Maternal Nursing: Complications

Maternal Nursing
Complications
DYSTOCIA
 Difficult labor
 Mechanical factor – uterine inertia;
sluggishness of contractions
 1. Hypertonic or primary uterine inertia
– intense, excessive contractions

resulting to ineffective pushing
 Diazepam/Valium – muscle relaxant
 2. Hypotonic or secondary – slow
irregular contraction resulting to
ineffective pushing
 Oxytocin
 Prolonged labor:
 Nullipara – normal-14-20 hours; >20
 Multipara – normal-10-14 hours; >14
 Maternal effect – exhaustion
 Fetal effect – fetal distress, caput
succedaneum or cephalhematoma
PRECIPITATE LABOR
 Labor of <3 hours
 Grand multiparity, induction of labor by
oxytocin, amniotomy
 Effects: premature separation of
placenta
 Fetal effect: subdural hemorrhage
 Maternal effect:
 1. Uterine inversion:
 Other causes – short cord, hurrying of
placental delivery, ineffective uterine fundal
pressure
 Never attempt to replace, never attempt to
remove placenta
 Don’t give oxytocic drug
 Tocolytic drug given
 2. Bleeding:
 Hypovolemic Shock
 Ealiest sign: tachycardia and
restlessness
 Late sign: hypotension
 Position – Trendelenderg
 IV – fast drip
UTERINE RUPTURE
 Causes:
 1. Previous classical CS
 2. Prolonged labor
 3. Abnormal presentation
 4. Multiple gestation
 5. Unwise use of oxytocin
 6. Obstructed labor
 Physiologic retraction ring – boundary
between upper and lower uterine
segment
 Pathologic retraction ring (Bandl’s
Ring) – suprapubic depression
 Sign of impending uterine rupture
 S/S: sudden, severe pain, profuse

bleeding, shock begins
Management
 Prepare for CS
 Fluid replacement therapy
 TAHBSO
AMNIOTIC FLUID
EMBOLISM
 Occurs when amniotic fluid is forced into an
open maternal uterine blood sinus
 Not preventable
 Risk factors: oxytocin administration, abruptio
placenta, hydramnios
 S/S: chest pain, frothy sputum
 Management: suctioning, endotracheal
intubation
 Death – in few minutes
 Risk for: DIC
PREMATURE LABOR
CONTRACTIONS
 1. Premature labor contractions-10mins
 2. Effacement – 60-80%
 3. Dilatation – 2-3cm
 Home Mgt:
 1. Complete bed rest
 2. Avoid sex
 3. Empty bladder
 4. Consult MD
 Hosp:
 Administration of Tocolytic –
Terbutaline
 Antidote – propranolol or inderal
 Crackles – notify MD
 Cervix open – steroid dexamethazone
 Preterm – cut cord ASAP

First Trimester
Bleeding
 A. Abortions – any interruption of a
pregnancy before a fetus is viable
 Spontaneous – miscarriage
 Causes:
 1. Abnormal fetal formation
 2. Rejection of the embryo
 3. Implantation abnormalities
 4. Infection
Classifications
 1. Threatened – bleeding and cramping but
the cervix is closed
 2. Inevitable/Imminent – uterine contractions
with cervical dilatation
 Types:
 Complete – all products of conception are
expelled
 Incomplete – membrane or placenta is
retained; D&C
 3. Missed – fetus dies; not expelled;
remain in the uterus 4-6 weeks; signs
of pregnancy ceases
 4. Habitual – recurrent pregnancy loss
 3 or more consecutive pregnancies

recult in abortion
 Defective spermatozoa or ova
 Deviations of the uterus

 A.1 Induced Abortion – therapeutic
abortion to save life of mom
Ectopic Pregnancy
 Implantation occurs outside the uterine
cavity
 Most common – fallopian tube
 Causes:
 Obstruction: adhesion of the fallopian
tube, congenital malformation, scars,

tumor
Assessment
 No menstrual flow
 Positive pregnancy test
 6-12 weeks – rupture of the tue
 Sudden, sharp, severe pain
 Shoulder pain
 Positive Cullen’s sign
 Tender mass in the Douglas’ cul-de-sac
Management
 V/S
 IV therapy
 Monitor I & O
 Surgery: depending on side

