MODULE 4 PREGNANCY, CHILDBIRTH, AND POSTPARTUM AT RISK

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MODULE 4 PREGNANCY, CHILDBIRTH, AND POSTPARTUM
AT RISK
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• PREGNANCY AT RISK
• PREGESTATIONAL
• GESTATIONAL
• CHILDBIRTH AT RISK
• PRELABOR COMPLICATIONS
• LABORRELATED COMPLICATIONS
• POSTPARTUM AT RISK

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MODULE 4 PART 1APREGESTATIONAL RISKSSUBSTANCE
ABUSE
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SUBSTANCE ABUSE DURING PREGNANCY

• ALCOHOL
• CNS DEPRESSANT
• INCIDENCE OF ABUSE HIGHEST IN MOTHERS 20-40 YEARS
  OF AGE
• PREGNANT WOMEN SHOULD AVOID ALCOHOL COMPLETELY
  DURING PREGNANCYWHY?
• ADVERSE MATERNAL EFFECTS
• ADVERSE FETUS/NEONATAL EFFECTS

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Fetal Alcohol Syndrome
Retrieved from http//www.aafp.org/afp/2005/0715/
p279.html
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SUBSTANCE ABUSE DURING PREGNANCY

• COCAINE AND CRACK
• PREVENTS REUPTAKE OF DOPAMINE, NOREPINEPHRINELEAD
  S TO VASOCONSTRICITION, TACHYCARDIA, HYPERTENSION
• ADVERSE MATERNAL EFFECTS
• ADVERSE FETAL/NEONATAL EFFECTS

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SUBSTANCE ABUSE DURING PREGNANCY

• MARIJUANA
• NO STRONG RESEARCH INDICATING TERATOGENIC EFFECTS
• SOCIAL FACTORS
• HEROIN/METHADONE
• ADVERSE MATERNAL EFFECTS
• ADVERSE FETAL/NEONATAL EFFECTS

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SUBSTANCE ABUSE DURING PREGNANCY

• BARBITURATES
• STIMULANTS
• CAFFEINE
• NICOTINE
• PSYCHOTROPICS
• METH

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MODULE 4 PART 1BPREGESTATIONAL RISKS DIABETES
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DIABETES MELLITUS IN PREGNANCY

• PATHOPHYSIOLOGY
• INSULIN PRODUCTION DECREASE BY PANCREAS
• WITHOUT ADEQUATE INSULIN, GLUCOSE DOES NOT ENTER
  CELLS, WHICH BECOME ENERGY DEPLETED
• BLOOD GLUCOSE LEVELS INCREASE
• CELLS BREAK DOWN PROTEIN AND FAT STORES FOR ENERGY

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DIABETES MELLITUS IN PREGNANCY

• EARLY PREGNANCY
• ESTROGEN, PROGESTERONE, OTHER HORMONES RISE TO
  STIMULATE INCREASED INSULIN PRODUCTION AND
  INCREASED TISSUE RESPONSE TO INSULIN
• STORAGE OF GLYCOGEN IN LIVER PRODUCES ANABOLIC
  STATE DURING IST HALF OF PREGNANCY

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DIABETES MELLITUS IN PREGNANCY

• 2ND HALF OF PREGNANCY PRESENTS WITH INCREASED
  RESISTANCE TO INSULIN AND DECREASED GLUSOSE
  TOLERANCE DUE TO
• SECRETION OF Hpl (INSULIN ANTAGONIST)
  PROLACTIN, INCREASED CORTISOL AND GLYCOGEN LEVELS
• RESULTS IN CATABOLIC STATE
• DIABETOGENIC EFFECT

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DIABETES IN PREGNANCY

• CLASSIFICATIONS
• ETIOLOGIC
• TYPE I
• TYPE II
• TYPE III
• TYPE IV
• BASED ON CAUSE
• WHITES
• CLASS A-T
• DESCRIBES EXTENT OF DISEASE

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GESTATIONAL DIABETES

• GESTATIONAL DIABETES
• WHY DOES THIS OCCUR?
• -- WHEN DOES THIS OCCUR?
• WHAT IS THE INCIDENCE OF THIS OCCURING DURING
  PRGNANCY?
• HOW IS IT DIAGNOSED?

