COMPLICATIONS OF THE CHILDBEARING EXPERIENCE OBSTETRIC COMPLICATIONS NURSING ALERT Many obstetric complications involve the possibility of hemorrhage

requiring blood replacement. Determine the patient's feelings and beliefs regarding the possibility of transfusions, and notify health care providers if transfusion is refused. ECTOPIC PREGNANCY Ectopic pregnancy is gestation located outside the uterine cavity (ie, implantation occurs at a site other than the endometrium). Because about 96% of ectopic pregnancies occur in the fallopian tubes, the term tubal pregnancy is commonly used. Pathophysiology and Etiology The fertilized ovum implants outside the uterus (see Figure 39-1, page 1260). o Most tubal pregnancies occur in the distal (ampullary) two-thirds of the tube. o Some are located in the proximal portion of the extrauterine part of the tube (isthmic). o Rarely, intrauterine and extrauterine gestations can exist as the same time (heterotopic pregnancy). Structural factors that prevent or delay the passage of the fertilized ovum include adhesions of the tube, salpingitis, congenital and developmental anomalies of the fallopian or uterine tube, previous ectopic pregnancy, use of an intrauterine device for more than 2 years, and multiple induced elective abortions. Functional factors include menstrual reflux and decreased tubal motility. Contributing factors may include: o History of pelvic inflammatory disease (PID). o Endometriosis. o Previous tubal surgery. o Uterine curettage. o Maternal age and race. o Renal disease or transplant. o Improved treatment for PID, which prevents total blockage of tubes, but may cause partial blockage. o Surgical corrections of fallopian tube occlusions. o Elective sterilizations being reversed at a later date.

Clinical Manifestations Abdominal or pelvic pain (most common). Irregular vaginal bleeding usually scanty and dark (most common). Amenorrheain 75% of the cases. Uterine size is usually similar to what it would be in a normally implanted pregnancy. Abdominal tenderness on palpation. Shoulder pain. Increased pulse and anxiety. Nausea, vomiting, faintness, or vertigo and syncope with abdominal pain may develop. Pelvic examination reveals a pelvic mass, posterior or lateral to the uterus, adnexal tenderness, and cervical pain on movement of the cervix.

NURSING ALERT Pain may become severe if a tubal rupture occurs, and clinical presentation will be that of shock. Diagnostic Evaluation Serum progesteronereflects production of progesterone by the corpus luteum, which is stimulated by a viable pregnancy; diagnostic with 97.5% sensitivity if serum progesterone levels are greater than or equal to 25 ng/mL (greater than or equal to 79.5 nmol/L), which would negate need for further testing. Serum -human chorionic gonadotropin (-hCG) (produced by trophoblastic cells)when done serially, will not show characteristic rise as in intrauterine pregnancy Transvaginal ultrasoundmay identify tubal mass and absence of gestational sac within the uterus Culdocentesisbloody aspirate from the cul-de-sac of Douglas indicates intraperitoneal bleeding from tubal rupture Laparoscopyvisualization of tubal pregnancy (considered the diagnostic gold standard) Laparotomyindication for surgery if there is any question about the diagnosis

Management Conservative Therapy Conservative therapy is chosen should the patient desire future childbearing. Treatment with methotrexate is fast becoming the standard of care for ectopic therapy. Methotrexate is given to hemodynamically stable patients who are eligible for treatment and meet the criteria listed below. o Single-dose methotrexate (50 mg/m2) I.M. o Multiple-dose methotrexate (1 mg/kg) I.M. every other day (days 1, 3, etc.), accompanied with Leucovorin (0.1 mg/kg) I.M. every other day (days 2, 4, 6, etc.). Regimen is followed until the -hCG drops 15% or more in 48 hours or four doses of methotrexate have been given. Goal of treatment is to remove ectopic pregnancy and preserve productive function. OR

Usually given on outpatient basis. Must meet criteria as set forth by the American College of Obstetrics and Gynecology (ACOG): o Ectopic size 4 cm or less. o Desire for future fertility. o Stable or rising hCG levels with peak values below 15,000 mIU/mL. o Tubal serosa intact. o No active bleeding. o Ectopic pregnancy fully visualized at laparoscopy and unruptured. o Selected cases of cervical and cornual pregnancy. Advantages of single-dose treatment o Eliminates adverse effects caused by multiple dosing: gastritis, stomatitis, increased hepatic transaminase levels, leukopenia, and thrombocytopenia. o Increased safety and patient acceptance. o Requires less medication, thus decreases patient follow-up and cost of treatment. Contraindications to methotrexate therapy: o Mass greater than 4 cm. o Evidence of acute intra-abdominal bleeding (acute abdomen, hypotension, or falling hematocrit). o Poor patient compliance. o History of active herpes or renal disease. o Presence of fetal cardiac activity. o Abnormal serum creatinine or aspartate aminotransferase (AST). o Active peptic ulcer disease. o Blood leukocyte count of less than 3,000 or a platelet count of less than 100,000.

Surgical Treatment If woman does not consent to or meet criteria for methotrexate, surgical intervention is instituted. The surgical procedure depends on the extent of tubal involvement and if rupture has occurred. o The surgery of choice used to preserve future fertility is a salpingostomy. o Should a woman not desire future fertility, the surgery of choice is salpingectomy. o Other surgeries range from removal of ectopic pregnancy with tubal resection, salpingostomy (removes conceptus leaving tube intact, yet scarred), and possibly salpingo-oophorectomy. Treat shock and hemorrhage if necessary. Administer RhIG (immune globulin) per your facility's policy if woman is Rh negative.

Complications Infertility Hemorrhage and death

Nursing Assessment Evaluate the following to determine pregnancy and to monitor for changes in patient's status, such as rupture or hemorrhage: Maternal vital signs Presence and amount of vaginal bleeding Amount and type of pain Presence of abdominal tenderness on palpation/shoulder pain Date of last menstrual period Presence of positive pregnancy test Rh type

Nursing Diagnoses Risk for Deficient Fluid Volume related to blood loss from ruptured tube Acute Pain related to ectopic pregnancy or rupture and bleeding into the peritoneal cavity Anticipatory Grieving related to loss of pregnancy and potential loss of childbearing capacity

Nursing Interventions Maintaining Fluid Volume Establish an I.V. line with a large-bore catheter, and infuse fluids and packed RBCs as prescribed. Obtain blood samples for complete blood count (CBC) and type and screen for whole blood, as directed. Monitor vital signs and urine output frequently, depending on condition.

Promoting Comfort Administer analgesics as needed and prescribed. Encourage the use of relaxation techniques.

Providing Support through the Grieving Process

Be available to patient and provide emotional support. Listen to concerns of patient and significant others. Be aware that family may be experiencing denial or other stage of grieving. Suggest referrals such as social worker, psychiatrist, and clergy, as appropriate. Suggest grief counseling.

Note: The term family may refer to a nontraditional group of persons, such as the patient and significant other, friend, sibling, parent, or grandparent. Patient Education and Health Maintenance Teach signs and symptoms related to ectopic pregnancy to women at risk including increased vaginal bleeding, severe abdominal pain, shoulder pain, nausea, and vomiting. Instruct woman to report to her primary care provider should signs and symptoms be present or to emergency department if condition is severe. Instruct woman to bring support persons with her when she comes to the facility. Encourage grief counseling and supportive care at home. Teach signs of postoperative infection, including fever, abdominal pain, and increased or malodorous vaginal discharge. Reinforce that chances of another ectopic pregnancy are increased and that subsequent conception potential may be decreased, based on health care provider's explanation. Discuss contraception. Teach signs of recurrent ectopic pregnancyabnormal vaginal bleeding, abdominal pain, menstrual irregularity.

Evaluation: Expected Outcomes Vital signs stable Verbalizes pain relief Patient and support person express sorrow over their loss

HYDATIDIFORM MOLE Hydatidiform mole (gestational trophoblastic disease) is an abnormal pregnancy resulting from a developmental anomaly of the placenta. It is characterized by the conversion of the chorionic villi into a mass of clear vesicles. There may be no fetus, or a degenerating fetus may be present. Pathophysiology and Etiology It is believed to be derived from genetic abnormalities as the paternal haploid, X-carrying set of chromosomes that reaches 46 XX by its own duplication. Not all moles have the 46 XX chromosomal makeup. It arises in fetal rather than maternal tissue. Large amounts of -hCG are present secondary to the proliferation of chorionic tissue. Assay values of -hCG are elevated in the condition. Contributing factors may include chromosomal abnormalities, malnutrition, hormonal imbalance, age under 20 or over 40, and low economic status.

Clinical Manifestations First trimester vaginal bleeding Absence of fetal heart tones and fetal structures Rapid enlargement of the uterus; size greater than dates -hCG titers greater than expected for gestational age Expulsion of the vesicles Hyperemesis (severe nausea and vomiting) Signs of preeclampsia before 24 weeks' gestation

Diagnostic Evaluation -hCG levelselevated Ultrasoundshows a characteristic picture of the mole in most cases

Management Suction curettage is the method of choice for immediate evacuation of the mole with possibility of laparotomy. Follow-up for detection of malignant changes because a complication is the development of choriocarcinoma of the endometrium. Administer RhIG (RhoGAM) per your facility's policy if woman is Rh negative.

Complications Significant blood loss Nursing Assessment Monitor maternal vital signs; note presence of hypertension. Assess the amount and type of vaginal bleeding; note the presence of any other vaginal discharge.

Assess the urine for the presence of protein. Palpate uterine height; if above the umbilicus, measure the fundal height. Determine date of last menstrual period and date of positive pregnancy test. Evaluate CBC results and Rh type.

Nursing Diagnoses Risk for Deficient Fluid Volume related to maternal hemorrhage Anxiety related to loss of pregnancy and medical interventions

Nursing Interventions Maintaining Fluid Volume Obtain blood samples for type and screen, and have 2 to 4 units of whole blood available for possible replacement. Establish and maintain I.V. line; start with a large needle to accommodate possible transfusion and large quantities of fluid. Assess maternal vital signs, and evaluate bleeding. Monitor laboratory results to evaluate patient's status.

Decreasing Anxiety Prepare the patient for surgery. Explain preoperative and postoperative care along with intraoperative procedures. Educate patient and family on the disease process. Allow the family to grieve over the loss of the pregnancy.

Patient Education and Health Maintenance Advise the woman on the need for continuous follow-up care. Provide reinforcement of follow-up procedures: o Measure -hCG levels every 1 to 2 weeks until normal then begin monthly testing for 6 months, then every 2 months for a total of 1 year. o Consider chemotherapy or hysterectomy if -hCG levels rise or begin to plateau or there is evidence of metastasis. Encourage ongoing discussion of care with health care provider.

Evaluation: Expected Outcomes Vital signs stable; laboratory work within normal limits Verbalizes concerns about self and related procedures; describes follow-up care and its importance

SPONTANEOUS ABORTION Spontaneous abortion is the unintended termination of pregnancy at any time before the fetus has attained viability (20 weeks' gestation or fetal weight of more than 500 g). (See Table 39-1.) Intended termination of a pregnancy is known as therapeutic or voluntary abortion and is accomplished through medical or, in most cases, surgical intervention. TABLE 39-1 Types of Spontaneous Abortions CLASSIFICATIONCLINICAL MANIFESTATIONS MANAGEMENT Threatened Vaginal bleeding or spotting Vaginal examination Mild cramps Bed rest (some clinicians will not limit activity in belief that the embryo will be aborted anyway) Tenderness over uterus, simulates mild labor or persistent lower Pad count backache with feeling of pelvic pressure Cervix closed or slightly dilated Symptoms subside or develop into inevitable abortion Inevitable Bleeding more profuse Cervix dilated Membranes rupture Painful uterine contractions Spontaneous abortion occurs in successive pregnancies (three or more) Embryo delivered, followed by dilatation and evacuation (D&E)

Habitual

D&E Treatment of possible causes: hormonal imbalance, tumors, thyroid dysfunction, abnormal uterus, incompetent cervix; with treatment, 70% to 80% carry a pregnancy successfully Hysterogram to rule out uterine abnormalities, infections Surgical suturing of the cervix if incompetent cervix is a causative factor

Incomplete

Fetus usually expelled Placenta and membranes retained Fetus dies in utero and is retained Maceration No symptoms of abortion, but symptoms of pregnancy regress (uterine size, breast changes)

D&E

Missed

Pathophysiology and Etiology

Real-time ultrasound, and if second trimester, fetal monitoring to determine if fetus is dead If fetus is not passed after diagnosis, oxytocin induction may be used. Retained dead fetus may lead to development of disseminated intravascular coagulation or infection Fibrinogen concentrations should be measured weekly

Cause frequently unknown, but 50% are due to chromosomal anomalies Exposure or contact with teratogenic agents. Poor maternal nutritional status. Maternal illness with virus, such as rubella, cytomegalovirus, active herpes, and toxoplasmosis, or specific bacterial microorganisms that put the pregnancy at risk. History of diabetes, thyroid disease, anticardiolipin antibodies, or lupus erythematosus. Smoking or drug abuse or both. Immunologic factor by which the mother and father are genetically similar, with similar major antigens that cause the maternal immune system to reject the embryo. Luteal phase defect. Postmature sperm or ova. Abnormal uterine development or structural defect in the maternal reproductive system (including an incompetent cervix). Imperfect sperm or ova. Environmental factors such as drugs, radiation, or trauma.

Clinical Manifestations Uterine cramping, lower back pain. Vaginal bleeding usually begins as dark spotting, then progresses to frank bleeding as the embryo separates from the uterus. -hCG levels may be elevated for as long as 2 weeks after loss of the embryo.

Diagnostic Evaluation Ultrasonic evaluation of the gestational sac or embryo Visualization of the cervix; presence of dilation or tissue evaluated

Complications Hemorrhage Uterine infection Septicemia Disseminated intravascular coagulation (DIC) in a missed abortion

Nursing Assessment Evaluate the amount and color of blood that is present; determine the time the bleeding began and any precipitating factors. Determine whether a positive pregnancy test has previously been obtained, also the date of the last menstrual period. Monitor maternal vital signs for indications of complications, such as hemorrhage, infection. Evaluate any blood or clot tissue for the presence of fetal membranes, placenta, or fetus.

Nursing Diagnoses Risk for Deficient Fluid Volume related to maternal bleeding Anticipatory Grieving related to loss of pregnancy, cause of the abortion, future childbearing Risk for Infection related to dilated cervix and open uterine vessels Acute Pain related to uterine cramping and possible procedures

Nursing Interventions Maintaining Fluid Volume Report tachycardia, hypotension, diaphoresis, or pallor, indicating hemorrhage and shock. Draw blood for CBC as well as type and screen for possible blood administration.

Establish and maintain an I.V. with large-bore catheter for possible transfusion and large quantities of fluid replacement. Inspect all tissue passed for completeness.

Providing Support through the Grieving Process Assess the reaction of patient and support person, and provide information regarding current status, as needed. Encourage the patient to discuss feelings about the loss of the pregnancy; include effects on relationship with the father. Do not minimize the loss by focusing on future childbearing; rather acknowledge the loss and allow grieving. Provide time alone for the couple to discuss their feelings. Discuss the prognosis of future pregnancies with the couple. If the fetus is aborted intact, provide an opportunity for viewing, if parents desire. Refer to chaplain or social worker if indicated or requested.

Preventing Infection Evaluate temperature every 4 hours if normal, and every 1 to 2 hours if elevated. Check vaginal drainage for increased amount and odor, which may indicate infection. Instruct on and encourage perineal care after each urination and defecation to prevent contamination.

Promoting Comfort Instruct patient on the cause of pain to decrease anxiety. Instruct and encourage the use of relaxation techniques to augment analgesics. Administer pain medications as needed and as prescribed.

