CARDIAC DISEASES, DYSFUNCTIONAL LABOR o May cause premature labor and delivery

AND OPERATIVE OBSTETRICS  Drug therapy

o Antibiotics (penicillin)
INCIDENCE RATE
 Prevent recurrent rheumatic fever
 Increase blood volume  Prevent bacterial endocarditis
 Heart disease complicates about 1% of  Prevents infection caused by
pregnancies streptococcus
 It remains a significant cause of maternal o Heparin
mortality: 2 types  Prevents coagulation problems
o Rheumatic heart disease  Does not cross the placental barrier
o Congenital heart disease (big molecules)
 BLOOD CIRCULATION o Diuretics
 Treat congestive heart failure
 Potassium loosing or Loop (
furosemide / lasics) – lalabas ang salt
RHEUMATIC HEART DISEASE
and potassium , heart contraction
 Sometimes follows a streptococcal pharyngitis INITIAL TREATMENT
 May cause scarring of the heart valves (mitral  Potassium sparing (aldactone/
valve) spironolactone) MAINTENANCE
 The mitral valve is the most common sit of MEDICINE
stenosis  Fluid regulation
 May lead to pulmonary hypertension, pulmonary  Low sodium diet
edema or congestive heart failure o Anti-arrythmic drugs (digitalis, digoxin)
 Clinical Manifestations:  Treat cardiac failure
o Easy fatigability  Treat arrhythmias
o Increased BP  Delivery
o Dyspnea, syncope (fainting) o Forcep assisted delivery
o Hemoptysis o Pain medication (opiods) to allow labor
o Paroxysmal nocturnal dyspnea without pain
o Chest pain with exertion o Low stirrups, Semi-upright position
 Assessment for specific signs and symptoms of o Safest anesthesia: epidural (check for
heart disease is part of every initial prenatal visit sudden hypotension)
 The severity of the disease is determine by ability  Diagnosis and Classification
to endure physical activity  Intrapartum Management
o CLASS 1: asymptomatic – no signs and o 300 to 500mL of blood is shifted from the
symptoms of cardiac insufficiency (no uterus and placenta into the central
restrictions, just like normal preggers) circulation
o CLASS 2: Signs and symptoms with  Extra fluid causes a sharp rise in
ordinary physical activity (walking very cardiac workload
slowly- minimal to moderate restrictions) o Vaginal delivery is recommended for a
o CLASS 3: signs and symptoms with less woman with heart disease unless there are
than ordinary physical activity (emotional / specific indications for caesarean birth.
environmental stressor) o Always check heart rate: bradycardia is
o CLASS 4: signs and symptoms even at normal
rest  Nursing care During Labor and Birth
 Effects of cardiac disease on pregnancy o Natural labor recommended
o Risk baby’s with congenital heart defects o Cardiac stabilization prior to labor if
o LBW or IUGR due to decreased placental necessary
perfusion o Lumbar epidural anesthesia – reduces
o If taking anticoagulants, could be stress of pushing
teratogenic o Monitor vital signs

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 o Semi-fowler’s or side-lying position
o Provide oxygen
o Continuous fetal monitoring
o Limit prolonged labor
o Minimize maternal pushing and use of the
valsalva maneuver
o Encourage open glottis pushing
 Cardiac 1&2
o Avoid strenuous activity
o Rest between activities
 Cardiac 3
o 3rd trimester restriction
o Not allowed to work, complete bed rest
only
 Cardiac 4
o Not allowed to get pregnant
o Managed like a cardiac 3 patients
INTRAPARTUM COMPLICATIONS
Dysfunctional Labor – one that does not result in
normal progress of cervical effacement, dilation and
fetal descent
TYPES:
 F & E imbalance
 Hypoglycemia
 Excessive analgesia and anesthesia
 Maternal catecholamine secreted in response to
stress or pain
 CPD
 Uterine over distention
HYPOTONIC DYSFUNCTION
 Coordinated but weak
 Known as “Secondary arrest” (multiparas)
 Occurs during active phase
 Maternal fatigue and frustration may occur
 Fetal hypoxia not commonly seen
NURSING MANAGEMENT
 Upright position
 Amniotomy before Pitocin (for the uterus to have
more space)
 Timed cervical exams
 Augementin by IV or Pitocin (Oxytocin)
administration
 If fatigues and dehydrated rest and fluids
 If with fetal distress – CS delivery

