN, MD

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LOW IMPLANTATION

DEGREES OF PLACENTA PREVIA PARTIAL PLACENTA PREVIA

TOTAL PLACENTA PREVIA

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Management of PLACENTA PREVIA  Hospitalization  bed rest  side-lying or Trendelenburg position for at least 72 hours  ultrasound shows the location and degree of obstruction  no vaginal/ rectal exam unless delivery would not be a problem (if it becomes necessary, it must be done in OR under sterile conditions)  amniocentesis for lung maturity  monitor for changes in bleeding and fetal status  daily Hgb and Hct; keep IV line and make blood available (blood typed and cross matched- 2 units)  Delivery by cesarean if evidence of fetal maturity, excessive bleeding, active labor, other complications  Home - if bleeding ceases and pregnancy to be MARY LOURDES NACEL no G. CELESTE, RN, MD maintained – limit activity; douching, enemas, 292 coitus; monitor FM; NST at least every 1-2 wk

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Abruptio placenta – premature separation of normally implanted placenta; may be marginal (near edge) with dark red vaginal bleeding or central (at center) with concealed bleeding; life threatening to fetus and mother Common among women with hypertension, short umbilical cord and alcohol use; also by direct trauma MARY LOURDES NACEL G. CELESTE, RN, MD

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 -

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Characterized by: painful (sharp, stabbing) vaginal bleeding/ epigastric pain uterine rigidity and tenderness: abdomen is tender, painful and tense (board-like) rapid signs and symptoms of maternal shock and/or fetal distress (altered FHR) May lead to Couvelaire uterus (blood infiltrating the uterine musculature) forming a hard, board-like uterus without apparent bleeding External bleeding may seem out of proportion to symptoms (shock) displayed by the woman MARY LOURDES NACEL G. CELESTE, RN, MD

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PREMATURE SEPARATION OF THE PLACENTA

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Abruptio placenta  Manage signs and symptoms - Keep woman in lateral position (not supine) - Oxygenation (to limit fetal anoxia) - FHR monitoring; VS monitoring - Baseline fibrinogen (if bleeding is extensive, fibrinogen reserve may be used up in the body’s attempt to accomplish effective clot formation) MARY LOURDES NACEL G. CELESTE, RN, MD

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Abruptio placenta - NO IE or rectal examination, No enema - Keep IV open for possible blood transfusion  prepare for immediate delivery usually, cesarean section 

Postoperatively monitor for complications – Infection – Renal failure – Disseminated intravascular coagulation (DIC) MARY LOURDES NACEL G. CELESTE, RN, MD

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Disseminated Intravascular Coagulation (DIC)  

Disorder of blood clotting  Fibrinogen levels fall below effective limits Symptoms  Bruising or bleeding  massive hemorrhage initiates coagulation process causing massive numbers of clots in peripheral vessels (may result in tissue damage from multiple thrombi), which in turn stimulate fibrolytic activity, resulting in decreased platelet and fibrinogen levels and  signs and symptoms of local generalized bleeding (increased vaginal blood flow, oozing IV site, ecchymosis, hematuria, etc)  monitor PT, PTT, and Hct, protect from injury; no IM injections; early anticoagulant therapy is controversial MARY LOURDES NACEL G. CELESTE, RN, MD

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Diabetes – interaction of

diabetes and pregnancy may cause serious problems for mother and fetus/newborn

Classification  Type I – insulin-dependent (IDDM)  Type II – non insulin-dependent (NIDDM)  Gestational diabetes (GDM)  Impaired glucose tolerance (IGT) MARY LOURDES NACEL G. CELESTE, RN, MD

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Effects of diabetes on pregnancy  Maternal  long-standing diabetes and/or poor control before conception can increase risk of maternal infections – monolilial vaginitis, pyelonephritis, UTI  Polyhydramnios (>2,000 ml amniotic fluid)  pregnancy-induced hypertension (PIH), and consequent preterm labor  Instrumental or cesarean delivery  Postpartum bleeding MARY LOURDES NACEL G. CELESTE, RN, MD

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Fetal and neonatal effects of gestational diabetes Due to hyperglycemia – in more severe cases, congenital anomalies- neural tube defect, cardiac, GI and renal defects macrosomia (large for gestational age but may have immature organ systems) and IUGR < prematurity Delayed lung maturity - respiratory distress syndrome (RDS) in neonate Neonatal hypoglycemia Neonatal hyperbilirubinemia Neonatal polycythemia untreated ketoacidosis can cause coma and death of mother and fetus MARY LOURDES NACEL G. CELESTE, RN, MD

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Gestational diabetes Women who do not begin in pregnancy with diabetes become diabetic during pregnancy (approximately 2 – 3%) usually normal response to glucose load before and after pregnancy abnormal response is usually noted after 20 weeks, when insulin need accelerates, bringing about symptoms; some gravidas will need exogenous insulin but majority are controlled by diet; oral hypoglycemics must not be used because they maybe teratogenic and increase the risk of neonatal hypoglycemia MARY LOURDES NACEL G. CELESTE, RN, MD

