Midwifery Obstetrical Nursing

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Midwifery Obstetrical Nursing

PagesTopicsAntenatal AssessmentIntranatal AssessmentPostnatal AssessmentNewborn AssessmentSyllabusWelcome to Midwifery Obstetrical Nursing Blog!!Welcome to Midwifery and Obstetrical Nursing Blog!

This blog is a platform for me to share all my lecture notes on Midwifery Nursing. Hope this will be useful to all the nursing students out there! Happy Reading!
Saturday, 30 November 2013 Gestational Diabetes Mellitus
Gestational diabetes (GDM) is acondition in which women without previously diagnosed diabetesexhibit high blood glucose levels during pregnancy.

Gestational diabetes generallyhas few symptomsand it is most commonly diagnosed by screeningduring pregnancy. Diagnostic tests detect inappropriately high levels of glucosein blood samples. Gestational diabetes affects 3-10% of pregnancies. Nospecific cause has been identified, but it is believed that the hormonesproduced during pregnancy increase a woman's resistance to insulin,resulting in impaired glucose tolerance.

Babies born to mothers withgestational diabetes are at increased risk of problems typically such as being large forgestastional age (which may lead to delivery complications), low bloodsugar, and jaundice. Gestational diabetes is a treatable condition andwomen who have adequate control of glucose levels can effectivelydecrease these risks.

Women with gestational diabetes are at increased risk ofdeveloping type 2 diabetes mellitus after pregnancy,while their offspring are prone to developing childhoodobesity, with type 2 diabetes later in life. Most patientsare treated only with diet modification and moderate exercise but some take anti-diabetic drugs, including insulin.


RISK FACTORS

Previousdiagnosis of gestational diabetes or prediabetes, impaired glucose tolerance, or impaired fasting glycaemia
Family history revealing a first degreerelative with type-2 diabetes
Maternal age - a woman's risk factor increasesas she gets older (especially for women over 35 years of age)
Ethnic background (those with higher riskfactors include African-Americans, Afro-Caribbeans,Native Americans, Hispanics,Pacific Islanders, and people originating fromthe Indian subcontinent)
Being overweight,obeseor severely obese increases the
A previous pregnancy which resulted in a childwith a high birth weight (90th centile, or 4000g
Previous poor obstetric history

PATHOPHYSIOLOGY
The precise mechanisms underlying gestationaldiabetes remain unknown. The main cause of GDM is increased insulin resistance.
Pregnancy hormones and other factors are thoughtto interfere with the action of insulin as it binds to the insulinreceptor. The interference probably occurs at the level of the cellsignaling pathway behind the insulin receptor.
Since insulin promotes the entry of glucose intomost cells, insulin resistance prevents glucose from entering the cellsproperly. As a result, glucose remains in the bloodstream, where glucose levelsrise.
More insulin is needed to overcome thisresistance; about 1.5-2.5 times more insulin is produced than in a normalpregnancy.
Insulin resistance is a normal phenomenonemerging in the second trimester of pregnancy, which progresses thereafter. Itis thought to secure glucose supply to the growing fetus.
Placental hormones, and to a lesser extent increased fat deposits duringpregnancy, seem to mediate insulin resistance during pregnancy. Cortisoland progesteroneare the main culprits, but human placental lactogen, prolactinand estradiolcontribute too.
Because glucose travels across the placenta, thefetus is exposed to higher glucose levels. This leads to increased fetal levelsof insulin(Hyperinsulinemia).
The growth-stimulating effects of insulin canlead to excessive growth and a large body (macrosomia).
After birth, the high glucose environmentdisappears, leaving these newborns with ongoing high insulin production andsusceptibility to low blood glucose levels (hypoglycemia)

DIAGNOSIS

Bloodglucose testing : A fasting plasma glucose level 125mg/dLor a casual plasma glucose 200 mg/dL meets the threshold for the diagnosisof diabetes.

Fasting and 2 hourspostprandial venous plasma sugar during pregnancy.
Fasting 2h Postprandial Result 100 mg/dl 145mg/ dl Not diabetic 125 mg/ dl 200 mg/ dl Diabetic 100-125 mg/dl 125-200 mg/dl Border line indicates glucose tolerance test.

