OB

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Justine Manangan

Infection/Immunity

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Metritis:
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Most common cause of postpartum infection

S&S of metritis: fever, chills, nausea, tachycardia, pelvic pain, and foul-smelling lochia
Higher incidence in C-section
Causes: poor hygiene, Group B strep
Mastitis :
Teaching: continue to breastfeed as long as breasts are not too sore or if there is bleeding or drainage from the

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nipples. pump and dump

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Wear a support bra but not all day.

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S&S: breasts can be red, swollen, tender. Mom may have fever, chills, flu-like (malaise) symptoms.

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Can be one-sided (unilateral)

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Antibiotic treatment

Toxoplasmosis:
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Worry about someone with cats (grows in cat litter)

Treatment with sulfonamides
Undercooked meat, soil
Hepatitis B:
General (how you get it)

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Mother (what she gets)

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Baby (what baby gets)

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Baby of a Hep B+ mom gets both Hep B vaccine and HBIG

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Mom gets HBIG

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Viral Hepatitis
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Systemic viral infection

Type A transmitted fecal-oral route contaminated food, poor sanitation; self-limiting (goes away)
Type B and C transmitted by blood and sexual contact
Vaccines are available for types A and B.

Rubella (German Measles):

Dont get pregnant for 1-3 months.
Tell anyone who is pregnant that you got the live vaccine and stay away.

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Cytomegalovirus (CMV)
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Leading cause of congenital infection, with morbidity and mortality at birth and sequelae.

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Primary infection most dangerous to fetus

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Genital Herpes:
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Expect a C-section if active lesions.

Vaginal delivery is recommended if theres no active lesions.
NO CURE; Antiretrovirals: Acyclovir, Zovirax, Valtrax
Genital irritation, dysuria, inguinal tenderness, reoccurs locally, tingling, itching
Group B Strep:
Most common cause of sepsis and meningitis

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Do group B strep culture at 35-36 weeks.

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Treat with Penicillin G (3 doses) at labor. IV antibiotic 4hr prior to birth.

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Pelvic Inflammatory Disease (PID)
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Caused by chlamydia and gonorrhea (asymptomatic), IUD, sex during menses, douching

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Classic symptoms: lower abdominal tenderness, adnexal tenderness, cervical motion tenderness

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Treatment: antibiotic, bed rest, oral fluids, pain management

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S&S: elevated temp, elevated sed rate, pain, painful urination, N/V.
Complications: ectopic pregnancy, sterility
Chlamydia
Most common STI in the US.
Asymptomatic

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Azithromycin and doxycycline

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Urine test for chlamydia and gonorrhea

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Bartholinitisinflammation of bartholin gland; Salpingitisinflammation of tube, ectopic pregnancy, sterility can

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result; Infertility

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Gonorrhea
Azithromycin and ceftriaxone
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With chlamydia, ceftriaxone and doxycycline

Give Rocephin to mother, EES ointment to infant.
Bartholin abscess, vaginal discharge.
Mostly asymptomatic
Can cause chorioamnionitis, preterm labor, PROM, metritis, neonatal conjunctivitis

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Syphilis
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Do RPR and/or VDRL blood tests

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Patient can have chancre, rash on palms and soles of feet, alopecia

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Can cause stillborn, abortion, retardation

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Penicillin G, doxycycline, erythromycin

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Justine Manangan

BAD. Can cause systemic complication in the later stage

Bacterial Vaginosis
Fishy odor; Whiff test
Flagyl (oral metronidazole) and clindamycin (Cleocin cream)
Preterm, PROM/PPROM, chorioamnionitis, postpartum, endometritis, PID

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Candidiasis
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Vaginal discharge: thick, white, curdlike,

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Pruritis

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Wear cotton underwear

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Candida is a normal constituent in vagina; pathologic when vaginal environment altered.

Trichomoniasis
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Metronidazole (Flagyl)
Causes discharge (yellow/green/gray frothy or bubbly)
Human Papillomavirus (HPV)
Gardasil, Cervarix
Warts (condylomata), cervical cancer
NO CURE; Cryotherapy

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Human Immunodeficiency Virus (HIV)
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HAARThighly active antiretroviral therapy (from 20% chance to 1-2%)

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Dont breastfeed

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Sharing needles, sexually transmitted

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Urinary Tract Infection
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Dysuria, urinary frequency, hematuria

Increase fluids, cotton underwear
Alkaline drinks to transform to acid in the bladder: cranberry juice, grapes, plum, apple + vitamin C
Urine culture and sensitivity
Antibiotics
Pyelonephritis: flank pain

OB

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Justine Manangan

Antepartum

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Trimesters: Weeks 113, 1426, 2740
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Quickening: 16-20 weeks; first fetal movement