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60 -70 % chance of GDM in the next pregnancy 40% of those with GDM may develop DM Assessment Risk factors (GDM) – obesity, family history of diabetes; patient history of gestational diabetes, hypertension/PIH, recurrent UTI's, monilial vaginitis, polyhydramnios; previously large infant (9 lb/4,000 g or more), previously unexplained death/anomaly or stillbirths; glycosuria, proteinuria on two or more occasions MARY LOURDES NACEL G. CELESTE, RN, MD

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Diabetes – at 24-28 wk for all gravidas Screen blood glucose level 1 hour after 50 g concentrated glucose solution Three-hour glucose tolerance test OGTT 100 mg glucose normal findings: FBS: 80-100 mg/dL 1 h: <190 mg/dL 2 h: <165 mg/dL 3 h: <145 mg/dL If two or more abnormal findings, significant for diabetes Glycosylated hemoglobin (HbA1c) – measures control over the past 3 mo; elevations (>68%) in first trimester are associated with increased risk of congenital anomaly and spontaneous abortion; in the last trimesterMARY with macrosomia LOURDES NACEL G. CELESTE, RN, MD 305

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GDM        

Mx  Diet: 20% calories from Polydipsia protein; 50% from Polyphagia carbohydrates; 30% from Polyuria fats; increased dietary Hyperglycemia fibers; not less than 1800 calories per day Dizziness, if  Exercise: to lower blood hypoglycemic glucose Hydramnios  Stress Management Macrosomia (large  Try diet first; then Insulin: fetus) usually short acting Possible PIH, (regular) insulin combined moniliasis with immediate acting  NO ORAL HYPOGLYCEMIC AGENT! –passes through the placenta and can be teratogenic MARY LOURDES NACEL G. CELESTE, RN, MD 307

Hypertension disorders 

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Preexisting hypertension (HTN) – diagnosed and treated before pregnancy; requires strict medical and obstetrical management Pregnancy-induced hypertension (PIH) – no prior incidence, develops during pregnancy and resolves during postpartum period Pre-eclampsia (synonymous with PIH) – may progress from mild, which can usually be managed as outpatient, to severe, which requires hospitalization; triad of symptomatology: Hypertension (vascular effect) Edema (interstitial effect) Proteinuria (kidney effect) Mild Severe MARY LOURDES NACEL G. CELESTE, RN, MD

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Pregnancy-Induced Hypertension Vasospasm occurs during pregnancy  Symptoms Hypertension Proteinuria Edema 

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Pregnancy-Induced Hypertension

Mild preeclampsia Severe preeclampsia Eclampsia Gestational hypertension

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Pregnancy-Induced Hypertension  HELLP

syndrome

Hemolysis Elevated Liver Enzymes Low Platelets

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Mild Preeclampsia – Elevated BP : 140/90 or – Increase of +30/ +15 mmHg on two consecutive occasions at least 6 hours apart as compared to first-trimester BPs – Edema: generalized edema that does not clear overnight, or more significantly, facial; sudden weight gain >2 lbs/wk (2nd trimester); >1 lb/wk (3rd trimester) – Proteinuria 1+ - 2+ in two consecutive tests at least 6 hours apart or 300 mg/L in a 24-h specimen – May be managed at home MARY LOURDES NACEL G. CELESTE, RN, MD

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Severe Preeclampsia – BP 150-160/100-110, increased edema 3+ - 4+ proteinuria – Oliguria (Urine output <500 ml/ 24 hours) – Complaints of headache, visual changes, epigastric pain, extreme irritability – Hyperreflexia – HELLP – hemolysis (significantly decreased Hct), elevated liver enzymes (Hepatic dysfunction- SGOT, SGPT), low platelet count – Managed in the hospital MARY LOURDES NACEL G. CELESTE, RN, MD

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FOR PREECLAMPSIA Assess BP, protein level in urine, changes in level of consciousness, weight, FHT, vaginal bleeding, FHT Bedrest Left lateral recumbent position (to avoid pressure on vena cava) High protein diet Seizure precautions (note headaches, visual changes, dizziness and epigastric pain) MARY LOURDES NACEL G. CELESTE, RN, MD

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Eclampsia (obstetrical emergency!!!) - when convulsions, coma, HTN crisis or shock occurs Hypertension Proteinuria Convulsions Coma Death is from cerebral hemorrhage, circulatory collapse, or renal failure May be maternal recurrence, cerebral hemorrhage, DIC, and fetal hypoxia – ensure patent airway (suction and O2 as necessary); monitor mother for signs and symptoms of cerebral hemorrhage, placenta abruptio, pulmonary edema; may require invasive hemodynamic monitoring; IV with large-bore needle, type and cross-match blood available for emergency transfusion; monitor fetal status; MgSO4 IV; immediate delivery if signs and LOURDES NACEL G. CELESTE, RN, MD 316 symptoms do notMARY subside

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FOR ECLAMPSIA Maintain IV line Keep Oxygen and airway equipment available at bedside Minimize stimuli Medication as ordered (Magnesium sulfate, Valium, Apresoline) Side rails up and padded Aspiration precaution post ictal phase

