Module III - OB

• Gestional HTN
• Preeclampsia
• Chronic HTN
• Chronic with superimposed gestational or preeclampsia

Onset of hypertension after the 20th week of gestation

• BP higher than 140/90 on 2 seperate occasions 4-6 hours apart
• Edema, but no proteinuria

• HTN with protenuria that develops after 20 weeks
• Can be mild or severe

• Proteinuria
• Edema
• Weight Gain
• Increase in blood pressure
• Headache
• Visual changes
• Abdominal pain
• Intrauterine growth restriction (IUGR)
• Abnormal labs

• 65% 1st baby disease
• Multiple pregnancies
• Diabetes
• Less than 19 yrs of age
• Vascular disease
• Hydatiform mole
• Dietary deficiencies
• Familial tendencies
• ABO Rh incompatibilities

a rare mass or growth that forms inside the uterus at the beginning of a pregnancy

• Early recognition
• Complete bed rest
• Increase fluid and protein
• Decrease sodium
• Hydralizine
• Labetolol
• Nifedipine
• Methyldopa
• Possible termination
• Induce Labor

Blood pressure greater than 160/110 and greater than 5 grams of protin in 24 hour urine

• Rapid increase in blood pressure
• Rapid weight gain
• Generalized edema
• Severe headache
• Visual changes
• Nausea
• Drowsiness
• Increased reflexes
• Clonus
• Oliguria
• Nervousness/irritability

• Immediate hospitalization
• Magnesium sulfate
• Frequent BP's
• Diuretics if necessary
• IV glucose solution

• Delivery as indicated
• Low stimulation
• Constant observation
• Suction and trach equipment

• Watch for seizures up to 48 hours after delivery
• Watch for increase output
• Rest and quiet environment
• Promote bonding

Convulsive state of preeclampsia

• Matures faster
• Dependent upon gestation and maternal stability
• Delayed bonding

• H-Hemolysis of RBC's
• EL-Elevated liver enzymes
• LP-Low platelets

• Same as preeclampsia
• Large drop in hematocrit
• Hypoglycemia

• Same as preeclampsia
• Imminent delivery
• May require life support

HTN that is present & observable before pregnancy or diagnosed before the 20 weeks gestation

HTN before 20 weeks and new onset proteinuria

• Sudden increase in proteinuria
• Sudden increase in BP in woman who was previously well controlled
• Thrompocytopenia
• Elevated liver enzymes

• Drug of choice for hypertensive problems
• Therapeutic level 4-7 mEq/L
• Smooth muscle relaxer
• CNS depressant

Greater than 12 mEq/L

• Apresoline (arterioler vasodilator)
• Labetalol (beta-blocking agent)
• Procardia (calcium channel blocker)
• Aldomet (alpha 2-receptor agonist)

Abnormal implantation of the placenta

• Complete
• Partial
• Marginal or low lying

• Scarred site of implantation
• Multiple pregnancies
• Multiparity
• Decreased vascularity of upper uterine segment

• PAINLESS vaginal bleeding in 2nd or 3rd trimester
• Uterus relaxes between contractions

• Sonogram
• Bed rest until 36 weeks
• Stool softener
• Monitor bleeding/contractions
• No vaginal/rectal exams
• H & H, type and cross match
• C-section most of the time

Count and weight of pads

• PP hemorrhage
• Infection
• Anemia
• Shock
• Neonatal complication

Premature seperation of all or part of placenta after the 20th week and before birth

• Complete
• Partial

• Multigravida
• Previous abortion
• Abdominal Trauma: abuse, motor vehicle accident
• Drug use
• Short cord
• PIH (preeclampsia)

• PAINFUL uterine bleeding (severe pain)
• Increased uterine size
• Shock
• Hypertonic contraction

• Decreased H&H
• Decreased coagulation (increased risk DIC)
• Positive Apt (Blood in amniotic fluid)
• Positive Kleinhauer-Betke (KB) (Fetal cells mixed w/maternal cells)

• Shock
• DIC
• Fetal Hypoxia
• Renal Failure

• Vaginal delivery
• C/S for fetal distress
• Type and cross match
• Clotting factor
• Hysterectomy

• Leading cause of maternal death
• 1/3 babies die with 20% or more abruption

• History prior to discovery of insulin
• Perinatal mortality currently 5%
• Rarely can get pregnant
• Rarely able to carry baby to full term

• Constant need for glucose
• Maternal insulin does not cross the placenta
• 1st trimester-increased insulin production (lower blood glucose)
• 2nd trimester-increased insulin resistance (higher blood glucose)

• Class A1-Gestation DM diet controlled
• Class A2-Gestation DM insulin/medication controlled
• Class B-Onset 20 years of age or greater & duration less than 10 years
• Class C-Onset 10-19 years of age & duration 10-19 years

• Class D-Onset less than 10 years and duration of 20 years or background of retinopathy or HTN not pregnacy related
• Class R-Proliferative retinopathy or vitreous hemorrhage
• Class F-Nephropathy with more than 500mg/dl protein in 24 hour period
• Class RF-Criteria for both R and F co-exist
• Class H-Artherosclerotic heart disease clinically evident
• Class T-Prior renal transplantation