Second Trimester
Bleeding
 Hydatidiform Mole – gestational
trophoblastic disease
 Abnormal proliferation and
degeneration of the trophoblastic villi
 “Bunch of grapes”
 Occur most: low protein intake, women

older than age 35 years, women of
Asian heritage
 Types:
 Complete – all trophoblastic villi swell
and become cystic; normal

chromosome component; may lead to
choriocarcinoma
 Partial:
 Some villi form normally
 Rarely lead to choriocarcinoma
 69 chromosomes
Assessment
 Expand faster than normal; symphysis
pubis at 12 weeks
 High level of hCG
 Preeclampsia at 12 weeks
 16 weeks – vaginal bleeding–spotting
or profuse
 Clear-fluid vesicles passed
Management
 D&C
 Methotrexate – prevent
choriocarcinoma
 Dactinomycin – metastasis
 hCG monitoring
 Avoid pregnancy for at least 1 year

PREMATURE CERVICAL
DILATATION
 Incompetent cervix
 Cervix that dilates prematurely
therefore cannot hold a fetus until term
 1st symptom: show, increased pelvic
pressure, uterine contraction follows
 20th week
 Cervical cerclage – McDonald or

Shirodkar procedure; 12-14 weeks
Third Trimester
Bleeding
 Placental anomalies
Placenta Previa
 Low implantation of the placenta
 Low-lying placenta – lower rather than in the
upper portion of the uterus
 Marginal implantation – placental edge
approaches the cervical os
 Partial placenta previa – occludes a portion
of the cervical os
 Total placenta previa – totally obstructs the
cervical os
 Risks:
 Increased parity
 Advanced maternal age
 Past cesarean birth
 Past uterine curettage
 Multiple gestation
 Male fetus
Assessment
 Bleeding – abrupt, painless, bright red;
begins at 30 weeks
 Not engaged
 DX: UTZ
Management
 Cautioned to: avoid sex, get adequate rest
 Side-lying – bleeding
 Estimate blood loss
 Apt or Kleihauer-Betke test – determine if blood is
maternal or fetal
 No pelvic or rectal exam
 Assess v/s – BP: q 5 to 15 minutes
 IV therapy
 Monitor I&O – q 1hour
 Prepare for CS
 Betamethasone – hastens lung maturity;less than 34wks
Abruptio Placentae
 Premature separation of the placenta
 20th week; may occur during the first or second stage of
labor
 Risks:
 High parity
 Advanced maternal age
 Short umbilical cord
 Chronic hypertensive disease
 PIH
 Direct trauma
 Cocaine/cigarette use
Assessment
 Sharp, stabbing pain high in the
fundus – initial separation
 Couvelaire uterus – uteroplacental
apoplexy; blood infiltrate the uterine
musculature
 A hard, boardlike uterus
 Signs of shock follow
 DIC syndrome can occur

Management
 IV therapy
 v/s q 5-15mins
 Lateral positioning
 No vaginal, pelvic exam, enema
 Fibrinogen baseline
 DIC – IV of fibrinogen or
cryoprecipitate
Other Abnormal
Placenta
 Placenta circumvallata – fetal surface of the
placenta presents a central depression
surrounded by thickened grayish white ring
 Placenta marginata – fold side of chorion
reaches just to the edge of placenta
 Battledore placenta – cord inserted
marginally rather than central
 Placenta bipartita – placenta divides into 2
lobes
 Vilamentous insertion of cord – cord divides
into small vessels before it enters the
placenta
 Vasa placenta – vilamentous insertion of th
eocrd has implanted in cervical os
 Placenta succenturiata – one or more
accessory lobe is located at a distance from
the main placenta
Hypertensive Disorders
 Pregnancy-Induced Hypertension –
vasospasm occurs during pregnancy
in both small and large arteries
 Classic signs: Hypertension,
proteinuria, edema
 Symptoms: Rarely occur before 20
weeks
 Solved 6 weeks post partum
 RISKS:
 Women of color
 Multiple pregnancy
 Primiparas under 20, over 40
 Low socio-economic status
 5 or more pregnancies
 Hydramnios
 Heart disease, diabetes, renal involvement
 Essential hypertension
Gestational
Hypertension
 Elevated BP – 140/90 mm Hg
 No proteinuria or edema
 No drug therapy is necessary

