Maternal Nursing

Complications
 DYSTOCIA
 Difficult labor
 Mechanical factor – uterine inertia;

sluggishness of contractions
 1. Hypertonic or primary uterine inertia

– intense, excessive contractions

resulting to ineffective pushing
 Diazepam/Valium – muscle relaxant
 2. Hypotonic or secondary – slow
irregular contraction resulting to
ineffective pushing
 Oxytocin
 Prolonged labor:
 Nullipara – normal-14-20 hours; >20

 Multipara – normal-10-14 hours; >14

 Maternal effect – exhaustion

 Fetal effect – fetal distress, caput

succedaneum or cephalhematoma
 PRECIPITATE LABOR
 Labor of <3 hours
 Grand multiparity, induction of labor by

oxytocin, amniotomy
 Effects: premature separation of

placenta
 Fetal effect: subdural hemorrhage
 Maternal effect:
 1. Uterine inversion:
 Other causes – short cord, hurrying of
placental delivery, ineffective uterine fundal
pressure
 Never attempt to replace, never attempt to
remove placenta
 Don’t give oxytocic drug
 Tocolytic drug given
 2. Bleeding:
 Hypovolemic Shock

 Ealiest sign: tachycardia and

restlessness
 Late sign: hypotension

 Position – Trendelenderg

 IV – fast drip
 UTERINE RUPTURE
 Causes:
 1. Previous classical CS

 2. Prolonged labor

 3. Abnormal presentation

 4. Multiple gestation

 5. Unwise use of oxytocin

 6. Obstructed labor
 Physiologic retraction ring – boundary
between upper and lower uterine
segment
 Pathologic retraction ring (Bandl’s
Ring) – suprapubic depression
 Sign of impending uterine rupture

 S/S: sudden, severe pain, profuse

bleeding, shock begins
 Management
 Prepare for CS
 Fluid replacement therapy

 TAHBSO
 AMNIOTIC FLUID
EMBOLISM
 Occurs when amniotic fluid is forced into an
open maternal uterine blood sinus
 Not preventable
 Risk factors: oxytocin administration, abruptio
placenta, hydramnios
 S/S: chest pain, frothy sputum
 Management: suctioning, endotracheal
intubation
 Death – in few minutes
 Risk for: DIC
 PREMATURE LABOR
CONTRACTIONS
 1. Premature labor contractions-10mins
 2. Effacement – 60-80%
 3. Dilatation – 2-3cm
 Home Mgt:
 1. Complete bed rest
 2. Avoid sex
 3. Empty bladder
 4. Consult MD
 Hosp:
 Administration of Tocolytic –

Terbutaline
 Antidote – propranolol or inderal

 Crackles – notify MD

 Cervix open – steroid dexamethazone

 Preterm – cut cord ASAP

 First Trimester
Bleeding
 A. Abortions – any interruption of a
pregnancy before a fetus is viable
 Spontaneous – miscarriage
 Causes:
 1. Abnormal fetal formation
 2. Rejection of the embryo
 3. Implantation abnormalities
 4. Infection
 Classifications
 1. Threatened – bleeding and cramping but
the cervix is closed
 2. Inevitable/Imminent – uterine contractions
with cervical dilatation
 Types:
 Complete – all products of conception are
expelled
 Incomplete – membrane or placenta is
retained; D&C
 3. Missed – fetus dies; not expelled;
remain in the uterus 4-6 weeks; signs
of pregnancy ceases
 4. Habitual – recurrent pregnancy loss

 3 or more consecutive pregnancies

recult in abortion
 Defective spermatozoa or ova

 Deviations of the uterus

 A.1 Induced Abortion – therapeutic
abortion to save life of mom
 Ectopic Pregnancy
 Implantation occurs outside the uterine
cavity
 Most common – fallopian tube

 Causes:

 Obstruction: adhesion of the fallopian

tube, congenital malformation, scars,

tumor
 Assessment
 No menstrual flow
 Positive pregnancy test
 6-12 weeks – rupture of the tue
 Sudden, sharp, severe pain
 Shoulder pain
 Positive Cullen’s sign
 Tender mass in the Douglas’ cul-de-sac
 Management
 V/S
 IV therapy