• SAB or Fetal demise
• Gestational HTN
• Polyhydramnios
• Infections
• Delivery mode

• CNS
• Cardiovascular
• Urinary
• GI
• Macrosomia
• Intrauterine growth restriction (IUGR)
• Hypoglycemia

• Diet-Most women 2000 to 2200 cal/day
• Glucose levels-4x daily
• Insulin Therapy
• Exercise
• Fetal Surveillance

• Prevent dehydration
• Maintain 80-120 blood sugar
• Fetal monitoring

• Insulin requirements decrease
• Bottle feeding-7 to 10 days
• Breast feeding-until weaned

Carbohydrate intolerance during pregnancy

24-28 weeks gestation

• Usually disappears after delivery
• Can recur in future pregnancies

• Weight reduction
• Good nutrition
• Exercise

Patient will be classified as gestational diabetic if blood sugar levels are met or exceeded in two or more blood draws.

• Fasting: 95mg/dl
• 1 Hour: 180mg/dl
• 2 Hour: 155mg/dl
• 3 Hour: 140mg/dl

Exessive or intractable vomiting during pregnancy

• Gastroenteritis
• Pyelonephritis
• Pancreatitis
• Cholecystitis
• Hepatitis

• Primiparas
• Obesity
• Less than 20 years old
• Multifetal gestation
• Hydatiform mole
• Increased levels of estrogen or HCG

• Vomiting
• Tachycardia
• Dehydration
• Decreased urine output
• Hypotension
• Rapid weight loss (5% of pre-pregnancy wt)
• Fluid and electrolyte imbalance
• Jaundice
• Increased BUN

• Combat starvation
• Fluid and electrolyte
• Diet changes
• Rest/psychotherapy

Good with therapy

• Greatest strain 28-32 weeks
• Maternal death
• Encouraged to not get pregnant

• I-asymptomatic at normal levels of activity
• II-symptomatic with activity
• III-symptomatic with normal activity
• IV-symptomatic at rest

• Calcium Blockers
• Anticoagulants

• Spontanious Abortion (SAB)
• Preterm labot
• IUGR

• Pregressive generalized edema
• Crackles
• Pulse irregularity
• Sudden inability to perform activities
• Increased resp & dyspnea
• Cyanosis lips/nail beds

Usual workup with additional EKG

• 8-10 hours sleep with 30 min nap after eating
• Activity limited
• Treat infections
• Diet
• HOB elevated
• Be on left side
• Breast feeding discouraged for III and IV
• No C/S
• Decrease 2nd stafe of labor

Increased risk for fluid loss and increased blood loss

Labor that begins after the 20th week and before the 37th week of gestation

• PROM
• Placenta previa
• Polyhydramnios
• Infection
• Multiples
• Maternal age less than 18 or greater than 40
• Nutrition
• Smoking/drinking/drug use
• Previous PTL/2nd trimester abortion
• Uterine anomalies (fibroids)
• Abdominal surgeries during pregnancy
• Increased stress
• Incompetent cervix
• Prolonged standing
• Night work
• Heavy lifting

• Bloody show
• Backache
• Pressure/cramping
• Contractions
• Diarrhea
• Cervical changes
• ROM

• Monitor fetus
• Hydration
• Bed rest
• Tx for UTI (#1 cause of PTL)
• Medications

• Magnesium Sulfate
• Terbutaline
• Betamethasone
• Indocin
• Procardia

If labor under control and no other symptoms then can continue pregnancy until term

Long or difficult delivery caused by abnormalities in the powers, passage or passenger

contractions

• Primary - hypertonic
• Secondary - hypotonic

• Fatigue
• Lack of feeling

• CPD
• Macrosomia
• Android pelvis

• Subq
• PO

Calcium channel blocker

Closes the ductus arteriosis

• Latent phase
• Contractions are uncoodinated, frequent & painful
• May not be uterine relaxation between contractions
• No further dilatation or effacement

• Rest
• Analgesic
• Ambien

• Active phase of labor
• Progression stops
• Contractions are weak or stop

• Increase contractions
• Analgesia
• IV fluids
• Rule out CPD, fetal malposition

• Maternal: Inadequate pelvis
• Soft tissue issues(fibroids, previa, full bladder)
• Fetal: Malposition or malpresentation
• Macrosomia
• CPD (cephalepelvic disproportion)

• Maternal
• Fetal

• Pin
• Persistent ROP
• Prolonged 2nd stage

• Assisted delivery
• manual rotation
• Delivery with low forceps or vacuum extractor
• C/S

The fetal head is delivered but the anterior shoulder cannot pass under the pubic arch

• Macrosomia
• Pelvic abnormalities

• Slowing of labor progress
• Increasing caput
• Turtle sign

• Uterine atony
• Uterine rupture
• Episiotomy extension or lacerations
• Infection