Oral Glucose Challenge Test:
Also called the O'Sullivan test.
It is performed between 2428 weeks, andcan be seen as a simplified version of the oral glucose tolerance test (OGTT).
It involves drinking a solution containing50 grams of glucose, and measuring blood levels 1 hour later.
A plasma value above 130-140mg/dl one hour afteris commonly used as a threshold for performing a 3-hour OGTT.

Oral Glucose Tolerance Test (OGTT)
Prerequisites: - Normal diet for 3 days before the test.
- No diuretics 10 days before.
- At least 10 hours fast.
- Test is done in the morning at rest.

Procedure: Giving 75gm (100 gm by other authors) glucose in 250 ml water orally

Criteria for glucose tolerance test: The following are thevalues which the American Diabetes Association considers tobe abnormal during the 100 g ofglucose OGTT:
Fasting blood glucose level 95mg/dl1 hour blood glucose level 180mg/dl2 hour blood glucose level 155mg/dl3 hour blood glucose level 140mg/dl
If any 2 or more of these values are elevated, the patient is consideredto have an impaired glucose tolerance test.

Glycosylated haemoglobin (Hb A1(


It is normally accounts for 5-6% of the totalhaemoglobin mass. A value over 10% indicates poor diabetes control in theprevious 4-8 weeks.

If this is detected early in pregnancy, there isa high risk of congenital anomalies .

If this is detected in late pregnancy itindicates increased incidence of macrosomia and neonatal morbidity andmortality.

The mean glucose represented by the hemoglobinA1c level can be calculated using the "rule of 8's." A value of 8percent equals 180 mg/dl, and each 1 percent increase or decrease represents 30 mg/dl.

Assessment for asymmetric fetal growth byultrasonography, particularly in early third trimester, may aid in identifyingfetuses that can benefit from maternal insulin therapy

Maternalsurveillance should include blood pressure and urine protein monitoring todetect hypertensive disorders.

MANAGEMENT

Medical nutrition therapy should include the provision of adequatecalories and nutrients to meet the needs of pregnancy and should be consistentwith the maternal blood glucose goals that have been established. Noncaloricsweeteners may be used in moderation.

Diet therapy is critical to successful regulation of maternaldiabetes. A program consisting of three meals and several snacks is used formost patients. Dietary composition should be :
ü50-60% carbohydrate,
ü20%protein,
ü25-30% fat withless than 10% saturated fats, up to 10% polyunsaturated fatty acids, and theremainder derived from monosaturated sources

Insulin Therapy
Insulin therapy is recommendedwhen medical nutrition therapy fails to maintain self-monitored glucose at thefollowing levels:
Fasting plasma glucose 105 mg/dL 1-hour postprandial plasma glucose 155 mg/dL 2-hour postprandial plasma glucose 135 mg/dL
Goal of Insulin Therapy
Self-blood glucose monitoringcombined with aggressive insulin therapy has made the maintenance of maternalnormoglycemia (fasting and premeal glucose between 50-80mg/dl and 1 hourpostprandial glucose 140mg/dl)
Twice daily ( before breakfastand before dinner) injections of a combination of short and intermediate actinginsulins are usually sufficient to control most patients otherwise asubcutaneous insulin pump is used.

The total first dose of insulinis calculated according to the patients weight as follow:
In the first trimester.......... weight x 0.7
In the secondtrimester........ weight x 0.8
In the third trimester...........weight x 0.9

If the total dose ofinsulin is less than 50 units/ day, it is given in a single morningdose with the ratio: Short acting (regular or Actrapid)/Intermediate (NPH orMonotard) = 1 : 2

In higher doses, Asa general rule, the amount of intermediate-acting insulin will exceed theshort-acting component by a 2:1 ratio. Patients usually receive two thirdstheir total dose with breakfast and the remaining third in the evening as acombined dose with dinner
Insulin Dose adjustment
Home glucose monitoring with a reflectance meterby measuring fasting and preprandial glucose values 4 times a day (30-40min)before each meal.
Allvalues are recorded in a daily log.
Inpatients who are not well controlled, a brief period of hospitalization isoften necessary for the initiation of therapy. Individual adjustments to theregimens implemented can then be made.
KETOACIDOSIS

As pregnancy is a state of relative insulinresistance marked by enhanced lipolysis and ketogenesis, diabetic ketoacidosismay develop in a pregnant woman with glucose levels barely exceeding 200 mg/dl.
Thus,DKA may be diagnosed during pregnancy with minimal hyperglycemia accompanied bya fall in plasma bicarbonate and a pH value less than 7.30.

