Antepartal Complications

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  • 1. Maternal and Child Health NursingAntepartal Complication MATERNAL and CHILD HEALTH NURSING PREGNANCY COMPLICATION Lecturer: Mark Fredderick R. Abejo RN, MAN_____________________________________________________________________________ PREGNANCY COMPLICATIONS ( ANTEPARTAL )A. Abortion - termination of pregnancy before the fetus is viable (20 weeks or a weight of 500 g) TYPES DEFINITION S/S NURSING INTERVENTION1. Threatened The continuation of Bleeding or Bedrest, Restrictive activity, Sedation, Avoid coitus the pregnancy is in spotting closed for 2 weeks following last evidence of bleeding doubt cervix Rhogam indicated when a young patient has a threatened abortion in the first trimester and a laboratory studies reveal an Rh negative and the husband is Rh positive2. Inevitable Threatened loss Bleeding and Save tissue fragments that can be cervical dilation prevented; abortive process is going on3. Complete Products of Minimal Continuous monitoring conception are bleeding totally expelled4. Incomplete Some fragments Profuse Dilatation & Curettage; are retained inside bleeding Use of oxytocin: the uterine cavity Oxytocin nasal spray should be administered while the client is sitting with her head in a vertical position. A nasal preparation must not be administered with the client lying down or the head tilted back because this could cause aspiration. Evacuation5. Missed Retention of the Intermittent Evacuation, D & C products of bleeding; conception after absence of fetal death uterine growth6.Habitual / 3 spontaneous Provide IV, Monitor bleeding, Count perineal pads, Recurrent abortions occurring psychological support successively NOTE:Because spontaneous abortion is threatening, all perineal pads must be inspected for the products of conception. Fluid replacement is necessary because of blood lossB. Ectopic PregnancyA pregnancy that occurs in another than uterine site, with implantation usually occurring in fallopian tubes  A ruptured ectopic pregnancy is a medical emergency due to the large quantity of blood that may be lost in the pelvic and abdominal cavities.  Shock may develop from blood loss, and large quantities of I.V. fluids are needed to restore intravascular volume until the bleeding is surgically controlled.  Pain may be caused by a ruptured or distended fallopian tube or blood in the peritoneal cavity.MCHN Abejo
  • 2. Maternal and Child Health NursingAntepartal Complication Causes Signs and Symptoms Diagnostic Tests Management Narrowing of  Vaginal Bleeding  Culdocentesis  Monitor amount of tube  Knife-like abdominal pain  Culdoscopy bleeding Pelvic  Referred pain on the right  Radioimmunoassay of  Assess vital signs infection shoulder elevated serum  Assess abdominal Endometriosis  Pelvic pressure of pelvic qualitative -Beta-HCG pain Smoking fullness  Abdominal  Blood transfusion History of  Cullen’s sign Ultrasound  Surgery: IUD usage  Pain unilaterally, with  Blood samples of Hgb Salpingostomy . cramping and tenderness and Hct; blood type  Administer Rhogam  Mass in the adnexal or cul- and group for Rh (-) client de-sac  Slight, dark vaginal bleeding  Profound shock if rupture occurs Symptoms of Shock: decreased BP increased RR, fast but thready pulse. This is the number 1 complication.C. Hydatidiform mole / Trophoblastic Disease / Molar Disease Gestational trophoblastic neoplasm that arise from the chorion; characterized by the proliferation anddegeneration of the chorionic or trophoblastic villi.MCHN Abejo
  • 3. Maternal and Child Health NursingAntepartal ComplicationA patient with Hydatidiform mole has a positive signs of pregnancy but is not pregnant.The #1 Complication is ChoriocarcinomaThe Three H of H-mole 1.Hyper - emesis gravidarum 2. increase Hcg 3. increase incidence for piH PREDISPOSING TYPES MANIFESTATIONS DIAGNOSTIC MANAGEMENT FACTORS TESTS Low  Complete/  Vaginal bleeding  HCG titer  Molar evacuation socioeconomic classical parts  Excessive N/V determination / D&C status of the villi are  Rapid  Ultrasound  Chemotherapy Women below affected enlargement of the  X-ray of the  Monitor HCG 18 or above 35 uterus abdomen levels Intake of  Incomplete/  (+) Pregnancy test  Delay Clomid partial- some  Possible PIH childbearing plans (Clomiphene parts are  Abdominal for a year Citrate) normal cramps  Perineal pad Women of  Absent FHR counts asian heritage The #1  Elevated HCG  Instruct the Complication of titer: 1-2 million couple to have H-mole is IU; Normal level: VAGINAL REST choriocarcinoma 400,000 IU ( no sex) for 1 year.D. Incompetent Cervix - Painless premature dilatation of the cervix (usually in the 16th to 20th week) INCOMPETENT CERVIXSynonyms  Dysfunctional cervixPredisposing/Contributing  Repeated dilatation of the cervix,Factors:  maternal DES ( Diethylstilbestrol) Exposure,  Traumatic injuries to the cervix.  