1) Problems of powers REPONSIBILITIES FOR OXYTOCIN DRIP

a. Infective contractions  Piggy back with plain IVF as the other bottle
b. Ineffective maternal pushing
 Evaluate contractions and fetal heart rate
2) Problems of passenger
 Observe for TETANIC CONTRACTIONS (may
a. Fetal size
rupture, less than 2 minutes between
b. Abnormal fetal presentation or position
contractions lasting longer than 60 seconds)
c. Multifetal pregnancy
 Observe for fetal distress
d. Fetal anomalies
3) Problems of the passage  Contraindications
a. Abnormal pelvis o Any obstruction interfering decent of the
b. Soft tissue obstruction (myomas, abnormal fetus (CPD)
growth of a mass in the cervical area) o Condition endangering uterin rupture (high
4) Problem of the Psyche parity, previous CS, overdistended Uterus)
a. Prolonged labor o Hypertonic, uncoordinated uterine
b. Precipitate labor contraction
o Fetal distress
PROBLEMS OF POWER o Placenta previa
INEFFECTIVE CONTRACTIONS HYPERTONIC DYSFUNTION

 Hypotonic  Women in latent phase of labor, primiparas

 Hypertonic  Uterine muscles are in state of greater than
normal muscle tension (every 1 ½ minutes
Causes of Ineffective Contraction
lasting for 90 seconds)
 Maternal fatigue  Uterine resting tone: high
 Maternal activity  Contractions are irregular and painful = maternal
exhaustion
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 Can lead to fetal anoxia RISK OF MACROSOMIA

NURSING MANAGEMENT  CPD

 Dysfunctional labor
 Therapeutic rest is achieved using drugs:
 Soft tissue laceration
o Morphine
 Postpartum hemorrhage
o Nalbuphine (Nubain)
 Fetal:
o Butarphanol (Stadol)
o Meconium aspiration, asphyxia, shoulder
o Short acting barbiturates to promote rest
dystocia (fractured clavicle)
o Low dose epidural
o Narcotic antagonist (Narcan - Naloxone) ABNORMAL PRESENTATIONS
 Tocolytic agents (RITODRINE)
o Oxytocin is CONTRAINDICATED  Shoulder presentation
 If contraction remain uncoordinated, prepare for o AKA transverse lie
CS o Occurs in abnormalities affecting the uterus
 Rest and comfort measures (bath, warm) (tumors)
o Fetus is too large
 Monitor FHR
o Gestational diabetes
 Administer fluids
o CS delivery
 IV line is open
o Delayed or difficult birth of the shoulder
HYPO HYPER o Urgent situation because of a cord prolapse
 MUSCLE TONE  GREATER THAN o McRobert’s maneuver – woman flexes her
ARE DEFECTIVE normal muscle thigh sharply against her abdomen which
AND INADEQUATE tension sharpens her pelvic curve
 Occurs during the  Contractions are o Suprapubic pressure – pushes the fetal
active phase poor posterior shoulders downward to displace it
 Contractions are  Noted on the latent from above the mother’s symphysis pubis
low or frequent phase  Breech Presentations
 Contractions are o Complete, frank, incomplete
irregular and painful
ROTATIONS ABNORMALITIES

