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complications exist, as single fetus presents by vertex and labor is completed within
24 hrs. The course of labor has 4 stages:
The first stage of labor is the longest. There are three phases within the first
stage: Early or latent phase, Active phase and Transition phase. At the end of the
first stage, the cervix is dilated to 10 centimeters. In mothers having their first child,
this stage usually lasts 12 to 16 hours. For women having second or subsequent
children, the first stage lasts around 6-7 hours.
Early/Latent
Active
~1~
then 60 seconds for at least an hour.
If you have had previous deliveries, the active phase of labor can proceed
more quickly. When you are in active labor, you will be concentrating on the
task at hand, and will not feel like doing anything else. Contractions are
growing stronger, longer and closer together. Contractions will be about 3-4
minutes apart, lasting 40 to 60 seconds. You may have a tightening feeling in
your pubic area and increasing pressure in your back. If you have learned
breathing techniques, begin using them now. Pain medication is often given
at this stage. If you have chosen to have an epidural anesthetic, it is usually
given at this stage.
Transition
The second stage begins from the time the cervix is fully dilated(10 cm) until
the baby is born. This stage of labor lasts anywhere from one contraction up to two
hours. The baby's head stretches your vagina and perineum (the skin between the
vagina and rectum). This may cause a burning sensation. Some women may feel as
if they are having a bowel movement, and feel the urge to push, or bear down. The
labor nurse or physician will tell you when it is time to push. It is important that you
not push until instructed. Pushing too early will cause the cervix to become
edematous, or swollen. "Crowning" occurs as the widest part of the head appears at
~2~
the vaginal opening. In the next few pushes, the baby is born. Mucous and amniotic
fluid will be removed from the baby's mouth and nose with a bulb syringe. The baby
will take its first breath, and may begin to cry. Immediately after birth, the baby is still
connected to the placenta by the umbilical cord. The cord is clamped and cut.
The third stage of labor, or the placental site, begins with the birth of the infant
and ends with the delivery of the placenta. Two separate phases are involved:
placental separation and placental separation and placental expulsion. Signs of
placental separation includes: calkin’s sign, uterus becomes mobile, sudden gushing
of blood and lengthening of umbilical cord. The types of placental delivery or
presentation includes: schultze’s mechanism, which is the shiny “clean” side first
bluish side and duncan’s mechanism, appears to be rough, ”dirty”, reddish maternal
side out first.
After birth of the infant, the uterus can be palpated as a firm, round mass just
inferior to the level of the umbilicus. After few minutes of rest, uterine contractions
begin again, and the organ assumes a discoid shape. It retains this new shape until
the placenta has separated, approximately 5 minutes after the birth of the infant.
This stage is really more about getting back to normal than anything else --
the hour or two after delivery when the tone of the uterus is established and the
uterus contracts down again expelling any remaining contents. These contractions
are hastened by breast-feeding, which stimulates production of the hormone
oxytocin. Your blood pressure, temperature and heart rate will stabilize in much the
same way a marathon runners does: a little at a time during the hour after the
placenta is delivered. Contractions will cease. Your uterus will harden, doing its job
~3~
to tighten around the blood vessels that had supplied the placenta and your baby
with nutrients. Your midwife or doctor will keep an eye on you, make sure the entire
placenta was expelled and take a look at the umbilical cord. If you had an
episiotomy, this is when you'll get a few sutures.
• Trauma from the delivery may tear tissue and vessels leading to significant
postpartum bleeding.
• Uterine atony (Tone) refers to the inability of the uterus to contract and may
lead to continuous bleeding. Retained placental tissue and infection may
contribute to uterine atony.
• Tissue refers to any cellular debris from the placenta or fetus that may be left
in the uterus, causing the uterus to not contract.
• Thrombin refers to some failure of clotting, such as with diseases known as
coagulopathies.
~4~
Postpartum anemia increases the risk of postpartum depression. Blood transfusion
may be necessary and carries associated risks. In the most severe cases,
hemorrhagic shock may lead to anterior pituitary ischemia with delay or failure of
lactation (i.e., postpartum pituitary necrosis).
Tone
~5~
Uterine Massage. Brisk blood flow after delivery of the placenta should
alert the physician to perform a bimanual examination of the uterus. If the
uterus is soft, massage is performed by placing one hand in the vagina
and pushing against the body of the uterus while the other hand
compresses the fundus from above through the abdominal wall (Figure 1).
The posterior aspect of the uterus is massaged with the abdominal hand
and the anterior aspect with the vaginal hand.
