CERVICAL INSUFFICIENCY (PREMATURE CERVICAL DILATATION)

- termed an incompetent cervix

-cervix that dilates prematurely and therefore cannot retain a fetus until term
- the first symptom is show (a pink-stained vaginal discharge) or increased pelvic
pressure, which then is followed by rupture of the membranes and discharge of the
amniotic fluid
- this commonly occurs at approximately week 20 of pregnancy
- it is associated with increased maternal age, congenital structural defects, and
trauma to the cervix, such as might have occurred with a cone biopsy or repeated
D&Cs
- diagnosed by an early ultrasound before symptoms occur, it is usually diagnosed
only after the pregnancy is lost.
-a surgical operation termed cervical cerclage can be performed to prevent this
from happening in a second pregnancy
-approximately weeks 12 to 14, purse-string sutures are placed in the cervix by the
vaginal route under regional anesthesia.
-This procedure is called a McDonald or a Shirodkar procedure after the surgeons
who perfected the technique.
-n a McDonald procedure, nylon sutures are placed horizontally and vertically
across the cervix and pulled tight to reduce the cervical canal to a few
millimeters in diameter
- a Shirodkar technique, sterile tape is threaded in a purse- string manner under
the submucous layer of the cervix and sutured in place to achieve a closed cervix.
Although routinely accomplished by a vaginal route, sutures may be placed by a
transabdominal route.
-women remain on bed rest (perhaps in a slight or modified Trendelenburg position)
for a few days to decrease pressure on the new sutures
-the sutures are removed at weeks 37 to 38 of pregnancy so the fetus can be born
vaginally
-Be certain to ask women who are reporting painless bleeding (also the symptoms of
spontaneous miscarriage) whether they have had past cervical operations to remind
them they may have sutures in place.

PLACENTA PREVIA
-the placenta is implanted abnormally in the lower part of the uterus, is the most
common cause of painless bleeding in the third trimester of pregnancy
It occurs in four degrees
implantation in the lower rather than in the upper portion of the uterus
(low-lying placenta)
marginal implantation (the placenta edge approaches that of the cervical os)
implantation that occludes a portion of the cervical os (partial placenta
previa),
implantation that totally obstructs the cervical os (total placenta previa).
-Increased parity, advanced maternal age, past cesarean births, past uterine
curettage, multiple gestation, and perhaps a male fetus are all associated with
placenta previa.
- the placenta appears to have been implanted correctly. Suddenly, however, it
begins to separate and bleeding results. This occurs in about 10 out of 1,000
pregnancies and, because it can lead to extensive bleeding, is the most frequent
cause of perinatal death
-
Assessment
- sonogram done to date the pregnancy
-bleeding with placenta previa doesn�t usually begin, however, until the lower
uterine segment starts to differentiate from the upper segment late in pregnancy
(approximately week 30) and the cervix begins to dilate.
-The bleeding is usually abrupt, painless, bright red, and sudden enough to
frighten a woman.
Therapeutic Management
-Immediate Care Measures
-place the woman immediately on bed rest in a side-lying position.
-Inspect the perineum for bleeding and estimate the present rate of blood loss.
- (test strip procedures) can be used to detect whether the blood is of fetal or
maternal origin.
-Obtain baseline vital signs to determine whether symptoms of hypovolemic shock are
present
-Continue to assess blood pressure every 5 to 15 minutes or continuously with an
electronic cuff
-record fetal heart sounds and uterine contractions (an internal monitor for either
fetal or uterine assessment is contraindicated).
- Hemoglobin, hematocrit, prothrombin time, partial thromboplastin time,
fibrinogen, platelet count, type and cross-match, and antibody screen will be
assessed to establish baselines, detect a possible clotting disorder, and ready
blood for replacement if necessary
-Monitor urine output frequently, as often as every hour,
-Administer intravenous fluid as prescribed, preferably with a large-gauge catheter
to allow for blood replacement through the same line.
-the safest birth method for both mother and baby is often a cesarean birth
- careful speculum examination of the vagina and cervix to establish the degree of
fetal engagement and to rule out another cause for bleeding, such as ruptured
varices or cervical trauma.
- oxygen equipment available in case the fetal heart sounds indicate fetal
distress, such as bradycardia or tachycardia, late deceleration, or variable
decelerations during the exam.
-. Betamethasone, a steroid that hastens fetal lung maturity, may be prescribed for
the mother to encourage the maturity of fetal lungs if the fetus is less than 34
weeks gestation

-: Fear related to outcome of pregnancy after episode of placenta previa bleeding

PREMATURE SEPARATION OF THE PLACENTA (ABRUPTIO PLACENTAE)

- the placenta appears to have been implanted correctly. Suddenly, however, it
begins to separate and bleeding results. This occurs in about 10 out of 1,000
pregnancies and, because it can lead to extensive bleeding, is the most frequent
cause of perinatal death
-The separation generally occurs late in pregnancy; even as late as during the
first or second stage of labor.
-The primary cause of premature separation is unknown, but certain predisposing
factors are high parity, advanced maternal age, a short umbilical cord, chronic
hypertensive disease, hypertension of pregnancy, direct trauma (as from an
automobile accident or intimate partner violence), vasoconstriction from cocaine or
cigarette use, and thrombophilic conditions that lead to thrombosis formation
-It also may be caused by chorioamnionitis or infection of the fetal membranes and
fluid
-Yet another possible cause is a rapid decrease in uterine volume, such as occurs
with sudden release of amniotic fluid as can happen with polyhydramnios

Assessment
- experiences a sharp, stabbing pain high in the uterine fundus as the initial
separation occurs.
- If labor begins with the separation, each contraction will be accompanied by pain
over and above the pain of the contraction. Tenderness can be felt on uterine
palpation.
-Heavy bleeding usually accompanies premature separation of the placenta, although
it may not be readily apparent
- signs of hypovolemic shock usually follow quickly
- The uterus becomes tense and feels rigid to the touch
-assess when the time the bleeding began, whether pain accompanied it, the amount
and kind of bleeding, and her actions to detect if trauma could have led to the
placental separation
- Initial blood work should include hemoglobin level, typing and cross- matching,
and a fibrinogen level and fibrin breakdown products to detect DIC.

Therapeutic Management
- A woman needs a large-gauge intravenous catheter inserted for fluid replacement
and oxygen by mask to limit fetal anoxia
-Monitor fetal heart sounds externally and record maternal vital signs every 5 to
15 minutes to establish baselines and observe progress.
- Keep a woman in a lateral, not supine, position to prevent pressure on the vena
cava and additional interference with fetal cerculation
- do not perform any abdominal, vaginal, or pelvic examination on a woman with a
diagnosed or suspected placental separation.
- If DIC has developed, cesarean birth may pose a grave risk because of the
possibility of hemorrhage during the surgery and later from the surgical incision
-Intravenous administration of fibrinogen or cryoprecipitate (which contains
fibrinogen) can be used to elevate a woman�s fibrinogen level prior to and
concurrently with surgery
- a hysterectomy might be necessary to prevent exsanguination.
-Death can occur from massive hemorrhage leading to shock and circulatory collapse
or renal failure from circulatory collapse.