Lightening: 36 weeks; baby drops, mom breathes easier, increased urinary frequency
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S&S of pregnancy:
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Presumptive (subjective: uterine and breast enlargement)

Probable (objective: +pregnancy test, abdominal enlargement, Braxton, Ballottement, Goodells, etc.)
Positive (diagnostic: ultrasound, fetal movement felt by MD, FHT)
S&S of mom in 3rd trimester: hemorrhoids, urinary frequency, lordosis, etc.
Fundal height: umbilicus @ 20-22 weeks. 22 weeks = 22 cm 2; xiphoid process @36 weeks.
Small fundal height: wrong date, low amniotic fluid, growth problem
Large fundal height: wrong date, high amniotic fluid, macrosomia, multiple fetus (twins)
Naegeles Rule: 1st day of LMP + 7 days minus 3 months, then add one year.
GTPAL: twins count as 2 in L, but as 1 everywhere else.
Pelvic Assessments:
Gynecoid pelvis is the most favorable pelvis for child bearing
Anthropoid is favorable
Android and Platypelloid are not favorable for vaginal birth.
Screening:
(1) First prenatal visit: full STD screen
(2) 5-6 weeks: ultrasound to detect pregnancy
(3) 10-12 weeks: FHT heard via Doppler
(4) 10-13 weeks (usually 11th wk): CVSgenetic makeup of fetus, risk of miscarriage,
(5) 11-14 weeks: 1st trimester screenBhCG, PAPPA (plasma protein A)
(6) 15-18 weeks: quad panel

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(7) 15-18 weeks: amniocentesisto detect chromosomal abnormalities (AFP)

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(8) 18-24 weeks: ultrasoundanatomy and placental location/pregnancy dating, fetal anomalies, amniotic volume,

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fetal presentation

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(9) 24-28 weeks: GTT, Hgb, CBC, RhoGAMgive @28 weeks and within 72 hr after birth.

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(10) 34 weeks: amniocentesisL/S ratio for lung maturity

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Quad Panel: AFP, hCG, estriol, inhibin A (15th-18th week)
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Quad panel checks for Down syndrome, trisomy 18, neural tube defects

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hCGconfirms pregnancy

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Estriol

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AFP (alpha feto-protein)for PKU; high = neural tube defect, low = Downs syndrome.

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Ultrasound: need full bladder.
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Amniocentesis:
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15-18th: to detect chromosomal abnormalities.

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34th: L/S ratio (surfactant; lung maturity): 2:1 normal, 3:1 diabetic

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Chorionic Villus Sampling (CVS)
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10-13th: sample of chorionic villi from fetal portion of placenta

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Genetic makeup of fetus.

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Non Stress Test (NST):
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Reactive = 2 movements in 20 mins 15 bpm x 15 seconds

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Unsatisfactory (non-reactive) NST, mom should try to eat something.

Biophysical Profile: after + CST (bad) or nonreactive NST.

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Assesses fetal breathing, fetal movement amniotic fluid volume, FHR, and reactivity (reflexes) as measured in NST.
2 points for each category. Max total is 10, but max is 8 if failed NST.
Done for preeclampsia, IUGR, still-birth, diabetes, FHR assessment.
Daily Fetal Movement Count (DFMC)
Bad if none in 12 hours. Call MD (fetal hypoxia)
Want 10-12 times in an hour.
10 times in 2 hours, done 2-3 times a day
<5/hour can mean fetal hypoxiamust do NST or CST
Instruct: Do same time everyday
Do when baby is most active
Call MD if there is a significant change from previous or if non in 12 hours. (can wait 12 hours, then call MD).
NEONATAL ABSTINENCE SCORING TOOL (FINNEGAN SCORE)
Higher score = higher the severity of withdrawal symptoms.
Used by physicians to prescribe (usually Morphine) to newborns exhibiting symptoms.

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Substance Abuse:
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Justine Manangan

1. Alcohol. Fetal alcohol spectrum disorder (FASD), cranio-facial malformations, neurological problems: IQ deficient,
spontaneous abortion, IUGR
2. Nicotine. Vasoconstriction, low birth weight (LBW) infants, IUGR, miscarriage, abruption, decreased blood flow to
placenta, increased risk to SIDS.
3. Caffeine. Vasoconstriction, fetal stimulation, does not cause birth defects when used alone. May be related to IUGR
when consumption is > 3-4 cups of coffee/day (300 mg/day)
4. Marijuana. Most common illicit drug used in America and by women 18-44 y/o. Crosses the placenta. May result in
preterm birth, IUGR, LBW, hyperactive startle reflex, newborn tremors
5. Cocaine. VASOCONSTRICTION. Crack is most commonly used form. It is smoked and absorbed through the

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pulmonary vasculature. Readily crosses the placenta. Causes maternal and fetal tachycardia, increase in BP,

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decreased uterine flow, and increased vascular resistance. Fetus suffers from decreased blood flow and oxygenation

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because of placental and fetal vasoconstriction. Abruption, abortion, IUGR, CNS defects, Snow baby syndrome:

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babies are born addicted to cocaine. May cause fetal depression: lethargy, poor suck, hypotonia, weak cry, and

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difficult in arousal or excitability: high-pitched cry, hypotonicity, rigidity, irritability, inability to console.