Congenital anomaly  Trauma to the cervix (surgery / birth) 1. Uterine anomaly 2. Habitual abortion 3. Pre-term laborInitial Signs  Show (a pink-stained vaginal discharge)  #1 Sign: Rupture of membranes and discharge of amniotic fluidLate signs: Pressure or heaviness on the lower abdomen.Cardinal/Pathognomonic/maj  The cervix dilates painlessly in the second trimester of pregnancy.or sign: Bloody show  PROM  Painless dilatation  Birth of dead/non-viable fetusScreening or initial diagnostic Ultrasoundtest:Conformity test: UltrasonographyBest major surgery: Cervical Cerclage, McDonald CerclagePossible surgical Sterility, rupture of the cervix premature delivery, pelvic bleedingcomplication: and infection.MCHN Abejo
  • 4. Maternal and Child Health NursingAntepartal ComplicationDisease complication #1 Hemorrhage, Ectopic pregnancy, birth defects, viruses and pregnancy diseases, diabetes in pregnancy, HPNBest position before and after  Side lying positionsurgery  Prone positionBest side equipment  SuctionNursing Intervention  Pre-op: Encourage patient to maintain bed rest  Post-op: Check for excessive vaginal discharge and severe pain.  Bed rest in trendelenburg position  Administer tocolytic medications as ordered Eg; Ritodrine Hydrochloride (Yutopar): Terbutaline sulfate (Brethine): Magnesium Sulfate, Hydroxyzine hydrochloride (Vistaril) is a common drug ordered to counteract the effect of terbutaline (Brethine)  Surgery: Cervical Cerclage  Shirodkar-Barter Technique ( internal os) permanent suture: subsequent delivery by C/S.  Mc Donald Procedure ( external os)-suture removed at term with vaginal delivery  Usually 4-6 weeks after vaginal delivery is the safe period for a patient to resume sexual activity, when the episiotomy has healed and the lochia had stopped  - Monitor V/S and report HPN Monitor FHR  Limit activities  Observe for Ruptured BOW  Avoid vaginal douche  Avoid coitusE. DIABETES MELLITUS Gestational diabetes mellitus (pregnancy induced) A pregnant, insulin-dependent diabetic is at risk for sudden hypoglycemia because insulin needs and metabolism are affected b pregnancy, making sudden hypoglycemic episodes more common for diabetics. Changes in the glucose-insulin mechanism: o Early in pregnancy:  A. Increase production of insulin  B. Maternal glucose is consumed by fetus o Late in pregnancy:  A. Mother develops insulin resistance  B. The presence of placental insulinase breaks down insulin rapidlyB. Description of Diabetes in Pregnancy 1. Maternal glucose crosses the placenta but insulin does not 2. During the first trimester, maternal insulin needs decrease 3. The fetus produces its own insulin and pulls glucose from the mother, which predisposes the mother to hypoglycemic reactions 4. During the second and third trimesters, increases in placental hormones cause an insulin-resistant state, requiring an increase in the clients insulin dose 5. Diabetes mellitus is more difficult to control during pregnancy & occurs during the second or third trimester. Premature delivery is more frequent. The newborn infant of a diabetic mother may be large in size but will have functions related to gestational age rather than size. The newborn infant of a diabetic mother is subject to hypoglycemia, hyperbilirubinemia, respiratory distress syndrome, and congenital anomalies. Stillborn and neonatal mortality rates are higher in pregnancies of a diabetic woman NOTE: The greatest incidence of insulin coma during pregnancy occurs during the second and the third months, the incidence of the diabetic coma during pregnancy occurs around the sixth months.MCHN Abejo