 Monitor I & O

 Surgery: depending on side

 Second Trimester
Bleeding
 Hydatidiform Mole – gestational
trophoblastic disease
 Abnormal proliferation and
degeneration of the trophoblastic villi
 “Bunch of grapes”

 Occur most: low protein intake, women

older than age 35 years, women of
Asian heritage
 Types:
 Complete – all trophoblastic villi swell

and become cystic; normal

chromosome component; may lead to
choriocarcinoma
 Partial:
 Some villi form normally

 Rarely lead to choriocarcinoma

 69 chromosomes
 Assessment
 Expand faster than normal; symphysis
pubis at 12 weeks
 High level of hCG

 Preeclampsia at 12 weeks

 16 weeks – vaginal bleeding–spotting

or profuse
 Clear-fluid vesicles passed
 Management
 D&C
 Methotrexate – prevent

choriocarcinoma
 Dactinomycin – metastasis

 hCG monitoring

 Avoid pregnancy for at least 1 year

 PREMATURE CERVICAL
DILATATION
 Incompetent cervix
 Cervix that dilates prematurely
therefore cannot hold a fetus until term
 1st symptom: show, increased pelvic
pressure, uterine contraction follows
 20th week

 Cervical cerclage – McDonald or

Shirodkar procedure; 12-14 weeks
 Third Trimester
Bleeding
 Placental anomalies
 Placenta Previa
 Low implantation of the placenta
 Low-lying placenta – lower rather than in the
upper portion of the uterus
 Marginal implantation – placental edge
approaches the cervical os
 Partial placenta previa – occludes a portion
of the cervical os
 Total placenta previa – totally obstructs the
cervical os
 Risks:
 Increased parity

 Advanced maternal age

 Past cesarean birth

 Past uterine curettage

 Multiple gestation

 Male fetus
 Assessment
 Bleeding – abrupt, painless, bright red;
begins at 30 weeks
 Not engaged

 DX: UTZ
 Management
 Cautioned to: avoid sex, get adequate rest
 Side-lying – bleeding
 Estimate blood loss
 Apt or Kleihauer-Betke test – determine if blood is
maternal or fetal
 No pelvic or rectal exam
 Assess v/s – BP: q 5 to 15 minutes
 IV therapy
 Monitor I&O – q 1hour
 Prepare for CS
 Betamethasone – hastens lung maturity;less than 34wks
 Abruptio Placentae
 Premature separation of the placenta
 20th week; may occur during the first or second stage of
labor
 Risks:
 High parity
 Advanced maternal age
 Short umbilical cord
 Chronic hypertensive disease
 PIH
 Direct trauma
 Cocaine/cigarette use
 Assessment
 Sharp, stabbing pain high in the
fundus – initial separation
 Couvelaire uterus – uteroplacental
apoplexy; blood infiltrate the uterine
musculature
 A hard, boardlike uterus

 Signs of shock follow

 DIC syndrome can occur

 Management
 IV therapy
 v/s q 5-15mins

 Lateral positioning

 No vaginal, pelvic exam, enema

 Fibrinogen baseline

 DIC – IV of fibrinogen or

cryoprecipitate
 Other Abnormal
Placenta
 Placenta circumvallata – fetal surface of the
placenta presents a central depression
surrounded by thickened grayish white ring
 Placenta marginata – fold side of chorion
reaches just to the edge of placenta
 Battledore placenta – cord inserted
marginally rather than central
 Placenta bipartita – placenta divides into 2
lobes
 Vilamentous insertion of cord – cord divides
into small vessels before it enters the
placenta
 Vasa placenta – vilamentous insertion of th
eocrd has implanted in cervical os
 Placenta succenturiata – one or more
accessory lobe is located at a distance from
the main placenta
Hypertensive Disorders
 Pregnancy-Induced Hypertension –
vasospasm occurs during pregnancy
in both small and large arteries
 Classic signs: Hypertension,
proteinuria, edema
 Symptoms: Rarely occur before 20
weeks
 Solved 6 weeks post partum
 RISKS:
 Women of color
 Multiple pregnancy
 Primiparas under 20, over 40
 Low socio-economic status
 5 or more pregnancies
 Hydramnios
 Heart disease, diabetes, renal involvement
 Essential hypertension
 Gestational
Hypertension
 Elevated BP – 140/90 mm Hg
 No proteinuria or edema