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6. Heroin/Opiates. Preterm labor, PROM, abruption, newborn sepsis and death, malnutrition, intellectual impairment.

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Increased rate of stillbirths but not congenital anomalies. 50-75% of infants go through withdrawal within the first 48

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hours after birth. Withdrawal symptoms similar for heroin and methadone: jittery/hyperactive, shrill and persistent cry,
frequent yawning or sneezing, increased tendon reflexes but Moro reflex is decreased, poor feeding and sucking,
tachypnea, diarrhea, sweating and hypo/hyperthermia. 5-10x increase in SIDS for infants undergoing withdrawal.
Need to treat withdrawal symptoms or infant may have vomiting and diarrhea, apnea, dehydration, and convulsions.
7. Methadone. A synthetic opiate. Given to heroin addicts. May not have signs of withdrawal until 1 week after birth. Also
use Suboxone for heroin addicts.
8. Methamphetamines. Effects are not well known but seem to be dose related. High doses during pregnancy seem to
be related to low birth weight, premature births, and perinatal mortality. Cleft lip and palate and cardiac defects are
also common. R/t GERD infants.
9. Sedatives. Easily crosses the placenta. CNS depression, delayed lung maturity, infants may exhibit withdrawal
symptoms due to their dependence on the substance.

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Justine Manangan

Intrapartum

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True labor: uterine contractions with cervical changes. Contractions must be 510 min and keep getting stronger.
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False labor: Braxton Hicks, or back pain goes away.

Factors Influencing the Onset of Labor:
Uterine stretch
Progesterone withdrawal
Increased oxytocin sensitivity
Increased release of prostaglandins

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Signs Preceding Labor
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Braxton Hicks Contractions: strong, infrequent uterine contractions

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Lightening: fetuss presenting part descends into the pelvis

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Bloody Show: brown or blood tinged cervical mucus

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Cervical changes: effacement and dilation

Stages of Labor
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First Stage
Latent

03 cm

contractions q 5-10 min

Duration 1540 sec

mild> moderate

Active

47 cm

contractions q 2-5 min

Duration 4060 sec

mod> strong

Transition

810 cm

contractions q1-2 min

Duration 4590 sec

mod> strong

Second Stage

10 cm

contract q 1-3 min or <

Duration 4590 sec

mod> strong

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Third Stage: Dirty Duncan or Shiny Schultz.

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Fourth Stage: First 4 hours after birth and end up to 6 weeks later.

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(1) Presentation
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Vertex, military, brow, face, frank, complete, single footling, double footling

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Frank breech: legs straight up to face (like an Olympic diver in pike position).

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(2) Lie: longitudinal/vertical, transverse/horizontal, oblique
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(3) Attitude: refers to the relationship of fetal body parts to each other (flexion/extension)
(4) Position: occipital bone, right or left, anterior or posterior.
(5) Station: Location of fetus at 0 station = level with ischial spinesengagement
-1 station = 1cm above ischial spines
Ferguson Reflexthe urge to push
Fetal monitoringexternal monitoring (ultrasound transducer [FHR/FHT] and tocotransducer [contractions]) and internal
monitoring (spiral electrode [heart beat], IUPC [strength of contractions in mm Hg], fetal scalp electrode [FHR])

OB

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VEAL > CHOP

Justine Manangan

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Variable deceleration > Cord compression
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An abrupt decrease in FHR.

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Repositioning, O2, increase IV, may need to D/C pitocin if prolonged variable.

Early deceleration > Head compression

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Benign; usually occur when the laboring mom is 47 dilated

No treatment necessary
Accelerations > Okay; oxygenated
Late > Placental insufficiency
Decel begins after the contraction begins and the lowest part of the decel occurs after the peak of the contraction.

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Does not return to baseline until after contraction is over.

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Stop the Pitocin, increase IV, O2 @10-12 L via nonrebreather mask, reposition, call MD if present.

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Episodic changes in FHR are ominous.
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Periodic changes in FHR usually reflect pain. Occur with labor and are expected.
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Bishop Score: > the number, the more favorable the cervix for successful induction

Drugs used for induction: CHOM

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Cytotecripens cervix
If a mom is given a narcotic analgesic before delivery, watch the APGAR score and expect it may be <7 and the infant may
need some form of resuscitation.
Stadol (butorphanol)
Nubain (nalbuphine)

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Fentanyl (sublimaze)

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Narcan: antidote for narcotics.