  • 5. Maternal and Child Health NursingAntepartal Complication GESTATIONAL DIABETESDefinition  A type of Diabetes where only pregnant women gets where her blood sugar rate elevates but never had a high blood sugar rate before pregnancy.Synonyms Diabetes during PregnancyPredisposing/Contributing  Hyperglycemia develops during pregnancy because of the secretionFactors of placenta hormones such as Prolactin, Progesterone& Corticosteroids  Maternal age more than 35  Previous macrosomic infant  Previous unexplained stillbirth  Previous pregnancy with GDM  Family history of DM  Obesity  Hypertension  FBS more than 140 mg/dlInitial Signs 3-P’s: Polyuria, Polydipsia and Polyphagia MATERNAL SIGNS & SYMPTOMS: 1.Excessive thirst 2. Hunger 3. Weightless 4. Blurred vision 5. Frequent urination 6. Recurrent urinary tract infections and vaginal yeast infections 7. Glycosuria and ketonuria 8. Signs of pregnancy-induced hypertension 9. Polyhydramnios 10. Fetus large for gestational ageLate signs Fatigue, weakness, sudden vision changes, tingling or numbness in handsCardinal/Pathognomenic/majo Weight loss, fatigue, nausea, and vomiting excessive thirst, decreaser sign urinationScreening or initial diagnostic 50 gms oral glucose challenge testtestConfirmative test  3- hour glucose tolerance test will be performed to confirm diabetes mellitus  Glycosolated Hemoglobin less than 8%Best diet Strict Diabetic Diet Calories in diet should consist of 50% to 60% carbohydrates, 12% to 20% protein, and 20% to 30% fat NOTE: Because insulin does not pass into the breast milk, breastfeeding is not contraindicated for the mother with diabetes. Breastfeeding is encouraged; it decreases the insulin requirements for insulin-independent clients. Breastfeeding does not increase the risk of maternal infection; it leads to an increased caloric demand. Infants of diabetic mothers often display jitteriness in response to hypoglycemia after birthBest diet for the disease: Well-balanced Caloric DietDisease complication Maternal Complications: PIH, Placental disorders, stillbirth, macrosomia, neural tube defects. Fetal Diabetic Complications: Macrosomia Pre-eclampsia Hydramnios Congenital anomalies NOTE: The incidence of congenital anomalies among infants of diabetic pregnancies is three to four times higher than that in general population and is related to the high maternal glucose levels during the third to sixth gestational weeks.Best side equipment  Glucometer  Insulin Equipment  #1 Eternal Electronic Fetal Heart Rate monitoringMCHN Abejo
  • 6. Maternal and Child Health NursingAntepartal ComplicationBest drug  Insulin therapy ( don’t use Oral hypoglycemics, they are Teratogenic)Nature of the drug  InsulinNursing Diagnosis  #1 High Risk for fluid volume deficit related to polyuria and dehydration  Imbalanced nutrition related to imbalanced of insulin, food and physical activity  Potential heath care deficit related to physical improvements or social factors..Nursing Intervention MANAGEMENT  Screen clients between the 24th and 28th weeks of pregnancy  Prenatal visits bimonthly for 6 months and weekly thereafter.  Calories in diet should consist of 50% to 60% carbohydrates, 12% to 20% protein, and 20% to 30% fat  Observe client closely for an insulin since a precipitous drop in insulin required is usual  Monitor for signs of infection or post hemorrhage  If a pregnant diabetic is in labor, her blood glucose should be monitored hourly.  The preferred method of administration if insulin is required during labor is intravenous OTHER IMPORTANT MANAGEMENT: Urine testing Blood glucose determination Insulin administration Dietary management Exercise Fetal surveillance: (* Non-stress test * contraction stress test * amniocentesis)F. CARDIAC DISEASE CLASSIFICATION EFFECTS MANAGEMENT Class I Asymptomatic Retarded growth Goal is to reduce Class II Asymptomatic at rest; Fetal distress workload of heart symptomatic with heavy physical To relieve fetal distress let Promote rest activity the patient lie on her side Promote a healthy diet Class III Asymptomatic at rest; Educate regarding symptomatic with ordinary activity Premature labor medication Class IV Symptomatic with all You don’t have to notify Educate regarding activity; symptomatic at rest the physician if the patient avoidance of infection complains of a Promote reduction of a. Class I: no limitation of activities. No “fluttering” sensation in physiologic stress symptoms of cardiac insufficiency. her chest because of taking terbutaline b. Class II: slight limitation of activity, (Brethine) SQ for Asymptomatic at rest. Ordinary premature contractions activities causes fatigue, palpitations because it is a common and dyspnea side effect unless vital signs indicate stress c. Class II: marked limitation of activities, comfortable at rest, less than ordinary activities causes discomforts d. Class IV: unable to perform any physical activity without discomfort. May have the symptoms during rest.MCHN Abejo