Trauma
Tissue
Thrombin
Lab Studies
CLASSSIFICATION:
Total placenta previa – implantation that totally obstructs the cervical os
Partial placenta previa – implantation that occludes a portion of the
cervical os
Marginal placenta previa - placenta edge approaches the cervical os
Low-lying placenta – implantation in the lower rather than in the upper
portion of the uterus
CLINICAL MANIFESTATIONS:
Cardinal sign is painless vaginal bleeding, which usually appears near the
end of the second trimester or later. Bleeding 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 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
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 the diagnosis.
Sterile speculum examination can also confirm placenta previa.
MANAGEMENT
Conservative management with bed rest and hospitalization until fetus is
mature and delivery can be accomplished.
If woman is discharged, she needs availability of immediate transport for
recurrent bleeding.
IV access and at least 2 units of blood should be available at all times.
Continuous maternal and fetal monitoring.
Cesarean section is often indicated if the degree of previa is >30% or if
there is excessive bleeding.
Vaginal delivery may sometimes be attempted in a marginal previa without
active bleeding.
A pediatric specialty team may be needed at delivery due to prematurity
and other neonatal complications.
COMPLICATIONS
Fetal mortality resulting from hypoxia in utero and prematurity.
Immediate hemorrhage, with possible shock and maternal death.
Postpartum hemorrhage resulting from decreased contractility of uterine
muscle.
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 ion hemoglobin and hematocrit status.
HEALTH TEACHINGS
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
no to have vaginal examinations.
If discharged, inform the woman to:
o Avoid intercourse or anything per vagina.
o Limit physical activity.
o Have an accessible person in the event of an emergency.
o Go to the hospital immediately for repeat bleeding or uterine
contractions >6 per hour.
CLINICAL MANIFESTATIONS:
Sudden onset, intense, localized, uterine pain/tenderness with (external)
or without (occult) vaginal bleeding.
Uterine contractions may be low amplitude and high frequency.
FHR may change depending on the degree of hemorrhage; increased
FHR, late decelerations and decreased viability.
Abdominal pain is often present due to increased uterine activity.
Abruptio placenta grades:
o Grade 0 (mild) – small retroplacental clot or small rupture of
marginal sinus; <100 ml blood
o Grade 1 (moderate) – small retroplacental clot; detachment <50%;
>100 ml but <500 ml blood
o Grade 2 (moderate to severe) – significant retroplacental clot;
detachment approaches 50%; blood loss approaches 500 ml
o Grade 5 (moderate to severe) – significant retroplacental clot;
detachment >50%; >500 ml
DIAGNOSTIC EVALUATION
Ultrasound is done but is not always sensitive enough to rule out
diagnosis.
Laboratory screen for APT on mother’s blood to check for fetal
hemoglobin.
MANAGEMENT
This depends on the maternal and fetal status and degree of bleeding.
Mild – conservative management with bed rest, tocolytics and evaluation
of fetus with fetal assessment methods until fetal lung maturity can be
established and delivery accomplished.
Moderate – augment labor if stable and decreased blood loss. Vaginal
delivery is accomplished if cervix dilates. If fetal or maternal status
deteriorates and blood loss excessive, cesarean delivery is performed.
Moderate to severe – restore and maintain maternal physiologic status;
IV/blood replacement.
A pediatric specialty team may be needed at delivery due to prematurity
and other neonatal complications.
COMPLICATIONS
Maternal shock
DIC
Amniotic fluid embolism
Postpartum hemorrhage
Prematurity
Maternal/fetal death
Rapid labor and delivery
NURSING ASSESSMENT
Determine the amount and type of bleeding and the presence or absence
of pain.
Monitor maternal and fetal vital signs.
Palpate the abdomen for contractions.
Measure and record fundal height.
Prepare for possible delivery.
HEALTH TEACHINGS
Provide information to the woman and her family regarding etiology and
treatment for abruptio placenta.
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 immediately if excessive bleeding and pain occur
at home.
Periodic changes
Accelerations
Early Decelerations
Late Decelerations
FIGURE 6. Late deceleration with loss of variability. This is an ominous pattern, and
immediate delivery is indicated.