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Magnesium Sulfate Drug of choice for the prevention and treatment of convulsion Therapeutic level is 4 – 7 mg/ 100 ml Given slowly piggy back IV but may be irritating to vein or IM given Z tract method Monitor RR closely as respiration may be depressed Poor urinary excretion may lead to toxicity. Accurate I and O (catheterization) Monitor deep tendon reflex (DTR), absence means increase in magnesium level Monitoring of maternal and fetal vital signs Antidote is Calcium gluconate MARY LOURDES NACEL G. CELESTE, RN, MD

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Labor induction with IV oxytocin (administered simultaneously with MgSO4), or in severe cases, cesarean delivery may be indicated In cases of severe hypertension, seizures may still occur 24-48 h postpartum; monitor MgSO4 or hydralazine may be continued postpartum MARY LOURDES NACEL G. CELESTE, RN, MD

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PHARMACOLOGICAL MANAGEMENT OF PREGNANCY-INDUCED HYPERTENSION Medications Side Effects Nursing Considerations Magnesium sulfate Flushing, sweating CNS depressant, anticonvulsant Symptoms of toxicity: Monitor BP, P, R, FHR at least every 15 sudden drop in BP, min; MgSO4 levels and DTR prior to respirations <12/min, administration, mental status urinary output <25-30 frequently; have resuscitation ml/hr, equipment and calcium gluconate/ decreased/absent DTRs, chloride (antidote) in room toxic serum levels Hydralazine Tachycardia, palpitations Vasodilator (Apresoline) Headache Maintain diastolic BP Nausea and vomiting 90-100 mm Hg for adequate Orthostatic hypotension uteroplacental flow; monitor FHT and neonatal status Diazepam Risk of neonatal Sedative, anticonvulsant (Valium) depression if given Monitor FHT and neonatal status within 24 h of delivery Methyldopa May masks symptoms of Used for chronic HTN (Aldomet) preeclampsia; Monitor maternal, fetal, and neonatal risk of maternal vital signs orthostatic Monitor maternal mental status hypotension and decreased pulse and BP in neonate for 2-3 d Hemolytic anemia Propranolol Decreased heart rate, Take apical rate before giving MARY LOURDES NACEL G. CELESTE, RN, MD (Inderal) depression, Monitor BP, EKG hypoglycemia

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Hydramnios – excessive amniotic fluid (2,000 ml) exceeding the normal volume of 500 – 1,000 ml AF Rapid enlargement of the uterus Increased weight Difficult to palpate and to auscultate fetus due to excessive fluid Shortness of breath because of compression of the diaphragm Ultrasound finding of excessive fluid MARY LOURDES NACEL G. CELESTE, RN, MD

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Using ultrasound, we measure the amniotic fluid index (AFI) The maternal abdomen is divided into 4 quadrants; find the largest vertical pocket of fluid in each quadrant AFI < 5 : OLIGOHYDRAMNIOS AFI > 20 : POLYHYDRAMNIOS MARY LOURDES NACEL G. CELESTE, RN, MD

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Oligohydramnios  In the absence of ROM is associated with 40x increase in perinatal mortality  Associated with congenital anomalies (renal agenesis, polycystic kidney disease, obstruction of the GU system) particularly of the genitourinary system and growth restriction  Caused by chronic uteroplacental insufficiency  Pregnancies at term complicated with oligohydramnios should be delivered MARY LOURDES NACEL G. CELESTE, RN, MD

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Polyhydramnios  AFI > 20  Associated with diabetes, multiple gestation , hydrops and congenital abnormalities  Asssociated with neural tube defects, obstruction of the alimentary canal and hydrops  Increased risk of malpresentation and prolapsed cord MARY LOURDES NACEL G. CELESTE, RN, MD

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Hydramnios Risk Factors  Maternal diabetes  Infant with esophageal atresia  Monozygotic twins  Infant with neural tube defect  Large placenta

Mx:  Maintain bedrest to rdeuce pressure on cervix and to prevent premature labor  Monitor for rupture or uterine contraction  Avoid constipation by bulk in the diet  Amniocentesis guide by ultasound (slow to prevent premature separation of placenta)

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PRECIPITOUS DELIVERY Assessment  Determine that transport to hospital/birthing center is not possible  Evaluate mother’s cognitive status and explain actions 

Nursing management  Remain with patient; do not attempt to prevent birth  Prepare sterile or clean environment  Support infant’s head; apply slight pressure to control delivery  Slip nuchal cord, if present, over head  Deliver shoulders, trunk, holding head downward to facilitate drainage  Dry baby and place on mother’s abdomen  Hold placenta as delivered  Wrap infant in blanket and put to breast  Check for bleeding and fundal tone  Comfort mother and family; arrange transport to MARY LOURDES NACEL G. CELESTE, RN, MD 326 hospital

CARDIAC DISEASE Assessment  Monitor vital signs and do EKG as heart lesion (especially those of the mitral valve) may become aggravated by pregnancy  Chest pain  Dyspnea  Treatment of heart disease in pregnancy is determined by the functional capacity of the heart, and type of delivery will be influenced by the mother’s status and the condition of fetus Nursing Management  Encourage rest  Encourage moderation in physical activity  Explain importance of avoidance of upper respiratory infections  Be alert for signs of heart failure: increase of dyspnea; tachycardia  Monitor activity level MARY LOURDES NACEL G. CELESTE, RN, MD

