ANGELES UNIVERSITY FOUNDATION College of Nursing COMPETENCY APPRAISAL II Maternal Nursing I. POSTPARTAL INFECTIONS Causes: A.

Endogenous: Normal Flora B. Exogenous: Anaerobic Strep (Hospital Personnel, Manipulation, Breaks in Aseptic Technique, Coitus, PROM) General Signs and Symptoms: Malaise, Anorexia, Fever, Chills and Headache General Management Monitor VS and temp every 2 4 hrs COMPLETE bed Rest; Position of comfort Proper Nutrition : High calorie; High protein Increased Fluid Intake : 3-4L Encourage frequent voiding. Monitor I/O Analgesics Antipyretics and Antibiotics A. Perineal Infection Pain, heat, pressure in the perineum Inflammation of suture line, 1- 2 inches sloughed Removal of sutures; resuture Hot sitz bath or warm compress B. Endometritis Placental point of entry; Peritonitis and Pelvic Thrombophlebitis Abdominal tenderness, Prolonged severe afterpains Uncontracted (tender and large) uterus, pain Dark brown, foul smelling lochia Ileus Oxytocin administration Fowlers position. Pain management. C. Thrombophlebitis Increased production of clotting factors Femoral Malaise, Chils, Fever + Homans sign Diminished pulses Shiny white skin Pain, stiffness, swelling Pelvic Severe chills Dramatic temp changes Pulmo. Embolism

Superficial Palpable thrombus Pain and Tenderness Warm and Pinkish

Assessment Bed rest, leg elevated Use bed cradles. Hot packs/ Moist heat Elastic stockings. Analgesics. Antibiotics Heparin Na IV Monitor for Pulmonary Embolism

Never massage leg. Avoid crossing legs. Avoid prolonged sitting. Avoid constricting clothes. Avoid pressure behind knees.

D. Mastitis Staph aureus Breasfeeding mothers, 2- 3 weeks Fever, chills, tachycardia, malaise, abdominal pain Reddening, swelling, inflammatory signs Handwashing, breast care Warm water, Or Cold application Let breast milk dry on nipples clean bra Good breastfeeding techniques Manual expression of breast milk Analgesics

Antibiotics

II. BLEEDING/HEMORRHAGE A. First Trimester Bleeding 1. Abortion Types Threatened Signs/ Symptoms Spontaneous vaginal bleed Moderate bright red Low uterine cramping Management CBR 24-48 Coitus Restriction Hormone therapy Monitor V/S Count perineal pads Maintain IV Monitor for hemmorhage RhoGAM Complete VS iNC

Imminent/ Inevitable Missed

Cervical Dilatation and Effacement No inc in FH, FHT 2 wks signs of Abortion 3 or more successive pregnancies

Habitual

2. Ectopic Pregnancy Pregnancy OUTSIDE of UTERUS; Fallopian Tube :AMPULLA Spotting to bleeding: Dark red or brown Ruptures in 12 weeks SEVERE, SHARP, KNIFE LIKE, Lower Quadrant (L/R) Referred shoulder pain Rigid Abdomen Cullens Sign Excruciating pain upon IE Shock Methotrexate MGT: Salpingostomy, Salpingectomy Nursing Care: COMBAT SHOCK B. Second Trimester Bleeding 1. Hydatidiform Mole Chorionic Villi: Proliferation and degeneration Grape like clusters; Antecedent of choriocarcinoma Low SE status with low protein intake <18 yrs old and >35 years old Marked nausea and vomiting Fundic Ht Increase, Weight gain No Fetal Heart Tones th Signs of toxemia before 24 AOG Clear, fluid, grape sized vesicles th nd Vaginal bleeding by 4 wk/2 Tri Bright red/ dark brown, Slight, profuse and intermittent High levels of HCG High levels of HCG Snowstorm pattern on UTZ D&C, Vacuum Aspiration Oxytocin for Contraction MTX HCG monitoring q 1-2 weeks until NORMAL; 1 2 months/year Prophylaxis

2. Incompetent Cervical Os Premature dilation of the cervix Congenital/ Hormonal/Trauma Show and uterine contractions Ruptured membranes Painless cervical dilatation Bed Rest, Hydration, Tocolysis TH Cerclage 14-18 AOG McDonalds: NSD

