Chapter 12 Care of the Obstetric Patient Copyright

Pre-existing Conditions That Can Complicate Pregnancy Factors that can contribute to a high-risk pregnancy: • Diabetes mellitus • Heart disease • Substance abuse Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

PREGNANCY COMPLICATIONS Ectopic Pregnancy Copyright © 2010 Wolters Kluwer Health | Lippincott Williams &

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. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

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 Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

• 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 Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Pregnancy complications • Hyperemesis gravidarum – Severe nausea and vomiting – Cause dehydration and weight loss – Normal “morning sickness stops by the 12 th week – Continues into the second trimester – Often requires hospitalization for enteral nutrition Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

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 Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

PREGNANCY COMPLICATIONS Preeclampsia/Eclampsia § Gestational Hypertension § bp greater than 140/90 § Develops after 20 th week of gestation § Can lead to death of mother and baby § Md orders § Bed rest § antihypertensive meds § hospitalization Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

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 Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

PREGNANCY COMPLICATIONS Placenta Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

PREGNANCY COMPLICATIONS Placenta Previa Copyright © 2010 Wolters Kluwer Health | Lippincott Williams &

PREGNANCY COMPLICATIONS Abruptio Placentae Copyright © 2010 Wolters Kluwer Health | Lippincott Williams &

Pregnancy Complications • Pre-term labor – Occurs between 20 th and 37 th 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) Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

• Tell the nurse – c/o low back pain or abdominal pain – Urinary urgency – Fluid leaking from the vagina – May signify labor is starting Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

• 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 Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

• Pre-term premature rupture of membranes (pre-term PROM) – Prior to 37 th week of pregnancy – Baby’s lungs are not fully developed – MD • medication to maintain pregnancy to get past 37 th week. • Bedrest • Help with ADL’s Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Multiple Gestation • Twins (the most common) • Triplets • Quadruplets • Quintuplets • Multiple gestation can sometimes cause a pregnancy to be “high-risk” Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

• 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 Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

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. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

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 Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

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 Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

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 Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

• 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 Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Signs of Labor • Lightening – Baby begins to move down into the pelvis – Abdomen changes appearance “dropped” – Usually indicates labor in 2 weeks Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

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 Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Signs of Labor • Braxton-Hicks contractions – Irregular contractions that occur with more freauency as labor approaches – Irregular frequency and intensity Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

• primipara-=a women delivering her first baby • Multipara= a women who has delivered a baby – First stage of labor differs for each Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

First Stage of Labor • Divided into three stages: – Early latent phase • Mild discomfort, backache • 5 -8 minutes apart for 20 -35 seconds Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

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 Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

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

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 Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

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 Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

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 Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

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) Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Abnormal Fetal Presentation Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

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 Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

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 Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Postpartum Complications • Hemorrhage – Greatest first hour after delivery – Can occur 24

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 Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

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. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Question When caring for a patient with incompetent cervix, you should report to the nurse right away which of the following observations? A. The patient has abdominal pain B. The patient has uterine contractions C. There is fluid leaking from the vagina D. All of the above Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

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

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. A. True B. False Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

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? A. 4 B.

Answer B. 3 The three phases of the first stage of labor are: early

Question What are some postpartum complications? A. Hemorrhage B. Puerperal infection C. Thrombophlebitis D.

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. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins