PREGNANCY INDUCED HYPERTENSION

Disorder characterized by hypertension,

edema and proteinuria- appearing after
20th to 24th week of pregnancy and
disappearing 6 weeks after delivery . It
occurs in about 7-10 percent of all
pregnancies
RISK FACTORS
 Pre-existing  Mother's age
hypertension (high younger than 20 or
blood pressure) older than 40
 Kidney disease  Multiple fetuses
 Diabetes
(twins, triplets)
 Hypertension with a
 African-American
previous pregnancy
race
THERAPEUTIC MANAGEMENT
1. Prevent progression to preeclampsia
 Decrease salt intake
 8 hours of sleep per night
 Exercise
 No alcohol, caffeine, or junk food
 6-8 oz water/day
 Prenatal vitamins
2. Monitor closely
Check urine for protein
Fetal growth/activity
 WHEN TO CALL A DOCTOR?

 Headache
 Blurred vision
 Increased
swelling
HELLP Syndrome
is a life-threatening pregnancy complication
usually considered to be a variant of
preeclampsia. Both conditions usually occur
during the later stages of pregnancy, or soon
after childbirth.
HELLP syndrome was named by Dr. Louis
Weinstein in 1982 after its characteristics:
Hemolysis
Elevated
Liver enzymes and
Low
Platelets
H- Hemolysis
 Rupturing of red blood cells
 Can be detected several ways:
1. Abnormal peripheral blood smear
2. Elevated serum bilirubin
3. Low serum haptoglobin
4. Significant drop in H&H (not related to blood loss)
5. Low RBCs
E Elevated L Liver enzymes
AST or ALT > 2x normal ○ Normal
L Low
P Platelet count
<100,000 mcL
Assessment
Low platelets → petechiae
Anemia → headache,
tachycardia
Elevated liver enzymes →
nausea, vomiting
Therapeutic Management
1. Induction of Labor
Using medication to cause labor to
begin
Can only be done if the baby is stable
and a vaginal delivery is planned and
safe.
Medication used to stimulate contractions -
oxytocin.
Must monitor contractions while on
oxytocin; if there are too long (greater than
1.5 minutes) or too close together (less than
2 minutes apart), the baby is not getting
enough oxygen and the oxytocin should be
discontinued.
2. Amniotomy
 Using a hook or the finger to break the amniotic
sac.
 “Breaking the water”
 This helps stimulate labor and can make pushing
more efficient if the mother is fully dilated.
 Observe the color, odor, and condition of the
amniotic fluid.
 Malodorous fluid can indicate an infection.
3. Episiotomy
Done if the opening is not large enough to
accommodate the fetus at the end of a
vaginal delivery.
An incision is made in the vagina to make
the opening larger.
This allows the fetus to exit the birth canal.
4. Forceps-Assisted Delivery
 Forceps are a tool used if there is difficulty
delivering the head of the baby.
 Manual pressure used to help pull baby out.
 Must be mindful to monitor for injury;
laceration to skull of baby or vaginal tissue of
mother.
 Also puts the mother at risk for PPH
5. Vacuum-Assisted Delivery
Another technique that can be used to aid in
the delivery of the head of the baby.
Suction is applied to the head of the baby
and pulled while the mother pushes.
No more than three attempts
Assess skull of infant and monitor for
trauma.
6. External Version
 This is a technique used when the baby is not in an
appropriate position for vaginal delivery.
 Healthcare provider (most likely your obstetrician)
will place their hands on the belly to turn your baby
to a head-down position. The procedure is done
externally by applying firm pressure to your
abdomen. This pressure lasts several minutes and
can cause the uterus to cramp.
7. Caesarean Section
If vaginal delivery is not safe, infant is
unstable or unable to tolerate a
vaginal delivery, a caesarean section
will be performed surgically
PRETERM LABOR
-Onset of regular labor before the 37th
completed week of gestation
Clinical Findings
 Four or more contractions (or tightening and
relaxing of the muscles in your uterus) in one
hour that don’t go away after changing your