Shirodkar: CS No coitus, prolonged standing, heavy lifting Monitor for contractions, bleeding and rupture of membranes and signs of infection

C. Third Trimester Bleeding 1. Placenta Previa Improperly implanted Low lying/Partial/Complete Increased Parity Advanced Maternal Age Rapid succession of pregnancies Dx: UTZ PAINLESS BRIGHT RED VAGINAL BLEEDING Uterus is soft, relaxed and non tender Maternal VS, FHT, Fetal Activity IE? Complete Bed Rest , Side Lying Prepare O2 and Blood IV and Tocolytics Hemorrhage, Infection, Prematurity 2. Abruptio Placenta th Premature separation of placenta from uterine wall after 20 week and before delivery Maternal Hypertension Increasing parity, Maternal Age Sudden release of amniotic fluid Short umbilical cord Direct trauma Hypofibrinoginemia Dark red vaginal bleeding, or absence of bleeding SEVERE, SHARP, KNIFE LIKE PAIN, Fundic region Signs of Shock Couvelaire uterus Fetal distress Monitor Maternal V/S, and FHT WOF excessive vaginal bleeding, abdominal pain and increase in fundic height Maintain bedrest. Administer 02, IV, Blood products Trendelenburg position Left lateral position Monitor uterine activity Vaginal delivery Cesarian delivery DIC on the postpartum D. Postpartum Bleeding 1. Early Postpartum Bleeding a. Uterine Atony Overdistention of Uterus CS Placental Accidents Prolonged and Difficult labor WOF increased pulse rate MASSAGE Ice compress, oxytocin administration, empty bladder Bimanual compression Hysterectomy

2. Late a. Retained Placental Fragments Dilatation and Curettage b. Hematoma Ice compress Oral Analgesics Incision and Ligation

III. HIGH RISK PREGNANCY

A. Anemia Iron deficiency Postpartum Infection Fatigue, H/A, Pallor, Tachycardia HgB: < 10 g/dL; Hct: 30% Monitor HgB and Hct every 2 weeks Iron and Folic acid supplements Vitamin C and tea Iron, Folic Acid, Protein Blood Transfusion Oxytocin, with excessive bleeding B. Cardiac Disease Increased plasma volume, cardiac output ND Blood volume at maximum for last weeks of 2 trimester Functional Classification of Cardiac Disease Class I Class II Uncompromised Slightly compromised; slight limitation of physical activity Ordinary physical activity causes sx Markedly compromised ; limitation of physical activity Less ordinary activity causes excessive fatigue, palpitations, dyspnea, or anginal pain Inability to perform any physical activity w/o discomfort Sx of cardiac insufficiency present at rest Cough and respiratory congestion Dyspnea and fatigue Palpitations and tachycardia Peripheral edema Chest pain Respiratory infection Heart failure and pulmonary edema Warn about obesity. Monitor V/S, FHT, Fetal condition Limit physical activity. Stress rest. Monitor for signs of cardiac rest and decompensation. Prevent anemia. Low sodium diet Labor: V/S monitor. Cardiac monitor. External fetal monitor. Bed Rest. Side lying, Head and shoulders elevated.

Class III

Class IV

C. Diabetes Mellitus Maternal glucose crosses, placenta does not. First trimester: maternal insulin needs decrease Second and third: insulin needs increase Placental delivery: abrupt decrease of hormones, decrease insulin requirements Fetus produces own insulin, pulls glucose from mother. Predisposes the mother to hypoglycemic reactions. D. Gestational Diabetes Mellitus ND rd 2 or 3 trimester; Pancreas unable to respond th Screening during 24 28 week AOG 3 OGTT confirmatory After delivery, EUGLYCEMIC state S/sx of Hyperglycemia, Blurred vision, Recurrent UTI and yeast infection, Gestational Hypertension, Polyhydramnios, LGA Dietary changes, Insulin, Exercise: 65 130 mg/dl Monitor serum glucose, urine for glucose and ketones Weight monitoring Proper caloric intake + insulin therapy WOF for complications (Preeclampsia) and Infection Assess Fetal Status and Fetal Compromise Monitor Fetal Status and prepare CS Regulate insulin and provide glucose IV Postpartum Interventions: Observe for hypoglycemia. Reregulate insulin needs after the first day.