Mild Preeclampsia
 BP – 140/90 mm Hg; taken twice 6
hours apart
 SBP 30mm Hg above baseline
 DBP 15 mm Hg above baseline
 Proteinuria – 1+ or 2+
 Edema – upper part of the body
 Weight gain – 2lb/wk in 2nd trimester; 1

lb/wk in 3rd trimester
Severe Preeclampsia
 BP 160/110 mm Hg
 DBP – 30 mm Hg above baseline
 Proteinuria – 3+ or 4+
 Edema – puffiness of the face and hands
 Reduced urine output – 400-600ml/24 hrs
 Severe epigastric pain
 Pulmonary edema – short of breath
 Cerebral edema – visual disturbances, sever
headache, marked hyperreflexia
Eclampsia
 Seizure
 Coma may occur
Management
 Promote bed rest – decrease O2 demand;
greater sodium excretion
 Prevent convulsion or seizure precaution:
– Dimly lit room; quite calm environment
– Minimal handling
– Avoid jarring
 Prepare the following:
– Tongue depressor
– Turn to side
 Ensure high protein intake – 1g/kg/day
– Na – moderation
 Antihypertensive drug – Hydalazine
(Apresoline)
 Convulsion – MgSO
4
 Evaluate physical parameters for
MgSO4 toxicity:
 1. Decreased deep tendon reflex –
absent patellar reflex-1st sign
 2. Hypotension
 3. Decreased urine output
 4. Respiratory depression – RR <12
 Antidote – Ca gluconate
POSTPARTAL
HEMORRHAGE
 Blood loss front he uterus greater than
500ml within 24-hour period
 Greatest danger – first 24 hours
 Signs of Shock:
 Pulse rate increases then becomes

weak and thready
 BP drops
 Skin – cold and clammy

Management
 Uterine pack - <48 hours only; prevent
puerperal sepsis
 Supine position and oxygen
administration (4 L/min)
 Blood replacement
Uterine Atony
 Relaxation of the uterus
 Most frequent cause
 Multiple gestation
 Hydramnios
 Large baby (more than 9 lbs)
 Presence of uterine myomas (fibroid
tumors)
 Massage
 Empty bladder
 Oxytocin (Pitocin)/Methylergonovine
(Methergine)
 Bimanual massage
 Hysterectomy – last resort

Lacerations
 Cervical – cervical repair
 Vaginal – rare
 Causes:
 Operative birth
 Rapid birth
 Perineal:
 1st degree – vaginal mucous membrane and
skin of the perineum to the fourchette
 2nd – vagina, perineal skin, fascia, levator
ani muscle, perineal body
 3rd – entire perineum, external sphincter of
the rectum
 4th – entire perineum, rectal sphincter, some
mucous membrane of the rectum
Disseminated
Intravascular Coagulation
 Deficiency in clotting ability caused by
vascular injury; fibrinogen falls below
effective level
 Increased coagulation but bleeding defect
exists throughout the body
 Associated – premature separation of the
placenta, missed early miscarriage, fetal
death in utero
 Early s/s – easy bruising or bleeding
 Premature separation of placenta –
end pregnancy
 IV administration of heparin
 Bleeding during pregnancy – blood or
platelet transfusion
SUBINVOLUTION
 Incomplete return of the uterus to its
prepregnant size and shape
 Small retained placental fragment
 Mild endometritis
 Myoma
 Management: Methergine-0.2 mg
4x/day
 Antibiotic - endometritis
PERINEAL
HEMATOMAS
 Collection of blood in the subcutaneous
layer of tissue of the perineum
 Injury to blood vessels
 May occur at the site of episiotomy of
laceration
 Rapid, spontaneous births
 Perineal varicosities
 Absorbed in 3-4 days
Management
 Mild analgesic
 Ice pack
 Ligation of the vessel

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Maternal Nursing

– intense, excessive contractions

 Multipara – normal-10-14 hours; >14

 Maternal effect – exhaustion

 Fetal effect – fetal distress, caput

 Ealiest sign: tachycardia and

 5. Unwise use of oxytocin

 S/S: sudden, severe pain, profuse

 Cervix open – steroid dexamethazone

 Preterm – cut cord ASAP

 3 or more consecutive pregnancies

 Deviations of the uterus

 Obstruction: adhesion of the fallopian

tube, congenital malformation, scars,

 Surgery: depending on side

 Occur most: low protein intake, women

and become cystic; normal

 Rarely lead to choriocarcinoma

 16 weeks – vaginal bleeding–spotting

 Avoid pregnancy for at least 1 year

 Cervical cerclage – McDonald or

 Advanced maternal age

 Past cesarean birth

 Past uterine curettage

 Signs of shock follow

 DIC syndrome can occur

 No vaginal, pelvic exam, enema

 No drug therapy is necessary

 DBP 15 mm Hg above baseline

 Edema – upper part of the body

 Weight gain – 2lb/wk in 2nd trimester; 1

 3. Decreased urine output

 4. Respiratory depression – RR <12

 Pulse rate increases then becomes

 Skin – cold and clammy

 Large baby (more than 9 lbs)

 Presence of uterine myomas (fibroid

 Hysterectomy – last resort

 Bleeding during pregnancy – blood or

 Ligation of the vessel

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