Community and Home Care Considerations Teach patient with threatened abortion signs and symptoms of hemorrhage. Discuss emergency access to care with patient and support personnel. If the woman should pass anything through her vagina, instruct her not to discard it, but to bring it to the facility with her for evaluation. Explain to woman to bring her support persons with her to the facility.

Patient Education and Health Maintenance Provide the names of local support groups for couples who have experienced an early pregnancy loss. Resolve Through Sharing groups may be available through a local hospital. Discuss with the couple the methods of contraception to be used. Explain the need to wait at least 3 to 6 months before attempting another pregnancy. Teach the woman to observe for signs of infection (fever, pelvic pain, change in character and amount of vaginal discharge), and advise to report them to provider immediately. Provide information regarding genetic testing of the products of conception if indicated; send the specimen according to policy.

Evaluation: Expected Outcomes Vital signs remain normal; minimal blood loss Expresses feelings regarding the loss of the pregnancy by demonstrating normal signs of grief No signs of infection, temperature normal, performs perineal care Verbalizes relief of pain

HYPEREMESIS GRAVIDARUM Hyperemesis gravidarum is exaggerated nausea and vomiting that persists during pregnancy. Hyperemesis gravidarum can be experienced with or without food intake at any time of the day. Pathophysiology and Etiology Occurs during the first 16 weeks' gestation. Cause unknown but may possibly result from high levels of beta-hCG or estrogen. Accompanied by appetite disturbances that are intractable in nature. Psychological factors including neurosis or altered self-concept may be contributory. Seen in molar pregnancies, multiple gestation, and history of hyperemesis in previous pregnancies. Slowed gastric motility occurs. The persistent vomiting may result in fluid and electrolyte imbalances, dehydration, jaundice, and elevation of serum transaminase.

Clinical Manifestations

Persistent vomiting; inability to tolerate anything by mouth. Dehydrationfever, dry skin, decreased urine output. Weight loss (up to 5% to 10% of body weight). Severity of symptoms increases as the disease progresses.

Diagnostic Evaluation Tests may be done to rule out other conditions causing vomiting (cholecystitis, appendicitis, pancreatitis, thyroid disease, or hepatitis). Liver function studieselevated alanine aminotransferase (ALT) and AST up to four times normal in severe cases. Prothrombin time (PT), partial thromboplastin time (PTT) usually normal. Blood urea nitrogen (BUN) and creatininemay be slightly elevated. Serum electrolytesmay be hypokalemia, hyponatremia or hypernatremia; loss of hydrogen and chloride. Ketones in blood and urine.

Management Try withholding food and fluid for 24 to 48 hours, or until vomiting stops and appetite returns; then restart small feedings. Control of vomiting may require antiemetics (if benefit to therapy outweighs the risks of drugs), such as: o The phenothiazinesprochlorperazine (Compazine, injectable or rectal suppository); promethazine (Phenergan); or chlorpromazine (Thorazine). o Droperidol (Inapsine). o Metoclopramide (Reglan)do not give in combination with phenothiazines. o Meclizine (Antivert). o Methylprednisolone (recently found to more helpful than promethazine; 16 mg three times per day for 3 days then tapered over 2 weeks). Control of dehydration through I.V. fluidstypically 1 to 3 L of dextrose solution with electrolytes and vitamins, as needed. Bicarbonate may be given for acidosis. Most women respond quickly to restricting oral intake and giving I.V. fluids, but repeated episodes may occur. Rarely, total parenteral nutrition is needed. Rarely, complications of hepatic or renal failure or coma could result from disease progression.

Complications Hypovolemia and renal insufficiency Electrolyte imbalance

Nursing Assessment Evaluate weight gain or loss pattern. Compare the prepregnant weight with the current weight. Evaluate 24- or 48-hour dietary recall. Evaluate environment for factors that may affect the woman's appetite. Determine if woman is ingesting nonfood substances (known as pica), such as starch, clay, or toothpaste. Monitor vital signs for tachycardia, hypotension, and fever due to dehydration. Assess skin turgor and mucous membranes for signs of dehydration.

Nursing Diagnoses Risk for Deficient Fluid Volume related to prolonged vomiting Imbalanced Nutrition: Less Than Body Requirements related to prolonged vomiting Ineffective Coping related to stress of pregnancy and illness Fear related to concerns for fetal well-being

Nursing Interventions Maintaining Fluid Volume Establish an I.V. line, and administer I.V. fluids as prescribed. Monitor serum electrolytes, and report abnormalities. Medicate with antiemetics as prescribed. Maintain nothing-by-mouth (NPO) status except for ice chips until vomiting has stopped. Assess intake and output, urine specific gravity and ketones, vital signs, skin turgor, and fetal heart rate (FHR) as indicated by condition.

Encouraging Adequate Nutrition Advise the woman that oral intake can be restarted when emesis has stopped and appetite returns. Begin small feedings. Suggest or provide bland solid foods; serve hot foods hot and cold foods cold; do not serve lukewarm. o Avoid greasy, gassy, and spicy foods.

o Provide liquids at times other than mealtimes. Suggest or provide an environment conducive to eating. o Avoid strong food odors that may trigger vomiting. o Keep room cool and quiet before and after meals. o Keep emesis pan handy, yet out of sight. Administer parenteral calorie replacement if multiple antiemetic treatments and enteral tube feeding have been unsuccessful. Consult with a dietitian as indicated.

Strengthening Coping Mechanisms Allow patient to verbalize feelings regarding this pregnancy. Encourage patient to discuss any personal stress that may have a negative effect on this pregnancy. Refer the patient to social service and counseling services as needed.

Allaying Fears Explain the effects of all medications and procedures on maternal as well as fetal health. Accentuate the positive signs of fetal well-being. Praise mother for attempts at following nutritious diet and healthy lifestyle.

Patient Education and Health Maintenance Educate the woman about proper diet and nutrition. Educate the woman about healthy weight gain. Educate the woman on the need for child care during the periods of severe nausea and vomiting. Encourage the woman to move slowly, avoiding quick changes of position. Quick changes of position can cause vertigo and then nausea and vomiting. Educate the woman on the need to take antiemetics during the nausea phase, before vomiting occurs. Educate the woman on tips to assist with hyperemesis gravidarum. o Eat dry toast or crackers before rising from bed or anytime nausea begins. o Get fresh, outside air daily. o Lie down in a semiprone position. o Drink spearmint or peppermint tea. o Take 50 to 100 mg of vitamin B6 daily. o Avoid food odors. o Eat smaller, frequent meals. Educate the woman that if all interventions fail, she should contact her primary care provider.

Evaluation: Expected Outcomes Demonstrates signs of normal hydration with no ketosis 6 hours after treatment initiated. Urine output adequate; urine specific gravity within normal limits; blood pressure (BP) stable Tolerates small, bland feedings without vomiting Verbalizes concerns and stresses related to pregnancy Mother expresses confidence in infant's well-being

PLACENTA PREVIA Placenta previa is the abnormal implantation of the placenta in the lower uterine segment, partially or completely covering the internal cervical os (see Figure 39-2, see page 1266). Classification may change during labor as the cervix dilates. Placenta previa occurs in 1 in 200 live births. FIGURE 39-2 Degrees of placenta previa. (A) Low implantation. (B) Partial placenta previa. (C) Total placenta previa. Pathophysiology and Etiology Classified as: o Total placenta previathe placenta totally covers the cervical os. o Partial placenta previathe placenta partially covers the cervical os. o Marginal placenta previathe placenta lies within 2 to 3 cm of the internal os, but does not cover it. o Low-lying placentathe exact relationship of the placenta to the os has yet to be determined, or placenta previa is suspected before the third trimester. In cases of low-lying placenta previa, the placenta may migrate upward as the uterus stretches and grows. The cause is unknown, but risk factors include: o Previous myomectomy. o Endometritis. o Scarred uterus or vaginal birth after cesarean delivery (VBAC). o Multiparity. o Previous abortion. o Multiple births.

o Erythroblastosis. o Rh isoimmunization. o Previous placenta previa. As the uterus enlarges during pregnancy, additional risks include hemorrhage and increased likelihood of cesarean delivery. One possible etiologic theory states that the embryo will implant in the lower uterine segment if the decidua in the uterine fundus is not favorable or if implantation is delayed. About 80% of placenta previa episodes occur in multiparas. Incidence increases after age 35, and further increases after age 40.

Clinical Manifestations The cardinal sign is sudden onset of painless vaginal bleeding, typically near the end of the second trimester or later. Bleeding occurs in 80% of cases and appears without warning. Initial episode is rarely fatal and usually stops spontaneously, with subsequent bleeding episodes occurring spontaneously; each episode is more profuse than the previous one. Bleeding from placenta previa may not occur until cervical dilation occurs and the placenta is loosened from the uterus. With a complete placenta previa, the bleeding will occur earlier in the pregnancy and be more profuse.

Diagnostic Evaluation Transabdominal ultrasound is the method of choice to show location of the placenta. If findings are questionable, transvaginal ultrasound can improve the accuracy of diagnosis. Due to bleeding tendencies, however, this must be done by a highly skilled technician. Sterile speculum examination can also confirm placenta previa.

Management If bleeding is minimal and stops, conservative management with bed rest and hospitalization until fetus is mature and term delivery can be accomplished. If woman is discharged, she needs availability of immediate transport to the hospital for recurrent bleeding. If bleeding is heavy, I.V. access should be established immediately, along with CBC and type and crossmatching for at least 4 units of blood. Continuous maternal and fetal monitoring. Amniocentesis may be done, if time permits, to determine fetal lung maturity for possible delivery. Cesarean delivery is usually indicated if the degree of previa is more than 30% or if there is excessive bleeding. The cesarean delivery may be performed immediately. Vaginal delivery may occasionally be attempted in marginal previa or low-lying placenta without active bleeding. In these cases, the operating room staff and anesthesia personnel may be present in the operating room or delivery room to facilitate either vaginal or cesarean delivery as indicated. A neonatal specialty team is needed at delivery due to prematurity or other neonatal complications.

Complications Placenta accreta (abnormally adherent to uterine wall), especially if placenta previa exists with maternal history of uterine surgery. Immediate hemorrhage, with possible shock and maternal death Postpartum hemorrhage resulting from decreased contractility of uterine muscle Increased risk for anemia secondary to increased blood loss and infection secondary to invasive procedures to resolve bleeding. Intrauterine growth restriction (IUGR), especially with maternal history of multiple antepartum bleeding episodes. Congenital anomalies, ie, neurodevelopmental abnormalities, especially with maternal history of multiple antepartum bleeding episodes, due to subtle degrees of fetal hypoxia. Fetal mortality resulting from hypoxia in utero and prematurity

Nursing Assessment Determine the amount and type of bleeding; also, review any history of bleeding throughout this pregnancy. Inquire as to the presence or absence of pain in association with the bleeding. Record maternal and fetal vital signs. Palpate for the presence of uterine contractions. Evaluate laboratory data on hemoglobin and hematocrit status. Assess fetal status with continuous fetal monitoring.

NURSING ALERT Never perform a vaginal examination on anyone who is bleeding until a placenta previa has been ruled out, as such an examination may puncture the placenta. Nursing Diagnoses Ineffective Tissue Perfusion, Placental, related to excessive bleeding causing fetal compromise

Deficient Fluid Volume related to excessive bleeding Risk for Infection related to excessive blood loss and open vessels near cervix Anxiety related to excessive bleeding, procedures, and possible maternal-fetal complications

Nursing Interventions Promoting Tissue Perfusion Frequently monitor mother and fetus. Pulse, respirations, and BP should be taken every 5 to 15 minutes in the presence of active bleeding or if the patient is unstable. After stabilization, vital signs should be taken every 30 to 60 minutes and every 4 hours during expectant management phase. Administer I.V. fluids, as prescribed. Position patient on her side to promote placental perfusion. Administer oxygen by face mask, as indicated. Prepare for emergency delivery and neonatal resuscitation, as needed.

Maintaining Fluid Volume Establish and maintain a large-bore I.V. line, as prescribed, and draw blood for type and screen/cross for blood replacement. Repeat type and screen every 72 hours while hospitalizedwill depend upon patient's condition. Draw blood for CBC, platelets, PT/PTT, fibrinogen, and type and cross for 4 units packed red blood cells (PRBCs), as directed, if profuse bleeding occurs or delivery is scheduled. Assist the patient to a sitting position to allow the weight of fetus to compress the placenta and decrease bleeding. Inspect bleeding every 1 to 2 hours when stable, or more frequently as indicated. Note character, color, and estimated amount of bleeding. Maintain strict bed rest during any bleeding episode. If bleeding is profuse and delivery cannot be delayed, prepare the woman physically and emotionally for a cesarean delivery. Administer blood or blood products protocol per your facility's policy.

NURSING ALERT Women who have had a placenta previa are at risk for postpartum hemorrhage because of the decreased contractility of the lower uterine segment and the large space the placenta occupied. Preventing Infection Use aseptic technique when providing care. Evaluate temperature every 4 hours if membranes are intact; if ruptured membranes, hypothermia, or hyperthermia, evaluate temperature every 1 to 2 hours. Evaluate white blood cell (WBC) and differential count. Teach perineal care and hand-washing techniques. Assess odor of all vaginal bleeding or lochia.

Decreasing Anxiety Explain all treatments and procedures, and answer all related questions. Encourage verbalization of feelings by patient and family. Provide information on a cesarean delivery, and prepare patient emotionally. Inform the woman and her support persons that long-term hospitalization or prolonged bed rest may be necessary and inform them of the effects.

Community and Home Care Considerations Home care for patients with placenta previa and other antenatal bleeding disorders can occur if the following criteria are met: o No active bleeding. o No signs and symptoms of preterm labor (PTL). o Home close to medical facilitymaximum of 15 to 20 minutes away. o Emergency support readily available. Teach the woman signs and symptoms of hemorrhage. Woman is to report to Labor and Delivery immediately if bleeding occurs. Monitor vaginal discharge and bleeding after each urination and bowel movement. Instruct the woman on doing home uterine activity monitoring (HUAM) daily by palpation or electronic telemetry units, if applicable. Instruct the woman on fetal movement counts (kick counts) to be performed on daily basis. Perform daily or twice weekly nonstress test (NST) or home visits and daily provider contact. Instruct the woman to have support persons readily available. Instruct the woman that there is to be nothing in the vagina. Discuss alternative methods of sexual gratification.

Patient Education and Health Maintenance

Educate the woman and her family about the etiology and treatment of placenta previa. Educate the woman to inform medical personnel about her diagnosis and not to have vaginal examinations. Educate the woman who is discharged from the hospital with a placenta previa to avoid intercourse or anything per vagina, to limit physical activity, to have an accessible person in the event of an emergency, and to go to the hospital immediately for repeat bleeding or more that 6 uterine contractions per hour.

Evaluation: Expected Outcomes Fetal condition stable Absence of shock, stable vital signs, absence of bleeding Does not develop symptoms of an infection Verbalizes concerns and understanding of procedures and treatments

ABRUPTIO PLACENTAE Abruptio placentae is premature separation of the normally implanted placenta before the birth of the fetus. It may be classified as partial, complete, or marginal. Hemorrhage can be either occult or apparent. With an occult hemorrhage, the placenta usually separates centrally, and a large amount of blood is accumulated under the placenta. When an apparent hemorrhage is present, the separation is along the placental margin, and blood flows under the membranes and through the cervix (see Figure 39-3). FIGURE 39-3 Abruptio placentaepremature separation of the placenta. Pathophysiology and Etiology Frequently, the etiology is unknown, but risks include: o History of abdominal trauma. o Maternal hypertension. o Umbilical cord anomaly (eg, short umbilical cord); presence of a uterine anomaly or tumor. o Increased parity (> 6). o Advanced maternal age. o Cigarette smoking. o Cocaine or amphetamine abuse. Additional risks include multiple gestation, preterm premature rupture of membranes (PPROM) at less than 34 weeks' gestation, uterine fibroids, previous abruptio placentae, and supine hypotension. Hemorrhage occurs into the decidua basalis, which then forms a hematoma. This hematoma can expand as the bleeding increases; the enlarged size of the hematoma further detaches the placenta from the uterine wall.