position or relaxing
 Regular tightening or low, dull pain in your
back that either comes and goes or is
constant (but isn’t relieved by changing
positions or other comfort measures).
 Lower abdominal cramping that might feel
like gas pain (with or without diarrhea).
 Increased pressure in your pelvis or vagina.
 Persistent menstrual-like cramps.
 Increased vaginal discharge or discharge
that’s mucus-like or tinged pink.
 Leaking of fluid from your vagina. This
could be amniotic fluid.
 Vaginal bleeding.
Nursing Care
 Determine gestational age
 Assess uterine tone
 Auscultate fetal heart tones and apply EFM
(Electronic Fetal Monitoring)
 Obtain vaginal/urine cultures
 Assess for leaking amniotic fluid
Ferning—Microscopically, amniotic fluid will
resemble the leaves of a fern plant
Nitrazine paper—Due to the alkaline nature
of amniotic fluid, the nitrazine paper will
change from yellow to blue
 Perform vaginal exam to determine dilation
and effacement of the cervix
 Position side-lying (1. May slow down or stop the signs
and symptoms; 2. It improves circulation, giving
nutrient-packed blood an easier route from your heart
to the placenta to nourish your baby.)
 Initiate IV fluids as ordered
 Administer corticosteroid to mother (accelerates
maturity of fetal lungs)
 Initiate tocolytic therapy (drugs that prevent preterm
labor and immature birth by suppressing uterine
contractions (tocolysis))
 Tocolytic Nursing Precautions
Medication
Magnesium  Monitor for respiratory depression
Sulfate  Assess deep tendon reflexes
ANTIDOTE:  Watch level of consciousness
Calcium gluconate  Monitor intake and output
 Assess fetal heart tones
 Monitor for contractions
 Auscultate lungs
 Report magnesium sulfate levels
β-adrenergic  Monitor for hypotension
agonist  Assess for tachycardia
 terbutaline  Assess patient for tremors
 ritodrine  Assess for pulmonary edema
 Screen glucose/potassium
 Assess for cardiac arrhythmias and
chest pain
 Monitor fetal heart tones
 Monitor contractions
Prostaglandin May lead to premature closure of
antagonist ductus arteriosus (a normal blood
 indomethacin vessel that connects two major
arteries — the aorta and the
pulmonary artery — that carry
blood away from the heart)
Calcium channel  Monitor for hypotension
blockers  Assess for tachycardia
 nifedipine
Premature Rupture of Membrane
is a rupture (breaking open) of the membranes (amniotic
sac) before labor begins. If PROM occurs before 37 weeks of
pregnancy, it is called preterm premature rupture of
membranes (PPROM).
 PROM occurs in up to 10% of all pregnancies. Up to 95% of
all births occur within 28 hours of PROM when it happens
at term (37 weeks).
 PPROM occurs in about 3% of pregnancies. Studies show
PPROM is more likely to affect twin pregnancies.
Most common causes include:
 Low socioeconomic conditions (as women in lower
socioeconomic conditions are less likely to receive proper
prenatal care)
 Sexually transmitted infections, such as chlamydia and
gonorrhea
 Previous preterm birth
 Vaginal bleeding
 Cigarette smoking during pregnancy
 Unknown
Symptoms:
 Leaking or a gush of watery fluid from the vagina
 Constant wetness in underwear
Treatment
 Monitoring for signs of infection, such as fever, pain,
increased fetal heart rate, and/or laboratory tests.
 Corticosteroids that may help mature the lungs of the
fetus (lung immaturity is a major problem of premature
babies). However, corticosteroids may mask an infection
in the uterus.
 Antibiotics (to prevent or treat infections)
 Tocolytic (medications used to stop preterm labor)
 Women with PPROM usually deliver at 34 weeks if
stable. If there are signs of abruption,
chorioamnionitis, or fetal compromise, then early
delivery would be necessary.)
Prolapsed Umbilical Cord
-Umbilical cord slips below/wedges next to presenting
part
May lead to fetal hypoxia due to cord compression