Variable Decelerations
Variable decelerations are shown by an acute fall in the FHR with a rapid
downslope and a variable recovery phase. They are characteristically variable in
duration, intensity and timing. They resemble the letter "U," "V" or "W" and may
not bear a constant relationship to uterine contractions. They are the most
commonly encountered patterns during labor and occur frequently in patients
who have experienced premature rupture of membranes and decreased amniotic
fluid volume. Variable decelerations are caused by compression of the umbilical
cord. Pressure on the cord initially occludes the umbilical vein, which results in
an acceleration (the shoulder of the deceleration) and indicates a healthy
response. This is followed by occlusion of the umbilical artery, which results in
the sharp downslope. Finally, the recovery phase is due to the relief of the
compression and the sharp return to the baseline, which may be followed by
another healthy brief acceleration or shoulder (Figure 7).
FIGURE 7. Variable deceleration with pre- and post-accelerations ("shoulders"). Fetal heart rate
is 150 to 160 beats per minute, and beat-to-beat variability is preserved.
Usually, there are three primary characteristics of this condition, including the
following:
• high blood pressure (a blood pressure reading higher than 140/90 mm Hg,
or a significant increase in one or both pressures)
• edema (swelling)
Severe headaches
Changes in vision, including temporary loss of vision, blurred vision or
light sensitivity
Upper abdominal pain, usually under the ribs on the right side
Nausea or vomiting
Dizziness
Decreased urine output
Sudden weight gain, typically more than 2 pounds a week.
Pathophysiology Events
Vasospasm
The cause of PIH is unknown. Some conditions may increase the risk of
developing PIH, including the following:
Classification
PIH is classified as gestational hypertension, mild preeclampsia, severe
preeclampsia, and eclampsia, depending on how far advanced it has become.
Gestational Hypertension
A woman is said to have gestational hypertension when she
develops an elevated blood pressure (140/90 mmHg) but has no
proteinuria or edema.
Mild Preeclampsia
A woman is said to be mildly preeclamptic when her blood pressure
rises to 140/ 90 mmHg, taken on two occasions at least 6 hours apart.
With mild preeclampsia, in addition to the hypertension the woman has
proteinuria ( 1+ or 2+ on a reagent test strip on a random sample). Edema
also may present. This develops, as mentioned, because of the protein
loss, sodium retention, and lowered glomerular filtration rate. Edema
begins to accumulate in the upper part of the body, rather than just the
ankle edema of pregnancy. A weight gain of more than 2lb/wk in the
second trimester or 1lb/wk in the third trimester usually indicates abnormal
tissue fluid retention.
Severe Preeclampsia
A woman has passed from mild to severe preeclampsia when her
blood pressure has risen to 160/110 mmHg or above on at least two
occasions 6 hours apart at bed rest or her diastolic pressure is 30 mm Hg
above the prepregnancy level. Marked proteinuria, 3+ or 4+ on a random
urine sample or more than 5g in a 24-hour sample, and extensive edema
are also present.
Eclampsia
This is most severe classification of hypertension of pregnancy.
Convulsion or coma accompanied by signs and symptoms of
preeclampsia.
Nursing Management
Medical Management
Multiple births occur when multiple fetuses are carried during one
pregnancy. Since 1970, the prevalence of multiple births has been increasing
because of more widespread use of assisted reproductive technologies to treat
infertility. Multifetal pregnancies are high-risk pregnancies with numerous
associated fetal and neonatal complications. Researchers have studied twins in
an attempt to separate the influence of genetic and environmental factors on both
fetal and postpartum development.
Pathophysiology
Dizygotic twins, which sometimes are called fraternal twins, are produced
when 2 sperm fertilize 2 ova. Separate amnions, chorions, and placentas are
formed in dizygotic twins (see Media file 1). The placentas in dizygotic twins may
fuse if the implantation sites are proximate. The fused placentas can be easily
separated after birth.
Monozygotic twins develop when a single fertilized ovum splits during the
first 2 weeks after conception. Monozygotic twins are also called identical twins.
An early splitting (ie, within the first 2 d after fertilization) of monozygotic twins
produces separate chorions and amnions (see Media file 1). These dichorionic
twins have different placentas that can be separate or fused. Approximately 30%
of monozygotic twins have dichorionic/diamniotic placentas.
Etiology
Mortality/Morbidity
Race
Age
CLINICAL
History
Physical
Causes
Risk factors for multifetal pregnancy can be divided into natural and
induced. Risk factors for natural multifetal pregnancy include advanced maternal
age, family history of dizygotic twins, and race. Induced multifetal pregnancies
occur following infertility treatment via the use of ovulation-inducing agents or
gamete/zygote transfer.
WORKUP
Lab Studies
• CBC count: In TTTS, the donor twin is frequently anemic at birth. The
recipient twin is polycythemic at birth.
• Calcium level: Hypocalcemia is common in premature infants, especially
the donor twin in TTTS.