• Asphyxia
• Brachial plexus damage
• Clavical or humerus fracture

• Call for Help
• Evaluate for Episiotomy
• Legs for McRoberts maneuver
• Suprapubic Pressure
• Enter maneuvers (Internal Rotation)
• Remove Posterior arm
• Roll the patient

• Dystocia
• Fetal position
• Active herpes or STI
• Fetal distress/prolapsed cord
• Repeat c/s
• Maternal and/or fetal complications

• Classical
• Low transverse

• Prepare for procedure
• Expect anger
• Encourage family involvement
• Encourage bonding

Low transverse

• Recovery
• Early ambulation
• Diet
• Assess incision
• SCD's

The cord lies between the presenting part of the fetus & the cervix

• Fetal bradycardia with variable decelerations during contractions
• Palpation of cordon vag exam

• Prompt recognition
• Call for help
• SVE to push up on presenting part
• Reposition patient
• O2 via mask
• Continue to monitor fetal heart rate
• Prepare for stat c/s

• Can happen anytime
• Found after ROM

• Separation of previous classic c/s births
• Uterine trauma (accidents, trauma)
• Congenital uterine anomaly

• Vomiting
• Faintness
• Increased abdominal tenderness
• Hypotonic uterine contractions
• Lack of progress in dilation
• Fetal distress

• Emergancy c/s
• Blood administration as indicated
• Possible hysterectomy

• IV access
• Bood transfusion
• Administer oxygen
• Prepare for emergency surgery
• Support the woman's family

Anaphylactoid Syndrome of Pregnancy

Amniotic fluid containing debris such as vernix, hair, skin cells, or meconium enters the maternal circulation causing the release of histamine, prostaglandins, thromboxan, etc.

• Respiratory distress
• Circulatory collapse

• Acute dyspnea
• Severe hypotension
• Restlessness
• Dyspnia
• Cyanosis
• Pulmonary edema
• Respiratory arrest
• Hypotension
• Tachycardia
• Shock
• Cardiac arrest
• Coagulation failure: bleeding from incision sites, venipuncture sites, trauma (lacerations), petechiae, ecchymoses, purpura
• Uterine atony

• Maternal: multiparity
• Tumultuous labor
• Abruptio placentae
• Oxytocin induction of labor
• Fetal: Macrosomia
• IUFD
• Meconium passage

• Acute dyspnea
• Severe hypotension

• Advanced age
• Minority race
• Placenta previa
• Preeclampsia
• Forceps-assissted or cesearan birth
• Rapid labor
• Meconium staining

• Assist with resuscitation efforts
• CPR must be conducted with uterus displacement

A perimortem c/s should occur within 5 min for optimal fetal survival

ANY infection of birth canal postpartally which may involve the uterus and adjacent structures

• Hemorrhage
• Trauma during L&D
• Preexisting anemia
• Excessive vaginal exams
• PROM
• Prolonged labor and dehydration

• Increased temperature 100.4+ after 24 hours pp
• Tachycardia
• Increased WBC
• Uterine tenderness
• Malaise
• Chills/Anorexia

• Episiotomy
• Perineum
• Vulva
• Vagina

• Heat in area
• Burning on urination
• Foul odor to lochia
• Increased temp
• Redness and edema
• Discomfort in area

• Analgesics
• Culture discharge
• Early ambulation
• Increased fluids: po and iv
• Increased protein and calories in diet
• Antibiotics
• Sitz bath 3-4 times a day
• Emotional support
• Semi-fowlers position

• Antepartum and intrapartum infection
• Intrauterine infection involving leukocyte infiltration of the fetal membrane and amniotic fluid

• Maternal fever
• Fetal tachycardia
• Preterm ROM (most common symptom)
• Odor to vaginal discharge &/or amniotic fluid

• Antibiotics
• Monitor fetus
• Culture fluid
• Induce labor
• C/S for cases of fetal distress
• Prompt diagnosis

Good if diagnosed early and interventions begun

Same as preeclampsia plus epigastric pain

Same as preeclampsia plus seizure precautions

Guarded

• Eat every 2-3 hours
• Seperate liquids form solid food, alternating evey 2-3 hours
• Eat a snack at bedtime
• Eat dry, bland, low-fat, high-protein foods
• Cold foods may be better tolerated than warm foods
• Eat what sounds good rather than trying to balance foods
• Follow the salty and sweet approach
• So-called junk foods are okay
• Eat proteins after sweets
• Dairy products may stay down easier than other foods
• If vomiting even while stomach is empty, suck on a popsicle
• Try ginger tea: peel and finely dice a knuckle-sized piece of ginger and place it in a mug of boiling water. Steep for 5 to 8 minutes and add brown sugar to taste
• Try warm ginger ale (with sugar, not artifical sweetener) or water with a slice of lemon
• Drink liquids from a cup with a lid

• Well balanced diet
• Iron and Folic acid supplementation
• High protein
• Adequate calories to gain weight
• Increased fluids and fiber

Vaginal birth after ceesarean