Possible cause
 Rupture of membranes without engaged presenting
part
 Non-cephalic fetal presentation
Symptoms
 Prolonged variable deceleration
 Pulsating cord palpated upon vaginal exam
 Visible cord at introitus
Nursing actions
 Stay with patient and call for assistance
 Apply sterile glove and hold pressure of presenting part
off umbilical cord
 Place patient in Trendelenburg position
 Notify physician
 Monitor fetal heart tones
 Place sterile saline gauze over any exposed cord
 Prepare patient for cesarean birth
Uterine Inversion
-a potentially life-threatening complication of
childbirth. Normally, the placenta detaches from
the uterus and exits the vagina around half an hour
after the baby is delivered. Uterine inversion means
the placenta remains attached, and its exit pulls the
uterus inside-out. A woman who has experienced
uterine inversion is at risk of it happening again in
subsequent pregnancies.
Uterine inversion is graded by its severity. This includes:
 Incomplete inversion - the top of the uterus (fundus) has
collapsed, but the uterus hasn’t come through the cervix.
 Complete inversion - the uterus is inside-out and coming
out through the cervix.
 Prolapsed inversion - the fundus of the uterus is coming out
of the vagina.
 Total inversion - both the uterus and vagina protrude
inside-out (this occurs more commonly in cases of cancer
than childbirth).
Risk factors
 Prior deliveries.
 Long labor (more than 24 hours).
 Use of the muscle relaxant magnesium sulphate
during labor.
 Short umbilical cord.
 Pulling too hard on the umbilical cord to hasten
delivery of the placenta, particularly if the placenta
is attached to the fundus.
 Placenta accreta (the placenta has invaded too
deeply into the uterine wall).
 Congenital abnormalities or weaknesses of the
uterus.
Some of the signs of uterine inversion could include:
 The uterus protrudes from the vagina.
 The fundus doesn’t seem to be in its proper position
when the doctor palpates (feels) the mother’s abdomen.
 The mother experiences greater than normal blood loss.
 The mother’s blood pressure drops (hypotension).
 The mother shows signs of shock (blood loss).
 Scans (such as ultrasound or MRI) may be used in some
cases to confirm the diagnosis.
Management
 Attempts to reinsert the uterus by hand.
 Administration of drugs to soften the uterus during
reinsertion.
 Flushing the vagina with saline solution so that the water
pressure ‘inflates’ the uterus and props it back into position
(hydrostatic correction).
 Manual reinsertion of the uterus while the woman is under
general anesthetic.
 Abdominal surgery to reposition the uterus if all other
attempts to reinsert it have failed.
 Antibiotics to reduce the risk of infection.
 Intravenous liquids.
 Blood transfusion.
 Intravenous administration of oxytocin to trigger
contractions and stop the uterus from inverting again.
 Emergency hysterectomy (surgical removal of the
uterus) in extreme cases where the risk of maternal
death is high.
 Close monitoring in intensive care for a few days, if
necessary.
Uterine rupture refers to a full-thickness disruption of the
uterine muscle and overlying serosa. It typically occurs during
labor, and can extend to affect the bladder or broad
ligament.
There are two main types:
 Incomplete – where the peritoneum overlying the uterus
is intact. In this case, the uterine contents remain within
the uterus.
 Complete – the peritoneum is also torn, and the uterine
contents can escape into the peritoneal cavity.
Risk Factors
 Previous CS– this is the greatest risk factor for uterine
rupture.
 Classical (vertical) incisions carry the highest risk.
 Previous uterine surgery – such as myomectomy.
 Induction – (particularly with prostaglandins) or
augmentation of labor.
 Obstruction of labor – this is an important risk factor to
consider in developing countries.
 Multiple pregnancy.
 Multiparity.
The most common presenting symptom is sudden
severe abdominal pain, which persists between
contractions. The patient may also experience shoulder-
tip pain (from diaphragmatic irritation) and/or vaginal
bleeding.
Significant hemorrhage can produce signs
of hypovolemic shock; such as tachycardia and
hypotension.
Fetal monitoring may reveal fetal distress or absent heart
sounds.
Treatment
 The baby is delivered by emergency c-section, and the
uterus is repaired
 Hysterectomy (if the damage to uterus is extensive
and the bleeding can't be controlled)
Placenta Accreta
-occurs when the placenta attaches too deeply to the
uterine wall. This is a serious condition that can cause
complications for the baby and mother, especially
during the delivery.
Placenta increta and placenta percreta are similar to
placenta accreta, but more severe.
 Placenta increta is a condition where the placenta
attaches more firmly to the uterus and becomes
embedded in the organ's muscle wall.
 Placenta percreta is a condition where placenta
attaches itself and grows through the uterus and
potentially to the nearby organs (such as the
bladder).
Risk Factors:
 Previous Cesarean section
 Abnormal position of the placenta within the uterus,
including placenta previa (a condition where the placenta
sits low in the uterus, usually over the cervix)
 Maternal age greater than 35
 Previous surgery on the uterus, such as fibroid removal or
treatment of uterine scar tissue
 In vitro fertilization
 Some accreta patients have none of these known risk
factors
Complications and Risks for the Baby
 Premature birth