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Watch for maternal hypotensionincrease IV flow rate, turn on L side, O2 @ 1015 L/min, turn off Pitocin, notify

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anesthetist, assess cervical dilation and notify OB MD.

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Analgesia given to mom prior to delivery can cause low fetal respirations and bradycardia. Watch monitor. After birth of
infant, infant may need some form of resuscitation.
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C/section: low transverse c/section incision.

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VBACvaginal birth after cesarean.

Precipitous Labor< 3 hours from the onset of contractions to the time of birth.
If you note tachycardia on FHR, check moms temperature
Betamethasone helps produce surfactant for lung development of the fetus, but it is given to the mother, not the baby during
pregnancy.

OB

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Justine Manangan

Postpartum

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Watch for bleeding, want fundus firm and midline after delivery.
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Urinary retention is the #1 cause of uterine atony

Uterine atony is the #1 cause of postpartum hemorrhage.
For postpartum hemorrhage, massage the fundus, put baby to breast, stimulate nipples > oxytocin.
Two main concerns related to lochia: infection and metritis as well as hemorrhage
Causes of afterpains: multiple births, full bladder, breastfeeding, hydramnios, macrosmia (anything that can stretch the
uterus)

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Milk comes in in 72 hours. Warm compress or warm shower can help with let down.
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To relieve engorgement if mom is not going to breastfeed: apply ice to breasts for 1520 mins every other hour, support bra
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24 hr/day, no stimulation of nipples (avoid warm water), cabbage leaves.

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RhoGAM: (-) mom with (+) baby get RhoGAM within 72 hours after birth.
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Indirect Coombs is done at first prenatal visit on mother who is Rh- and has a possibility of carrying an Rh+ fetus.

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Direct Coombs is done (directly) on fetal cord blood to detect presence of maternal antibodies.

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Postpartum blues is normal and can last for up to 2 weeks.

Postpartum depression can last for much longer. Often times, mom wont shower or care for the baby.

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Justine Manangan

Newborn

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Airway and thermoregulation are priorities.
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Ductus venosusconnects umbilical cord to inferior vena cava

Ductus arteriolesconnects pulmonary artery to aorta
Foramen ovaleanatomical opening between R an L atria
APGAR: appearance, pulse, grimace, activity, respirations. Done at 1 and 5 minutes immediately after birth. After 1st
assessment, wait before putting baby on mom. Repeat the 5 min check. You dont want to put the baby on the mother and
then have to take the baby away from her.

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0-3 pointsthe baby is in serious danger and need immediate resuscitation.

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4-6 pointsthe babys condition is guarded and may need more extensive clearing of the airway and supplementary

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oxygen.

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7-10 pointsare considered good and in the best possible health.

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Anthropometric measurements: weight, length, head and chest circumference.

Weight: 2500-4000 grams (5 lb 8 oz to 8 lb 14 oz)

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Length: 45-55 cm (18-22 in)

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Head: 32-38 (13-15 in); 2-3 cm larger than chest circumference.

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Chest: 30-36 (12-14 in)

Vital signs:
Temp: 97.999.7 F

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Heart rate: 110-160

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Respirations: 30-60 breaths/min

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Blood pressure: 50-75/30-45

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Proper identification: footprints, bracelets (2 for baby, 1 for mom, 1 for dad)
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Surfactant lowers the lung surface tension.
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Normal L/S ratio is 2:1 in normal moms and 3:1 in diabetic moms
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Betamethasone helps produce surfactant for lung development of the fetus, but it is given to the mother, not the baby during
pregnancy.
Apneic periods lasting more than 15 seconds with cyanosis and heart rate changes require further evaluation.
Hyperbilirubinemia is an elevated level of bilirubin (a yellow bile pigment produced during the destruction of RBCs) in the
blood.
Two types: conjugated (direct) or unconjugated (indirect)

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Justine Manangan

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Jaundice (yellowing of the body tissues and fluids) results when there is an imbalance between the rate of bilirubin
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production and bilirubin elimination.

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Physiologic jaundice does not usually appear until the 3rd or 4th day of life due to the limitations and abnormalities of
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bilirubin metabolism.

