NURSING CARE MANAGEMENT 102 midterm BY: JULIET M.

DELA CRUZ, RN,MN,MPA

(NCM 102 )

HEMORRHAGIC ( BLEEDING ) conditions on late part of pregnancy 1. PLACENTA PREVIA Improperly implanted placenta in lower uterine segment or over internal os Low implantation of placenta causes / predisposing factors : a. History of suction curettage for induced or spontaneous abortion b. Advance maternal age c. Smoking/ cocaine d. Poor vascularity e. Uterine fibroid tumors f. Multiple pregnancies g. Previous uterine surgery 4 TYPES OF PLACENTA PREVIA 1. Low- lying placenta 2. Marginal implantation 3. Partial placenta previa 4. Complete/ total placenta previa ASSESSMENT FINDINGS: 1. Bleeding 2. FHR 3. Uterus Complications to the mother/ baby Life threatening

Presenting part has difficulty entering the pelvis CS delivery Placenta accrete IUGR and congenital anomalies Diagnostic Tests Pelvic exam under double set up Lab studies ( dec in maternal Hgb) Transvaginal UTZ scanning to determine placental position Radiologic test 4 TYPES OF PLACENTA PREVIA 1. Low- lying placenta 2. Marginal implantation 3. Partial placenta previa 4. Complete/ total placenta previa ASSESSMENT FINDINGS: 1. Bleeding 2. FHR 3. Uterus Medical Treatment IV fluid therapy Vaginal birth delivery Patient remains in the hospital for bed rest Betamethasone drug Nursing Interventions: 1. Ensure complete bed rest to avoid premature delivery 2. Place the patient immediately in a side lying/ lateral trendelenberg position to prevent maternal shock and fetal hypoxia

3. Assess the duration of pregnancy and the time bleeding bega 4. Instruct the woman to estimate the amount and color of blood 5. Ready blood for replacement 6. Maintain sterile condition 7. No rectal and vaginal examination 8. Make provision for STAT CS 9. Monitor VS 10. Assess uterine tone 11. Teach client to identify and report signs of bleeding and cramping 12. Have oxygen ready 2. ABRUPTIO PLACENTA premature separation of the placenta from uterine wall, usually occurs after 20th week of pregnancy manifested by rigid, tender and irritable uterus. Generally occurs late in pregnancy or during first and second stage of labor Cause : UNKNOWN PREDISPOSING FACTORS 1. Cocaine/ cigarette 2. Advance maternal age 3. Thrombophilitic condition 4. Chronic hypertensive disease 5. High parity 6. Short umbilical cord 7. PIH 8. Direct trauma Assessment findings/ signs & symptoms 1. Bleeding dark red and painful 2. FHR Mild- strong and regular

Moderate- barely audible, irregular Severe- absent 3. uterus/ abdomen rigid and boardlike, tender, remains firm bet contractions 4. Couvelaire uterus/ uteroplacenta apoplexy- caused by the blood infiltrating the uterine musculature forming hard, boardlike uterus with or without external bleeding 5. Pain Uterus agonizing, tearing or irritable ; sharp stabbing pain high in the uterine fundus Complications Disseminated intravascular coagulation (DIC) leads to severe bleeding Shock and circulatory collapse due to severe hemorrhage Renal failure Maternal death Fetal hypoxia/ death Need for hysterectomy Diagnostic test Pelvic examination CBC and blood typing, may indicate low Hct,hgb &plt ct Prothrombin time maybe prolonged Fibrinogen test maybe low Abdominal utz Treatment and management / nursing interventions Oxygen Ensure bedrest Anticipate coagulation problems (DIC) IVF/BT Monitor vital signs

MIO Monitor vaginal bleeding Sidelying position Prepare for stat delivery Keep the woman informed of what is happening Dont perform any pelvic or vaginal exam Provide support COMPLICATIONS OF LABOR AND DELIVERY 1. DYSTOCIA - abnormal or difficult labor It results from differences in the normal relationships bet any of the five essential factors of labor Mechanical dystocia causes Maternal 1. Contracted pelvis 2. Obstructive tumor 3. Ineffective contractions 4. Excessive analgesia Fetal causes: Failure of the vertex to rotate as in occiput posterior Malpresentation, Malformation of the fetus Disproportion of maternal pelvis and fetal presentation Assessment : 1. Evaluate fetal presentation, position and size 2. Nonengagement of fetal head may indicate a contracted pelvic 3. Note any known uterine or fetal anomalies 4. X-ray pelvimetry is used for eval of cephalopelvic disproportion