  • 7. Maternal and Child Health NursingAntepartal Complication PREGNANCY INDUCED HYPERTENSION (TOXEMIA OF PREGNANCY)NAME OF THE PRE-ECLAMPSIA ECLAMPSIADISEASE MILD SEVERESynonym (PREGNANCY-INDUCED HYPERTENSION)Predisposing /  Primiparas younger than age 20 years or older than 40 yearsContributing factors  women from low socioeconomic background because of poor nutrition  women of color; women with heart disease  diabetes with vessel or renal involvement  essential hypertension  poor calcium and magnesium intake  hydatidiform mole  multiple gestation  polyhydramnios  pre-existing vascular diseaseInitial Sign  B≥140/90 mmGh  BP≥160/110 mmHg or  temperature rises on at least two diastolic pressure≥110 sharply to 39.4°C or occasion ≥ 6 hours mmHg on two 40ºC (103ºF to apart occasions at least 6 104ºF) from hours apart with the increased cerebral  proteinuria of 1-2+ patient on bedrest edema; reflexes on a random become hyperactive sample; weight gain  proteinuria ≥5 b/24 h over 2 lbs per week or 3+ to 4+ on  premonition that in second trimester qualitative assessment “something is and 1 lb per wk, (urine dipstick) happening”; third trimester epigastric pain and  extreme edema in nausea; urinary  mild edema in hands and output less than 30 upper extremities or face/”puffiness” ml/h faceLate Sign Signs of Worsening PIH  Oligauria ≤400 to 500 During pregnancy, or Impending Seizures: ml/24h blurred vision may be a  cerebral or visual danger sign of  BP 160/110 mm Hg disturbances (altered preeclampsia or or above level of consciousness eclampsia,  headache, scotomata, complications that  Epigastric pain or blurred vision) require immediate  Decreased urinary  epigastric pain or attention because they output RUQ pain, pulmonary can cause severe  Visual changes edema or cyanosis maternal and fetal  Headache  impaired liver consequences. function of unclear etiology  thrombocytopenia (platelet count <150,000); development of eclampsia elevated serum creatinine > 1.2 mg/dlCardinal / Hypertension and proteinuria are the most significant. Edema is significant onlyPathognomonic/ Major if hypertension and proteinuria or signs of multi-organ system involvement areSign present.Nursing Diagnosis and Fluid volume excess Maintaining Fluid BalanceNursing Interventions related to 1. Control IV intake using a continuous infusion pathophysiologic pump. changes of PIH and 2. Monitor input and output strictly; notify health care increased risk of fluid provider if urine output is <30 ml/h. overload. 3. Monitor hematocrit levels to evaluate intravascular fluid status. 4. Monitor vital signs every hour.MCHN Abejo
  • 8. Maternal and Child Health NursingAntepartal Complication 5. Auscultate breath sounds every 2 hours, and report signs of pulmonary edema (wheezing, crackles, shortness of breath, increased pulse rate, increased respiratory rate). Altered tissue Promoting Adequate Tissue Perfusion perfusion, Fetal 1. Position on side, preferably the left side to cardiac and cereral, promote placental perfusion. related to altered 2. Monitor fetal activity. placental blood flow 3. Evaluate NST to determine fetal status. caused by vasospasm 4. Increase protein intake to replace protein lost and thombosis. through kidneys. Risk for injury related Preventing Injury to convulsions. 1. Instruct on the importance of reporting headaches, visual changes, dizziness, and Decreased cardiac epigastric pain. output related to 2. Instruct to lie down on left side if symptoms are decreased preload or present. antihypertensive 3. Keep the environment quiet and as calm as therapy. possible. 4. If patient is hospitalized, side rails should be padded and remain up to prevent injury if seizure occurs. NOTE: The patient with a diagnosis of PIH should be close to the nurses’ station because she requires close observation. The patient also should be placed in a room with decreased stimuli. Maintaining Cardiac Output 1. Monitor IV intake using a continuous infusion pump. 2. Monitor input and output strictly; notify primary care provider if urine output is < 30 ml/h. 3. Monitor maternal vital signs; especially mean blood pressure and respirations. 4. Assess edema status, and report pitting edema of ≥ + 2 to primary care provider. 