Chapter 12 Care of the Obstetric Patient

Pre-existing Conditions That Can Complicate Pregnancy Factors that can contribute to a high-risk pregnancy: Diabetes mellitus Heart disease Substance abuse

PREGNANCY COMPLICATIONS Ectopic Pregnancy

Spontaneous Abortion In a complete abortion, all of the products of conception are expelled. In an incomplete abortion, some, but not all, of the products of conception are expelled. (For example, the placenta may remain in the uterus.) In a missed abortion, the fetus dies and the products of conception remain in the uterus.

Pregnancy Complications Incompetent cervix Unable to remain closed for the duration of the pregnancy No known cause Early delivery results Cervical cerclage procedure Suture tied around the cervix Complete bedrest

Care of the patient with incompetent cervix Emotional support Fear of losing the baby causes anxiety and worry Report Abdominal pain Uterine contractions Fluid leaking from the vagina

Pregnancy complications Hyperemesis gravidarum Severe nausea and vomiting Cause dehydration and weight loss Normal “morning sickness stops by the 12th week Continues into the second trimester Often requires hospitalization for enteral nutrition

Pregnancy complications Gestational diabetes Pregnancy induced Usually develops during the second trimester No history of diabetes Increases risk of development of type II later Risks Large babies cause difficult delivery

Preeclampsia/Eclampsia PREGNANCY COMPLICATIONS Preeclampsia/Eclampsia Gestational Hypertension bp greater than 140/90 Develops after 20th week of gestation Can lead to death of mother and baby Md orders Bed rest antihypertensive meds hospitalization

Gestational hypertension Report to the nurse right away if a preeclampsia/eclampsia patient: Complains of blurred vision Is irritable or seems especially tense Complains of severe heartburn Has decreased urinary output Has puffy or swollen face and hands

PREGNANCY COMPLICATIONS Placenta

PREGNANCY COMPLICATIONS Placenta Previa

PREGNANCY COMPLICATIONS Abruptio Placentae

Pregnancy Complications Pre-term labor Occurs between 20th and 37th week Danger due to baby’s lungs are not full developed Reason if often not known Risks Previous preterm labor Multiple pregnancy Uterine or cervical problems Age of mother (less than 16 or older than 40)

Tell the nurse c/o low back pain or abdominal pain Urinary urgency Fluid leaking from the vagina May signify labor is starting

Premature rupture of membranes (PROM) Occurs prior to due date Before labor begins Md may make labor begin if the mother does not go into labor within 24 hours Mother and baby become at risk for infection

Pre-term premature rupture of membranes (pre-term PROM) Prior to 37th week of pregnancy Baby’s lungs are not fully developed MD medication to maintain pregnancy to get past 37th week. Bedrest Help with ADL’s

Multiple Gestation Twins (the most common) Triplets Quadruplets Quintuplets Multiple gestation can sometimes cause a pregnancy to be “high-risk”

Monozygotic One egg is fertilized Share a placenta Always same gender Dizygotic Two eggs are fertilized Each baby has own placenta May be the same gender or different

Divided into 4 categories INFERTILITY Divided into 4 categories Problems with the man's reproductive system. Problems with the woman's fallopian tubes. Problems with the woman's uterus and/or cervix. Problems with ovulation.

LABOR AND DELIVERY Vaginal birth Mother is not high risk or there are no problems with the pregnancy Cesarean section birth Complications that cause stress on mother or baby

Responsibilities of the PCT Vary from facility to facility May include Basic care and advanced care skills routine vital signs assisting with ambulation Toilteing preparation of sterile supplies collection of blood samples from umbilical cord clean the patient after delivery

Labor and Delivery- process Oxytocin is released by the pituitary gland causing the uterus to contract in the upper muscular portion Contractions push the baby downward against the cervix Pressure of the baby on the cervix causes it to dilate (the opening becomes larger) When the cervix is fully dilated the baby passes into the birth canal (vagina) The placenta is delivered