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COMPARISON OF DIABETES MELLITUS AND GESTATIONAL
DIABETES
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DIABETES MELLITUS IN PREGNANCY

• INTRAPARTAL MANAGEMENT
• WHEN TO DELIVER
• LABOR MANAGEMENT, INSULIN REQUIREMENTS
• POSTPARTAL MANAGEMENT
• INSULIN REQUIREMENTS
• BREAST FEEDING

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DIABETES IN PREGNANCY

• CHALLENGES, INFLUENCES
• MATERNAL RISKS
• FETAL, NEWBORN RISKS

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DIABETES MELLITUS IN PREGNANCY

• CLINICAL TREATMENT
• GTT CRITERIA
• LAB ASSESSMENT
• ANTEPARTAL MANAGEMENT
• DIET
• GLUCOSE MONITORING
• INSULIN REQUIREMENTS
• FETAL EVALUATION

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MODULE 4 PART 1CPREGESTATIONAL RISKSINFECTIONS
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HIV IN PREGNANCY

• RISKS TO MOTHER
• RISKS TO FETUS/NEONATE
• ANTEPARTUM, INTRAPARTUM, POSTPARTUM TREATMENT
  CARE

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TORCH

• TOXOPLAMOSIS
• OTHER
• GBS
• RUBELLA
• CYTOMEGALIVIRUS
• HERPES

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TORCH

• MATERNAL RISKS
• FETAL RISKS
• ANTEPARTUM, INTRAPARTUM, POSTPARTUM TREATMENT AND
  CARE

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GROUP B STREPTOCOCCUS

• INCIDENCE
• TESTING
• TREATMENT
• NURSING INTERVENTIONS

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GESTATIONAL PREGNANCY RISKS

• BLEEDING DISORDERS
• HYPERTENSIVE DISORDER
• Rh ALLOIMMUNIZATION
• ABO INCOMPATIBILITY
• DOMESTIC VIOLENCE
• SURGERY, TRAUMA

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MODULE 4 PART 2AGESTATIONAL ONSET
COMPLICATIONSBLEEDING DISORDERS
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BLEEDING DISORDERS

• ECTOPIC PREGNANCY
• TREATMENT, RISKS
• GESTATIONAL TROPHOBLASTIC DISEASE
• HYDATIFORM MOLE
• CHORIOADENOMA DESTRUENS
• CHORIOCARCINOMA
• TREATMENT, RISKS

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GESTATIONAL RISKS

• INCOMPETENT CERVIX
• CERCLAGE
• HYPEREMESIS GRAVIDARUM
• FLUID ELECTROLYTE ISSUES
• DEHYDRATION
• RISKS TO FETUS
• NURSING CARE

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Cerclage
Retrieved from www.drlindagalloway.wordpress.com
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GESTATIONAL RISKS

• PREMATURE RUPTURE OF MEMBRANES
• PROM
• PPROM
• NST, BPP
• RISKS
• NURSING CARE

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Positive Fern Test
Retrieved from commons.wikimedia.org
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MODULE 4 PART 2B GESTATIONAL COMPLICATIONS AND
RISKSPREGNANCY REDUCED HYPERTENSION

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PREGNANCY INDUCED HYPERTENSION--PIH

• PREECLAMPSIA/ECLAMPSIA
• CHRONIC HYPERTENSION
• CHRONIC HYPERTENSION WITH SUPERIMPOSED
  PREECLAMPSIA OR ECLAMPSIA
• TRANSIENT HYPERTENSION

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PREECLAMPSIA

• DISEASE OF THEORIES
• MOST COMMON HYPERTENSIVE DISORDER IN PREGNANCY
• PATHOPHYSIOLOGY
• CAUSE UNKNOWN
• 5-7 OF ALL PREGNANCIES
• GENERALIZED VASOSPASM, DECREASE IN CIRCULATING
  BLOOD VOLUME

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Preeclampsia
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PREECLAMPSIA