Assess dietary needs Monitor for postpartum infection or postpartum hemorrhage

E. Disseminated Intravascular Coagulation Causes Abruptio placentae Amniotic fluid embolism Gestational hypertension IUFD Liver disease Sepsis Signs and Symptoms Signs of Bleeding Decreased fibrinogen, plt. Ct, Hct Inc PT, PTT, Clotting Time, Fibrin Degradation products Remove underlying cause. Implement interventions for blood loss. Monitor urine output and maintain at 30 ml/hr. F. Pregnancy Induced Hypertension th nd 24 week 2 week postpartum HYPERTENSION; EDEMA; PROTEINURIA Age ; Multigravida Low Socio economic status Multigravida Co morbidities nd Roll over Test: 28- 32 week of pregnancy Lateral recumbent to supine position; +20 mmHg Mild Preeclampsia 1-5lbs/week Upper Extremity Edema 140/90 (+30 mmhg/15 mmHg) Proteinuria 0.5 gms/liter Severe Preeclampsia 160/110 Proteinuria 5gm/liter , 24 hours Cerebral/Visual disturbances Pulmonary edema/Cyanosis Elev. Liver; Oliguria Aura

ECLAMPSIA: CONVULSIONS; Increased BUN, Uric Acid

Mild Hypertension Monitor BP. Monitor Fetal Activity Rest Periods Lateral Position Anti HPN meds Monitor I/O Evaluate renal fxn

Mild Pre Eclampsia Monitor Neurologic Status Monitor DTR Adequate fluids Monitor for HELLP

Severe Pre Eclampsia MgSO4 Monitor Mg toxicity Prepare for induction of labor

Remain with client. Call for help. Ensure open airway. Turn client to side. O2 at 8-10L/min Monitor FHT Meds for seizures. Complete Bed Rest Diet : High CHON/CHO

ECLAMPSIA Insert oral airway. Suction. Prepare for delivery. Document occurrence.

Mild Preeclampsia Moderate Na Restriction No added salt Fish paste, sauce, canned good

Severe Preeclampsia Salt Poor (3 grams, Na /day)

Diuretics 20-30 ml/hr UO Fatigue and muscle weakness Monitor I/O

K Supplement WOF D-D Interactions

Barbiturates Sedation

Magnesium Sulfate CNS Dep. Vasodilator Cathartic

10gms(RED)

IV. PROBLEMS WITH LABOR AND DELIVERY A. Premature Rupture of Membranes Gestational age determines intervention INFECTION! Fluid pooling in vaginal vault Nitrazine test positive. V/S Monitoring; Fetal Monitoring Avoid vaginal examinations Antibiotics as needed. B. Prolapsed Umbilical Cord Displaced between presenting part and amnion or protruding Compression of cord, fetal circulation compromise Feeling something is coming out Visible/palpable cord FHR is irregular and slow Violent fetal activity Elevate fetal presenting part via finger pressure Extreme Trendelenburg/ Modified Sims/ Knee Chest Oxygen, 8-10 LPM via face mask Monitor fetal heart rate and assess fetal hypoxia IV fluid Prepare for immediate birth. Document event and patient response. C. Precipitous Labor and Delivery Labor < 3 hours Preciptous delivery made available Stay with the client. Keep client calm. Do not keep fetus from being delivered. D. Dystocia Difficult Labor: prolonged and painful Power/Passenger/Passageway Hypotonic/Hypertonic Contractions DHN, infection, Fetal Injury, Death Monitor maternal and fetal well being Administer prophylactic antibiotic. IV, I/O monitoring Instruct on proper breathing Monitor color of amniotic fluid Monitor for cord prolapse after membrane rupture E. Fetal Distress Fetal heart rate < 120 beats/min or >160 bpm Meconium stained amniotic fluid Fetal hyperactivity Severe variable decelerations Late decelerations Lateral Position Oxygen, 8 10 LPM, Face mask Discontinue oxytocin Monitor maternal and fetal status Prepare for cesarean delivery PREPARED BY: J. DELFIN RN, MN