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Cardiac Disease 

Left-sided heart failure  Right-side heart failure  Dyspnea,  Distended liver and Orthopnea spleen  Paroxysmal  Ascites nocturnal dyspnea (PND)  Peripheral edema  Rales, cough  hepatomegaly  Chest pain, cardiac arrhythmia, syncope during or after exertion  Extreme fatigue, pallor cyanosis MARY LOURDES NACEL G. CELESTE, RN, MD 328

Common Nursing Diagnoses:  Potential for decreased cardiac output  Activity intolerance  Risk for infection  Potential for fetal injury

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Classifications of Cardiac Disease  CLASS I (shows no - No limitation of 





CLASS I (shows no No limitation of signs of cardiac activity insufficiency) CLASS II (ordinary - Slight limitation of physical activity may activity result in discomfort and signs of cardiac insufficiency) - Marked limitation of CLASS III (less than activity ordinary activity results in excessive feelings of fatigue, dyspnea) - Symptoms present CLASS IV (signs of at rest cardiac insufficiency may be experienced even at rest; physicial *** Class I & II usually do well in activity increases the MARY LOURDES NACEL G. CELESTE, RN, MD 330 pregnancy discomfort)

CARE OF PREGNANT WOMEN WITH CARDIAC DISEASE  Reduce cardiac workload – promote rest, infection prophylaxis, prevention of anemia, provision of adequate calories/ fiber/ nutrients and no added salt (2.5 g/day); reduce streaa and anxiety; delivery without bearing down (eg, forceps assisted, pain relief)  Strengthen cardiac function –administer medication (eg, digoxin)  Prevent volume overload  Monitor fetal well-being MARY LOURDES NACEL G. CELESTE, RN, MD

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Isoimmunization (Rh Incompatibility) Rh: major blood group antigen of importance during pregnancy  Rh (-) negative mother is carrying a fetus with Rh (+) positive blood  Incompatibility between the mother’s Rh (-) and fetus’ Rh (+) can lead to Hemolytic disease of the newborn 

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Rh Sensitization and Prevention Rh- mother carries Rh+ fetus

Rh+ fetal blood may mix with Rh- maternal blood Mother’s immune system produces Rh antibodies in response to Rh+ fetal blood cells Antibodies remain in maternal blood following pregnancy Maternal antibodies attack Rh+ fetus in the next pregnancy, resulting in hemolysis

antibodies pregnancy, NOT

Mother receives Rhogam to prevent her immune system from producing Rh so in a subsequent Rh+ fetal blood cells are

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destroyed

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If a tear in the placenta occurs and there was no treatment, the next Rh+ positive fetus will have RBCs destroyed by the maternal Rh antibodies. This causes hemolysis of fetal RBCs and then -anemia which in turn causes fetal edema – Hydrops fetalis or Erythroblastosis fetalis (a syndrome with a hyperdynamic state, heart failure, diffuse edema, ascites and pericardial effusion) MARY LOURDES NACEL G. CELESTE, RN, MD

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RhoGAM  Rh immune globulin given to gravidas who are Rh(-) if there is suspicion of feto-maternal bleeding (amniocentesis, miscarriage, vaginal bleeding and delivery), during any trimester, after delivery and prophylactically at 28 weeks MARY LOURDES NACEL G. CELESTE, RN, MD

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MATERNAL ANTIBODY FORMATION AGAINST THE RH ANTIGEN

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ABO INCOMPATIBILITY  The problem occurs when the maternal blood enters fetal circulation.  Most common: mother is Type O and the fetus is either Type A, B, or AB  The mother’s plasma naturally contains antiA and anti B antibodies  With weaker hemolytic effect than Rh antibodies and only affect mature RBC’s  Number of antibodies is limited to the amount of maternal blood that entered circulation  May affect fetus of the 1st pregnancy  Affected newborn will become jaundiced in the first 3 days of life MARY LOURDES NACEL G. CELESTE, RN, MD

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Possible combinations for ABO INCOMPATIBILITY MOTHER A B O

FETUS B A A, B, AB

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Infections in Pregnancy Tuberculosis  Neither the disease nor the treatment is threatening to the mother or newborn  Late afternoon fevers, nightsweats, weight loss, malaise  Sputum Microscopy / Chest X-ray with abdomnal shield  TB drugs : Rifampicin, Izoniazid, Pyrazinamide, Ethambutol (RIPE)  Breastfeeding is not affected by the medications of TB MARY LOURDES NACEL G. CELESTE, RN, MD

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Rubella (German Measles)  Virus crosses the placenta and had deleterious effects on 50-90% of the fetus in the 1st trimester (deafness, psychomotor prolems, microcephaly)  S/S: 3-day rash which disappears upon pressure on the skin; fever; lymphadenopathy  Rubella immunization during childhood  Women immunized should NOT be pregnant for at least 3 months following vaccination  Immune serum globulin for maternal symptoms; does not alter fetal outcome  Strict isolation during the disease  May breastfeed after the disease MARY LOURDES NACEL G. CELESTE, RN, MD

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Syphilis  Can cross the placenta at any time and can cause 100% fetal infection if primary and secondary infection is untreated and 6-14% fetal infection in latent syphilis 