5. Monitor oxygenation saturation levels with pulse oximetry. Report oxygenation saturation rate of <90% to primary care provider.Screening/Initial Blood pressure over 140/90, or increase of 30 mm systolic, 15 mm diastolic overdiagnostic test pre-pregnancy level.Confirmatory Test 24-hour urine for protein of 300 mg or greater; elevated serum BUN and creatinine; increased deep tendon reflexes and clonus; blood pressure changes meeting criteria for diagnosisBest Diet The woman needs a moderate to high-protein, moderate-sodium diet to compensate for the protein she is losing.Disease Complications Abruptio placentae (Hypertension in PIH leads to vasopasm. This in turn causes the placenta to tear away from the uterine wall (abrupto placentae) disseminated intravascular coagulation; HELLP syndrome; prematurity; intrauterine growth restriction (IUGR) from decreased placental perfusion; maternal/fetal death; hypertensive crisis; acute renal failure; hemorrhage; cerebrovascular accident; blindness; hypoglycemia; hepatic ruptureBest Position SEVERE PRECLAMPSIA: Lateral recumbent position ECLAMPSIA: to prevent aspiration, turn the woman on her side to allow secretions to drain from her mouth.Beside Equipment Infusion pump; pulse oximeterMCHN Abejo
  • 9. Maternal and Child Health NursingAntepartal ComplicationBest Drug Mgnesium sulfate: 4-6 loading dose of 50% give IV over 15-30 mins followed by a maintenance dose (secondary infusion) of 1-4 g/h or IM injection or 10 g (5 g in each buttock) as a loading dose followed by 5 g every 4 hours Administer antihypertensives such as hydralazine (Apresoline) as prescribed, to prevent a cerebrovascular accidentNature of the Drug Best tocolytic agent; antihypertensive; anticonvulsant/eclampsia #1 Complication of MgSO4 is : Respiratory DepressionPRIORITY DRUG Reflexes, respiration and urinary output are priority assessments duringASSESSMENT: administration of magnesium sulfate therapy in patients with PIH.SIDE EFFECT If the patient’s magnesium levels increase above the therapeutic range (4 to 8 mg/dl), the absence of reflexes is often the first indication of toxicity. Reflexes often disappear at serum magnesium levels of 8 to 10 mg/dl. Respiratory depression occurs at levels of 10 to 15 mg/dl, and cardiac conduction problems occur at levels of 15 mg/dl and higher. Urinary output of less than 30ml/hour may result in the accumulation of toxic levels of magnesium.Proper Assessment of Assessment Patellar ReflexesAbnormal Reflexes  Position the client with legs dangling over the edge of the examining table or lying on back with legs slightly.  Strike the patellar tendon just below the kneecap with the percussion hammer.  Normal Response: Flexion of the arm at the elbow. Clonus  Position the client with legs dangling over the edge of the examining table.  Support the leg with one hand and sharply dorsiflex the client’s foot with the other hand.  Maintain the dorsiflexed position for a few seconds; then release the foot. Normal Response: (Negative Clonus Response)  Foot will remain steady in the dorsiflexed position.  No rhythmic oscillation of jerking of the foot will be felt.  When released, the foot will drop to a plantar flexed position with no oscillations. Abnormal Response: (Positive Clonus Response)  Rhythmic oscillations when the foot is dorsiflexed.  Similar oscillations will be noted when the foot drops to the plantar flexed position.G. BLEEDING DISORDERS AFFECTING THE PLACENTA Placenta: contains 20 cotyledons, weighs 400-600 grams. Develops on the 3rd month. Form from Chorionic villi & deciduas basalis. Deciduas (meaning endometrial changes & growth) Functions: Main source of nourishment & acts a transfer organ for metabolic purposes for the fetus. Placental Problem Placental separation is characterized by a sudden gush or trickle of blood from the vagina, furtherprotrusion of the umbilical cord from the vagina, a globular-shaped uterus, and an increase in fundal height. Withcervical or vaginal laceration, the nurse notes a consistent flow of bright red blood from the vagina. With postpartumhemorrhage, usually caused by uterine atony, the uterus isnt globular. Uterine involution cant begin until theplacenta has been delivered.MCHN Abejo
  • 10. Maternal and Child Health NursingAntepartal Complication PLACENTA PREVIA PLACENTA PREVIADefinition  Improperly implanted placenta in the lower uterine segment near or over the internal cervical os  Total: the internal os is entirely covered by the placenta when cervix is fully dilated  Marginal: only an edge of the placenta extends to the internal os  Low-lying placenta: implanted in the lower uterine segment but does not reach the osPredisposing Factor Maternal age Parity (no. Of pregnancy) Previous uterine surgeryAssessment . Painless . Heavy bleeding . Soft, non tender, relaxed uterus w/ normal tone . Shock in proportion to observed blood loss . Signs of fetal distress usually not presentComplication  Anemia  #1hemorrhage  #2shock,  renal failure  #3 disseminated intravascular coagulation  cerebral ischemia, maternal and fetal deathTherapeutic