Pathologic jaundice occurs when total bilirubin levels increase by more than 5 mg/dL/day, exceed 17 mg/dL in a term infant
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or 1014 mg/dL in preterm infants, and produce visible jaundice within the first 24 hours following birth.
Unconjugated bilirubin is highly toxic to neurons; therefore, the infant with severe hyperbilirubinemia is at increased risk for
bilirubin encephalopathy, which is associated with total bilirubin levels of greater than 25mg/dL in normal term infants.
Assess for risk factors that may increase bilirubin levels (prematurity, hypoglycemia, infection, hypothermia, significant
bruising, delayed cord clamping, family history of jaundice, inadequate feeding, delayed stooling, male gender, and ethnicity)

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Provide adequate treatment (phototherapy, adequate nutrition, fluid therapy, or exchange transfusion).
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Etiologies and risk factors include physiologic jaundice of the newborn, hemolytic anemia (e.g., G6PD, ABO
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incompatibility, Rh incompatibility, infection), polycythemia, blood extravasation, defects of conjugation (Crigler-Najjar

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syndrome, Lucey-Driscoll syndrome), breastfeeding and human milk jaundice, metabolic disorders (galactosemia,

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hypothyroidism), increased enterohepatic circulation of bilirubin and substances or disorders that affect the binding of

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bilirubin to albumin (drugs, asphyxia, acidosis, infection, hypothermia, and hypoglycemia).

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Signs and symptoms include elevated total and direct serum bilirubin levels, jaundice, icteric sclera, lethargy, and poor
feeding.
The causes of newborn jaundice can be classified into three groups: overproduction, decreased bilirubin conjugation, and
impaired secretion.
Total and direct bilirubin. Establishes diagnosis of hyperbilirubinemia.
Serum bilirubin levels alone do not predict the risk for brain injury due to bilirubin kernicterus, although it is associated with
levels of more than 25 mg/dl in normal, term infants.

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Complete blood count with differential. Detects hemolysis, infection, anemia (Hgb less than 14 g/dl), or polycythemia
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(Hct greater than 65%). Hct less than 40% (cord blood) indicates severe hemolysis.
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Total serum protein. Detects reduced binding capacity (less than 3.0 g/dl).
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Serum glucose. Detects hypoglycemia (less than 40 mg/dl). Tested by heel-stick sample.

Phototherapy: cover eyes and perineum, monitor temperature, frequent position changes, may cause dehydration and
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frequent loose stools (assess); encourage frequent feedings.

Discontinue when bilirubin levels are within an acceptable range.
The full-term newborn has the capacity to swallow, digest, metabolize, and absorb food taken in soon after birth.
Vitamin K is administered because the newborns GI cannot synthesize vitamin K yet.
Newborns stomach capacity is 30 to 90 mL (1 to 3 ounces), with a variable emptying time of 2 to 4 hours.

OB

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Newborns excrete a fair amount of lipids, resulting in fatty stool.
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The term newborn requires an intake of 108 kcal/kg/day from birth to 6 months of age
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Meconium is the first stool (greenish black, has a tarry consistency)
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Transitional (thin, brown to green)

Milk stools (yellow, mushy/pasty)

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Newborns who are fed early pass stools sooner, which helps to reduce bilirubin buildup.
SGAweight less than the 10th percentile on standard growth charts (usually <5.5 lb)
AGAweight between 10th and 90th percentiles
LGAweight more than the 90th percentile on standard growth charts (usually >9 lb)
Circumcisionpetroleum jelly helps with pain, clean with water and soap gently

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Priority is pain relief, bleeding, urination (bc of swelling)
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Light, sticky, yellow drainage (part of healing process) may form over head of penis.
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With umbilical cord care, use of alcohol is recommended to promote drying.
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Clean 2-3 times a day or with each diaper change.
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Do not give tub baths.

Never pull on cord or attempt to loosen it.

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Justine Manangan

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Justine Manangan

Prematurity

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Preterm labor is defined as uterine contractions and cervical changes between 20 and 37 weeks gestation.
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Second leading cause of infant mortality.

Risk factors: infections: UTI, chorioamnionitis, bacterial vaginosis

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Bacterial vaginosis may lead to PROM
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PPROM: preterm premature rupture of membraneswater breaks before
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contractions and before 37 weeks; box 19.3

Diagnostic test for ROM: speculum exam (1) pool of amniotic fluid (2)
nitrazine paper turns bright blue (3) fern under microscope (sodium chloride
crystals)
Preterm labor signs and symptoms: q10 min contractions lasting more than
an hour; lower abdominal cramping, may be menstrual-like; dull, intermittent

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back low pain; urinary frequency; pelvic and/or suprapubic pressure or pain;

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change in vaginal discharge; ROM

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Predicting who may be at risk for preterm labor:
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Fetal Fibronectin: glycoproteins produced by the chorion found

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between the uterus and the fetal membranes. Appear in the

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cervicovaginal fluids in any gestation prior to delivery

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Cervical length examinations: >3 cm in length indicates that

delivery in <14 days is unlikely

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Tocolytics stop contractions and stop preterm labor: MINT

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Mag sulfatecauses CNS depression. Flushed, weak, loss of DTRs, hypotension, decreased respirations, and

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decreased urinary output.