• PRENATAL FACTORS INCREASING RISK OF PIH
• PRIMIGRAVIDA
• ESSENTIAL HYPERTENSION
• AGE EXTREMES (UNDER 17 OR OVER 35 YEARS OLD)
• UNDERWEIGHT OR OVERWEIGHT
• FAMILY HISTORY OF HYPERTENSION
• DIAGNOSIS OF PIH IN PREVIOUS PREGNANCY
• DIABETES MELLITUS

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PREECLAMPSIA

• CHARACTERIZED BY
• DEVELOPMENT OF HYPERTENSION
• 30MM HG INCREASE IN SYSTOLIC AND 15 MM HG
  DIASTOLIC OVER BASELINE ON AT LEAST 2 OCCASIONS 6
  OR MORE HOURS APART
• PROTEINURIA ,HYPERREFLEXIA
• EDEMA
• MATERNAL RISKS
• FETAL/NEONATAL RISKS

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PREECLAMPSIA

• CLINICAL MANAGEMENT/CARE
• ANTEPARTAL MANAGEMENT
• MILD PREECLAMPSIA
• SEVERE PREECLAMPSIA
• INTRAPARTAL MANAGEMENT
• POSTPARTAL MANAGEMENT
• HELLP SYNDROME
• ECLAMPSIA

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H E L L P Syndrome

• H hemolysis- distortion and rupture of RBCs
• E elevated
• L liver enzymes- fibrin deposits obstruct
  blood flow
• L low
• P platelet count

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MODULE 4 PART 2CGESTATIONAL RISKS
COMPLICATIONS Rh ISOIMMUNIZATION
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Rh SENSITIZATION

• ANTIGEN-ANTIBODY RESPONSE
• IF AN Rh-NEGATIVE WOMAN IS EXPOSED TO Rh POSITIVE
  BLOOD, EITHER THROUGH TRANSFUSION OR A PRIOR
  PREGNANCY, SHE PRODUCES IMMUNOGLOBULIN (Ig)G
  ANTIBODY (ANTIRhD)
• INDIRECT COOMBS TEST
• DIRECT COOMBS TEST

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Figure 135d Anti-Rh-positive antibodies
(triangles) are formed.
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Figure 135b Pregnancy with Rh-positive fetus.
Some Rh-positive blood enters the mothers
bloodstream.
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Figure 135e In subsequent pregnancies with an
Rh-positive fetus, Rh-positive red blood cells
are attacked by the anti-Rh-positive maternal
antibodies, causing hemolysis of the red blood
cells in the fetus.
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Rh SENSITIZATION

• RhoGAM
• PROVIDES PASSIVE ANTIBODY PROTECTION AGAINST Rh
  ANTIGENS
• ERYTHROBLASTOSIS FETALIS
• HYDROPS FETALIS
• KERNICTERUS

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MODULE 4 PART 2CBLEEDING COMPLICATIONS
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PRE-LABOR COMPLICATIONS

• PREMATURE RUPTURE OF MEMBRANES
• PRETERM LABOR
• BLEEDING
• MULTIPLE GESTATION
• AMNIOTIC FLUID ALTERATIONS

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ABRUPTIO PLACENTAE

• ABRUPTIO PLACENTAE
• PREMATURE SEPARATION OF PLACENTA FROM UTERINE
  WALL
• THREE TYPES
• MARGINAL
• CENTRAL
• COMPLETE
• CLINICAL MANAGEMENT

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Figure 1911a Abruption placentae. Marginal
abruption with external hemorrhage.
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Figure 1911c Complete separation.
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Figure 1911b Central abruption with concealed
hemorrhage.
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PLACENTA PREVIA

• PLACENTA PREVIA IMPLANTATION OF PLACENTA IN
  LOWER UTERINE SEGMENT
• THREE CLASSIFICATIONS
• LOW PLACENTAL IMPLANTATION
• PARTIAL PLACENTA PREVIA
• TOTAL PLACENTA PREVIA
• CLINICAL MANAGEMENT