Clinical Manifestations Sudden onset, intense, localized, uterine pain/tenderness with (external) or without (occult) vaginal bleeding; however, approximately 10% of women present with only concealed hemorrhage. Uterine contractions may be low amplitude and high frequency. Uterine baseline resting tone may be elevated, making assessment of uterine activity difficult. Changes in the FHR may commonly be the first sign of maternal hemodynamic imbalance. The FHR may be increased (tachycardia) or decreased (bradycardia), or may demonstrate repetitive late decelerations or decreased or absent variability. Fetal response depends on the amount of blood loss and the extent of uteroplacental insufficiency present. Abdominal pain is commonly present due to increased uterine activity, although it is a less constant symptom than vaginal bleeding. Pain in mild cases may be difficult to distinguish from pain of labor contractions. Nausea and vomiting. Patient may exhibit signs and symptoms of rapid labor progress and delivery.

Diagnostic Evaluation Based on woman's history, physical examination, laboratory studies, and signs and symptoms, including vaginal bleeding, abdominal pain, uterine contractions, uterine tenderness, fetal distress. Not all may be seen in every case. Ultrasound is done to exclude placenta previa, but is not always sensitive enough to either diagnose or rule out abruptio placentae. Laboratory screen for erythrocyte rosette on mother's blood to check for fetal cells in the maternal circulation. KleihauerBetke acid elution tests have also been recommended to determine maternal-fetal hemorrhage by assessing maternal blood for the presence of fetal hemoglobin; however, the test has been found to be of little value in the general workup of patients with abruptio placentae.

Management Management depends on the maternal and fetal status and degree of bleeding; however, any patient with suspected abruptio placentae should be admitted immediately. Depends on maternal and fetal status. In fetal compromise, severe hemorrhage, coagulopathy, poor labor progress, or increasing uterine resting tone, emergent cesarean delivery is highly recommended. If the mother is hemodynamically stable and the fetus is stable (reassuring FHR tracing) or has already died in utero (intrauterine fetal demise), vaginal delivery may be recommended. If mother is not hemodynamically stable, she may need stabilization with I.V./blood/blood products replacement to maintain urine output at 30 to 60 mL/hour and hematocrit at least 30%. With rapid infusion of fluids, monitor woman for signs/symptoms of pulmonary edema.

A neonatal specialty team is necessary at delivery due to prematurity and neonatal complications.

Complications Maternal shock DIC Anaphylactoid syndrome of pregnancy (formerly amniotic fluid embolism) Postpartum hemorrhage Acute respiratory distress syndrome Sheehan's syndrome (postpartum pituitary necrosis) Renal tubular necroses Rapid labor and delivery Maternal death Prematurity Fetal death

Nursing Assessment See Table 39-2. CHARACTERISTIC Onset Bleeding Pain and uterine tenderness Fetal heart tone Presenting part Shock Delivery TABLE 39-2 Characteristics of Abruptio Placentae and Placenta Previa ABRUPTIO PLACENTAE PLACENTA PREVIA Third trimester Third trimester (commonly at 32-36 weeks) May be concealed, external dark hemorrhage, or Mostly external, small to profuse in amount, bright bloody amniotic fluid red Usually present; irritable uterus, progresses to Usually absent; uterus soft boardlike consistency May be irregular or absent Usually normal May be engaged Usually not engaged Moderate to severe depending on extent of concealed Usually not present unless bleeding is excessive and external hemorrhage Immediate delivery, usually by cesarean section Delivery may be delayed, depending on size of fetus and amount of bleeding

Determine the amount and type of bleeding and the presence or absence of pain. Monitor maternal and fetal vital signs, especially maternal BP, pulse, FHR, and FHR variability. Palpate the abdomen. o Note the presence of contractions and relaxation between contractions (if contractions are present). o If contractions are not present, assess the abdomen for firmness. Measure and record fundal height to evaluate the presence of concealed bleeding. Prepare for possible delivery.

Nursing Diagnoses Ineffective Tissue Perfusion: Placental related to excessive bleeding, hypotension, and decreased cardiac output, causing fetal compromise Deficient Fluid Volume related to excessive bleeding Fear related to excessive bleeding, procedures, and unknown outcome

Nursing Interventions Maintaining Tissue Perfusion Evaluate amount of bleeding by weighing all pads. Monitor CBC results and vital signs. Position in the left lateral position, with the head elevated to enhance placental perfusion. Administer oxygen through a snug face mask at 8 to 12 L/minute. Maintain oxygen saturation level above 90% by using pulse oximetry monitoring. Evaluate fetal status with continuous external fetal monitoring. Encourage relaxation techniques. Prepare for possible cesarean delivery if maternal or fetal compromise is evident.

Maintaining Fluid Volume Establish and maintain large-bore I.V. line for fluids and blood products as prescribed. Evaluate coagulation studies. Monitor maternal vital signs and contractions. Monitor vaginal bleeding, and evaluate fundal height to detect an increase in bleeding.

Decreasing Fear Inform the woman and her family about the status of herself and the fetus.

Explain all procedures in advance when possible or as they are performed. Answer questions in a calm manner, using simple terms. Encourage the presence of a support person.

Patient Education and Health Maintenance Provide information to the woman and her family regarding etiology and treatment for abruptio placentae. Encourage involvement from the neonatal team regarding education related to fetal/neonatal outcome. Teach high-risk women the signs and symptoms of placental abruption and increased uterine activity. Instruct woman to report to Labor and Delivery immediately should excessive bleeding or pain occur at home. Instruct woman to have emergency plan in place for transport to medical facility expediently. It is important to have support persons aware of procedures as well.

Evaluation: Expected Outcomes FHR within normal range, without a loss of variability Absence of shock, demonstrated by stable maternal vital signs after initiation of treatment Demonstrates concern; asks questions

HYPERTENSIVE DISORDERS OF PREGNANCY Hypertensive disorders of pregnancy, which affect the placenta, are considered the most common medical complications of pregnancy, affecting 12% to 22% of all pregnancies. Classification Chronic Hypertension Hypertension that is present and observable before pregnancy or that is diagnosed before the 20th week of gestation. Preeclampsia and Eclampsia Preeclampsiadiagnosis is determined by increased BP accompanied by proteinuria. o BP increases are either systolic BP greater than or equal to 140 mm Hg or diastolic BP greater than or equal to 90 mm Hg. o Diastolic BP is determined as Korotkoff V (disappearance of sounds). o Gestational hypertension is confirmed based on two determinations of no more than 1 week apart. o Proteinuria is urinary excretion of greater than or equal to 0.3 g protein in a 24-hour specimen. A random test usually indicates greater than or equal to 30 mg/dL (1+ on dipstick); however, it is recommended that the diagnosis of proteinuria be determined by the 24-hour urine specimen method rather than the random test. o Preeclampsia is categorized as mild or severe. Severe preeclampsia criteria include: Systolic BP of greater than or equal to 160 mm Hg or diastolic BP of greater than or equal to 110 mm Hg differentiate between mild and severe forms. Proteinuria of greater than or equal to 2 g in 24 hours (2+ to 3+ on qualitative examination). Increased serum creatinine (greater than 1.2 mg/dL). Persistent headache or cerebral or vision disturbances. Persistent epigastric pain. Platelet count less than 100,000/mm3 or evidence of microangiopathic hemolytic anemia (with increased lactic acid dehydrogenase). HELLP syndrome Eclampsiahypertension with seizures in a preeclamptic patient that cannot be contributed to an underlying neurologic condition. Note: Eclampsia was previously referred to as toxemia because it was thought to be caused by toxins. The term eclampsia is more commonly used.

Preeclampsia/Eclampsia Superimposed on Chronic Hypertension In women with hypertension and no proteinuria early in pregnancy (prior to 20 weeks' gestation) and new-onset proteinuria, defined as greater than or equal to 0.3 g protein in a 24-hour specimen. In women with hypertension and proteinuria before 20 weeks' gestation o Sudden increase in proteinuriagreater than or equal to 0.3 g protein in 24-hour specimen, or two dipstick tests of 2+ (100 g/dL), with values recorded at least 4 hours apart, with no evidence of urinary tract infection (UTI). o Sudden increase in BP in a woman whose BP was previously well controlled. o Thrombocytopenia (platelet count less than 100,000/mm 3). o Increase in ALT or AST to abnormal levels.

Gestational Hypertension BP elevation detected for first time in pregnancy, without proteinuria. This classification includes: o Women with preeclampsia syndrome who have not yet manifested proteinuria o Women who do not have the syndrome Final differentiation as to whether the woman had preeclampsia syndrome is determined postpartum. o If she does not develop preeclampsia and her BP has returned to normal by 12 weeks postpartum, the woman is given the diagnosis of transient hypertension of pregnancy. o However, if her BP remains elevated after 12 weeks' postpartum, the woman is given the diagnosis of chronic hypertension.

Therefore, the diagnosis of gestational hypertension is used during pregnancy only until a more definitive and specific diagnosis can be made during the postpartum period. Pathophysiology and Etiology Actual cause is unknown. Theories of the etiology include the exposure to chorionic villi for the first time, or in large amounts, along with immunologic, genetic, and endocrine factors. The disease is more commonly seen in primigravidas. Chronic hypertension, hydatidiform mole, multiple gestation, polyhydramnios, preexisting vascular disease, obesity, and diabetes mellitus may predispose a patient to preeclampsia. Adolescents (younger than age 17) and women older than age 35 are at higher risk. Multisystem disease with widespread vasospasms occur and result in increased resistance in vascular flow, increasing the arterial BP and causing endothelial damage. Stimulates platelet and fibrinogen use, causing hypoxic damage to vulnerable organ systems. Increased sensitivity to angiotensin II occurs before the onset of hypertension. Hemoconcentration occurs due to the vasoconstriction or as a result of increased vascular permeability or a combination of both. Will see increased hematocrit (not consistent with normal pathophysiology of pregnancy where hematocrit decreases). Decreased placental production of prostacyclin and increased thromboxane A2.

BOX39-1 HELLP Syndrome HELLP syndromeconsisting of Hemolysis of RBCs, Elevated Liver enzymes, and Low Platelets (<100,000 mm 3)is a severe complication of pregnancy-induced hypertension. These findings are frequently associated with disseminated intravascular coagulation (DIC) and, in fact, may be diagnosed as DIC. The hemolysis of erythrocytes is seen in the abnormal morphology of the cells. The elevated liver enzyme measurement is associated with the decreased blood flow to the liver as a result of fibrin thrombi. The low platelet count is related to vasospasm and platelet adhesions. Treatment is similar to treatment for preeclampsia with close monitoring of liver function and bleeding. These women are at increased risk for postpartum hemorrhage. Complaints range from malaise, epigastric pain, and nausea and vomiting to nonspecific viral syndromelike symptoms.

NURSING ALERT The risk of preeclampsia is increased for multigravida women if they have a new partner (father of the baby different than the previous children) due to new genetic makeup of the fetus. Clinical Manifestations Elevated BP o Mild preeclampsiasystolic BP greater than 140 mm Hg or diastolic BP greater than 90 mm Hg. o Severe preeclampsiasystolic BP greater than 160 mm Hg or diastolic BP greater than 110 mm Hg. Proteinuria o Mild preeclampsiagreater than 0.3 g/24 hour specimen (1+ on qualitative assessment [urine dipstick]). o Severe preeclampsia proteinuria2 g in 24 hours (2+ to 3+ on qualitative examination). P.1272

Other symptoms in severe preeclampsia: o Increased serum creatinine (> 1.2 mg/dL) o Persistent headache or cerebral or visual disturbances (altered level of consciousness [LOC], headache, scotomata, or blurred vision). o Hyperreflexiadeep tendon reflexes (DTRs) increased (3+ to 4+)/clonus (> 2 beats). o Persistent epigastric pain. May have impaired liver function of unclear etiology (may be due to decreased hepatic function). o Platelet count less than 100,000/mm3 or evidence of microangiopathic hemolytic anemia (with increased lactic acid dehydrogenase) Eclampsiaseizures or coma without neurologic or febrile origin in patient with preeclampsia; third trimester and 48 hours postpartum are most common times for occurrence.

Diagnostic Evaluation A 24-hour urine for protein of more than 0.3 g (mild); more than 2.0 g (severe). Serum BUN, serum creatinine, and serum uric acid to evaluate renal function and glomerular filtration capability, specifically creatinine clearance, uric acid clearance, and urea clearance. Liver function tests (AST, ALT). Coagulation studies, specifically platelets, antithrombin III, and factor VIII levels.

Lipid panel to assess high-density lipoprotein (HDL) and low-density lipoprotein (LDL); HDL levels are decreased in preeclamptic women whereas LDL levels are elevated. Sonogram, NST to evaluate placenta and fetus DTRs and clonus evaluation to assess level of disease process BP changes meeting criteria for diagnosis

Management Directed toward decreasing the maternal BP through the use of inpatient hospitalization or conservative management and antihypertensive medications along with increase in dietary protein and an increase in calories, if indicated. Delivery is appropriate therapy; however, delivery may endanger the fetus due to fetal lung immaturity. Expectant management (wait and watch) can be considered if the following maternal and fetal factors are present: o Controlled hypertension o Urinary protein of any amount o Oliguria (< 0.5 mL/kg/hour) that resolves with routine fluid/food intake o AST or ALT greater than 2 times upper limit of normal without epigastric pain or right upper quadrant (RUQ) tenderness o Biophysical profile (BPP) more than 6 o Amniotic fluid index (AFI) more than 2 cm o Ultrasound fetal weight more than 5th percentile Delivery should be achieved within 72 hours if any of the following occur: o Uncontrolled hypertension o Eclampsia o Platelet count less than 100,000/mm3 o AST or ALT more than two times upper limit of normal with epigastric or RUQ tenderness o Pulmonary edema o Compromised renal function o Abruptio placentae o Persistent severe headache or visual changes o Repetitive late or nonreassuring variable decelerations o BPP less than 4 on two occasions 4 hours apart o AFI less than 2 cm o Ultrasound estimated fetal weight < 5th percentile o Reverse umbilical artery diastolic flow

Pharmacologic Therapies Magnesium sulfate (MgSO4) may be given either I.V. or I.M. The I.V. route is preferred; I.M. administration is reserved for eclamptic patients without I.V. access. o A 4- to 6-g loading dose of 50% MgSO4 is usually given I.V. over 15 to 30 minutes followed by a maintenance dose (secondary infusion) of 2 to 3 g/hour. o The therapeutic level for magnesium sulfate is a serum level of 4 to 7 mEq/dL). o Actions: decreases neuromuscular irritability and blocks the release of acetylcholine at the neuromuscular junction; depresses vasomotor center; depresses central nervous system (CNS) irritability. Phenytoin (Dilantin), although proposed for eclampsia prophylaxis, is not a first-line therapy in the United States. If seizures develop and the patient is not on MgSO 4, 2 g may be given I.V. every 15 minutes to a maximum of 6 g. If the patient is already on MgSO4, then give 1 to 2 g I.V. and continue to check magnesium levels to assess toxicity/therapeutic levels. If seizures continue, paralytic agents may be necessary and the patient may require mechanical ventilation. Calcium gluconate is kept at bedside (but must remain secure) as a reversal agent for magnesium toxicity. o Dosage is 1 g (10 mL of 10% solution) by slow I.V. push. o Signs of MgSO4 toxicity include loss of deep tendon reflexes, including knee-jerk reflex, respiratory depression, oliguria, respiratory arrest, and cardiac arrest.