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Indocininhibits prostaglandin (anti-inflammatory agent)

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Nifedipinerelaxes smooth muscle (calcium channel blocker)

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Terbutalinerelaxes smooth muscle, patient becomes hyper and tachycardia.

Tocolytic Side Effects
Tachycardia: Maternal > 120; Fetal > 180
Hypotension
Hypokalemia

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Hyperglycemia

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N/V

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Palpitations

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Pulmonary edema

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Assessments/Interventions
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Explain medication
Know unit protocols
Vitals q15-30min
EFM (External fetal monitor)
Baseline labs
Hourly I&O

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Fetal glucocorticoid therapy to mature fetal lungsbetamethasone (Celastone); stimulates surfactant production

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(twice to mom 24 hrs apart)

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Preterm Newborn
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Body system immaturity affecting transfusion to extrauterine life; increasing risk for complications

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Respiratory systemnot enough surfactant

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Cardiovascular systemcompromises more because it is used to having 1 way of circulation without needing the

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lungs. NICU. closure of foramen ovale and ductus arteriosus.

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GI systemcant coordinate breathing, sucking; NEC (necrotizing enterocolitis); vitamin K

Renal systemF&E imbalances; babies cannot concentrate urine; medicine can become toxic
Immune systemnot working properly; risk for infection
Central nervous systemthermoregulation; if depressed, keep the baby warm.

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Preterm Newborn: Common Characteristics
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Weight < 5.5 lb
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Scrawny appearance
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Poor muscle tone

Minimal subcutaneous fat

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Undescended testes
Plentiful lanugofades
Poorly formed ear pinna
Fused eyelids
Soft spongy skull bones

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Matted scalp hair
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Absent to few creases in soles and palms
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Minimal scrotal rugae; prominent labia and clitoris
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Thin transparent skin
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Abundant vernix caseosafades
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Perfusion5

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Chronic hypertension is hypertension that exists prior to pregnancy or that develops before 20 weeks gestation.

Gestational hypertension is hypertension identified after 20 weeks gestation without proteinuria. BP returns to normal by
12 weeks postpartum.
Preeclampsia is hypertension after 20 weeks gestation with proteinuria.

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Eclampsia is the onset of seizure activity in a woman with preeclampsia.

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PREECLAMPSIA
Preeclampsia is a multisystem, vasopressive disease process that targets the cardiovascular, hematologic, hepatic, renal,
and central nervous systems.
Preeclampsia causes generalized vasospasm which results in elevation of blood pressure and reduced blood flow to the
brain, liver, kidneys, placenta, and lungs.
Drug choice for treatment of severe preeclampsia is magnesium sulfate.
Mild preeclampsia, which presents as a maternal blood pressure of 140/90 and +1 to +2 proteinuria on urine dipstick, can
often be managed at home after the patient has had a careful assessment of her signs and symptoms, a physical
examination, laboratory tests, and evaluation of fetal well-being.
Since lying in the lateral side position decreases pressure on the vena cava, the woman is instructed to maintain this
position as much as possible.
Severe preeclampsia, >160/110, proteinuria of more than 5 g in 24 hours, +3 or more proteinuria on urine dipstick, oliguria
of less than 400 mL in 24 hrs; headaches, blurred visions, blind spots, epigastric pain, thrombocytopenia, pulmonary
edema, HELLP, hyperreflexia, rapid gain weight.
Seizure prophylaxis with magnesium sulfate, which has been universally accepted as the drug of choice because of its
CNS-depressant action.
The use of antihypertensive agents in severe preeclampsia is generally indicated when diastolic blood pressures reach or
exceed 110 mm Hg; Apresoline
Invasive hemodynamic monitoring may be required if any of the following are present:

Oliguria unresponsive to a fluid challenge

Pulmonary edema
Hypertensive crisis refractory to conventional therapy
Cerebral edema
Disseminated intravascular coagulation (DIC)
Multisystem organ failure

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MAGNESIUM SULFATE
Magnesium sulfate is a CNS depressant.

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When administering mag sulfate, assess the DTR, BP, RR, urinary output, LOC.

Magnesium sulfate is always given via infusion pump.

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The antidote for magnesium sulfate is calcium gluconate.

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The therapeutic serum magnesium level is 47 mEq/L
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Toxic is >8 mEq/L which could have side effects such as: oliguria (<30 mL/hr), no DTR, < 12 respirations, < LOC

COMPLICATIONS OF PREECLAMPSIA

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Maternal: abruptio placenta, chronic renal problems, detached retina, chronic hypertension, HELLP, DIC.

Fetal: prematurity, IUGR, asphyxia

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ECLAMPSIA

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Assessments:
DTRs (brachial, wrist, patellar, or Achilles tendons). CNS changes such as headaches and hyperreflexia indicate
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preeclampsia, which may progress to eclampsia.