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2nd trimester infections cause spontaneous abortion, preterm labor, stillbirth and congenital anomalies 3rd trimester infection causes enlarged liver, spleen, skin rash and jaundice in a newborn Dx: (+) VDRL; presence of a chancre for 10 days to 3 months if primary, low-grade fever 4-6 weeks after the chancre; asymptomatic for 5-20 years Tx: Syphilis <1 year: Benzathine Penicillin G, 1 dose >1 year: 3 doses of Benzathine Penicillin Gl; will prevent congenital syphilis MARY LOURDES NACEL G. CELESTE, RN, MD 342

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Herpes Simplex Virus Type 2  Associated with infection in the newborn (almost half exposed to herpes in vaginal delivery will become infected)  S/S: headache, generalized itching, malaise, low grade fever and burning in the area where vesicles will appear, inguinal and pelvic lymphadenopathy with pain, pain in urination; vesicles in the labia, vaginal, perianal and endocervical area for 2-6 weeks; recurrent lesions  Presumptive dx done in pap smear, viral isolation from the lesion  Pregnancy considerations: Cesarean section- most probable course for delivery; good handwashing; cleaning of room using universal precautions  Health teaching: NO sexual activity in the presence of lesions and 10-14 days after lesions subsided; keep vulva clean and dry in the presence of lesions; sitz bath; use foley catheter if retention persists; povidone- iodine douche and acyclovir NOT used during pregnancy MARY LOURDES NACEL G. CELESTE, RN, MD 344 MARY LOURDES NACEL G. CELESTE, RN, MD

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Gonorrhea  S/S: profuse and purulent vaginal discharge, itching of the vulva, painful urination and (+) cervical smear  Can cause spontaneous abortion, preterm delivery or PROM; if present at the time of delivery, it can cause gonoccocal ophthalmia (associated with severe eye  

infection and blindness) Tx: Ceftriaxone or Spectinomycin or Probenecid with Amoxicillin 0.5% Erythromycin or 1% Tetracycline ointment for newborn babies MARY LOURDES NACEL G. CELESTE, RN, MD

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HIV Infection

 Transmission through the placenta (greatest near term); delivery due to exposure in birth canal secretions and blood(60%) and breast milk  Focus of care: treat the infection; reduce the risk of perinatal transmission through maintenance or reduction of viral load  Tx: oral Zidovudine initiated at 14-34 weeks AOG and continued throughout pregnancy, IV dose during labor and delivery and neonatal dose 8-12 hours after delivery  Suggested mode of delivery depends on viral load: >1000 copies/ml, CS might reduce transmission  Bathe the newborn as soon as possible after delivery; all needle procedures made after the bath MARY LOURDES NACEL G. CELESTE, RN, MD

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Type

Syphilis

Signs/Symptoms

Diagnostic Tests

Nursing Considerations

VDRL, RPR, FTA

Transmission and Incubation Mucous membrane or skin; congenital 10-90 d

Painless chancre fades after 6 wk Copper-colored rash on palms and soles Low-grade fever Cardiac/CNS dysfunction Congenital – “sniffles” May result in blindness, pegged notch permanent teeth (Hutchinson teeth) Thick discharge from vagina Frequently asymptomatic in females

Culture of discharge from cervix or urethra

Mucous membrane or skin; congenital 2-7 d

Painful vesicular genital lesions Difficulty voiding Recurrence in times of stress, infection, menses

Direct examination of cells HSV antibodies

Mucous membrane of skin; congenital Virus can survive on objects such as towels 3-14 d

Men – urethritis, dysuria Women – thick vaginal discharge with acrid odor

Direct examination of cells Enzyme-linked

Mucous membrane; sexual contact 1-3 wk

IM ceftriaxone (Rocephin) 1 time and PO doxycycline BID for 1 wk: IM aqueous penicillin with PO probenicid to delay penicillin urinary excretion PO tetracycline or doxycycline is used to treat chlamydia, which coexists in 45% of cases Monitor for complications, pelvic inflammatory disease Acyclovir (not cure) Emotional support Sitz baths Local medication Client must notify sexual contacts Monitor Pap smears on regular basis – increased incidence of cancer of cervix Precautions for vaginal delivery Notification of contacts May cause sterility Treat with tetracyclineor doxycycline PO

Gonorrhea

Genital herpes (HSV-2) (simplex)

Chlamydia

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Treat with penicillin G IM For PCN allergy – erythromycin for 10-15 d Retest for cure

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Condylomata acuminata (venereal warts)

Initially single, small papillary lesion spreads into large cauliflowerlike cluster on perineum and/or vagina or penis; may be itching/burning

Human Generalized fatigue, immunorecurrent fever, etc. deficiency virus (HIV)

Direct exam Mucous Biopsy membrane; sexual contact; congenital 1-3 mo

Blood test ELISA

Curettage, cryotherapy with liquid nitrogen or podophyllin resin Keratolytic agents Avoid intimate sexual contact until lesions are healed Strong association with incidence of genital dysplasia and carcinoma Atypical, pigmented, or persistent warts should be biopsied Notify contacts Sexual contact See section of HIV with infected infection persons

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Problems of the Reproductive Tract