Antihypertensive Drug Therapy May be used when the diastolic pressure reaches or exceeds 105 mm Hg or when cerebrovascular accident is impending. The goal of antihypertensive therapy is to reduce the BP to a level that will provide the mother with a margin of safety (95 to 100 mm Hg) without compromising adequate uterine perfusion. Hydralazine (Apresoline) is the drug of choice. o Hydralazine relaxes the arterioles and stimulates cardiac output via direct peripheral vasodilation. o Dosage: 5 mg I.V. push followed by 5 mg I.V. or 10 mg I.M., given 5 to 10 mg every 20 to 30 minutes to a maximum dose of 20 mg (I.V.) to 30 mg (I.M.). o Onset of action can occur in 10 to 20 minutes, with peak action in 20 minutes after administration; duration of the drug can last from 3 to 8 hours. o If desired response not obtained after 20 to 30 mg, change agents and consider hemodynamic monitoring. o Adverse effects of hydralazine include flushing, headache, maternal and fetal tachycardia, palpitations, uteroplacental insufficiency with subsequent fetal tachycardia, late decelerations, and worsening hypertension (if hypertension due to elevated cardiac output). Rebound hypotension is possible if drug given too rapidly. Labetalol (Normodyne)used in place of hydralazine. o Contraindicated in women with asthma, heart failure and/or second- or third-degree heart block. o Alpha/beta-adrenergic blocker that decreases systemic vascular resistance without reflex tachycardia; it slows the maternal heart rate. Cardiac monitoring is required. o Administered either I.V. bolus or titrated drip.

If I.V. bolus: initial dose 20 mg; if effect is suboptimal after 10 minutes, give 40 mg I.V.; if effect is still suboptimal after a subsequent 10 minutes, then give 80 mg I.V. for two additional doses. Maximum dose is 220 mg. o Onset of action is 1 to 2 minutes, with peak of action at 10 minutes, and duration of drug effect lasting 6 to 16 hours. o Adverse effects of labetalol include transient fetal and neonatal hypotension, bradycardia, and hypoglycemia. Small doses excreted in breast milk. Alpha-methyldopa (Aldomet) o Safe and well tested; however, it has a delayed onset of 4 to 6 hours even with I.V. administration, limiting its usefulness for hypertensive emergencies. o Can cause somnolence (sleepiness) in some patients. Nifedipine (Procardia) o Calcium channel blocker that decreases BP by blocking the intracellular pathways of calcium movement causing smooth muscle relaxation and vasodilatation. o Onset of action occurs in 5 to 19 minutes, with peak action occurring in 10 to 20 minutes, and duration of effect lasting 4 to 8 hours. o Adverse effects include hypotension, palpitations, nausea, headache, fetal acidosis related to uteroplacental insufficiency. Sodium nitroprusside (Nipride)potent, short-acting, direct vasodilator; used only when all other agents have failed and the patient has life-threatening hypertension. o Given in titrated drip only with onset of action occurring in 15 to 30 seconds. Initial dose started at 0.25 mcg/kg/minute and titrate to desired effect. Maintenance dose is increased by 0.25 mcg/kg/minute every 5 minutes. Average dose is 3 mcg/kg/minute with the range being 0.5 to 10 mcg/kg/minute. o Onset of action occurs in 30 seconds to 2 minutes, with peak action occurring in 1 to 2 minutes and duration of effect lasting 3 to 5 minutes. o Actions: potent vasodilator with direct effect on arterial and venous smooth muscle. o Adverse effects include nausea, diaphoresis, anxiety, headache, bradycardia, electrocardiogram (ECG) changes, tachycardia, raised intracranial pressure, decreased reflexes, blurred vision, crosses placenta, and cyanide toxicity. o Dilute in dextrose 5% in water (D5W) only, and do not mix with any other drug. o Continuous BP monitoring with arterial line and ECG monitoring, along with central hemodynamic monitoring should be considered. o Arterial blood gas (ABG) levels need to be monitored for metabolic acidosis, which may be an early sign of cyanide toxicity. Nitroglycerinindicated for hypertension refractory to conservative pharmacologic therapy. o Dosage: initial dose is 5 to 10 mcg/min; subsequent doses titrated to the desired response by increasing the dose 5 mcg/min every 3 to 5 minutes. o Actions: relaxes predominantly venous, but also arterial, vascular smooth muscle; decreases preload at low doses and afterload at high doses. o Must be diluted before administration in D5W or normal saline (NS). o Requires central hemodynamic monitoring (central venous pressure [CVP], pulmonary artery pressure, and pulmonary artery wedge pressure). o FHR variability may be decreased with this drug, and fetal stress may occur when mean arterial pressure (MAP) is greater than 106 mm Hg. o Hypovolemia must be corrected before use. o Adverse effects include hypotension, tachycardia, nausea, vomiting, pallor, sweating, headache, flushing of skin, methemoglobinemia (with I.V. doses greater than 7 mcg/kg/minute). DRUG ALERT Nifedipine (Procardia) is not recommended for use during hypertensive crisis as it drops the BP too quickly, resulting in maternal death. DRUG ALERT Sodium nitroprusside (Nipride) is contraindicated for antepartum use because it crosses the placenta and causes fetal cyanide toxicity. DRUG ALERT Sodium nitroprusside solution is light sensitive and should be covered in foil and changed every 24 hours. Correction of Hypovolemia

Correct hypovolemia before initiation of antihypertensive therapy. Avoid abrupt and usually profound drops in BP. Maintain diastolic BP between 95 and 100 mm Hg diastolic to maintain uteroplacental perfusion.

Complications Complications of preeclampsia affect many body systems, including cardiovascular, renal, hematologic, neurologic, hepatic, and uteroplacental systems. Abruptio placentae DIC HELLP syndrome Maternal or fetal death Hypertensive crisis Pulmonary edema; cerebral edema Oliguria; acute renal failure Thrombocytopenia

Hemorrhage; stroke Blindness Fetal intolerance of labor Hypoglycemia Hepatocellular dysfunction; hepatic rupture Prematurity Intrauterine growth restriction (IUGR) from decreased placental perfusion

Nursing Assessment Evaluate BP using the correct size cuff and same arm for each measurement. The sitting position is recommended with the (preferably right) arm supported in a horizontal position at the level of the heart. In the side-lying position, the dependent arm should be used, but the patient should not be lying on it. Check the protein level of a spot urine specimen and initiate a 24-hour urine specimen. Measure weight daily when the patient is stable. Evaluate DTRs and clonus. Evaluate fetal status with NST, fetal movement (kick) counts, BPP, and contraction stress test (CST) via nipple stimulation or oxytocin challenge test (OCT). Evaluate uterine activity for high-frequency, low-intensity uterine contractions. Observe for signs and symptoms of disease escalation. Monitor for signs of MgSO4 toxicityabsent knee-jerk reflex, respiratory depression, oliguria. Discontinue MgSO 4, and notify health care provider Serum magnesium level every 6 to 8 hours per your facility's policy.

Nursing Diagnoses Excess Fluid Volume related to pathophysiologic changes of gestational hypertension and increased risk of fluid overload Ineffective Tissue Perfusion: Fetal Cardiac and Cerebral related to altered placental blood flow caused by vasospasm and thrombosis Risk for Injury related to seizures or to prolonged bed rest or other therapeutic regimens Anxiety related to diagnosis and concern for self and fetus Deficient Diversional Activity related to prolonged bed rest Decreased Cardiac Output related to decreased preload or antihypertensive therapy

Nursing Interventions Maintaining Fluid Balance Control I.V. fluid intake using a continuous infusion pump. Monitor intake and output strictly; notify health care provider if urine output is less than 30 mL/hour. Monitor hematocrit levels to evaluate intravascular fluid status. Monitor vital signs every hour. Auscultate breath sounds every 2 hours, and report signs of pulmonary edema (wheezing, crackles, shortness of breath, increased pulse rate, increased respiratory rate).

Promoting Adequate Tissue Perfusion Position on side to promote placental perfusion. Monitor fetal activity. Evaluate NST to determine fetal status. Increase protein intake to replace protein lost through kidneys.

Preventing Injury Instruct on the importance of reporting headaches, visual changes, dizziness, and epigastric pain. Instruct to lie down on left side if symptoms are present. Keep the environment quiet and as calm as possible. If patient is hospitalized, side rails should be padded and remain up to prevent injury if seizure occurs. If patient is hospitalized, have oxygen and suction setup, along with a tongue blade and emergency medications, immediately available for treatment of seizures. Assess DTRs and clonus every 2 hours. Increase frequency of assessment as indicated by patient's condition.

DRUG ALERT Keep calcium gluconate at bedside as the reversal agent for magnesium toxicity. Dosage is 1 g (10 mL of a 10% solution) slow I.V. push. Be cautious with concurrent administration of opioids, CNS depressants, calcium channel blockers, and betaadrenergic blockers. Decreasing Anxiety and Increasing Knowledge Explain the disease process and treatment plan including signs and symptoms of the disease process.

Explain that preeclampsia does not lead to chronic hypertension. Discuss the effects of all medications on the mother and fetus. Allow time to ask questions and discuss feelings regarding the diagnosis and treatment plan.

Promoting Diversional Activities Explain the need for bed rest to the woman and her support persons. Explore woman's hobbies/diversional activities. Instruct family to arrange for easy access to TV, phone, computer, and stereo to limit woman getting out of bed. Instruct family to arrange for community support (eg, church, women's groups).

Maintaining Cardiac Output Control I.V. fluid intake using a continuous infusion pump. Monitor intake and output strictly; notify primary care provider if urine output is less than 30 mL per hour. Monitor maternal vital signs, especially mean BP and respirations. Assess edema status, and report pitting edema of +2 to primary care provider. Monitor oxygenation saturation levels with pulse oximetry. Report oxygenation saturation rate of less than 90% to primary care provider.

Community and Home Care Considerations Mild preeclampsia may be treated at home. Ensure that patient meets criteria set forth by ACOG for home management: o Gestational age more than 20 weeks. o BP less than 150/100 mm Hg sitting position or less than 140/90 mm Hg lateral position. o No headache or visual disturbances present. o No epigastric pain, marked edema, clonus, or DTRs greater than +2. o Must have available BP equipment. Ensure that patient has daily phone contact with primary care provider. Make periodic home visits, either daily or twice weekly. Teach woman signs and symptoms of disease progression. Teach woman at-home BP monitoring for two to four times daily in the same arm and the same physical position (eg, on left side, on right side). Obtain daily weights at the same time each day. Assess urine protein status daily on the first voided urine or obtain 24-hour urine each week. Teach woman to assess daily fetal movement (kick) counts; arrange for weekly NST.

Patient education and Health Maintenance Teach the woman the importance of bed rest in helping to control symptoms. Encourage the support of family and friends while on bed rest. Provide and suggest diversional activities while on bed rest. Provide information on tests and procedures to evaluate maternal-fetal status, such as laboratory tests, sonogram, NST. Include support of the neonatal team for discussion of fetal prognosis with the woman and her family.

Evaluation: Expected Outcomes No evidence of pulmonary edema; urine output adequate FHR within normal range; reactivity present No seizure activity Expresses concern for self and the fetus Maintaining bed rest and pursuing diversional activities BP and other vital parameters stable

POLYHYDRAMNIOS Polyhydramnios or hydramnios is an excessive amount of amniotic fluid in the amniotic sac. At 36 weeks gestation, approximately 1 L of fluid is present. The amount of amniotic fluid normally decreases after this time. The amount of amniotic fluid present is controlled in part by fetal urination and swallowing. Pathophysiology and Etiology The etiology is usually unclear. Normal amniotic fluid volume at term is 500 to 1,000 mL. The volume in polyhydramnios exceeds 2,000 mL between 32 and 36 weeks. Anomalies causing impaired fetal swallowing or excessive micturition may contribute to the condition. It can be associated with maternal diabetes (Type I or Type II), monozygotic multiple gestation, Rh isoimmunization, anomalies of the CNS including spina bifida and anencephaly, or anomalies of the GI tract, including tracheoesophageal fistula.

Clinical Manifestations Excessive weight gain, dyspnea. Abdomen may be tense and shiny. Edema of the vulva, legs, and lower extremities. Increased uterine size for gestational age usually accompanied by difficulty in palpating fetal parts and in auscultation of fetal heart. Nonreassuring FHR tracing; may show repetitive nonreassuring variable or late decelerations.

Diagnostic Evaluation A diagnosis is made based on the present symptoms and ultrasound evaluation revealing AFI greater than 25 cm. Ultrasound evaluation will show large pockets of fluid between the fetus and uterine wall or placenta. Difficult to palpate fetus or hear FHR; nonreassuring FHR tracing. Fundal height (FH) greater than age of gestation (AOG).

Management Depends on the severity of the condition and the cause; hospitalization is indicated for maternal distress or for intervention regarding fetal prognosis. If impairment of maternal respiratory status occurs, amniocentesis for removal of fluid may be performed. o The amniocentesis is performed under ultrasound for location of the placenta and fetal parts o The fluid is then slowly removed. o Rapid removal of the fluid can result in a premature separation of the placenta. o Usually 500 to 1,000 mL of fluid is removed.

Complications Dysfunctional labor with increased risk for cesarean delivery Postpartum hemorrhage due to uterine atony from gross distention of the uterus Although rare, fluid embolus is possible. Acute fetal hypoxia secondary to prolapsed cord or trauma if associated with diabetes Potential for delivery of a preterm neonate

Nursing Assessment Evaluate maternal respiratory status; frequently present with dyspnea. Evaluate FHR to assess fetal status. Inspect abdomen and evaluate uterine height and compare with previous findings. Evaluate for abdominal pain, edema, varicosities of lower extremities and vulva.

Nursing Diagnoses Ineffective Breathing Pattern related to pressure on the diaphragm Ineffective Tissue Perfusion: Placental related to pressure from excess fluid Impaired Physical Mobility related to edema and discomfort from the enlarged uterus Anxiety related to fetal outcome Risk for Injury related to overdistention of the uterus and possible hemorrhage

Nursing Interventions Promoting Effective Breathing Position to promote chest expansion with head elevated. Provide oxygen (8 to 12 L/minute) by face mask, if indicated. Limit activities and plan for frequent rest periods. Maintain adequate intake and output.

Promoting Placental Tissue Perfusion and Oxygen to Fetus Position on side if possible, with head elevated. If unable to position on side, use a wedge to displace the uterus to either side. Encourage passive or active assisted range of motion to the lower extremities. Monitor FHR as directed and assess for abnormal FHR pattern: decreased or absent variability, tachycardia, prolonged, nonreassuring, variable, or repetitive late decelerations. Provide good fluid intake and a diet adequate in protein, iron, and fluids. Administer oxygen at 8 to 12 L/minute per snug face mask as needed.

Promoting Mobility

Assist the woman with position changes and ambulation as needed. Advise on alternating activity with rest periods for legs. Instruct the woman to wear loose-fitting clothing and low-heeled shoes with good support.

Decreasing Anxiety Explain the cause of polyhydramnios, if known. Encourage the patient and family to ask questions regarding any treatment or procedures. Encourage expression of feelings. Prepare patient for the type of delivery that is anticipated and for the expected finding at the time of delivery. Encourage presence of support person.

Preventing Hemorrhage during Labor Use Friedman's curve to assess labor status. Follow augmentation and induction protocol per orders or your facility's policy. Notify primary care provider of inadequate or abnormal labor curve. Keep woman well hydrated and nourished. Administer oxytocin (Pitocin) immediately after delivery of placenta. Observe for changing vital signs indicating excessive blood loss: decreasing BP and increasing pulse. Have other ergotrate drugs available should oxytocin not be effective (eg, Methergine, Hemabate).

Patient Education and Health Maintenance Instruct the woman to notify her health care provider if she experiences respiratory distress. Teach the woman signs of PTL and the need to report them to health care provider.