Clonus. This is a sign of CNS irritability. If clonus is present, measure it as 1-4 beats or sustained.
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Signs and symptoms of impending eclampsia: visual disturbances, epigastric pain, vomiting, persistent or severe
headache, hyperreflexia, pulmonary edema, or cyanosis.
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Prevention Nursing Activities:

Administer magnesium sulfate via infusion pump, as ordered. Helps prevent seizures by acting on myoneural junction to
depress CNS.
Maintain a calm, quiet, restful environment with low lighting and minimal stimulation if CNS irritability is a potential
complication. Helps to prevent seizure activity.
Allow the woman to watch TV or do other quiet activities. Also, allow significant others at the bedside, but encourage quiet
and rest. The woman may become upset or anxious if she cannot have family/partner at the bedside or if she has no
activities or distraction.

HELLP SYNDROME

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Assessments:

Jaundice (although it is not often seen). Hemolysis occurs when RBCs are damaged during passage through small,
damaged blood vessels, resulting in hyperbilirubinemia, especially if liver congestion occurs.
Epigastric or right upper-quadrant abdominal pain. Associated with liver distention or ischemia, which occur when blood

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flow is obstructed due to fibrin deposits.

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Nausea, vomiting, malaise, and flulike symptoms. All are symptoms that can occur with HELLP syndrome.
Thrombocytopenia. Platelet count of less than 100,000/mm3.
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CBC, clotting factors, platelet count, and liver enzymes.
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Preventing Nursing Activities:

Start IV fluids as ordered with a catheter gauge large enough (16-20 gauge) to give blood or blood products if needed. The
woman may need blood or blood products if her condition worsens (e.g., if platelet count is less than 20,000/mm3). In
preeclampsia, the intravascular compartment loses fluid, so hypovolemia can occur very quickly. An IV catheter will be
more difficult to insert if this happens. An IV line is also necessary for administration of medications.
Prepare for immediate birth. Maternal mortality rates as high as 20% may occur with HELLP syndrome. Regardless of
gestational age, a woman with true HELLP syndrome should give birth. At 30 weeks gestation, labor may be induced with
oxytocin; prior to that, cesarean birth is indicated.

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BLEEDING DISORDERS
Early pregnancy: spontaneous abortion (miscarriage), ectopic pregnancy, molar pregnancy, incompetent cervix.

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Late pregnancy: placenta previa, abruptio placentae
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SPONTANEOUS ABORTION

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Spontaneous abortion is an unintended pregnancy loss before 20 weeks gestation.

Most common cause cause of bleeding in first trimester.

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The majority of spontaneous abortions are related to chromosomal defects.
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Late spontaneous abortion may be caused by incompetent cervix.

Incomplete, inevitable, and missed abortions are usually managed via a dilatation and curettage (D & C: the cervix is
dilated and a curette is inserted and used to scrape the uterine walls and remove the uterine contents)
For incompetent cervix, an emergent cerclage (placement of ligature to close the cervix) may be performed.

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Cytotec may be used for abortion

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Give RhoGAM to Rh-negative clients within 72 hours of abortion.
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ECTOPIC PREGNANCY
Ectopic pregnancy: implantation of fertilized ovum outside uterus and the most common site is the fallopian tube.

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Risk factors are: ascending infections, pelvic inflammatory disease (PID), use of IUD, or tubal surgery

Unilateral lower abdominal pain.

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Methotrexate is used as treatment for ectopic pregnancy. This is an option for stable healthy client with unruptured ectopic
pregnancy of 4 cm or less and no FH movement
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Surgical treatment is salpingostomy.

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Provide RhoGAM for Rh-negative mothers
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Douching can cause ectopic pregnancy
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MOLAR PREGNANCY

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Molar pregnancy is the abnormal growth of placenta; grape-like clusters; EMPTY OVUM that contains no maternal genetic
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material.
Vaginal bleeding during 1st trimesterbrown, like prune juice, with grape-like vesicles.
Hyperemesis gravidarum, severe hypertension, hyperthyroidism, pulmonary embolism.
Development of cancer: choriocarcinoma
Provide RhoGAM.
Monitor hCG until it reaches 0.

INCOMPETENT CERVIX

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Incompetent cervix is a painless cervical effacement and dilation without contractions or pain

Maternal DES (diethylstilbestrol) exposure or congenital uterine anomalies, cervical inflammation, previous cervical trauma
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Cerclage is a technique of reinforcing closure of cervix with sutures during pregnancy

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Patients who have an abdominal cerclage must give birth via cesarean section.

Before and after cerclage placement, prophylactic tocolytics (medications used in an attempt to stop labor) may be given
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to prevent uterine contractions.