INEFFECTIVE MATERNAL PUSHING  Persistent Occiput Posterior

o Fetus must rotate turn 135 degrees to be
 This may result from: born
o Use of nonphysiologic pushing technique o If fetus turns 45 degrees only, transverse
and position arrest will return
o Fear of injury  CLINICAL MANIFESTATIONS
o Decreased or absent urge to push
o Intense back pain because of the
o Maternal exhaustion
compression of the sacral nerve as the baby
o Analgesia/ anesthesia/ psychological rotates (back labor)
unreadiness to “let go” of the baby
 NURSING INTERVENTIONS
o Management: correct the cause,
1. Sacral pressure
“REFLEXIVE URGE TO PUSH”, UPRIGHT
2. Maternal positional changers
POSITION
 Hands and knees position
PROBLEMS WITH PASSENGER  Side lying
 Lunge
 Oversized baby
 Squatting
o Macrosomia: >8 lbs, 13 oz at birth (more
 Sitting on a chair, kneeling standing
than 4,000 gms)
 Using a birth ball
 Fetal anomalies
3. Therapy
o Hydrocephalus
 Forceps (Scanzoni’s maneuver)
o Anencephaly
 Vacuum Extraction
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DEFLECTION ABNORMALITIES RISK CONSIDERATIONS ASSOCIATED WITH
MULTIPLE GESTATION
 FACE PRESENTATION – asynclitism (the fetal
head is presenting in a different angle MATERNAL FETAL
o In face presentation, the presenting part is Anemia (check Abnormal presentation
too large to pass through the pelvis (nose, haematocrit level) that can cause cord
mouth, chin is felt during vaginal birth) prolapse
o Face presentation is associated with PIH Cord coil
abnormalities like previa, contracted pelvis, Uterine Dysfunction Premature births
prematurity, hydramnios and fetal Postpartum Fetal hypoxia
malformation hemorrhage
Abruption
o Delivery: vaginal birth – if the chin is anterior
and pelvic diameters are adequate, CS – if
posterior
o Cephalhematoma
 BROW OR MILITARY PRESENTATION ABNORMAL LABOR DURATION
o Rarest presentation; the head is neither  Normal progress of the following:
flexed nor extended o CERVICAL DILATION: 1.2 cm/hr (primi), 1.5
o Associated with obstructed labor cm/hr (multi)
o CS delivery o DESCENT: 1 cm/hr (primi), 2 cm/hr (multi)
o Complications
 Fetal injury particularly with a difficult EFFECTS OF PROLONGED LABOR
vaginal birth
 Maternal infection (matagal na open ang cervix)
 Prolapsed umbilical cord
 Neonatal infection
 LBW as a result of preterm gestations,
multiple pregnancy or IUGR  Maternal exhaustion (signs and symptoms of
 Fetal anomalies contributing to breech dehydration)
such as hydrocephalus  High levels of anxiety and fear during
 Complications secondary to placenta subsequent labor
Previa or CS  INTERVENTIONS:
o Diagnosis o Promote comfort
 Fetal heart location o Prevent infection
 LM
 Ultrasound
o Delivery PRECIPITATE LABOR
 CS or double set up
 Can lead to: precipitate delivery
 Maurice Smellie Veit Maneuver
 Piper’s forceps  Forceful contractions noted, less contraction
needed to deliver fetus
MULTIFETAL PREGNANCY  Labor that is completed fewer than 3 hours and
results in rapid birth
 IDENTICAL – monozygotic
 Associated with:
o Single ovum/ single egg
o Abruption
o 1 spermatozoon, 1 ovum
o Fetal meconium
o Babies look alike, same sex
o Maternal cocaine
o 1 placenta, 1 chorion, 2 amnion, 2 umbilical
o PP haemorrhage
cord
o Low APGAR
 NON-IDENTICAL – dizygotic (fraternal)
o Fetal head injuries, trauma
o 2 sperms, 2 ova
 Management:
o Same sex or opposite sex
o Side lying position
o 2 amnion, 2 chorion, 2 cord, 2 placenta
o O2 and IVF
o Tocolytic drug
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 Mother’s at risk: o No coitus, no breast stimulation, check temp
o Grand multi paras (every 2 hours), activity restriction, note for
o Small baby in good position uterine contractions
o Preterm baby
o Large pelvis
o Injudicious use of PITOCIN PRETERM LABOR

 CLINICAL MANIFESTATIONS:
RUPTURE OF MEMBRANES o Regular contractions for an hour
o Sensation that the baby is frequently “balling
 Rupture of amniotic sac before labor occurs is up”
normal if it occurs near term o Leaking or gushing of fluid from the vagina
 Early Rupture of the Membrane (EROM) – o Pain that feels like menstrual cramps, with
rupture during labor before transitional phase or without diarrhea
o Prevention of infection o A feeling of pressure in the pelvis or lower
 Preterm Premature Rupture of Membrane belly
(pPROM) – refers to the rupture earlier than 37 o A dull ache in your lower back, pelvic aream
weeks with or without contractions – associated lower belly, or thighs that does not go away
with premature births o Not feeling well, including having a fever,
 ETIOLOGY fatigue
o Chorioamnionitis  MODE OF DELIVERY: CS
o Infection of the vagina and cervix  PREDICTORS:
o Over distention of uterus o Cervico vaginal fibronectin – collected like a
o Maternal hormonal changes PAP tEst
o Recent sexual intercourse o Fetal fibronectin is a protein found in the
o Maternal stress fetal membranes and decidua
o Maternal nutritional deficiencies o It is found in the cervico vaginal area early in
 DIAGNOSTIC pregnancy
o Ph test o If large quantities are notes in the cervico
o Ferning test vaginal area at 22-37 weeks. AOG, the resul
 ASSESSMENT is positive
o Proper medical history o Cerclage – mcdonald’s suture (temporary),
o Gynaecological exam using a speculum shirodkar’s (permanent)
o Nitrazine (pH swab) o Cervical length (through ultrasound probe
o Cytologic (ferning) tests measurement)
o TVS (ultrasound to determine cervical o Cervix that is shorter than average length
length: if = or < than 25 mm cervix will dilate (less than 25 mm)
 SIGN and SYMPTOMS  TREATMENT:
o Feel either a slow trickle or a sudden gush o CBC
of warm fluid from your vagina o Tocolysis using:
 MANAGEMENT  MgSO4 (CNS depression)
o Antibiotic therapy should be given to  Beta adrenergic agonists (first line)
decrease risk of sepsis  Maternal pulmonary edema
o Ampicillin, amoxicillin, or erythromycin for 7  Calcium channel
days  Arterial vasodilation -> sudden
o Antenatal steroids if AOG is <30 weeks hypotension
o Tocolysis is also used  Prostaglandin synthesis inhibitors
o Induction of labor should happen at around (further dilation of the cervix, fetal
36 weeks constriction of the ductus arteriosus)