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PROBLEMS OF THE FEMALE REPRODUCTIVE TRACT Infectious processes Vaginal 

Simple vaginitis – characterized by a yellow discharge, itching, burning and edema; treated with dilute vinegar douche, antibiotics, sitz baths



Nonspecific vaginits (Gardnerella) – presumed to be bacterial  Gray-white discharge with foul/fishy odor; itching; “clue” cells on saline wet slide  May be treated locally with sulfa vaginal cream; more commonly with oral metronidazole (Flagyl), tetracycline (both of which are contraindicated in pregnancy), or ampicillin MARY LOURDES NACEL G. CELESTE, RN, MD

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Candida albicans – overgrowth of vaginal yeast - Odorless, cheesy white discharge; itching, inflamed vagina and perineum - vaginal

irritation, pruritus, with yeasty odor dysuria, (+)KOH or saline wet mount - The newborn has the risk of being infected upon passage in the vaginal canal  Clotrimazole type of antifungal agent for 7 days Candidiasis  Thrush in newborn

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Trichomonas vaginalis – protozoan infection - Profuse green/yellow/white, malodorous, frothy discharge, irritate genitalia, itching; “strawberry” cervix - positive motile protozoa in a saline wet mount -

Client and partner(s) are treated with metronidazole (Flagyl) and advised to use a condom during intercourse; concurrent alcohol ingestion with metronidazole causes severe GI symptoms

- Associated with preterm labor, premature rupture of membranes and postcesarean infection MARY LOURDES NACEL G. CELESTE, RN, MD

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Atrophic vaginitis – occurs after menopause - Pale, thin, dry mucosa, itching, dyspareunia - Treated with topical estrogen cream, watersoluble vaginal lubricants, and sometimes antibiotic vaginal suppositories and ointments 

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Toxic shock syndrome (TSS) -Characterized by sudden onset of high fever, vomiting, diarrhea, drop in systolic blood pressure, diffuse sunburn like macular red rash, later desquamation of palms and soles; usually due to Staphylococcus aureus - Potential involvement of kidneys, CNS, gastrointestinal system, hematological system, and/or cardiovascular system; therefore, early diagnosis and treatment are important MARY LOURDES NACEL G. CELESTE, RN, MD

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Toxic Shock syndrome  Reproductive age, near menses or postpartum period  Due to Staphylococcus Aureus  Related to use of tampons, cervical cap or diaphragm Manifestations: fever, rash on trunk, desquamation of skin, hypotension, dizziness, vomiting, diarrhea, myalgia, inflamed mucous membranes Diagnostics: Elevated BUN, Crea Elevated AST, ALT, total bilirubin Decreased platelets 

Management: IV fluids, fluid and electrolyte replacement Antibiotics renal dialysis Client education – change tampons 3-6 hours, avoid tampons 6-8 wks after childbirth, do not leave MARY LOURDES NACEL G. CELESTE, RN, MDdiaphragms>48357 hours

Pelvic inflammatory disease (PID) – local infection, usually gonorrhea and/or chlamydia, spreads/ ascends to the fallopian tubes, ovaries, and other organs -Characterized by lower abdominal pain and tenderness, malaise, fever, leukocytosis, and purulent vaginal discharge -Potential to cause adhesions that produce sterility and contribute to ectopic pregnancy -Management includes noting amount, color, and odor of drainage; systemic antibiotics; warm douches to increase circulation and promote drainage; rest and comfort measures; STD prevention 

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Chlamydia  Increased yellowish vaginal discharge, painful and frequent urination, bleeding between periods, mucopurulent cervicitis, (+) culture and antigen detection test  Tx: erythromycin (tetracycline not used during pregnancy)  Associated with premature rupture of membranes, preterm labor and endometriosis, low birth weight and perinatal mortality due to placental transmission  Can lead to infertility, ectopic pregnancy and endometritis MARY LOURDES NACEL G. CELESTE, RN, MD

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Problems related to breast Mastitis – infection of the breast (occurring most often during lactation) caused by inadequate cleanliness of the breast, infection in the infant, blood-borne infections, or plugged lactiferous ducts -Characterized by reddened, inflamed, and tender breast; exudates from the nipple; fever, fatigue, leukocytosis; and pain from stagnation of milk -Management includes administering systemic antibiotics, warm packs to promote drainage, and instructing the patient to wear a brassiere to support the breasts MARY LOURDES NACEL G. CELESTE, RN, MD

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Fibrocystic disease Characterized by multiple soft, tender, freely moving cysts that become enlarged during menstruation and subside during pregnancy, lactation, or after menopause -Management includes aspiration to relieve discomfort and instructing the patient to report to the physician any changes in shape or size MARY LOURDES NACEL G. CELESTE, RN, MD

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Fibrocystic breast disease

Most common benign condition of the breast  20-50 years old  Due to imbalance between hormones  Rare in postmenopausal women not taking HRT  Not risk for Ca except if patient has (+) family history and with atypical cellular changes on biopsy S/S: bilateral cyclic pain, tenderness, nipple discharge 

Dx: mammography, sonography, FNA Managementt: restrict Na, mild diuretic, Danazol (hormone inhibitor), Bromocriptine and Tamoxifen (to decrease symptoms)