 No drug therapy is necessary

 Mild Preeclampsia
 BP – 140/90 mm Hg; taken twice 6
hours apart
 SBP 30mm Hg above baseline

 DBP 15 mm Hg above baseline

 Proteinuria – 1+ or 2+

 Edema – upper part of the body

 Weight gain – 2lb/wk in 2nd trimester; 1

lb/wk in 3rd trimester
 Severe Preeclampsia
 BP 160/110 mm Hg
 DBP – 30 mm Hg above baseline
 Proteinuria – 3+ or 4+
 Edema – puffiness of the face and hands
 Reduced urine output – 400-600ml/24 hrs
 Severe epigastric pain
 Pulmonary edema – short of breath
 Cerebral edema – visual disturbances, sever
headache, marked hyperreflexia
 Eclampsia
 Seizure
 Coma may occur
 Management
 Promote bed rest – decrease O2 demand;
greater sodium excretion
 Prevent convulsion or seizure precaution:
– Dimly lit room; quite calm environment
– Minimal handling
– Avoid jarring
 Prepare the following:
– Tongue depressor
– Turn to side
 Ensure high protein intake – 1g/kg/day
– Na – moderation
 Antihypertensive drug – Hydalazine
(Apresoline)
 Convulsion – MgSO
4
 Evaluate physical parameters for
MgSO4 toxicity:
 1. Decreased deep tendon reflex –
absent patellar reflex-1st sign
 2. Hypotension

 3. Decreased urine output

 4. Respiratory depression – RR <12

 Antidote – Ca gluconate
 POSTPARTAL
HEMORRHAGE
 Blood loss front he uterus greater than
500ml within 24-hour period
 Greatest danger – first 24 hours

 Signs of Shock:

 Pulse rate increases then becomes

weak and thready
 BP drops

 Skin – cold and clammy

 Management
 Uterine pack - <48 hours only; prevent
puerperal sepsis
 Supine position and oxygen

administration (4 L/min)
 Blood replacement
 Uterine Atony
 Relaxation of the uterus
 Most frequent cause

 Multiple gestation

 Hydramnios

 Large baby (more than 9 lbs)

 Presence of uterine myomas (fibroid

tumors)
 Massage
 Empty bladder

 Oxytocin (Pitocin)/Methylergonovine

(Methergine)
 Bimanual massage

 Hysterectomy – last resort

 Lacerations
 Cervical – cervical repair
 Vaginal – rare

 Causes:

 Operative birth

 Rapid birth
 Perineal:
 1st degree – vaginal mucous membrane and
skin of the perineum to the fourchette
 2nd – vagina, perineal skin, fascia, levator
ani muscle, perineal body
 3rd – entire perineum, external sphincter of
the rectum
 4th – entire perineum, rectal sphincter, some
mucous membrane of the rectum
 Disseminated
Intravascular Coagulation
 Deficiency in clotting ability caused by
vascular injury; fibrinogen falls below
effective level
 Increased coagulation but bleeding defect
exists throughout the body
 Associated – premature separation of the
placenta, missed early miscarriage, fetal
death in utero
 Early s/s – easy bruising or bleeding
 Premature separation of placenta –
end pregnancy
 IV administration of heparin

 Bleeding during pregnancy – blood or

platelet transfusion
 SUBINVOLUTION
 Incomplete return of the uterus to its
prepregnant size and shape
 Small retained placental fragment

 Mild endometritis

 Myoma

 Management: Methergine-0.2 mg
4x/day
 Antibiotic - endometritis
 PERINEAL
HEMATOMAS
 Collection of blood in the subcutaneous
layer of tissue of the perineum
 Injury to blood vessels
 May occur at the site of episiotomy of
laceration
 Rapid, spontaneous births
 Perineal varicosities
 Absorbed in 3-4 days
 Management
 Mild analgesic
 Ice pack

 Ligation of the vessel