5. Monitor VS, FHT, contraction Management/ nursing interventions 1. If occiput posterior position Relieve back pain as much as posible by sacral pressure, back rubs, frequent change in position from side to side Observe the character and frequency of contractions and monitor fetal heart rate IV fluids are used to prevent dehydration and used to provide glucose needed for effective contractions When cervix is completely dilated, fetal head maybe rotated by physician Provide encouragement and reassurance to the woman throughout the labor 2. If breech presentation Labor maybe longer, since in a breech delivery, the soft buttocks do not aid in cervical dilatation as well as the head does in vertex presentation Analgesia may be limited in order not to interfere with the mothers ability to push effectively Amniotomy is not done until breech is well engaged because there is greater danger of prolapsed of the cord with footlong presentation or breech that does not fill the pelvic cavity Breech presentation maybe delivered spontaneously with strong contractions particularly in multipara 3. Ceasarean birth is performed if there is shoulder presentation, when the size of the fetus is excessive to the size of the pelvis, or when there is persistent occipital posterior presentation in which forcep rotation maybe difficult Functional Dystocia ( uterine dysfunction or enertia) Inertia- denote sluggishness of contractions, or the force of labor, has occurred A condition in which uterine contraction deviates from the normal Contributing factors: Uterine anomalies Over distension such as hydramnios or multiple pregnancy

Cervical scar Excessive anesthesia Assessment Contractions may differ in quality and synchronization of activity Contractions may also have inadequate intensity Evaluate contraction quality and pattern Prolonged labor maybe evident Monitor and evaluate progress of cervical dilatation, descent and rotation in birth canal Nursing Interventions according to 2 patterns of ineffective uterine contractions: 1. Hypertonic uterine dysfunction- muscle of the uterus is in a state of greater than normal tension Provide rest with the aid of sedatives Provide fluids to maintain hydration and electrolyte balance Observe for normal contractions when woman awakens Darkening room lights, and decreasing noise and stimulation Prepare for CS 2. Hypotonic uterine dysfunction- contractions are inadequate, too weak Pelvis is reevaluated for size IV fluids Oxytocin admin if pelvic size is adequate and fetal position, presentation and station are normal Rupture of the uterus- immediate laparotomy Prolapsed cord: 1. Relieve pressure on cord by placing mother in trendelenbrerg or knee chest position 2. Notify AP 3. Do not attempt to replace cord into uterus

4. If cord protrude at vagina cover with saline moistened sterile water 5. Monitor FHT 6. Prepare for CS 7. Oxygen admin 8. Increase IV rate PRETERM LABOR Is uterine contraction occuring after 20 weeks gestation and before 37 weeks completed gestation Risk factors of preterm labor 1. Socio economic risk factor Low socioeconomic status More than 2 children Maternal age No prenatal care Poor nutrition Lack of childbirth experience/ education 2. Medical / obstetric risk factors Previous preterm delivery Spontaneous or induced abortion Uterine anomalies Less than 1 year bet last birth Height below 5ft Multiple birth Placenta disorders 3. Lifestyle risk factors Smoking Excessive fatique

Stressful events 4. Risk factors in current pregnancy Uterine overdistention Bleeding Less wt gain Fetal/placental malformation Maternal illness/ dse Premature rupture of membranes Management: 1. Prevention of premature delivery CBR without BRP Monitor/evaluate uterine contraction Cervical consistency Symptoms are monitored Ivfluids MIO 2. medications/ tocolytics used in treatment of premature labor are: Magnesium Sulfate - stops uterine contraction with fewer side effects Beta adrenergic drugs decrease effect of calcium on muscle activation to slow or stop uterine contractions Nefidipine calcium channel blocker Indomethacin prostaglandin synthetase inhibitor Betamethasone given to improve fetal lung maturity 3. Health teaching 4. Reducing anxiety 5. Discharge teachings PREMATURE RUPTURE OF MEMBRANES (PROM)