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Fibroadenoma  2nd most common benign disorder  Teens, early 30’s  Not associated with breast Ca S/S: freely movable, solid, well defined, sharply delineated, rounded w/ a rubbery texture Dx: USG, FNA Mgmt: surgery of enlarged lesion MARY LOURDES NACEL G. CELESTE, RN, MD

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Intraductal Papilloma  Tumors growing in terminal portion of ducts  Potentially malignant S/S: unilateral mass/solitary nodule, bloody discharge Dx: ductogram followed by mammogram biopsy Mgmt: excision with follow up care MARY LOURDES NACEL G. CELESTE, RN, MD

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Hypoplasia or hyperplasia of the breast – may affect a woman’s self-concept; cosmetic surgery may be done to increase or reduce breast size Augmentation mammoplasty – inserts are placed under breast tissue Reduction mammoplasty – excessive tissue removed and the nipple is relocated MARY LOURDES NACEL G. CELESTE, RN, MD

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Cancer of the breast – rapidly growing tumor Assessment – small, mobile, painless lump; rash, or in more advanced cases, change in color, puckering or dimpling of skin, pain and/or tenderness, nipple retraction or discharge; axillary adenopathy; detection by mammography MARY LOURDES NACEL G. CELESTE, RN, MD

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Risk Factors: Age, female, family hx, HRT > 5 yrs, overweight after menopause, alcohol, no history of pregnancy or 1st pregnancy after age 30, never breastfeeding, early menarche, late menopause, radiation, upper socioeconomic areas, geographic location Dx: mammography, FNA, USG, MRI  May be managed by surgery, radiation therapy, and/or chemotherapy Tamoxifen (anti-estrogen) Emotional responses MARY LOURDES NACEL G. CELESTE, RN, MD

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Types of mastectomies  Partial (lumpectomy) – removal of involved tissue while preserving contour and muscle function; usually followed by radiation  Subcutaneous (adenomastectomy) – removal of breast tissue but skin and nipple remain intact; used with premalignant lesions  Simple – removal of the entire breast; a skin flap may be left for cosmetic reconstruction  Radical – removal of the breast as well as the major and minor pectoral muscles, all lymph nodes, fat, and fascia; a skin graft may be used to cover the area  Modified radical – the chest wall is resected, as well as all of the above  Superradical – the sternum is split and lymph nodes are dissected from the mediastinum MARY LOURDES NACEL G. CELESTE, RN, MD

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Nursing care in addition to routine postop care:  Inspect dressing and incision for bleeding  To prevent lymphedema (pooling of lymph circulation is involved arm), elevate it on a pillow, turn patient to back and unaffected side; avoid constricting clothing and using the arm for blood pressure measurement, IVs, injections  To prevent muscle contractures, encourage an exercise program with gradual progression from those that do not stress the incision to adduction and external rotation  Promote acceptance of new body image by providing emotional support

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Problems of the uterus 1. Fibroid (leiomyomas) – benign tumors on the myometrium  Assessment – backache, constipation, pain      

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Frequently asymptomatic Lower abdominal pain Fullness or pressure Menorrhagia Metrorhaggia dysmenorrhea

May predispose to uterine cancer – but potential for cancer is minimal 40 yrs old Smooth muscle cells present in whorls and arise from uterine muscle

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Dx: Ultrasonography  Management includes: Routine pelvic exam every 3-6 months surgery -hysterectomy (surgical removal of the uterus) or myomectomy (partial resection of the uterus) 

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Uterine displacements – caused by weakening of pelvic muscles; may be retrograde (retroversion and/or retroflexion) or forward displacement (anteversion and/or anteflexion) Assessment – discomfort, dysmenorrhea May contribute to infertility Management includes musclestrengthening exercises, insertion of a pessary, or surgery to shorten the muscles MARY LOURDES NACEL G. CELESTE, RN, MD

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Uterine prolapse – collapse of the uterus into the vagina due to weakened pelvic musculature

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Assessment – urinary incontinence, retention, constipation, backache, and vaginal discharge -dragging sensation in groin, backache in sacrum

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Management by insertion of a pessary or by surgical removal of the uterus MARY LOURDES NACEL G. CELESTE, RN, MD 373

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Cancer of the cervix – malignant tumor cells invade the cervix Assessment – often asymptomatic; with invasion, the primary sign is painless vaginal bleeding, later a watery, foulsmelling discharge progressively becomes darker; irregular menstrual bleeding, and menorrhagia, confirmed positive Pap smear and positive cervical MARY LOURDES NACEL G. CELESTE, RN, MD

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Preventable

Risk Factors: coitus at an early age Multiple sexual partners Sex partner with a history of numerous sexual partners Exposure to STD HPV infections Chemotherapy Contraceptive use>5 yrs Smoking Antenatal exposure to DES History of dysplasia MARY LOURDES NACEL G. CELESTE, RN, MD

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Diagnostics: Pap smear Colposcopy Endocervical curettage Management: Surgery  intravaginal radiation implants to deter tumor growth and metastatic invasion or hysterectomy