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Figure 1912a Placenta previa. Low placental
implantation.
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Figure 1912c Total placenta previa.
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Figure 1912b Partial placenta previa.
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MODULE 4 PART 2DSURGERY TRAUMA
INFECTIONDOMESTIC VIOLENCE
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• SURGERY
• TRAUMA FROM AN ACCIDENT
• INFECTION AFFECTING THE FETUS
• MATERNAL RISKS
• FETAL RISKS

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DOMESTIC VIOLENCE IN PREGNANCY

• INCIDENCE
• RESEARCH
• STATISITICS
• SIGNS AND SYMPTOMS

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DOMESTIC VIOLENCE IN PREGNANCY

• HOW DO WE ASSESS?
• WHEN DO WE ASSESS?
• WHAT DO WE DO IF THE WOMAN DISCLOSES ABUSE?
• MATERNAL RISKS
• FETAL RISKS

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MODULE 4 PART 3APRE-LABOR COMPLICATIONSAMNIOTIC
FLUID ALTERATIONS
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OLIGOHYDRAMNIOS

• SEVERELY REDUCED AMOUNT OF AMNIOTIC FLUID
• OCCURS IN
• POSTMATURITY
• IUGR
• FETAL RENAL MALFORMATION
• SOMETIMES IDIOPATHIC

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OLIGOHYDRAMNIOS

• FETAL RISKS
• CLINICAL MANAGEMENT
• CRITICAL THINKING
• WHAT TYPE OF DECELERATION MIGHT YOU EXPECT TO SEE
  ON THE FETAL MONITOR OF A WOMAN WITH
  OLIGOHYDRAMNIOS? WHY?

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HYDRAMNIOS

• HYDRAMNIOS gt 2000ML AMNIOTIC FLUID
• CAUSE UNKNOWN 20 ASSOCIATED WITH CONGENITAL
  ANOMALIES
• TWO TYPES
• CHRONIC
• ACUTE
• RISKS
• CLINICAL MANAGEMENT

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True knot
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MODULE 4 PART 3BPRE-LABOR COMPLICATIONSPRETERM
LABORLABOR RELATED COMPLICATIONS
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PRETERM LABOR

• NONRECURRENT
• SCREENING
• FACTORS CORRELATED WITH PRETERM LABOR

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PRETERM LABOR

• PRETERM RISK FACTORS
• LABOR THAT OCCURS BETWEEN 20-38 WEEKS
• PREVELANCE
• RESEARCH
• RECURRENT

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PRETERM LABOR

• TREATMENT/CARE
• HOME UTERINE ACTIVITY MONITORING
• TOCOLYSIS
• MGSO4
• NEPHEDIPINE
• PROSTAGLANDIN SYNTHESIS INHIBITORS
• BETAMETHASONE (FETUS)

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LABOR RELATED COMPLICATIONS

• DYSTOCIA
• POSTTERM PREGNANCY
• FETAL MALPOSITION, MALPRESENTATION
• MACROSOMIA
• FETAL DISTRESS

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LABOR RELATED COMPLICATIONS

• HYPERTONIC LABOR
• HYPOTONIC LABOR
• LABOR MANAGEMENT
• MATERNAL RISKS
• FETAL/NEONATAL RISKS
• PRECIPITOUS LABOR
• LABOR LESS THAN 3 HOURS

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LABOR RELATED COMPLICATIONS

• PROLAPSED UMBILICAL CORD
• AMNIOTIC FLUID EMBOLISM
• CEPHALOPELVIC DISPROPORTION
• COMPLICATION OF THIRD OR FOURTH STAGE OF LABOR

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Uterine Tachysystole
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LABOR RELATED COMPLICATIONS

• MACROSOMIA
• NEWBORN WEIGHT gt 4000 GMS
• OFTEN SEEN IN
• DIABETIC MOTHERS
• GRAND MULTIPARITY
• POSTTERM GESTATION
• LARGE PARENTS
• MATERNAL RISKS
• FETAL / NEONATAL RISKS

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MODULE 4 PART 3CLABOR RELATED COMPLICATIONS
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POSTTERM PREGNANCY, MALPOSITION