Delivery is done by the primary health care provider Obstetrician MD who specializes in obstetrics and gynecology in addition to medical school Certified nurse midwife RN who completes 1-2 years of additional graduate training Cannot perform c-sections

Signs of Labor Lightening Baby begins to move down into the pelvis Abdomen changes appearance “dropped” Usually indicates labor in 2 weeks

Signs of Labor Bloody show Blood tinged vaginal discharge that is mixed with mucous Mucous plug blocks opening to cervix during pregnancy Cervix softens and begins to efface (become thinner

Signs of Labor Braxton-Hicks contractions Irregular contractions that occur with more freauency as labor approaches Irregular frequency and intensity

primipara-=a women delivering her first baby Multipara= a women who has delivered a baby First stage of labor differs for each

First Stage of Labor Divided into three stages: Early latent phase Mild discomfort, backache 5-8 minutes apart for 20-35 seconds

First stage of Labor Mid/active phase Contractions become more frequent Discomfort increases Monitoring of contractions and FHR Transitional phase Most intense contractions every 2-3 minutes for as long as 80 seconds Cervix dilates from 7-10 cm Crowning

Second Stage of Labor Cervix is completely dilated Pushing stage Baby is delivered

Third Stage of Labor The placenta is delivered On average, delivery of the placenta takes between 5 and 20 minutes Nursing assistant’s responsibilities: Cleaning the perineal area Applying an ice pack and a perineal pad Changing soiled linens Monitoring vital signs every 15 minutes

Fourth Stage of Labor Begins with the delivery of the placenta and ends when the woman’s condition has been stabilized Vital signs continue to be monitored Nursing assistant will assist the patient with urination

Cesarean Delivery Delivery of the baby through a surgical incision made in the mother’s abdomen Necessary when a vaginal delivery is not possible or safe for the mother or baby Recovery time following a cesarean delivery is generally longer than the recovery time following a vaginal delivery

Possible Reasons for a Cesarean Delivery Anatomical difficulties Cephalopelvic disproportion (CPD) Baby’s head is too large to pass through the pelvis Abnormal fetal presentation Breech=legs or buttocks first Shoulder=may be repositioned by the MD Previous cesarean delivery Emergency procedure (if complication develops during pregnancy, labor, or delivery)

Abnormal Fetal Presentation

Nursing Assistant’s Role During Cesarean Delivery Serve as a scrub person Perform a surgical scrub, put on a sterile gown and gloves, and work within a sterile field Learn the steps of the cesarean section procedure, the names of the instruments used, and how to properly pass the instruments and other supplies to the doctor See Box 12-1

VBAC Vaginal birth after cesarean Possible if no complications during the pregnancy Uterine scar is located in lower portion of the uterus Previous pregnancy did not have a life threatening problem

Postpartum Complications Hemorrhage Greatest first hour after delivery Can occur 24 hours and up to 6 weeks after delivery

Postpartum Complications Puerperal infection An infection that develops after childbirth Affects structrues of the reproductive tract Other structures could be affected Urinary tract Wound breast

Postpartum Complications Thrombophlebitis Most common cardiovascular problem Clots form in deep veins of the legs or pelvis If break loose cause pulmonary embolism and respiratory/cardiac arrest.

Question When caring for a patient with incompetent cervix, you should report to the nurse right away which of the following observations? The patient has abdominal pain The patient has uterine contractions There is fluid leaking from the vagina All of the above

Answer D. All of the above All may be signs of an impending spontaneous abortion.

Question Tell whether the following statement is true or false. Usually, a woman with PROM will go into labor within 24 hours, but the doctor may choose to administer medications that make labor begin sooner to lower the risk for infection. True False

Answer A. True PROM puts the mother and the fetus at risk for infection.

Question How many phases are in the first stage of labor? 4 3 6 2

Answer B. 3 The three phases of the first stage of labor are: early latent, mid/active, and transitional.

Question What are some postpartum complications? Hemorrhage Puerperal infection Thrombophlebitis All of the above

Answer D. All of the above The postpartum period is the 6-week period of time following the birth. The most common postpartum complications include hemorrhage, infection, and thrombophlebitis.