Interventions > Ultrasonography to confirm the pressure of placenta previa. > Depends on location of placenta, amount of bleeding and status of the fetus. > Home monitoring with repeated ultrasounds may be possible with type I- low lying > Control bleeding > Replace blood loss if excessive > Cesarean birth if necessary > Betamethasone is indicated to increase fetal lung maturity.Nursing Diagnosis with #1 NURSING DIAGNOSIS: Potential fluid volume deficitNursing Intervention Maintain bed rest > #1 Assessment - Monitor maternal vital signs, FHR, and fetal activity > Assess bleeding (amount and quality) > Monitor and treat signs of shock > Avoid vaginal examination if bleeding is occurring > Prepare for premature birth or cesarean section > Administer IV fluids as ordered > Administer iron supplements or blood transfusion as ordered (maintain hematocrit level) > Prepare to administer Rh immune globulinMCHN Abejo
  • 11. Maternal and Child Health NursingAntepartal ComplicationBESTPOSITION The patient with placenta previa should be maintained on bed rest, preferably in a side-lying position. Additional pressure from an upright position may cause further tearing of the placenta from the uterine lining. Ambulating would therefore be indicated for this patient. Performing a vaginal examination and applying internal scalp electrode could also cause the placenta to be further torn from the uterine lining.Confirmatory Test > Ultrasound for placenta localization NOTE:  Manual pelvic examinations are contraindicated when vaginal  bleeding is apparent in the third trimester unit a diagnosis is  made and placenta previa is ruled out.  Digital examination of the cervix can lead to maternal and fetal hemorrhage.  A diagnosis of placenta previa is made by ultrasound.  The hemoglobin and hematocrit levels are monitored and external electronic fetal heart rate monitoring is initiated. Electronic fetal monitoring (external) is crucial in evaluating the status of the fetus who is at risk for severe hypoxia.Best Position > Left lateral position ABRUPTIO PLACENTAE ABRUPTIO PLACENTAEDefinition Premature separation of the placenta from the uterine wall after the 20 th week of gestation and before the fetus is delivered (Saunders page 299- 300)Synonyms > Placental abruption > Premature separation of placentaPredisposing Factor > Maternal age > Parity > Previous abruptio placentae, multifetal gestation > Hypertension NOTE: Abruptio placentae is associated with conditions characterized by poor uteroplacental circulation, such as hypertension, smoking and alcohol or cocaine abuse. It is also associated with physical and mechanical factors such as over distension of the uterus that occurs with multiple gestation or polyhydranions. In addition, a short umbilical cord, physical trauma, and increased maternal age and parity are risk factors.MCHN Abejo
  • 12. Maternal and Child Health NursingAntepartal ComplicationPathophysiology > Spontaneous rupture of blood vessels at the placental bed may due to lack of resiliency or to abnormal changes in uterine vasculature. > May be complicated by hypertension or by an enlarged uterus that can’t contract sufficiently to seal off the torn vessels > Consequently, bleeding continues unchecked, possibly shearing off the placenta partially or completely.Manifestation > Painful vaginal bleeding > Hypertonic to tetanic, enlarged uterus > Board-like rigidity of abdomen (Cullen Sign) > Abnormal/absent fetal heart tones > Pallor > Cool, moist skin > Bloody amniotic fluid > Rising fundal height from blood trapped behind the placenta > Signs of shock > Manifestation of coagulopathy NOTE: Uterine tenderness accompanies placental abruption, especially with a central abruption and trapped blood behind the placenta. The abdomen will feel hard and boardlike upon palpation as the blood penetrates the myometrium and causes uterine irritability. Observation of the fetal monitoring often reveals increased uterine resting tone, caused by failure of the uterus to relax in an attempt to constrict blood vessels and control bleeding.Complication > Hemorrhage, shock, renal failure, disseminated intravascular coagulation, maternal death, fetal death(Nursing Alert p.4)Therapeutic Interventions > Replacement of blood loss. > With moderate or severe separation or maternal or fetal distress: emergency childbirth. NOTE: The goal of management in abruption placentae is to control the hemorrhage and deliver the fetus as soon as possible. Delivery is the treatment of choic if the fetus is at term gestation or if the