Evaluation: Expected Outcomes Respirations at normal rate of 18 to 20 and unlabored FHR within normal limits without fetal compromise Verbalizes improved comfort; moves freely Discusses the pregnancy outcome realistically; questions regarding treatment for self and fetus Labor progresses, and involution occurs without hemorrhage

OLIGOHYDRAMNIOS Oligohydramnios is the marked decrease of amniotic fluid in the amniotic sac of less than 0.5 L between 32 and 36 weeks' gestation. Usually, the fluid is extremely concentrated. Cord compression and fetal compromise may occur and lead to a poor outcome. The infant will suffer from pulmonary hypoplasia (especially P.1277 if associated with Potter's syndrome) due to compression of the fetal chest and body by the uterine wall. Skeletal abnormalities can also occur due to a lack of fluid in the terminal air sacs if oligohydramnios occurs in the first or second trimester. Pathophysiology and Etiology Frequently related to fetal problems, such as obstruction in the urinary tract, renal agenesis, and IUGR (Any condition that prevents the formation of urine or the entry of urine into the amniotic sac usually results in oligohydramnios.) Associated with premature rupture of membranes (PROM) and severe preeclampsia where there is a significant decrease in fetal vascular volume causing decreased urine output Frequently seen in postdate pregnancies Placental insufficiency Premature separation of placenta from the uterus Twin-to-twin transfusion

Clinical Manifestations Prominent fetal parts on palpation of the abdomen Small-for-date uterine size Nonreassuring variable decelerations or repetitive late decelerations on fetal tracing

Diagnostic Evaluation Ultrasound evaluation of the AFIamniotic fluid of less than 5 cm total in all four vertical plane quadrants of the uterus is associated with lower perinatal mortality. AFI between 5 and 8 cm is considered borderline with treatment being provider driven. FH less than AOG.

Management

Frequent evaluation of fetal status through NST, BPP, CST, or OCT as indicated. Ultrasound is also done to further evaluate fetal renal and urinary systems along with fetal growth. Amnioinfusion (the installation of fluid into the amniotic cavity to replace normal volumes of amniotic fluid) during labor. o Protocols vary; usually begin with 800-mL bolus followed by a maintenance continuous infusion. o Fluid used is either NS or Ringer's lactate. o Assess for fluid returning during infusion. o Monitor uterine activity and FHR during the infusion. o No requirement for warming the fluid; however, recommendation is made to warm the fluid if Fetus is preterm. There is fetal compromise. Infusion rate is greater than 600 mL/hour. Delivery may be indicated for conditions, such as IUGR or fetal compromise.

NURSING ALERT Contraindications to amnioinfusion include suspected or diagnosed abruptio placentae, acute fetal compromise, fetal head is engaged and tightly applied to the cervix, or the inability to measure intrauterine pressures. Complications PTL Umbilical cord compression Passage of meconium Fetal/neonatal death

Nursing Interventions and Patient Education Evaluate fetal status by fetal monitoring. Evaluate maternal vital signs for signs of infection, especially if oligohydramnios is secondary to PROM. Assist with an amnioinfusion as indicated. Inform health care provider of fetal intolerance to labor (nonreassuring FHR patterns), assist the woman to a side-lying position, and treat as indicated.

MULTIPLE GESTATION Multiple gestation or multifetal pregnancy results when two or more fetuses are present in the uterus at the same time. Multiple gestation is not a complication of pregnancy; rather, it is a condition that presents an increased risk of morbidity and mortality for the mother and neonates. Etiology Types of twinning (see Figure 39-4, page 1278) FIGURE 39-4 Multiple gestations. (A) Dizygotic twins showing two placentas, two chorions, and two amnions. (B) Monozygotic twins with one placenta, one chorion, and two amnions. Dizygotic (fraternal)occurs when two separate ova are fertilized (ie, two separate eggs and two sperm). Dizygotic twins do not have the same genetic makeup and are as similar as other brothers and sisters. o Monozygotic (identical)occurs when one ovum divides early in gestation and two embryos develop (ie, one egg and one sperm). Monozygotic twins are identical in genetic makeup but size may vary due to unequal splitting of the cytoplasm. Etiology unclear for spontaneous monozygotic twins. o Intermediaryhalf-identical polar body or monovular-dispermic twinning. Artificially induced ovulation, as well as in vitro fertilization, in which multiple embryos are transferred into the uterus, increase the chances of multiple gestation. Increasing maternal age and parity increase the chance of twinning. Other terminology: o Monochorionicone chorionic membrane. o Monoamnioticone amniotic sac. o Dichorionictwo chorionic membranes. o Diamniotictwo amniotic sacs. o

Clinical Manifestations Usually, the uterus is large for gestational age (FH > AOG) during the second trimester. Usually, a uterus that is more than 2 cm larger than normal for gestational age is suggestive of multiple gestation and usually occurs at about 14 weeks' gestation for twins, or sooner for greater multiples Auscultation of two distinct and separate fetal hearts may occur with a Doppler late in the first trimester or with a fetoscope after 20 weeks' gestation. Ultrasound is the best screening test at present; used for 95% to 100% of cases. It may identify separate gestation sacs as early as 6 to 8 weeks. High initial quantitative -hCG levels in infertility care are typically the earliest indications of multiple gestation. However, due to the possibility of false positive results, ultrasound should be used to confirm the diagnosis in the presence of elevated -hCG levels.

Complications

Cardiopulmonary o Pulmonary edema o Complications from tocolysis o Preeclampsia Gastrointestinal o Acute fatty liver of pregnancy o Cholestasis of pregnancy o Hematologicanemia Obstetric o PTL or birth o Cervical effacement and dilatation o Increased incidence of cesarean delivery o Increased use of tocolysis o Antepartum hemorrhage o Abruptio placentae o Uterine rupture o Postpartum hemorrhage o Infections o Increased hospitalizations o Gestational diabetes o Polyhydramnios; oligohydramnios common with twins Spontaneous abortion IUGR Umbilical cord problems, such as entwinement, cord prolapse, or vasa previa Structural abnormalities, such as congenital heart defects, intestinal tract anomalies, neural tube defects, hydrocephaly, craniofacial defects, skeletal defects, anencephaly, encephalocele, or acardia (ie, absence of the heart). Conjoined twins Twin-to-twin transfusion syndrome

Management and Nursing Interventions Nutrition counselingstress increased caloric and protein intake as well as vitamin supplements to meet the demands of multiple gestation. Fetal evaluationencourage follow-up for serial sonograms during the pregnancy to evaluate growth and development and to detect IUGR. Explain NST, BPP, and amniocentesis for detection of fetal lung maturity. Percutaneous umbilical cord sampling may be used to establish fetal well-being if twin-to-twin transfusion is suspected. Evaluate the woman for signs and symptoms of obstetrical complications as noted above, which are more common in multiple gestation. PTL preventionexplain that hospitalization may be necessary for signs and symptoms of PTL. o Encourage bed rest and hydration. o Institute fetal monitoring and assist with tocolytic therapy, if ordered (see Tocolytic therapy, page 1280). Explain to the woman that mode for delivery depends on the presentation of the twins, maternal and fetal status, and gestational age. Cesarean delivery is commonly used for multiples other than twins; however, vaginal birth of triplets may be indicated in the presence of noncontracted pelvis, vertical lie of first triplet, unscarred uterus, and onset of labor at more than 32 completed weeks of gestation. Intrapartum management o Establish I.V. access to be prepared for emergency birth or other complications. o Provide for electronic fetal monitoring for each fetus. o Double setup is recommended for delivery. Guidelines for vaginal birth of twins: Availability of two units of crossmatched whole blood. I.V. access with large bore catheter. Surgical suite immediately available. An obstetrician and assistant experienced in vaginal births of twins. Best choice of anesthesia: epidural. Anesthesia provider capable of administering general anesthesia. Neonatal team for each neonate present at birth for neonatal resuscitation. o Pitocin induction/augmentation may be required secondary to hypotonic labor. o Postpartum hemorrhage may occur due to uterine atony. Emotional supportencourage family to discuss feelings about multiple births and identify ways in which they will need help. Refer to resources such as National Organization of Mothers of Twins Clubs, http://www.nomotc.org

Community and Home Care Considerations Discuss with woman and support persons the warning signs of PTL. Teach the woman uterine self-palpation. Woman is to evaluate uterine activity twice daily. Engage in home visits recommended for NST and FHR assessment as needed. Ensure weekly provider phone contact by patient.

COMPLICATIONS OF LABOR PRETERM LABOR Preterm labor is defined as cervical change or effacement and uterine contractions occurring after 20 weeks' gestation and prior to 37 completed weeks of gestation. It occurs in up to 12% of all pregnancies. Diagnosis involves 1) 20 to 36 weeks' gestation, 2) documented uterine contractions, and 3) documented cervical effacement of 80% or cervical dilatation of more than 1 cm.

Uterine irritability without cervical change is not PTL. Likewise, preterm birth (PTB) and low birth weight (LBW) are not synonymous; preterm birth is any birth that occurs before 37 completed weeks of pregnancy, whereas LBW refers to birth weight alone (< 2,500 g), regardless of gestational age. Pathophysiology and Etiology The exact etiology for PTL remains unknown, but may include: o Decidual hemorrhage (abruption). o Mechanical factors such as uterine overdistension or cervical incompetence. o Hormonal changes. However, certain changes in the body occur with the onset of spontaneous labor. o Cervical ripening occurs, which includes softening and shortening of the cervix. o Oxytocin receptors are present in the myometrium. o Prostaglandin levels in the amniotic fluid are increased.

Risk Factors for PTL Medical/obstetric predating the pregnancy o Prior preterm birth (triples the risk) o Multiple abortions o Low prepregnancy weight for height o Uterine/cervical abnormalities o Parity (0 or > 4) o Hypertension o Diabetes Current pregnancy related o Anemia o Multiple gestation o Placenta previa o Abruptio placentae o Fetal anomaly o Hydramnios (polyhydramnios, oligohydramnios) o Abdominal surgery o Infection o Bleeding in first trimester o Short interpregnancy interval o PROM o Cervical incompetence o UTIs/pyelonephritis Demographic o Maternal age younger than 17 or older than 34 o Black race (doubles the risk) o Low socioeconomic status o Unmarried o Low level of education Behavioral and environmental o Diethylstilbestrol exposure o Smoking (especially if more than 11 cigarettes/day) o Poor nutrition o Alcohol or other substance use o Late or no prenatal care o Domestic violence o Air pollution Other o Stress o Long working hours

Clinical Manifestations Uterine cramps (menstrual-like, intermittent or constant) Uterine contractions occurring at intervals of 10 minutes or less Low abdominal pressure (pelvic pressure) Dull low backache (intermittent or constant) Increase or change in vaginal discharge Feeling that baby is pushing down or that something is in the vagina Abdominal cramping with or without nausea, vomiting, or diarrhea

Management The focus of treatment is prevention of delivery of a preterm neonate starting with preconception care and focusing on the many risks attributable to preterm labor and birth. Preconception Care Baseline assessment of health and risks with advice to decrease the risks attributable to PTL/PTB. Pregnancy planning and identification of barriers to care.

Adjustment of prescribed and over-the-counter medications that may pose a threat to the developing fetus. Advice to improve maternal nutrition. Screening for and treatment of diseases. Genetic counseling for those with a history of genetic disease or a previously affected pregnancy.

Antepartum Treatment Educate mother regarding signs/symptoms of PTL (noted above). Instruct mother and provide resources for lifestyle modifications: o If mother smokes, encourage smoking cessation classes. o Ensure mother has a healthy diet and adequate maternal weight gain during pregnancy. Although home uterine activity monitoring (HUAM) has been used since the early 1980s, prospective studies do not support its efficacy; therefore, ACOG does not recommend its use. Initial treatment for a patient who is at risk for PTL is the use of bed rest in a left lateral position with continuous monitoring of fetal status and uterine activity. Hydration with I.V. fluids, with careful assessment of intake and output and auscultation of lungs to assess for the development of pulmonary edema. If this stops the contractions, tocolytic therapy is not needed.

Tocolytic Therapy If antepartum therapy is not successful, tocolytic therapy may be instituted. These drugs should be used only when the potential benefit to the fetus outweighs the potential risk. Betamimetic agentsTerbutaline (Brethine) is typically used for tocolysis; however, this drug is not Federal Drug Administration (FDA) approved for this use (it is FDA approved for treatment of asthma). Although ritodrine hydrochloride (Yutopar) is the only agent with FDA approval for use as a tocolytic, it is rarely used due to the significant adverse effects affecting woman and fetus. o Betamimetic drugs stimulate the 2 receptor cells located in smooth muscle, which decreases or stops uterine contractions. o Terbutaline and ritodrine may be administered I.V., subcutaneously, or orally after baseline assessments are obtained and strict intake and output is initiated. o Frequent monitoring is necessary to observe for adverse effects of increased pulse, shortness of breath, chest pain, decreased BP, hypervolemia, decreased potassium concentration, hyperglycemia, and hyperinsulinemia. o Before initiating administration of these medications, obtain the following laboratory tests: CBC with differential, electrolytes, serum glucose, BUN, creatinine, PT, and PTT. ECG should also be done, especially if using ritodrine. MgSO4interferes with smooth muscle contractility, although its exact mechanism of action is unknown. o Administration is I.V. on an infusion pump. o During administration, the woman is monitored for pulmonary edema, loss of deep tendon reflexes, decreased respirations, hypotension. Other maternal adverse effects include flushing, headache, nausea and vomiting, shortness of breath, and chest pain. o Serum magnesium levels are monitored. o Calcium gluconate is the antidote for MgSO4 and should be at the bedside. o If used, protocol is the same as for preeclampsia (see page 1272). Prostaglandin inhibitorsindomethacin (Indocin) inhibits contractions; however, after 34 weeks' gestation, indomethacin may cause premature closure of the fetal ductus arteriosus, increasing the risk of fetal pulmonary hypertension. o Administration is oral or rectal; short-term use is recommended for only 48 to 72 hours. o Suggested for use before 32 weeks' gestation, if fetus shows no evidence of IUGR and AFI is normal. Calcium channel blockersnifedipine (Procardia) relaxes smooth muscle by inhibiting the transport of calcium. o Administration is sublingual or oral. o Maternal adverse effects include headache, nausea, hepatotoxicity, and flushing from vasodilatation. Fetal adverse effects include decreased uteroplacental blood flow, fetal hypoxia, and bradycardia.