• Glucose level: Hypoglycemia is common in premature infants, especially if
TTTS is present.
• Bilirubin level: Hyperbilirubinemia due to TTTS may develop in
polycythemic infants.
Imaging Studies
TREATMENT
Medical Care
Medical care of the woman with multifetal pregnancy is beyond the scope
of this article.
• The specific medical care required by infants from multifetal births varies
and is dictated by whatever complications may be present. Many require
only routine newborn care, whereas those with significant prematurity or
other complications may require high-level intensive care in specialized
centers.
• The usual method of delivery for higher-order multiple births (eg, triplets,
quadruplets) is cesarean delivery. Cesarean delivery is also the usual
method of delivery for twins in the following situations:
•
o Breech/vertex presentation with the possibility of interlocking twins
o Monoamniotic twins
o Conjoined twins
o Congenital anomalies that threaten increased neonatal morbidity in
a twin
o Delayed interval delivery: Delayed interval delivery of remaining
fetuses in multifetal pregnancies at the border of viability is
becoming more common. Before 30 weeks’ gestation, delayed
delivery for 2 or more days is associated with improved survival in
the second twin.
• Delivery room management of infants from multifetal pregnancies requires
adequate personnel skilled in neonatal resuscitation. Infants from
multifetal pregnancies are at increased risk of birth asphyxia and
respiratory distress syndrome (RDS). Such infants may require bag mask
ventilation and endotracheal intubation in the delivery room.
• Partial exchange transfusion may be necessary in donor or recipient twins
from TTTS.
•
o Partial exchange transfusions are used to increase hemoglobin
concentrations in anemic donor twins while maintaining euvolemia.
Small aliquots (5-15 mL) of packed RBCs are infused (usually via
an umbilical venous catheter) following removal of an equal volume
of the infant's blood until a desired hemoglobin is attained. The
transfused packed RBCs should be appropriately cross-matched,
cytomegalovirus (CMV) negative, and irradiated.
o Partial exchange transfusions are used to decrease hemoglobin
concentrations in polycythemic recipient twins while maintaining
euvolemia. Small aliquots (5-10 mL) of either a colloid such as
fresh frozen plasma or a crystalloid such as a 0.9% saline solution
are infused (usually via an umbilical venous catheter) following
removal of an equal volume of the infant's blood until a desired
hemoglobin level is attained.
Consultations
MEDICATION
FOLLOW-UP
Complications
Prognosis
MISCELLANEOUS
Medical/Legal Pitfalls
• Most problems that could result in medical legal action against the health
professional involve prenatal and intrapartum care issues.
Special Concerns
Diamniotic/monochorionic placentation.
Monoamniotic/monoamniotic placentation.
Preliminary Signs of Labor
Before labor, a woman often experiences subtle signs that signal the
onset of labor. All pregnant women should be taught these signs so that they can
recognize when labor is beginning.
• Lightening
This changes a woman’s abdominal contour, because the uterus
becomes lower and more anterior. Lightening gives a woman relief from a
diaphragmatic pressure and shortness of breath that she has been
experiencing and in this way “lightens” her load. As the fetus sinks lower in
the pelvis, the mother may experience shooting leg pains from the
increased pressure on the sciatic nerve, increased amounts of vaginal
discharge, and urinary frequency from pressure on the bladder.
• Uterine Contractions
The surest sign that labor begun is productive uterine contractions.
Because contractions are involuntary and come without warning, their
intensity can be frightening in early labor.
• Show
As the cervix softens and ripens, the mucus plug that filled the
cervical canal during pregnancy (operculum) is expelled. The exposed
cervical capillaries leak blood as a result of pressure exerted by the fetus.
The blood, mixed with mucus, takes on a pink tinge and is referred to as
“show” or “bloody show.”
• Rupture of Membranes
Labor may begin with rupture of the membranes, experienced
either as a sudden gush or as scanty, slow seeping of clear fluid from the
vagina. Early rupture of membranes can be advantageous if it causes the
fetal head to settle closely into the pelvis, this can actually shorten labor.
BIBLIOGRAPHY
Book Sources:
Pillitteri, Adele. Maternal and Child Health Nursing: Care for the
Childrearing and Childbearing Family. 4th Edition. Volume 1.
Internet Sources:
http://www.emedicine.com/ped/TOPIC2599.HTM
http://www.fetalmonitorstrips.com/learn_more.html
http://www.moondragon.org/pregnancy/truefalselabor.html
http://www.riverwalk-obgyn.com/obcorner/tflabor.html