Is the loss of amniotic fluid or rupture of amniotic sac before the onset of labor PRETERM PREMATURE RUPTURE OF MEMBRANE ( PPROM) Is defined as the rupture of membrane before 37th week of gestation PROLONGED RUPTURE OF MEMBRANE ( PROLONGED ROM) Occurs when the membranes rupture more than 24 hours before birth/ delivery Assessment findings Report from mother of discharge of fluid PH of vaginal fluid will differentiate between amniotic fluid and urine or purulent discharge Chorioamnionitis is characterized by maternal fever and uterine tenderness which might cause preterm birth before 34 weeks Membranes may continue to leak, prolonging the loss of amniotic fluid for the fetus ( oligohydramnios) Diagnostic test of PROM Nitrazine paper moisened with vaginal fluid indicates PROM if it turns from yellow to dark blue, means amniotic fluid has alkaline pH Nursing interventions 1. Take FHT immediately as priority to prevent fetal hypoxia 2. Monitor VS( maternal/ fetal) 3. Calculate AOG 4. Observe for signs of infection 5. Observe color and odor of amniotic fluid 6. Examine for signs of cord prolapsed 7. Prepare for early birth POSTTERM PREGNANCY ( POST MATURE PREG) Defined as those pregnancies lasting beyond the end of the 42nd weeks

Assessment findings Decreased amounts of vernix also allow the drying of the fetal skin, resulting in a dry, parchment like skin condition Diagnostic test Measurement of fetal gestational age for fetal maturity Biophysical profile Medical / nursing management Directed toward ascertaining precise fetal gestational age and condition and determining fetal ability to tolerate labor Induction of labor/ CS Continual monitoring VS (fetal/ maternal) Support mother through labor Assist with amnio- infusion if ordered PROLAPSED UMBILICAL CORD Displacement of the cord in a downward direction, near the presenting part or in the vagina Obstetric emergency: if compression of the cord occur, fetal hypoxia may result in CNS damage / death Nursing interventions Check FHT If cord prolapsed into vagina , exert upward pressure against presenting part to lift part of the cord, reducing pressure on cord Cover cord with saline Position mothe rwhere gravity assist in getting presenting part off cord Oxygen administration Increase IVF Notify physician UTERINE RUPTURE

Is assoc. with previous uterine surgery such as CS, hysterectomy repair tears or other surgeries Fetal death follows after rupture unless emergency CS is accomplished Assessment: Sudden, severe pain during a strong labor contraction called tearing sensation, abdominal pain and tenderness; chest pain If complete rupture; labor may stop, rapid and weak pulse, cold and clummy skin, air hunger, BP dropped, impaired fetal O2nation and no FHT If incomplete: only localized tenderness, persistent aching pain over the lower uterine segment Therapeutic / nursing management Anticipate the need for CS Repair of uterus Hysterectomy BT if needed Admin oxytocin to reduce contraction PRECIPITUS LABOR AND DELIVERY Labor of less than 3 hours from time of 1st contraction to delivery Predisposing factors; Previous same history Multipara Large pelvis Unresistant soft tissue Small baby in good position Induction of labor by rupture of membranes and oxytocin Assessment Desire to push Medical management/ nursing interventions

Monitor FHT q 15min Stay with mother Dont prevent birth of baby Maintain sterile environment if posible Support babys head Following birth, evaluate infant for signs of trauma Dry to prevent heat loss Place baby on mothers abdomen Examine mother for cervical, vaginal and perineal lacertions Check for signs of placental separation Check mother for bleeding Cut cord when pulsation ceases AMNIOTIC FLUID EMBOLISM Is the escape of amniotic fluid containing debris such as meconium, lanugo and vernix caseosa into the maternal circulation, usually resulting in deposition of fluid in the pulmonary arterioles Rare but fatal Predisposing factors: Marginal placental separation Uterine rupture Hysterectomy Assessment findings Dyspnea Cyanosis Tachycardia Pulmonary edema Bleeding Signs of shock

Hypotension Death in minutes Medical / nursing management Emergency CPR Establish IV line for BT Prepare for emergency birth If cervix is dilated, forcep delivery is used to deliver fetus Keep patient informed ANOMALIES OF THE PLACENTA Placenta succenturiata- has one or more accesory lobes connected to the main placenta by blood vessel Placenta circumvallata the fatal side is covered with chorion Battledore placenta- the cord is inserted marginally rather than centrally Vasa previa- the umbilical vessels cross the cervical os, they would be delivered first before the fetus Placenta accreta- ussually deep attachment of the placenta to the uterine myometrium PROBLEMS WITH POSITION 1. Occipitoposterior 2. Breech presentation 3. Face presentation 4. Brow presentation 5. Shoulder dystocia 6. Macrosomia 7. Transverse lie