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PLACENTA PREVIA

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Placenta previa: implantation of the placenta in the lower uterine segment, near or over the internal cervical os.
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The abnormal location of the placenta can cause painless, bright red vaginal bleeding as the lower uterine segment
stretches and thins during the third trimester.
Depending on the placental location, the patient may need to adhere to strict bedrest and a cesarean birth may be
necessary.
Placenta previa may cause progressive hemorrhages
Higher incidence with multiple gestation and multiparity. Scarring and D&C.
May lead to shock, important to monitor maternal vital signs.
Assess blood loss by weighing pads
Maintain IV access with at least an 18-gauge needle and provide replacement fluids (LR)
Perform external fetal monitoring

ABRUPTIO PLACENTAE

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Abruptio placentae, or placental abruption, is the premature separation of a normally implanted placenta from the uterine
wall.
An abruption results in hemorrhage between the uterine wall and the placenta, causing abdominal pain and vaginal
bleeding.
Precipitating factors are maternal hypertension, cocaine abuse, and abdominal trauma
Client is at increased risk of depleting clotting factors and developing DIC=spontaneous internal bleeding
Abruption placentae classic sign: a painful, boardlike abdomen with dark red vaginal bleeding.
Start and maintain IV fluids, monitor I&O (accurate measurementurinary catheter)
Providing oxygen via snug-fitting mask.

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UMBILICAL CORD PROLAPSE

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Protrusion of the umbilical cord in advance of the presenting part.
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Cause: fetus is not firmly engaged, allowing room for umbilical cord to move beyond (prolapse) or alongside presenting
part (occult prolapse) causing cord compression that can lead to decreased oxygen transport and nonreassuring fetal
status.
Keep laboring client with ruptured membranes in horizontal position until fetal head is well engaged as preventive measure.
Place mothers hips higher than head: knee-chest or Trendelenburg
Perform sterile vaginal exam, pushing fetal presenting part upward with fingers to relieve pressure on cord until physician
or midwife arrives.
Provide oxygen.

MECONIUM ASPIRATION
Aspiration of meconium into tracheobronchial tree during first few breaths after delivery in a term neonate.

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Suction oropharynx then nasopharynx after neonates head is born, and while shoulders and chest still in birth canal, to

remove as much meconium as possible before babys first breath.

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Administer O2

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Anticipate need for mechanical ventilation, ECMO
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UTERINE RUPTURE

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Uterine rupture is a tear in the uterus, usually at the site of a previous scar.

Sudden fetal distress

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Very dangerous to the fetus: there are only 10-30 minutes before significant damage occurs to the fetus
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Uterine atony from bladder distention, tearing, and stimulation of Pitocin
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POSTPARTUM HEMORRHAGE

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Postpartum hemorrhage is blood loss of > 500 mL for vaginal birth and > 1,000 mL for cesarean birth.

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Most common cause is uterine atony.

Massage the fundus, and administer uterotonic (CHOM)
Uterotonics cause uterine contractions: Cytotec, Hemabate, Oxytocin, Metherine
Monitor for signs and symptoms of shock.
Shock vital signs: increased pulse and respirations, BP from normal to low, color is normal to pale, CNS is anxious to coma,
resp is from deep to shallow.
Most common type of shock is hypovolemic shock.
It is important to keep an open peripheral vascular line.
Restore fluid volume with isotonic fluids.
Blood transfusion.
Vasoactive medications to improve cardiac output: dobutamine, epinephrine, dopamine.

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Tissue Integrity

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Cervical laceration: skinmusclesphincterbutt wall
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Pain after episiotomyinspect perineal area

Hematoma after episiotomypainful vulva
Medication that affect tissue integrity is warfarin, topical steroid
Hydration!
Wound healing: vitamin C, iron, zinc, protein
Prevention of incontinence

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Ice first 24 hours
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Fistulas
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Thermoregulation

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Preterm babies have thinner skin because they have less brown fat (absent until 26-30 weeks)
Neutral Thermal Temperature
Neutral thermal temperature is the body temperature at which an individuals oxygen use and energy expenditure are
minimized.
A neutral thermal environment is one in which body temperature is maintained without an increase in metabolic rate
or oxygen use.

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Cold Stress
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Excessive heat loss that requires a newborn to use compensatory mechanisms to maintain core body temperature.

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Conversion of brown fat uses oxygen and glucose.

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Cold stressed infant will become hypoxic, hypoglycemic, and hypothermic.

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Blood gas and blood glucose levels are affected.

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Growth is affected as calories are used to maintain body temperature.

Methods of Heat Transfer
ConvectionOccurs when airflow carries heat to or from the body
RadiationRadiant energy exchange between objects not in direct contact
ConductionHeat exchange between objects in direct contact with one another
EvaporationLoss of heat when a liquid is converted to a vapor