bleeding is moderate to severe and mother or fetus is in jeopardy. > With mild separation without fetal distress and in the presence of some cervical effacement and dilatation: induction of labor may be attempted >Oxygen if necessary > Maintenance of fluid and electrolytes balance.Nursing Diagnosis with #1 NURSING DIAGNOSIS: Risk for fluid volume deficitIntervention > #1 Assessment: Monitor and FHR > Assess for vaginal bleeding, abdominal pain, and increase in fundal height > Maintain bed rest > Administer oxygen as prescribed > Monitor and report any uterine activity > Administer IV fluid as prescribed > Monitor I & O > Administer blood products as prescribed > Monitor blood studies > Prepare for the delivery of the fetus as quickly as possible > Monitor for signs of disseminated intravascular coagulation in the post- partum periodConfirmatory Test > Ultrasound detects retro-placental bleedingMCHN Abejo
  • 13. Maternal and Child Health NursingAntepartal Complication VENA CAVA SYNDROME Definition The venous return to the heart is impaired by the weight of uterus. Synonym Supine Hypotensive Syndrome Predisposing factors Thrombophlebitis NOTE: Contribute to clot formation motion include inactivity,reduced cordiac output, compression of the viens in pelvis or legs The most likely cause of supine hypotension is feeling dizzy, short of breath and clammy when lying back for long periods of time in patients 6 th month of pregnancy. The cause of supine hypotension during pregnancy is the weight of the uterus compresses the inferior vena cava, decreasing the return of blood to the heart, thus decreasing cardiac output, which lowers the blood pressure Initial sign  Fatique  proxymal nocturnal  dyspnea  orthopnea  hypoxia  cyanosis Late Sign Reduce renal perfection, Decrease glomerular filtration Cardinal sign Shock such as tachycardia NOTE: Caused by reduced cardiac output, respiratory distress, fatal distress Initial / Screening test FHT monitor NOTE: Above 160 or below 120 beats per minutes, Fetal PH below 7.5 Confirmatory test Amniotomy: NOTE: Above keeping the significant other improved of the progress of care, the fatal status would he the priority Nursing Diagnosis  Altered tissue perfection related to decrease blood circulation  Risk for altered Health maintenance related to insufficient knowledge of treatments, drug therapies, home care management and prevention of future infection  Altered comfort related to maladaptive coping Nursing Intervention  Closely monitor for shock and decreasing blood. Pressure, tachycardia, coal, clammy Skin  Maintain patient on bed rest to reduce Oxygen demands and risk for bleeding. Monitor prescribed medication given to preserve right Ventricular felling pressure and increase blood pressure  Instruct patient in self – care activities Provide information about anti smoking strategies and allow patient time to return demonstration of treatment to the done at home  Assess physical complaints matters of facts without emphasizing concern. Use deep – breathing, muscle relaxation, and imagery to relieve discomfort. Express a caring attitude Best major Surgery Caesarian Section – note if cervix is incomplete deleted. Best dirt for pre-operative Food and fluid are withheld before invasive procedure is not resumed until the client is stable and free of nausea & vomiting. Best diet for Disease Hypoallergenic Ionic diet Calcium increased Possible Surgical Interruption of vena cava, which reduce channel size. Complication Complication of Disease > Bleeding as a result of treatment NOTE: Observation of the fetal monitoring often reveal increase uterine rustling tone, caused by failure of the uterus to relax in an attempt to constrict blood vesicle and control bleeding > Respiratory failure. Best position pre-operative Sims Position NOTE: Turning to the left side to shift right of the fetus off the inferior vena cava. Bed Side Equipment Oxygen obtain equipment for external electronic fetal heart rate monitoring Oxygen with Cannula History of Disease Angina, myocardial infarctionMCHN Abejo