NURSING ALERT Discontinue tocolytic therapy if maternal pulse rate is greater than 120 beats/minute. Contraindications to tocolytic therapy Acute fetal distress (not to include intrauterine resuscitation) Intra-amniotic infection Eclampsia or severe preeclampsia Fetal demise Fetal maturity Maternal hemodynamic instability Severe bleeding of any cause Fetal anomaly incompatible with life Severe IUGR Cervix dilated more than 5 cm

Selected contraindications to betamimetic agents Maternal cardiac rhythm disturbance or other cardiac disease Poorly controlled diabetes, thyrotoxicosis, or hypertension

Selected contraindications to magnesium sulfate Hypocalcemia Myasthenia gravis Renal failure

Selected contraindications to indomethacin Asthma Coronary artery disease GI bleeding (current or past) Renal failure Suspected fetal cardiac or renal anomaly

Selected contraindications to nifedipine Maternal liver disease

Acceleration of Fetal Lung Maturity Corticosteroid administrationbetamethasone or dexamethasone o Pregnant women between 24 and 34 weeks' gestation with any possibility of PTL are candidates for this therapy. o Betamethasone is given I.M. in two doses of 12 mg each, 24 hours apart. o Decreases intraventricular hemorrhage (IVH), necrotizing enterocolitis (NEC), and respiratory distress syndrome (RDS) that may be a result of prematurity. o Timely administration is essential; given before delivery to mother; try to postpone delivery for 48 hours. o Serial administration of the agents is no longer recommended. Artificial surfactant therapy o Decreases ventilatory days for infants with RDS. o Given after delivery to infant directly into lungs by endotracheal tube

Complications Prematurity and associated neonatal complications, such as lung immaturity o IVH o RDS o Patent ductus arteriosus (PDA) o NEC o Financially costly Potential complications of tocolytic agents o Betamimetic agentshyperglycemia, hypokalemia, hypotension, pulmonary edema, cardiac insufficiency, arrhythmias, myocardial ischemia/necrosis, maternal death, neonatal cardiovascular toxicity o MgSO4pulmonary edema, respiratory depression (seen with toxic levels), cardiac arrest (seen with toxic levels), maternal tetany (seen with toxic levels), profound muscular paralysis (seen with toxic levels), profound hypotension (seen with toxic levels), hypotonia, neonatal bone abnormalities, decreased calcium levels o Indomethacinpulmonary hypertension, premature closure of PDA, hepatitis (rare; associated with chronic use), renal failure (rare; associated with chronic use), GI bleeding (rare; associated with chronic use) o Nifedipinetransient hypotension

Nursing Assessment During tocolytic therapy, assess the following: Fetal status by electronic fetal monitoring Uterine activity pattern Respiratory status (pulmonary edema is a common adverse effect) Muscular tremors Palpitations Dizziness/lightheadedness Urinary output Patient education to signs and symptoms of PTL Patient education to signs and symptoms of infection

Nursing Diagnoses Anxiety related to medication and fear of outcome of pregnancy Deficient Diversional Activity related to prolonged bed rest Risk for Injury to fetus secondary to prematurity Risk for Injury secondary to tocolytic therapy Compromised Family Coping secondary to hospitalization

Nursing Interventions Decreasing Anxiety P.1282 Promoting Diversional Activities Determine quiet craft activities that can be done in bed. Provide radio, books, computer, videos, and television. Encourage visits from family, especially other children and friends. If possible, encourage them to bring in favorite foods for the woman and to dine as a family. Know the contraindications and potential complications of tocolytic therapy. Explain the purpose and common adverse effects of tocolytic therapy. Provide accurate information on the status of the fetus and labor (contraction pattern). Allow the woman and her support person to verbalize their feelings regarding the episode of PTL and the treatment. If a private room is not used, do not place the woman in a room with a woman who is in labor or who has lost an infant. Encourage relationship with other patients who are also experiencing PTL.

Minimizing Injury to Fetus Encourage the woman to assume positions that will enhance placental perfusion. Monitor fetal status and labor progress. Assist with delivery of infant as needed. Notify provider of dysfunctional (protracted) labor curve.

Minimizing Risk of Drug-Related Injury Maintain accurate intake and output at least every hour (unless on low-dose maintenance therapy). Limit intake to 2,500 mL/day (90 mL/hour). Assess maternal vital signs in accordance with your facility's policy or protocol. Notify the primary health care provider if maternal pulse greater than 120 beats/minute. Assess for signs and symptoms of pulmonary edema. Discontinue infusion if adverse effects occur; notify primary health care provider. Educate the woman on tocolytic therapy, explaining the purpose and common adverse effects.

Promoting Maternal-Family Coping Encourage private time for woman and partner. Allow visitation with other children as tolerated by woman. Comment on strengths of the family unit. Encourage other family activities such as helping with homework. This will assist on maintaining the family unit.

Community and Home Care Considerations Use HUAM for home management of PTL if ordered (not recommended by ACOG). Ensure that woman meets following criteria for home management of PTL: o No evidence of active PTL. o No evidence of intra-amniotic infection. o Cervical dilatation less than 3 cm. Ensure that protocols or orders are in place for each of the following: o Warning signs for PTL. o Demonstration of uterine self-palpation by woman. o Twice-daily uterine activity assessment. o Monitoring vaginal discharge; signs of spontaneous rupture of membranes. o Assessment of urine frequency, signs and symptoms for UTI; diarrhea, pelvic heaviness/pressure, maternal temperature, uterine cramping/tenderness. o Frequent home visits; NST, FHR assessment, and vaginal examination evaluation necessary. o Daily provider-initiated phone consult.

Patient Education and Health Maintenance Educate the woman about the importance of continuing the pregnancy until term or until there is evidence of fetal lung maturity. Encourage the need for compliance with a decreased activity level or bed rest, as indicated. Teach the woman the importance of proper nutrition and the need for adequate hydration. Instruct the woman not to engage in sexual activity if diagnosed with PTL. Teach the woman the signs and symptoms of infection and to report them immediately.

Evaluation: Expected Outcomes Demonstrates concern about treatment and pregnancy outcome Participates in diversional activities No fetal compromise noted Adequate fluid intake and output Family focused on woman's well-being

PREMATURE RUPTURE OF MEMBRANES Premature rupture of membranes (PROM) is defined as rupture of the membranes before the onset of labor. PROM is independent of gestational age; when it occurs prior to term it is referred to as preterm PROM (PPROM). Due to confusion of the terms PROM and PPROM, the term prelabor rupture of membranes may be used in place of PROM. This condition occurs in 3% to 18.5% of pregnancies. Pathophysiology and Etiology The exact etiology of PROM is not clearly understood, although nonpathologic causes such as the combination of stretching of the membranes and biochemical changes are suspected to contribute. PROM is manifested by a large gush of amniotic fluid or leaking of fluid per vagina, which usually persists.

Diagnostic Evaluation Sterile speculum examination for identification of pooling of fluid in the vagina. Nitrazine testpositive test will change pH paper strip from yellow-green to blue in the presence of amniotic fluid taken from the vaginal canal. Fern testpositive test will reveal ferning on a slide viewed under a microscope. A swab of the posterior vaginal fornix is taken to obtain amniotic fluid.

Management When PROM is confirmed, the woman is admitted to the hospital and usually remains there until delivery. The woman is evaluated to rule out labor, fetal compromise, and infection and to establish gestational age. If all factors are ruled out, the woman is managed expectantly. Management of PROM at 36 weeks' gestation or greater focuses on delivery. Vaginal examinations are kept to a minimum to prevent infection.

Complications Premature labor and delivery Maternal infectionchorioamnionitis Increased rates of cesarean delivery Prematurity and associated complications Fetal or neonatal infection Hypoxia and asphyxia secondary to umbilical cord compression and coincident abruptio placentae Fetal deformation syndrome

Nursing Assessment Evaluate maternal BP, respirations, pulse, and temperature every 2 to 4 hours. If temperature or pulse is elevated, continue monitoring every 1 to 2 hours as indicated. Monitor the amount and type of amniotic fluid that is leaking, and observe for purulent, foul-smelling discharge. Evaluate daily CBC with differentials, noting any shift to the left (ie, increase of immature forms of neutrophils). Evaluate fetal status every 4 hours or as indicated, noting fetal activity and heart rate and uterine activity. Determine if uterine tenderness occurs on abdominal palpation.

Nursing Diagnosis Risk for Infection related to ascending bacteria

Nursing Interventions Preventing Infection Evaluate amount and odor of amniotic fluid leakage. Do not perform vaginal examinations without consulting the health care provider. Place patient on disposable pads to collect leaking fluid, and change pads every 2 hours or more frequently as needed. Review the need for good hand-washing technique and hygiene after urination and defecation. Monitor FHR and fetal activity every 4 hours or more frequently as indicated. Monitor maternal temperature, pulse respirations, BP, and uterine tenderness at least every 4 hours or more frequently as indicated.

Evaluation: Expected Outcomes No signs of infection

PRETERM PREMATURE RUPTURE OF MEMBRANES Preterm premature rupture of membranes (PPROM) is defined as rupture of membranes before 37 completed weeks' gestation with or without the onset of spontaneous labor. Recently, due to the confusion over the meaning of premature rupture of membranes (ie, before labor versus preterm), the term preterm prelabor rupture of membranes is used to signify rupture of membranes in preterm gestations. Pathophysiology and Etiology Exact cause is unknown. However, PPROM is likely to be either a pathologic intrinsic weakness or extrinsic factors causing the membranes to rupture prematurely. In PPROM, risk factors include: o Infection (amnionitis; group B beta-hemolytic Streptococcus) o Previous history of PROM or PTB o Hydramnios (polyhydramnios/oligohydramnios) o Incompetent cervix o Increased intrauterine volume (multiple gestation, fibroids, polyhydramnios) o Abruptio placentae o Cigarette smoking o Fetal anomalies o Coitus (intercourse) o Vaginal colonization with group B beta-hemolytic Streptococcus o Prenatal vaginal bleeding in more than one trimester

Diagnostic Evaluation Same as PROM. Ultrasound to assess amniotic fluid volume. Amniocentesis to inject indigo carmine or Evans blue dye. Watch for vaginal leakage of blue fluid to assess for ruptured membranes.

Management For PPROM, tocolytics, corticosteroids (to decrease the severity of RDS in the premature neonate), and prophylactic antibiotics are used. Management is influenced by gestational age. Initial management: o Confirm rupture of membranes. o Determine if bacterial infection is present at time of rupture by vaginal/cervical cultures. o Document age of gestation. o Determine fetal lung maturity by amniocentesis or vaginal culture. Active management: o Tocolytic therapy. o Antibiotic therapy. o Corticosteroid administration. o Amnioinfusion. Conservative management: o Bed rest. o Vital signs per your facility's policy and patient condition. o Monitor fetal well-being daily or more frequently as dictated by your facility's policy and patient condition.

Complications Maternal o Increased risk of intrauterine infection o Postpartum endometritis o Placental abruption Fetalinfection NeonatalRDS, infection, death

Nursing Assessment Evaluate maternal vital signs every 2 to 4 hours to include fetal assessment. If temperature or pulse is elevated, continue monitoring every 1 to 2 hours as indicated. Monitor for fetal tachycardia. Monitor for maternal chorioamnionitis (purulent, foul-smelling vaginal discharge, increased temperature, increased uterine activity). Minimize infection with decreased or no vaginal examinations, aseptic techniques, and appropriate pericare.

Strict bed rest with or without bathroom privileges. Evaluate daily CBC with differentials, noting any shift to the left. Supportive care for woman and her family.

Nursing Diagnosis Risk for Infection related to ascending bacteria

Also see Preterm Labor, page 1279. Nursing Interventions Preventing Infection Evaluate amount and odor of amniotic fluid leakage. Do not perform vaginal examinations without consulting the primary health care provider. Place patient on disposable pads to collect leaking fluid, and change pads every 2 hours or more frequently as needed. Review the need for good hand-washing technique and hygiene after urination and defecation. Monitor FHR and fetal activity every 4 hours or more as indicated. Monitor maternal temperature, pulse respirations, BP, and uterine tenderness at least every 4 hours or more as indicated. Administer antibiotics as prescribed.

Evaluation: Expected Outcomes No signs of infection

INDUCTION OF LABOR Induction of labor refers to measures used for the deliberate initiation (stimulation) of uterine contractions before the spontaneous onset of labor for the purpose of achieving a vaginal birth. Augmentation of labor refers to the stimulation of ineffective uterine contractions after spontaneous onset of labor to manage labor dystocia. Cervical ripening is the process of effecting physical softening and dilatation of the cervix in preparation for labor and delivery. Indications for Induction When the woman's life or well-being is in danger, or if the fetus may be compromised by remaining in the uterus any longer. Maternal: o Severe preeclampsia or hypertension o Fetal death o Chorioamnionitis Fetal (usually for pregnancy termination due to significant fetal compromise) o Diabetes mellitus o Postterm pregnancy, especially if associated with oligohydramnios o Hypertensive complications of pregnancy o IUGR o Isoimmunization o Chorioamnionitis o PROM with established fetal maturity Logistical: o History/risk of rapid labors o Distance from hospital o Psychosocial indications

Contraindications for Induction (Generally the same for spontaneous labor and vaginal birth.) Vaginal bleeding, known complete placenta previa or vasa previa Abnormal fetal position (transverse) Classic uterine incision Umbilical cord prolapse

Indications for Augmentation Uterine hypocontractility, after the maternal pelvis and fetal presentation have been assessed Dystocia

Contraindications for Augmentation Placenta or vasa previa Umbilical cord presentation Prior classical uterine incision Active genital herpes infection Pelvic structural deformities Invasive cervical cancer

Management Amniotomy (Artificial Rupture of Membranes [AROM]) Vulva is cleaned, vaginal examination done, amniohook is inserted through the cervix, and membranes are ruptured after the fetal presentation is evaluated. Fluid should be clear or cloudy without odor. Should make contractions stronger. FHRs are assessed continually for at least the next 20 minutes. Complications include umbilical cord prolapse or compression, maternal or fetal infection, and/or distorted fetal head.

Oxytocin Fetal monitoring is instituted. If membranes have ruptured, an intrauterine catheter and internal scalp electrode may be used but this is not required. A reactive NST is required by ACOG guidelines before the start of oxytocin. An I.V. is mixed with oxytocin and piggybacked into the primary I.V. at the port of entry nearest the skin insertion. According to your facility's policy, the drug may be mixed in the pharmacy and brought to the unit or mixed by the unit staff. The oxytocin is given only with an infusion pump and when constant monitoring of maternal and fetal status is available (with either nonelectronic or electronic methods of fetal assessment). The dose is increased as indicated by your facility's policy as designated by provider-driven ACOG guidelines. The goal is to establish a regular labor pattern that will produce cervical dilatation of 1 cm/hour in the active phase of laborusually, contractions occurring every 2 to 3 minutes lasting 45 to 60 seconds and an intensity of 50 mm Hg (moderate) or Montevideo units (MVUs) greater than 180 can produce such a pattern; however, cervical dilatation and effacement and fetal descent are the true indications of adequate labor. If oxytocin is discontinued for 5 to 10 minutes (regardless of the reason), and the FHR/uterine activity returns to reassuring pattern, oxytocin can be restarted at a lower rate (usually reduced by one-half). However, if the oxytocin has been discontinued for 30 to 40 minutes, it can be restarted at or near the initial dose because exogenous oxytocin has been metabolized and plasma levels are similar to that of a woman who has never received oxytocin. Complications include uterine hyperstimulation (more than five contractions in 10 minutes), uterine hypertonus (uterine resting tone greater than 25 to 30 mm Hg, depending on the type of intrauterine pressure catheter), contractions longer than 90 seconds in duration, coupling of contractions, fetal distress, increased incidence of cesarean delivery, and neonatal hyperbilirubinemia possibly from red blood cell trauma from intense contractions or decreased maturity of the neonate.

DRUG ALERT Administration of oxytocin requires strict intake and output, especially I.V. fluid monitoring. A major adverse effect of oxytocin is water toxicity, which can lead to heart failure. Symptoms of water toxicity include headache, nausea and vomiting, mental confusion, decreased urine output, hypotension, tachycardia, and cardiac arrhythmia. Prostaglandin E2 (PGE2) PGE2 is primarily used before induction of labor for cervical ripening, administered intracervically or vaginally If labor results from administration of PGE2, it is similar to spontaneous labor. Uterine hyperstimulation is a complication. PGE2 gel (Prepidil) is given by a catheter or diaphragm in doses ranging from 0.5 to 5 mg. o Unstable at room temperature; store in refrigerator; bring to room temperature just before administration (do not use microwave, warm water, or any other heating method to speed the warming process as the gel is sensitive to heat and may be inactivated). o Patient should stay recumbent for at least 30 minutes. If no response, additional doses may be administered every 6 hours. o Oxytocin should be delayed for 6 to 12 hours after last dose of gel. o Should be administered at or near labor and delivery/birthing suite (to monitor fetal and uterine statuscontinue monitoring for 30 minutes to 2 hours after administration). Cervidil is a solid, time-released suppository placed into the vagina. The suppository is 10 mg that releases 0.3 mg/hour. Requires continuous fetal monitoring as evidenced by manufacturer and research guidelines. o Keep frozen until immediately before use; unstable at room temperature; stable up to 3 years when frozen. o Patient is to stay supine for 2 hours after insertion; may ambulate after 2 hours. o Removal after 12 hours or at onset of labor; oxytocin may be delayed at least 30 to 60 minutes after removal. o Should be administered at or near labor and delivery/birthing suite (to monitor fetal and uterine statuscontinue monitoring while in place) and for at least 15 minutes after removal. Prostaglandin E1: Misoprostol (Cytotec) is a tablet containing prostaglandins. Misoprostol is not FDA approved for cervical ripening or labor induction. o Various dosing regimens available; however, lower rates of uterine hyperstimulation occur with lower doses (25 mcg versus 50 mcg) every 6 hours versus every 3 hours. o Redosing is withheld if more than two contractions in 10 minutes, adequate cervical ripening achieved (cervix 80% effaced and 3 cm dilated), the patient is in active labor, or FHR nonreassuring. o Patient should be observed for up to 2 hours after SROM. If cervix remains unfavorable, uterine activity minimal, FHR reassuring, and at least 3 hours since last dose, redosing is acceptable. o Oxytocin can be given after 4 hours after last dose. o Should be administered at or near the labor and delivery/birthing suite to allow continuous monitoring of fetal and uterine status. Uterine hyperstimulation is a complication. DRUG ALERT Adverse effects of misoprostol include shivering, backache, vomiting, diarrhea, shortness of breath, uterine hypertonus, or uterine rupture. Misoprostol is not recommended for women with a history of prior cesarean delivery or with uterine

scarring. Stripping the Membranes Separating the membranes from the lower uterine segment without rupturing the membranes Usually done during vaginal examination Membranes and amniotic fluid now act as a wedge to dilate cervix. Complications include maternal/fetal infection, PPROM, umbilical cord prolapse, precipitous labor and birth, and personal discomfort.

Active Management of Labor Augmentation protocol directed toward reducing cesarean deliveries due to dystocia in nulliparous woman. Goal is to have birth within 12 hours after admission to Labor and Delivery. Criteria for active management of labor: o Nulliparity. o Greater than 37 weeks' gestation. o Singleton pregnancy. o Active or true labor defined as contractions with bloody show, SROM, or complete (100%) cervical effacement. o AROM within 1 hour after labor has been diagnosed. o If no cervical change of at least 1 cm/hour, oxytocin augmentation is initiated. o Dosage is 6 U/minute, increase by 6 U/minute every 15 minutes until adequate labor achieved or to a maximum of 40 U/minute. o Hyperstimulation defined as more than seven uterine contractions in 15 minutes. o After true labor begins, one-to-one labor support recommended.

Complications Hyperstimulation Nonreassuring FHR tracing Uterine rupture

Nursing Assessment NURSING ALERT Make sure that patient is aware of the procedures to be used and all questions have been answered. Make sure that the provider has obtained informed consent before the start of the procedure. Before Induction Obtain a 20-minute NST to assess fetal well-being. Evaluate maternal vital signs, especially BP. Evaluate the patency of the I.V. site, if I.V. ordered.

After the Administration of Oxytocin Continuously monitor FHR and uterine activity, especially uterine resting tone, frequency, and duration. Assess maternal vital signs in accordance with your facility's policy. Temperature is taken every 2 to 4 hours, unless an amniotomy has been performed, and then every 1 to 2 hours. Limit vaginal examinations, especially after the membranes have ruptured. Maintain intake and output records, and watch for signs of water intoxicationdizziness, headache, confusion, nausea, vomiting, hypotension, tachycardia, decreased urine output. Evaluate I.V. site for patency and rate control for correct rate at least hourly.

Nursing Diagnoses Anxiety related to planned childbirth and outcome Ineffective Tissue Perfusion: Uteroplacental with altered oxygen to fetus related to strength of uterine contractions Acute Pain related to uterine activity

Nursing Interventions Decreasing Anxiety Teach or review the use of relaxation and distraction techniques. Before beginning any new procedure, explain the procedure to the woman and her support person. Answer questions that the woman and family may have.

Promoting Tissue Perfusion and Oxygen Supply to Fetus Assess fetal status and uterine contractions through the use of a monitor or auscultation/palpation. Assess for signs of uteroplacental insufficiency (decreased variability, abnormal baseline FHR, late decelerations). Place patient in lateral position to enhance placental perfusion.

Have oxygen set up with a mask ready, and administer as prescribed (8 to 12 L/minute by face mask) if decelerations occur. If hyperstimulation of the uterus or fetal compromise (late decelerations, nonreassuring variable decelerations, or absent STV) occurs, discontinue the infusion, maintain the primary I.V., and notify the health care provider immediately. Administer adequate fluid volume.

Controlling Pain Encourage use of breathing techniques, distraction, and nonpharmacologic comfort measures. Administer analgesia/anesthesia as prescribed. Maintain positive outlook and support as labor progresses.

Evaluation: Expected Outcomes Verbalizes understanding of the induction process No evidence of hyperstimulation or fetal compromise Labor progressing with pain controlled

DYSTOCIA Dystocia is abnormal labor resulting from abnormalities of uterine contractions or maternal expulsive forces (power), the fetal position, size, or presentation (passenger), or the pelvis or soft tissues (passage). Maternal psychological factors, such as fear, anxiety, and exhaustion, may play a role in dystocia. Usually, more than one cause exists at a time. Cephalopelvic disproportion (CPD) is a disparity between the size of the maternal pelvis and fetal head that prevents or precludes a vaginal birth. P.1287 Pathophysiology and Etiology Contraction Abnormalities Contractions that are not strong enough or frequent enough to produce a normal labor pattern will not result in dilatation and effacement or fetal descent within a normal time frame. Cause is unknown, although common causes are increased uterine tone, abnormal contraction pressure, hypotonic labor (prolonged latent phase, protracted or arrested active phase, or prolonged second stage of labor), and abnormal contraction pressure. Problems with the force of labor will result in ineffective contractions or ineffective bearing down (pushing) during the second stage of labor. Etiology of abnormalities in the force of labor include: o Early or excessive use of analgesia o Overdistention of the uterus o Excessive cervical rigidity o Grand multiparity (> 6) o Mild pelvic contraction o Postmature or large fetus

Passageway Abnormalities Abnormalities in the passageway may be the result of problems in the pelvis or soft tissues of the reproductive tract. Typically, problems with the passageway are a result of pelvic abnormalities that interfere with the engagement, descent, and expulsion of the fetus. o The size and shape of the pelvis are important. o Obstruction may result from problems of the soft tissue, such as a uterine or ovarian fibromyoma. Contractions of the inlet are noted when the anteroposterior diameter is less than 10 cm or the greatest transverse diameter is less than 12 cm. Contracted inlets may be of genetic origin or a result of rickets. Midpelvic contractions occur when the distance between the ischial spines is less than 9 cm. Usually, this is not detected early in labor because the fetal head has engaged, and molding along with caput formation gives the suggestion that the head has descended farther than it has. A contracted pelvic outlet is diagnosed when the distance between the ischial spines is less than 8 cm. When the pelvis is contracted and the fetus cannot fit through the pelvis, CPD exists.

Fetal Passage Abnormalities Normal fetal passage. o Normally, the fetus enters the pelvic inlet transversely and then rotates to an occiput anterior position, allowing for the smallest diameter of the fetal head to pass through the pelvis. o When the fetal head enters the pelvis posteriorly, it must rotate to the anterior position. This is done usually without problems if the fetus is of average size and well flexed and the contractions are a good quality. o Synclitismthe position of the fetal head in relation to the anteroposterior diameter of the maternal pelvis. Refers specifically to the position of the fetal head when the sagittal suture is halfway between the sacral promontory and symphysis pubis. If synclitism exists, the planes of the pelvis and the fetal skull are parallel with the same space all around the fetal head. Asynclitism. o Either posterior or anterior. o Posteriorposition of the fetal head when the sagittal suture is closer to the sacral promontory. o Anteriorposition of the fetal head when the sagittal suture is closer to the symphysis pubis.

If the fetus does not turn, then it remains in the posterior position and may slow down the progress of descent. o If the pelvis is large enough, or the fetus is small enough, the fetus can be born in the posterior position (occiput posterior). o If the pelvis is borderline and the contractions ineffective, a cesarean delivery may be necessary. Breech presentations occur in approximately 3% of all deliveries. o This presentation is more common in multiple gestations, increased parity, hydramnios, congenital dislocated hip, placenta previa, and preterm neonates. o Usually, the method of choice for delivery is a cesarean delivery. Shoulder presentation (transverse lie) occurs when the infant lies crosswise in the uterus. The infant is delivered by cesarean delivery, if external cephalic version (ECV) is unsuccessful. A large fetus has an increased risk of trauma in its attempt to fit through a normal size pelvis. A large infant may not fit through the pelvis, and CPD may result.

Diagnostic Evaluation Inadequate progress of cervical effacement, dilatation, or descent of the presenting part as determined by vaginal examination Evaluation of labor progress by recording and assessing serial vaginal examinations using Friedman's curve o Using Friedman's curve, a prolonged latent phase in the primigravida is more than 20 hours and in the multigravida it is more than 14 hours. o During the active phase, the cervix of a primigravida will normally dilate at least 1.2 cm/hour, and the multigravida 1.5 cm. In addition, the fetus should be descending through the birth canal. In the primigravida, the rate of descent is 1 cm/hour, and 2 cm/hour for the multigravida.

Management Treatment for contraction abnormalities involves stimulation of labor through the use of oxytocin. An intrauterine pressure catheter may be used. Management for maternal passageway or fetal passage problems involves delivery in the safest manner for the mother and fetus. o o Complications Maternal exhaustion Infection Postpartum hemorrhage Fetal distress Fetal or maternal trauma from instrumented delivery If the problem is related to the inlet or midpelvis, a cesarean delivery is indicated. If the size of the outlet is the problem, a forceps or vacuum extraction delivery may be performed.

Nursing Assessment Perform Leopold's maneuvers, and evaluate fetal presentation, position, and size. Using Friedman's labor curve, evaluate progress of labor, noting dilations and effacement in relation to time of labor along with descent of the fetal head. Monitor FHR and contraction status in accordance with standards of care and your facility's policy according to the stage of labor and risk status of woman. Monitor maternal vital signs in accordance with your facility's policy. Assess bladder fullness.

Nursing Diagnoses Acute Pain related to physical and psychological factors of difficult labor Anxiety related to threat of change in the health status of self and fetus

Nursing Interventions Promoting Comfort Review relaxation techniques. Encourage use of breathing techniques learned in prenatal classes. Encourage frequent change of position. Encourage voiding every 1 to 2 hours. Provide back rubs and sacral pressure as needed. Offer ice chips as needed to combat a dry mouth, if permitted. Provide a quiet room. Provide frequent encouragement to the woman and her support person. Administer pain medication for analgesia, as ordered. Assist with the administration of anesthesia, as indicated.

Decreasing Anxiety Provide anticipatory guidance regarding the use of medication, equipment, and procedures. Educate the woman about the administration of oxytocin (Pitocin). Discuss with the woman the nature of the contractions associated with an induced labor (ie, short acceleration, intense plateau, short deceleration, increased strength and intensity). Prepare the family for cesarean delivery, if necessary.

Evaluation: Expected Outcomes Verbalizes increased comfort Verbalizes understanding of procedures

UTERINE RUPTURE Uterine rupture is a spontaneous or traumatic rupture of the uterus, ie, the actual separation of the uterine myometrium or previous uterine scar, with rupture of membranes and extrusion of the fetus or fetal parts into the peritoneal cavity. Rupture occurs in about 1 in 15,000 births, with about 50% infant mortality. Dehiscence is the partial separation of the old uterine scar; the fetus usually stays inside the uterus and the bleeding is minimal when dehiscence occurs. Pathophysiology and Etiology Rupture of the scar from a previous cesarean delivery or hysterotomy o VBAC is associated with small, yet significant, risk of uterine rupture with poor fetal-maternal outcomes (see Box 39-2, page 1290). o The risk of uterine rupture increases with the number of previous cesareans. Uterine trauma related to manipulation with instrumentation (ie, curet) or abdominal trauma resulting from sharp objects (eg, knives, bullets), or accidents Uterine congenital anomaly Injudicious use of oxytocin; high doses of oxytocin Prostaglandin preparations (misoprostol; prepidil gel) Hyperstimulation; hypertonus Blunt or penetrating abdominal trauma Abnormal fetal lie Midforceps rotation of fetus to achieve vaginal delivery Multiple gestation or polyhydramnios causing uterine overdistention Previous terminations of pregnancy Grand multipara (> 6) Obstructed labor; maneuvers within the uterus Interdelivery interval (time between deliveries)

BOX 39-2 Vaginal Birth after Cesarean Selection criteria to identify women eligible for vaginal birth after cesarean (VBAC): o One or two low-transverse cesarean births o Clinically adequate pelvis o No other uterine scars or previous rupture o Physician (capable of monitoring labor and performing an emergent cesarean delivery) is immediately available throughout active labor o Anesthesia and surgical team available for emergent cesarean delivery. Contraindications for VBAC (due to high risk of uterine rupture): o Prior classic or T-shaped incision or other transfundal uterine surgery o Contracted pelvis o Medical or obstetrical complication that prevents/precludes vaginal delivery o Inability to perform emergency cesarean delivery because of unavailability of surgeon, anesthesia provider, sufficient personnel, physician capable of performing the cesarean delivery, or sufficient facility

Clinical Manifestations Clinical manifestations depend on the type of rupture, with the possibility that the clinical picture may develop over several hours. Developing Rupture Abdominal pain and tenderness Uterine contractions will usually continue but will diminish in intensity and tone Bleeding into the abdominal cavity and sometimes into the vagina Vomiting Syncope; tachycardia; pallor Significant change in FHR characteristicsusually bradycardia (most significant sign)

Violent or Traumatic Rupture Sudden sharp abdominal pain during or between contractions Abdominal tenderness

Uterine contractions may be absent, or may continue but be diminished in intensity and tone Bleeding vaginally, abdominally, or both Fetus easily palpated in the abdominal cavity Tense, acute abdominal with shoulder pain (if intra-abdominal bleeding present) Signs of shockrapid, weak pulse; cold, clammy skin; pale color; flaring of nostrils due to air hunger Chest pain from diaphragmatic irritation due to bleeding into the abdomen

Management Immediate stabilization of maternal hemodynamics and immediate cesarean delivery. Oxytocin is given to contract the uterus and control bleeding. The fetus is extracted as soon as possible, and the uterus is repaired, if possible. A hysterectomy may be done if bleeding cannot be controlled. After surgery, additional blood and fluid replacement is continued along with antibiotic therapy.

Complications Maternal Fetal Hypoxia leading to perinatal asphyxia (perinatal asphyxia can occur within 10 minutes after onset of prolonged decelerations resulting from uterine rupture when prolonged decelerations occur following an episode of late or nonreassuring variable decelerations) Long-term neonatal brain injury Death Bladder and ureteral injury Hysterectomy Concurrent complete or partial abruptio placentae; hemorrhage Hypovolemic shock Anemia, with possibility of transfusion Bowel laceration, with possibility of peritonitis Infection Death

Nursing Assessment Continuously evaluate maternal vital signs; especially note an increase in the rate and depth of respirations, an increase in pulse, or a drop in BP indicating status change. Observe for signs and symptoms of impending rupture (ie, lack of cervical dilatation, tetanic uterine contractions, restlessness, anxiety, severe abdominal pain, fetal bradycardia, or late or variable decelerations of the FHR). Assess fetal status by continuous monitoring. Speak with family, and evaluate their understanding of the situation.

NURSING ALERT Impending uterine rupture may be preceded by increasing uterine tonus. Nursing Diagnoses Deficient Fluid Volume related to active fluid loss from hemorrhage Ineffective Tissue Perfusion, Maternal Vital Organ and Fetal, related to hypovolemia Fear related to surgical outcome for fetus and mother

Nursing Interventions Maintaining Fluid Volume Start or maintain an I.V. as prescribed. Use a large-gauge catheter when starting the I.V. for blood and large quantities of fluid replacement. Maintain CVP and arterial lines, as indicated for hemodynamic monitoring. Maintain bed rest to decrease metabolic demands. Insert Foley catheter, and monitor urine output hourly or as indicated. Obtain and administer blood products as indicated.

Maintaining Maternal and Fetal Tissue Perfusion Administer oxygen using a face mask at 8 to 12 L/minute or as ordered to provide high oxygen concentration. Apply pulse oximeter, and monitor oxygen saturation as indicated.

Monitor ABG levels and serum electrolytes as indicated to assess respiratory status, observing for hypoventilation and electrolyte imbalance. Continually monitor maternal and fetal vital signs to assess pattern because progressive changes may indicate profound shock.

Reducing Fear Give a brief explanation to the woman and her support person before beginning a procedure. Answer questions that the family and woman may have. Maintain a quiet and calm atmosphere to enhance relaxation. Remain with the woman until anesthesia has been administered; offer support as needed. Keep the family members aware of the situation while the woman is in surgery and allow time for them to express feelings.

Patient Education and Health Maintenance Provide information and support regarding the possibility for future pregnancies. Encourage the support of family and friends. Inform the woman that, postoperatively, diet will be advanced with the return of bowel sounds. Educate the woman about the importance of ambulation to prevent intestinal gas and other postoperative complications.

Evaluation: Expected Outcomes Vital signs stable; no evidence of shock ABG levels within normal limits; FHR within normal limits Verbalizes concerns about self and her fetus

ANAPHYLACTIC SYNDROME OF PREGNANCY Anaphylactic syndrome of pregnancy, previously known as amniotic fluid embolism (AFE), 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 or debris in the pulmonary arterioles, resulting rapidly in respiratory distress, shock, and the possible development of DIC. Anaphylactic syndrome of pregnancy is rare (1 in 8,000 births), nonpreventable, and fatal. Pathophysiology and Etiology The exact mechanism that causes anaphylactic syndrome of pregnancy is unclear. Initially, a transient period of intense pulmonary vasospasms occurs, leading to right ventricular failure and hypoxemia. Left ventricular failure then occurs, with a mild to moderate rise in pulmonary artery pressure and a decrease in left ventricular stroke volume. It can occur in the intrapartum or postpartum period. Myometrial vessels are exposed, usually at the placental site, and contractions are especially forceful. A thromboplastin-like substance is found in amniotic fluid, which causes defibrination leading to DIC. Predisposing conditions include abruptio placentae; uterine rupture; intrauterine fetal demise; advanced maternal age (older than age 35); polyhydramnios; short, tumultuous labor; oxytocin induction; and high parity.

Clinical Manifestations Sudden dyspnea and chest pain Cyanosis, tachycardia Pulmonary edema Vomiting Seizures Shaking chills; diaphoresis Increasing restlessness and anxiety Coughing with frothy, pink sputum Profound shock due to: o Anaphylaxis, which causes vascular collapse. o Uterine bleeding with development of hypofibrinogenemia.

Diagnostic Evaluation Clinical picture of rapidly developing dyspnea, tachypnea, and cyanosis DIC confirmed by coagulation studies (prolonged thrombin time, PT, and partial prothrombin time, decreased factor V, VIII, X; decreased platelets; increased fibrin split products)

Management Transfer to tertiary care center if woman is not in one Endotracheal intubation Administration of I.V. crystalloid fluids Administration of blood products and heparin to combat DIC

Establishment of CVP line Immediate delivery of the fetus Initiation of cardiopulmonary resuscitation, if needed

Complications The maternal-fetal mortality is estimated to be greater than 85% due to DIC and cardiopulmonary collapse, especially if the syndrome occurs within 10 to 32 minutes after delivery or rupture of membranes. Nursing Assessment and Interventions Also see page 959 for care of patient with DIC. Be alert to signs and symptoms of potential anaphylactoid syndrome of pregnancy. Monitor maternal vital signs to assess for signs of shock. Monitor FHR for signs of distress (if situation happens before birth of fetus). Administer oxygen (8 to 12 L/minute) by face mask to assist respiratory status. Alert medical staff immediately, and assist with emergency procedures, such as delivery, and with the cardiopulmonary resuscitation as needed. Provide information and comfort to the family or support persons. If unable to do this personally due to the emergent needs of the woman, delegate another member of the staff to stay with the family or support persons.

PROLAPSED UMBILICAL CORD A prolapsed umbilical cord slips in front of or alongside the fetal presenting part. Types of cord prolapse include: Completethe cord can be felt on vaginal examination and be seen in the vaginal canal; membranes are ruptured. Changes in the FHR are evident. Occultthe cord cannot be felt on vaginal examination or be seen. The cord lies between the presenting part and the maternal pelvis; membranes can be intact or ruptured. Changes in the FHR are evident. Forelyingthe cord can be felt on vaginal examination, but cannot be seen; usually contained within intact membranes. The cord lies in front of the presenting part. Pathophysiology and Etiology A fetal cord prolapse may occur when there is adequate room between the fetal parts and the maternal pelvis. Predisposing factors include: Rupture of membranes, before the presenting part is not engaged in the pelvis More common in abnormal fetal positions, such as shoulder and foot presentations Prematuritysmall fetus allows more space around presenting part Polyhydramnioscauses greater amount of fluid to be released with greater force when membranes rupture Multifetal gestation Fetopelvic disproportion (ie, CPD) Abnormally long umbilical cord Result of interventions or maneuvers (ie, ECV or amniotomy)

Clinical Manifestations Cord may be seen protruding from vagina or palpated in the vagina or cervix. With compression, FHR pattern may show variable decelerations with contractions or between contractions; usually, fetal bradycardia is present.

NURSING ALERT Prolapsed cord should be suspected with FHR deceleration after rupture of membranes. Management Delivery of the fetus as soon as possible. Relief of pressure from the umbilical cord immediately. Change maternal positionusually in knee-chest position to relieve pressure of presenting part. Prepare for emergent delivery (vaginal or cesarean, whichever is deemed appropriate by situation)

Complications Maternal Fetal Prematurity Hypoxia Meconium aspiration Fetal death if delayed or undiagnosed Infection Risk for hemorrhage from emergency delivery Risk for increased perineal trauma from emergency vaginal forceps delivery Uterine atony related to anesthesia effect

Nursing Assessment and Interventions Observe for prolonged FHR deceleration. Identify complete or forelying cord prolapse with a vaginal examination by a qualified nurse or health care provider. If the cord is exposed to cold room air, there may be a reflex constriction of the umbilical blood vessels that further restricts the oxygen flow to the fetus. Do not pinch or squeeze the umbilical cord because it may cause the cord to spasm, which decreases umbilical blood flow and fetal oxygen leading to fetal hypoxia. Explain procedures as much as possible to the woman during this emergent situation. Administer oxygen by snug face mask at 8 to 12 L/minute. Relieve pressure from the presenting part of the fetus off the umbilical cord by manually pushing the presenting part upward with a gloved hand. Pressure must be relieved until the fetus is delivered by cesarean or vaginally. Do not remove hand until delivery is imminent

Provide constant support to the woman and her support persons. Encourage the woman to talk about her feelings regarding herself and the baby after delivery.

Community and Home Care Considerations If prolapsed cord occurs at home with rupture of membranes, have the mother or significant other look or feel in the vagina for the protruding cord. If the cord is visible or felt, PUSH the fetal presenting part UPWARD off the cord. Call 911. Feel the uterus for increased (above normal) fetal activity. Have mother lie on floor or bed with hips elevated above level of her head (Trendelenburg's position).

CESAREAN DELIVERY Cesarean delivery or birth is the surgical removal of the infant from the uterus through an incision made in the abdominal wall and an incision made in the uterus. About 25% of all births are cesarean. Types of Cesarean Delivery Uterine Incisions Low segment transverseincision made transversely in lower segment of uterus. o Incision is made in thinnest portion so blood loss is minimal and uterus is easier to open. o Lower segment is area of least uterine activity. o Postoperative convalescence is more comfortable. o Possibility of later rupture is lessened. o Incidence of postoperative adhesions and danger of intestinal obstruction are reduced. o It is the incision of choice. Classicvertical incision is made directly into the wall of the body of the uterus; usually done in emergency situations only. o Useful when bladder and lower segment are involved in extensive adhesions. o Selected when anterior placenta previa or emergency situation exists. o Useful when fetus is in a transverse lie. o Increased blood loss with classic cesarean. o Increased risk of uterine rupture in subsequent deliveries. T-extension (low transverse with vertical cut made in the middle of the horizontal incision) o May be extended upward into a classical incision if extra room is needed for delivery. o Commonly used with preterm deliveries

Abdominal Incisions Pfannenstiela horizontal incision right above the pubic hair line o Cosmetic advantage of not being seen because pubic hair covers incision o Decreased chance of dehiscence or hernia formation Verticala vertical incision made in the midline of the abdomen below the umbilicus to the pubis o Quicker procedure to perform o Provides better uterine visualization o Cosmetically less appealing o Greater chance of wound dehiscence and hernia formation

Indications for Cesarean Delivery CPD Uterine dysfunction, inertia, failure to progress Neoplasm obstructing birth canal or pelvis Hypertensive disorders of pregnancy Severe diabetes mellitus Uteroplacental insufficiency and oligohydramnios Malposition and malpresentation

Previous uterine surgery (cesarean delivery, myomectomy, hysterotomy) or cervical surgeryevaluated on an individual basis Complete or partial placenta previa Abruptio placentae Prolapse of the umbilical cord Fetal compromise Active genital herpes simplex Breech or shoulder presentation Multiple gestation more than three fetuses Conjoined twins Indications for cesarean hysterectomy: o Ruptured uterus o Intrauterine infection o Hemorrhage due to uterine atony that does not respond to oxytocin, prostaglandin, or massage o Laceration of major uterine vessel o Severe dysplasia or carcinoma in situ of the cervix o Placenta accreta o Gross multiple fibromyomas

Management NPO (except possibly ice chips) during labor. A blood sample should be typed and screened and available to be crossmatched if needed; a CBC is obtained. Anesthesia, regional or general, depends on the indication for surgery. Permit signed and witnessed; informed consent confirmed. A large-bore I.V. is established, and Foley catheter is inserted. An antacid is administered to reduce gastric acidity and the risk of aspiration pneumonia. Antibiotics may be given prophylactically. An abdominal preparation is done, and a grounding pad for electrocautery is applied.

Complications Increase in morbidity and mortality compared with a vaginal birth Hemorrhage, endometritis Paralytic ileus, intestinal obstruction Pulmonary embolism, thrombophlebitis Anesthesia accidents Bowel or bladder injury Anaphylactic syndrome of pregnancy (rare occurrence) Respiratory depression of the infant from anesthetic drugs Possible delay in mother-infant bonding

Nursing Assessment Before Delivery Assess knowledge of procedure. Perform admission assessment comparable to those used for labor and delivery admission (if not already admitted, ie, elective or routine) Obtain 20- to 30-minute fetal tracing strip to assess fetal and uterine status (if needed) Ensure informed consent obtained, permits signed/witnessed. Monitor maternal and fetal vital signs. Determine maternal blood type and Rh. Determine last time the woman ate or drank. Identify drug allergies; identify other allergies (eg, latex, Betadine, tape).

During Delivery Continue fetal assessment until abdominal preparation has been initiated. The FHR can still be assessed using sterile technique and a doptone (placed in sterile glove) if the start of surgery is delayed beyond 5 minutes (high-risk patients) or 15 minutes (low-risk patients) after abdominal preparation is completed. If a fetal spiral electrode is in place, continue assessment until abdominal preparation is completed (it should be removed before birth, but this is not required). Monitor and record maternal vital signs, FHR, condition of skin before incision, and woman's emotional status. Maintain an awareness of how the support person is doing and assist him/her as needed. Monitor and document maternal-neonatal status before transport to recovery room and help with transfer, as needed.

After Delivery Assess maternal vital signs every 15 minutes the first hour, every 30 minutes the second hour, and then hourly until she is transferred to the postpartum/labor and delivery (LDR(P)) unit or per your facility's protocol.

o o o

Respiratory: airway patency, oxygen needs, rate/quality/depth of respirations, auscultation of breath sounds, oxygen saturation readings. Circulation: BP, pulse, ECG, color. LOC: orientation and response to verbal/tactile/painful stimulation.

Assess postpartum status at same intervals: fundal position and contractions, condition of incision and abdominal dressing, maternal-neonate attachment, lochia (color, amount), neonate condition (if applicable); feeding preferences. Assess hourly intake and output (I.V., urine output) and bowel sounds. Perform pain assessment: evaluate level of anesthesia, medications given (amount/time/results)

Nursing Diagnoses Anxiety related to cesarean delivery Acute Pain related to surgical procedure Risk for Infection related to traumatized tissue Risk for Ineffective Parent/Infant Attachment related to interruption in bonding process

Nursing Interventions Relieving Anxiety Explain the reason for the cesarean delivery. Answer any questions the woman and her support person may have regarding a cesarean delivery. Allow the support person to attend the birth. Explain that a sensation of pressure will be felt during the delivery, but that little pain will occur. Instruct that any pain should be reported to the nurse. Explain all procedures before doing them. o Insert a Foley catheter; note amount and color of urine. (If epidural anesthesia is being used, delay this step, if possible, until after it has been administered). o Administer preoperative medications according the primary care provider's orders. o Position woman on surgical table with wedge in place. o Prepare abdomen in accordance with your facility's policy. o Apply grounding device according to manufacturer's policy. o Ensure availability of neonatal team as well as availability and proper working order of resuscitation equipment. o Perform duties of circulating nurse in accordance with your facility's policy. Make sure sponge, needle, and equipment count are correct in accordance with your facility's policy. o Assist with postsurgery preparation of patient for transport to recovery room.

Promoting Comfort Encourage use of relaxation techniques after medication has been given for pain. Monitor for respiratory depression up to 24 hours after epidural opioid administration. Monitor and instruct patient on use of PCA pump. Use a back rub and a quiet environment to promote the effectiveness of the medication. Support and splint the abdominal incision when moving or coughing and deep breathing. Encourage frequent rest periods, and plan for them after activities; also, place a DO NOT DISTURB sign on the door during rest and sleep periods. To reduce pain caused by gas, encourage ambulation, use of rocking chair, and lying as much on stomach as possible/tolerated.

DRUG ALERT Do not administer parenteral narcotics if patient is receiving epidural narcotics unless ordered by anesthesiologist or nurse anesthetist. Preventing Infection Although shaving the skin before delivery is no longer a standard of practice, it is still carried out in some facilities. If skin preparation includes shaving, shave skin carefully, avoiding any nicks in the skin. Next, carry out surgical skin preparation correctly. Postoperatively, use aseptic technique when changing dressings. Provide perineal care along with vital signs every 4 hours or as needed. Provide routine postoperative care measures to prevent urinary or pulmonary infection (see page 121).

Promoting Effective Bonding Encourage the woman and her support person to discuss their feelings regarding the cesarean delivery before and after the delivery. When talking of the birth, refer to it as a cesarean delivery or birth to imply that it is just another method of birth rather than a surgical experience. Encourage mother-child bonding as soon as possible. Emphasize that adjustments to parenting under any circumstances are necessary and normal.

Patient Education and Health Maintenance Teach the woman the football hold for breast-feeding so the infant is not lying on her abdomen. Teach the woman to observe for signs of infection (foul-smelling lochia, elevated temperature, increased pain, redness and edema at the incision rate) and to report them immediately. Assist the woman in planning for the assistance of friends, family, or hired help at home during the period immediately after discharge.

Evaluation: Expected Outcomes Verbalizes an understanding of the cesarean delivery procedure and postdelivery care Reports relief of pain Has no signs of infection Participates in care of self and infant