• POSTTERM PREGNANCY
• PREGNANCY 42 WEEKS PAST 1ST DAY OF LAST MENSTRUAL
  PERIOD
• MATERNAL RISKS
• FETAL/NEONATAL RISKS
• MALPOSITION
• OCCIPUT POSTERIOR
• PERSISTENT OCCIPUT POSTERIOR
• LABOR MANAGEMENT
• MATERNAL RISKS

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PROLAPSED UMBILICAL CORD

• PROLAPSED CORD WHEN CORD PRECEDES FETAL
  PRESENTING PART
• DECREASED BLOOD FLOW IN CORD LEADS TO FETAL
  DISTRESS
• MAY RESULT WITH RUPTURE OF MEMBRANES
• CLINICAL MANAGEMENT

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Nurse and Prolapsed cord
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AMNIOTIC FLUID EMBOLISM

• CLINICAL PRESENTATION
• CHEST PAIN
• DYSPNEA
• CYANOSIS
• HYPOTENSION
• TACHYCARDIA
• MASSIVE HEMORRHAGE
• CLINICAL MANAGEMENT

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AMNIOTIC FLUID EMBOLISM

• AMNIOTIC FLUID EMBOLISM AMNIOTIC FLUID MAY LEAK
  INTO CHORIONIC PLATE AND MATERNAL CIRCULATORY
  SYSTEM THROUGH
• TEAR IN AMNION OR CHORION
• PLACENTAL SEPARATION
• CERVICAL TEAR

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CEPHALOPELVIC DISPROPORTION (CPD)

• FETUS LARGER THAN PELVIC DIAMETERS
• PELVIC MEASUREMENTS
• PROLONGED LABOR
• CLINICAL MANAGEMENT

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MALPRESENTATION

• MALPRESENTATION
• BROW
• FACE
• BREECH
• SHOULDER
• TRANSVERSE LIE
• COMPOUND PRESENTATION

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MULTIPLE GESTATION

• INCREASED INCIDENCE OF MULTIPLE BIRTHS
• INCREASED INCIDENCE OF PRETERM LABOR
• FETAL AND MATERNAL IMPLICATIONS AND CARE

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FETAL DISTRESS

• FETAL DISTRESS
• CONTIBUTING FACTORS
• CORD COMPRESSION
• UTERO-PLACENTAL INSUFFCIENCY
• PREEXISTING MATERNAL OR FETAL DISEASE
• FETAL DISTRESS WARNING SIGNS
• MECONIUM STAINED AMNIOTIC FLUID

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FETAL DISTRESS

• OMINOUS FHR PATTERNS
• PERSISTENT LATE DECELERATIONS
• PERSISTENT SEVERE VARIABLE DECELERATIONS
• PROLONGED DECELERATIONS
• DECREASED VARIABILITY

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FETAL DEATH

• INTRAUTERINE FETAL DEATH
• POSSIBLE CAUSES
• PREECLAMPSIA
• ABRUPTIO PLACENTAE
• PLACENTA PREVIA
• DIABETES
• CONGENITAL ANOMALIES
• INFECTION

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FETAL DEATH

• ISOIMMUNE DISEASE
• NUCAL CORD
• UNKNOWN CAUSES
• PROLONGED RETENTION OF FETUS MAY LEAD TO
• DESSEMINATED INTRAVASCULAR COAGULATION (DIC)

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COMPLICATIONS OF THE THIRD FOURTH STAGE OF LABOR

• LACERATIONS
• 1ST DEGREE
• 2ND DEGREE
• 3RD DEGREE
• 4TH DEGREE
• SULCUS TEAR
• URETHRAL TEAR

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COMPLICATIONS OF THE THIRD AND FOURTH STAGE OF
LABOR

• PLACENTA ACCRETA
• ATTACHMENT OF PLACENTA DIRECTLY TO THE UTERINE
  WALL WITHOUT INTEVENING DECIDUA BASALIS
• UTERINE RUPTURE
• RETAINED PLACENTA
• UTERINE ATONY
• HEMMORHAGE