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PROLAPSED UMBILICAL CORD o Localized tenderness
o Persistent aching pain over the area of the
lower uterine segment
OCCULT PROLAPSE
o Changes in VS, FHR, uterine contractions
 Cord is often compressed by a shoulder or the noted
head o Management: CS
 Hypoxemia (severed bradycardia, sever variable
accelerations)
 Changing the woman’s position mat relieve
pressure on the cord
UTERINE INVERSION
OVERT PROLAPSE
 Uterus turn inside out after delivery of the fetus
 Occurs with ruptured membranes or the placenta
 Treatment begins with gently lifting the  Causes:
presenting part and continuously holding it off o Traction applied to the cord
the prolapsed cord to restore feral blood flow o Fundal pressure
while immediate caesarean delivery is one o Placenta accrete (adherent)
 Placing the woman on knee-chest position or o Congenital weakness of the uterus
side lying elevating the woman’s hips o Leads to hypovolemic shock
 Management:
o Manual reposition (use of general
UTERINE RUPTURE anesthesia to relax the uterus)
o Hysterectomy and IVF
 Occurs in 1:1500 births
 Accounts for 5% of maternal deaths
 Complete, direct communication between the AMNIOTIC FLUID EMBOLISM (ANAPHYLACTOID
uterine and peritoneal cavities SYNDROME)
 Incomplete: rupture into the peritoneum covering
the uterus or into the broad ligaments but not the  Amniotic fluid enters maternal uterine blood
peritoneal cavity sinuses through a small tear in the amnion or
 Cause: chorion when the membrane ruptures
o Fundal pressure  A multisystemic reaction to toxins rather than an
o Previous CS (LTCS) embolic phenomenon
o Hypertonic dysfunction  Incidine
o Prolonged lover o 1:8000
o Multiple gestation o Not preventable
o Abnormal presentation  Risk factors:
o Unwise use of Pitocin o Oxytocin administration
o Obstructed labor o Abruptio
o Traumatic maneuvers of forceps or vacuum o Hydramnios
 COMPLETE RUPTURE  Mortatlity
o Sudden severe pain during a strong o AFE constitute the leading cause of
contraction mortality during labor and the first few
o Tearing sensation postpartum hours
o Affects all layers o Maternal death usually occurs because of
o Fetus is beside the uterus (fetal death may sudden cardiac arrest, haemorrhage due to
occur) coagulopathy, or acute respiratory distress
o Bleeding is massive (from the torn uterine syndrome, and multiple organ failure
artery)  Diagnosis
o Shock o Establishment of diagnosis od AFE
 INCOMPLETE RUPTURE o Autopsy
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 Medications VACUUM SUCTION
o Packed RBC
 A cap like suction devise is applied to the fetal
o Fresh frozen plasma
head to facilitate delivery
o Cryoprecipitates
o Platelets  Traction is applied during uttering contraction
o Corticosteriods until descent of the fetal head is achieved.
 Assess newborn infant at birth and throughout
postpartum period for signs cerebral trauma
OPERATIVE OBSTETRICS  Monitor developing cephalhematoma
CAESAREAN BIRTHS

 Birth of fetus through transabdominal incision of ANESTHESIA

the uterus
 Purpose:  General – they are put to sleep, they might not
o To preserve the life or health of the mother wake up, not for cardio and respi problems
and her fetus  Regional
 Incisions o Epidural
o Classical CS – below umbilicus until above o Spinal – deeper, may result to spinal
the symphisis pubis paralysis
 Vertical incision made through the o 6-8 hours nakahiga, no pillow allowed (after
abdomen and uterus delivery)
 Made high in the uterus (ideal for o NURSING MANAGEMENT:
previa)  Move the feet to check for sensation
o Low Transverse/ Pfannenstiel incision  Ask if the patient has passed out flatus
 Made horizontally across the abdomen -> Check for bowel sounds -> Clear
and uterus just above the symphysis liquids (sips of warm water) ->
pubis GLEMCD -> soft diet (easy to digest
 May use surgical staples food)
 Catheterization is placed only for 24
hours, after 4 hours if the patient does
not void, catheter is put back again
FORCEPS DELIVERY
 Local
 Two-double-crossed, spoon like articulated
blades are used to assist in the delivery of the
fetal head
 Simpson’s forceps – commonly used types of
forceps in outlet delivery, used in substantial
molding of the fetal head, has elongated cephalic
curve
 Elliot forceps – has an adjustable pin for
regulating the lateral pressure on the handles,
mostly used in minimal molding
 Piper’s forceps – for breech presentations
 NURSING MANAGEMENT:
o Check for forceps marks (indication of
compression of a facial nerve)
o Observe the baby’s crying

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