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Types of hysterectomy  Subtotal – removal of the fundus only  Total – removal of the uterus (vagina remains intact)  Panhysterosalpingo-oophorectomy – removal of the uterus, fallopian tubes, and ovaries  Radical – removal of the lymph nodes in addition to the uterus, fallopian tubes, and ovaries  Nursing care – appropriate for internal radiation therapy or routine preoperation and postoperative care of patient with malignancy MARY LOURDES NACEL G. CELESTE, RN, MD

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Uterine (endometrial) cancer – slowly growing malignancy most often occurring postmenopausally Assessment – usually asymptomatic during early development; primary symptom is postmenopausal vaginal bleeding, followed by low pelvic and lower back pain, palpable uterine mass; diagnosis by endometrial biopsy MARY LOURDES NACEL G. CELESTE, RN, MD

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Risk Factors: Obesity Multiparity DM HPN Use of unopposed estrogen High fat diet Early menarche and late menopause Use of tamoxifen MARY LOURDES NACEL G. CELESTE, RN, MD

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Diagnosis: Pap smear Endometrial biopsy USG Management: TAHBSO counseling  Management includes internal and sometimes external radiation therapy; surgery; chemotherapy in advanced cases MARY LOURDES NACEL G. CELESTE, RN, MD

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Problems related to the ovaries  Benign Ovarian masses Ovarian cysts – benign tumors (rare after menopause); may or may not be painful; surgical removal may be recommended during fertile years for cysts larger than 8 cm – physiologic variations in menstrual cycle    

Dermoid cysts (cystic teratomas) – cartilage, bone, teeth, skin or hair can be observed Endometriomas (chocolate cysts) Manifestations Sensation of fullness, cramping, dyspareunia, irregular bleeding

Diagnostics: USG Management: MARY LOURDES NACEL G. CELESTE, RN, MD OCP to suppress ovarian function Surgery

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Ovarian cancer – leading cause of death from female reproductive malignancies because of rapid growth and spread and lack of early symptoms Assessment – family history of ovarian cancer, client history of breast, bowel, endometrial cancer, nulliparity, infertility, heavy menses, palpation of abdominal mass (late sign); diagnosis by ultrasound, CT, x-ray, IVP

Risk Factors: Increased age (mean age 59 yrs old) Fertility drugs Early menarche or late menopause Asbestos and talc exposure S/S: abdominal swelling or inc abdominal girth, bloating, pelvic pressure, mild constipation  

Management – surgical, chemotherapy, staging of tumor after removal Nursing care – foster verbalization of feelings, continuity of care, encourage support systems MARY LOURDES NACEL G. CELESTE, RN, MD

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Other alterations of female reproductive structures  Endometriosis – proliferation of aberrant endometrial tissue in the uterus, ovaries, fallopian tubes, and within the abdominal cavity and vagina  Assessment – backache, menstrual irregularities, and increasing dysmenorrhea - Bleeding results to inflammation, scarring of peritoneum and adhesions  Cause unknown  Common in 20-45 yrs old Manifestations  Pelvic pain – dull/cramping, related to menstruation  Dyspareunia  Abnormal uterine bleeding  Fixed tender retroverted uterus MARY LOURDES NACEL G. CELESTE, RN, MD  Palpable nodules in the cul de sac

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Risk Factors  Retrograde menstrual flow of endometrium  Physiologic disruption after gynecologic surgery or cesarean birth  Hereditary  Possible immunologic effect  

May potentially cause adhesions, which can result in sterility Management includes antiovulatory drugs (ovulation is the stimulus for the proliferation of tissue) and encouraging early childbearing because pregnancy helps to abate symptoms MARY LOURDES NACEL G. CELESTE, RN, MD

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Diagnostics: Laparoscopy     

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Management OCP-combination contraceptives to induce amenorrhea Analgesics NSAIDS Danazol – antiprogesterone; suppresses GnRH, low estrogen and high androgens to suppress ovulation, promotes amenorrhea and decreases endometrial support GnRH agonists ie leuprolide suppresses the menstrual cycle through estrogen antagonism Progestins ie Medroxyprogesterone – antiendometrial effect Discuss condition, symptoms, treatment Avoid delay of pregnancy because of risk of infertility surgery MARY LOURDES NACEL G. CELESTE, RN, MD

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Cystocele – protrusion of the bladder through the vaginal wall -Downward displacement of bladder, which appears as a bulge in the anterior vaginal wall -Related to genetics, childbearing, obesity, age -S/S: incontinence (interference with voiding and stress incontinence), vaginal fullness

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Management includes Kegel’s exercises; surgery (anterior colporrhaphy) to surgically shorten the muscles that MARY LOURDES NACEL G. CELESTE, RN, MD

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Vaginal Cancer  Upper 1/3 most common site  S/S: painless vaginal bleeding and discharge, urinary retention, bladder spasm, hematuria, frequency of urination, tenesmus, constipation, blood in the stool  Dx: pap smear, biopsy  Mx: radiation, surgery MARY LOURDES NACEL G. CELESTE, RN, MD

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Rectocele – protrusion of the rectum through the vaginal wall characterized by rectal pressure, heaviness, and hemorrhoids

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Posterior vaginal wall is weakened Anterior wall of rectum sags forward into the vagina S/S:constipation Mx: surgery

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Thank you!

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