  • 14. Maternal and Child Health NursingAntepartal ComplicationOTHER DISEASES AND CONDITIONName of the Disease Disseminated Intravascular CoagulationPredisposing / Overwhelming infections particularly bacterial sepsis; #1 abruption placenta;Contributing Factors eclampsia; amniotic fluid embolism; IUFD(Intra-uterine fetal death) or retention of dead fetus; burn; trauma; fractures; major surgery; fat embolism; sock; hemolytic transfusion reaction; malignancies particularly of lung, colon, stomach, and pancreas NOTE: Disseminated intravascular coagulation (DIC) is a state of diffuse clotting in which clotting factors are consumed. This leads to widespread bleeding. Platelet are decreased because they are consumed by the process, coagulation studies show no clot formation (and are thus normal to prolonged); and fibrin plugs may clog the microvasculature diffusely, oozing from injection sites, and presence of hematuria are signs associated with the presence of DIC. Swelling and pain in the calf of one leg are more likely to be associated with thrompophlebitis. (SaundersInitial Sign Coolness and mottling of extremities; pain; dyspnea; abnormal bleedingLate Sign Altered mental status; acute renal failureNursing Diagnosis & Risk for injury related Minimizing BleedingIntervention to bleeding due to 1. Institute Bleeding precautions thrombocytopenia 2. Monitor pad count/amount of saturation during menses; administer or teach self-administration of hormones to suppress menstruation as prescribed. 3. Administer blood products as ordered. Monitor for signs and symptoms of allergic reactions, anaphylaxis, and volume overload. 4. Avoid dislodging costs. Apply pressure to sites of bleeding for at least 20 mins, use topical hemostatic agents. Use tape cautiously. 5. Maintain bed rest during bleeding episode. 6. If internal bleeding is suspected, assess bowel sounds and abdominal girth. 7. Evaluate fluid status and bleeding by frequent measurement fo vital signs, central venous pressure, intake and output. Promoting Tissue Perfusion 1. Keep patient warm 2. Avoid vasoconstrictive agents (systemic or topical). Altered tissue perfusion 3. Change patient’s position frequently and perform (all tissues) related to ROM exercises. ischemia due to 4. Monitor electrocardiogram and laboratory test for microthrombi dysfunction of vital organs casued by ischemia – formation arrhythmias, abnormal arterial blood gases, increased blood urea nitrogen and creatinine. 5. Monitor for signs of vascular occlusion and report immediately. a. Brain – decreased level of consciousness, sensory and motor deficits, seizures, coma. b. Eyes – Visual deficits. c. Bone – Pain d. Pulmonary vasculature – chest pain, shortness of breath, tachycardia. e. Extremities – cold, mottling, numbness. f. Coronary arteries – chest pain, arrhythmias. g. Bowel – pain, tenderness, decreased bowel sounds.Screening or Initial PT; PTT; Platelet countDiagnostic TestConfirmative Test Decreased Fibrinogen level; increased fibrin split products; decreased anti-thrombin III levelBeside Equipment ECG; CVPBest Drug Heparin inhibits clotting components of DICNature of the Drug AnticoagulantMCHN Abejo
  • 15. Maternal and Child Health NursingAntepartal ComplicationName of the Disease Hyperemesis gravidarumDefinition Hyperemesis gravidarum is persistent, uncontrolled vomiting that begins in the first weeks of pregnancy and may continue throughout pregnancy. Unlike “morning sickness,” hyperemesis can have serious complications, including severe weight loss, dehydration, and electrolyte imbalance. NOTE: The defining factor for hyperemesis gravidarum should be the time of occurrence – and that is the 2nd trimester, usually the 14 – 16th week. If this is on the 1st trimester, usually this is morning sickness.Causes  Gonadotropine production  Psychological factors  Trophoblastic activityAssessment Findings  Continuous, severe nausea and vomiting  Dehydration  Dry skin and mucous membranes  Electrolyte imbalance  Metabolic acidosis  Non-elastic skin turgor  OliguriaDiagnostic Result  Arterial blood gas and analysis reveals alkalosis.  Hb level and HCT are elevated.  Serum potassium level reveals hypokalemia  Urine ketone levels are elevated.  Urine specific gravity is increased.Nursing Diagnosis  Fluid volume deficit  Altered nutrition; less than body requirements  PainTreatment  Total parenteral nutrition (TPN)  Restoration of fluid and electrolyte balance  Anti-emetics, as necessary for vomiting, for example Plasil , Hydroxyzine and ProchlorperazineNursing Intervention  Monitor vital signs and fluid intake and output to assess for fluid volume deficit.  Obtain blood samples and urine specimens for laboratory tests, including Hb level, HCT, urinalysis, and electrolyte levels.  Provide small frequent meals to maintain adequate nutrition.  Maintain I.V. fluid replacement and TPN to reduce fluid deficit and pH imbalance.  Provide em0otional support to help the patient cope with her condition. Teaching Topics  Using salt on foods to replace sodium lost by vomiting.MCHN Abejo