Complications and Risks for the Mother

 Hemorrhage
 Hysterectomy
 Cesarean Section
NURSING

of the
HEMORRHAGE
Postpartum hemorrhage is excessive
bleeding following the birth of a baby.
About 1 to 5 percent of women have
postpartum hemorrhage and it is more
likely with a cesarean birth.
Risk Factors
 High parity
 Overdistention of the uterus
 Precipitous labor or prolonged labor
 Medications (oxytocin, magnesium
sulfate)
Clinical Findings
 Perineal pad saturated in less than 1
hour
 Continuous trickle of vaginal bleeding
 Firm, bruised area on perineum
Interventions
 Fundal massage
 Monitor urine output
1. Check bladder status
2. Catheterize if needed
 Increase mainline IV fluids
 Closely monitor vital signs
 Administer oxygen
 Call primary health-care provider
1. May need suturing of laceration
2. May need evacuation of hematoma
3. May need evacuation of placental
fragments
 Administer medications that promote
uterine contraction as ordered
1. Oxytocin
2. Methylergonovine maleate (Methergine)
• If blood pressure 140/90, hold and call
primary care provider
3. Ergonovine maleate (Ergotrate)
4. Prostaglandin F2a (Prostin/Hemabate)
INFECTION
is usually diagnosed after 24 hours
have passed since delivery and the
woman has had a temperature of
100.4° F (38 °C) or higher on two
occasions at least 6 hours apart.
Symptoms
 Temperature elevation 100.4F
 Elevated white blood cell count
 Complaint of chills and aching
 Malaise
Interventions
 Obtain culture of discharge as ordered
 Report abnormal laboratory findings
 Administer antibiotic therapy as
ordered
 Consider medications
contraindicated for breastfeeding
 Monitor temperature
 Clean and monitor site
 Teach patient reportable signs and
symptoms
ENDOMETRITIS (UTERINE INFECTION)
- inflammation of the uterine endometrium.
- most common postpartum infection and
should be suspected in any postpartum
patient with unexplained fever.
Purulent or foul-smelling lochia supports
the diagnosis.
Contributing Factors
 Operative birth
 Long labor with multiple vaginal exams
 Internal monitoring
 Premature rupture of membranes
 Manual removal of placenta
Clinical Findings
 Subinvolution of the uterus
 Foul-smelling vaginal discharge
 Lower abdominal cramping
MASTITIS (BREAST INFECTION)
Mastitis is an inflammation of breast
tissue that sometimes involves an
infection. The inflammation results
in breast pain, swelling, warmth and
redness.
Contributing Factors
 Alteration in nipple integrity
 Delayed emptying of breast
milk
Clinical Findings
 Unilateral breast pain, warmth
and redness
 Malaise and flu-like symptoms
INCISIONAL INFECTION
classified into incisional SSIs, which
can be superficial or deep, and
organ/space SSIs, which affect the
rest of the body other than the
body wall layers
 Superficial incisional infection- involves
the skin and subcutaneous tissues.
 Deep incisional infections- involve deeper
tissues, including muscles and fascial
planes.
 Organ/space infection- involve any organ
apart from the incision site but must be
related to the surgical procedure.
Contributing Factors
 Inadequate care of incision
 Operative delivery
 Laceration
Clinical Findings
 Incision not well approximated
 Incision is red with purulent
drainage
URINARY TRACT INFECTION
common infections that happen
when bacteria, often from the skin
or rectum, enter the urethra, and
infect the urinary tract.
Contributing Factors
 Catheterization of bladder
 Retention of urine in bladder
Clinical Findings
 Dysuria
 Frequency of urination
 Flank pain
POSTPARTUM DEPRESSION
is a medical condition that many
women get after having a baby. It's
strong feelings of sadness, anxiety
(worry) and tiredness that last for a
long time after giving birth.
Risk Factors
 History of depression or anxiety
disorder
 Prenatal depression
 Inadequate social or partner support
 Large number of life stressors
Clinical Findings
 Symptoms extend beyond 2 weeks
postpartum; may occur 3–12 months after
birth
 Extreme or unswerving sadness
 Compulsive thoughts
 Feelings of inadequacy
 Inability to care for infant and/or self
 Suicidal thoughts
Interventions
 Psychotherapy
 Medications
 THROMBOPHLEBITIS/
DEEP VEIN THROMBOSIS
an inflammatory process that causes a blood
clot to form and block one or more veins,
usually in the legs. The affected vein might be
near the surface of the skin (superficial
thrombophlebitis) or deep within a muscle
(deep vein thrombosis, or DVT).
Risk Factors
 Varicosities
 Advanced maternal age
 Obesity
 Long periods of bed rest
 Occupation that requires long periods
of standing
 Clotting disorder
Etiology
 Increased clotting factors in
postpartum period
 Infection in the vessel lining to
which a clot attaches
Clinical Findings
 Pain with dorsiflexion
 Affected site hot to touch
 Swelling, redness, and pain to
affected leg
Interventions
 Administer anticoagulants
 Monitor coagulation profile
 Compression stockings
 Apply warm, moist heat
 Rest
Observe for symptoms of:
 Pulmonary embolism
 Dyspnea
 Chest pain
 Hemoptysis
 TEACHING TIPS:
POSTPARTUM COMPLICATIONS
Teach the patient to report the
following signs and symptoms to the
primary health-care provider.
Signs of Infection
 Elevated temperature
 Localized redness or pain to either breast
 Persistent abdominal tenderness
 Persistent pain to perineum
 Burning, frequency, or urgency of urination
 Foul odor to lochia
 Redness, pain, or discharge at incision
Signs of Uterine Subinvolution
 Change in the character of
lochia
 Increased amount of lochia
 Resumption of bright red color
 Presence of clots
 Signs of
Thrombophlebitis/Deep Vein
Thrombosis:
 Pain, increased temperature and
redness to legs
Signs of Postpartum Depression
 Extreme or unswerving sadness
 Compulsive thoughts
 Feelings of inadequacy
 Inability to care for infant and/or
self
 Suicidal thoughts