Clinical signs of volume depletion follow thesymptoms of hyperglycemia, which include
oPolydipsia and polyuria.
oMalaise.
oHeadache.
oNausea/ Vomiting.
Occasionally, diabetic ketoacidosis may presentin an undiagnosed diabetic woman receiving β-mimetic agents to arrest pretermlabor.

Because of the risk of hyperglycemia anddiabetic ketoacidosis in diabetic women . Terbutaline and magnesium sulfate hasbecome the preferred tocolytic for cases of preterm labor in these cases.

SometimesAdministration of antenatal corticosteroids to accelerate fetal lung maturationcan cause significant maternal hyperglycemia and precipitate DKA. In diabeticpatients.

Anintravenous insulin infusion will usually be required and is adjusted on thebasis of frequent capillary glucose measurements.

Meticulouscorrection of metabolic and fluid abnormalities.

Everyeffort should therefore be made to correct maternal condition beforeintervening and delivering a preterm infant.

ANTEPARTUM FETAL EVALUATION
Antepartum fetal monitoring tests arenow used primarily to avoid unnecessary premature intervention allowing thefetus to benefit from further maturation in utero.
Ultrasound
Ultrasound is a valuable tool in evaluating fetal growth, estimating fetal weight, and detecting hydramnios and malformations.Maternal serum α-fetoprotein (MSAFP) at 16 weeks' gestation is often used in association with a detailed ultrasound study during the second trimester in an attempt to detect neural tube defects and other anomalies. Normal values of MSAFP for diabetic women are lower than in the nondiabetic population .Ultrasound examinations should be repeated at 4- to 6-week intervals to assess fetal growth. The detection of fetal macrosomia, the leading risk factor for shoulder dystocia, is important in the selection of patients who are best delivered by cesarean section.
Maternal assessment of fetal activity
Maternal hypoglycemia, while generally believed to be associated with decreased fetal movement, may actually stimulate fetal activity.
The Non Stress Test (NST(
Done weekly at 28 weeks and Twice weekly at 34 weeks Remains the preferred method to assess antepartum fetal well-being in the patient with diabetes mellitusIf the NST is nonreactive, a biophysical profile (BPP) or contraction stress test is then performed .

Doppler Umbilical Artery Velocimetry
Doppler umbilical artery velocimetry has been proposed as a clinical tool for antepartum fetal surveillance in pregnancies at risk for placental vascular disease.It is found that Doppler studies of the umbilical artery may be predictive of fetal outcome in diabetic pregnancies complicated by vascular disease. Elevated placental resistance as evidenced by an increased systolic/diastolic ratio is associated with fetal growth restriction and preeclampsia in these high-risk patients.
TIMING AND MODE OFDELIVERY
There is very little evidence to support either elective delivery or expectant management at term in pregnant women with insulin-requiring diabetes.
When antepartum testing suggests fetal compromise, delivery must be considered.
Delivery by cesarean section usually is favored when fetal distress has been suggested by antepartum heart rate monitoring.

If a patient reaches 38 weeks' gestation with a mature fetal lung profile and is at significant risk for intrauterine demise because of poor control or a history of a prior stillbirth, an elective delivery is planned.

During labor, continuous fetal heart rate monitoring is mandatory. Labor is allowed to progress as long as normal rates of cervical dilatation and descent are documented. Arrest of dilatation or descent despite adequate labor should alert the physician to the possibility of cephalopelvic disproportion.

INSULIN MANAGEMENT DURING LABOUR AND DELIVERY

Usual dose of intermediate-acting insulin is given at bedtime. Morning dose of insulin is withheld. Intravenous infusion of normal saline is begun. Once active labor begins or glucose levels fall below 70 mg/dl, the infusion is changed from saline to 5% dextrose and delivered at a rate of 2.5 mg/kg/min. Glucose levels are checked hourly using a portable meter allowing for adjustment in the infusion rate. Regular (short-acting) insulin in administered by intravenous infusion if glucose levels exceed 140 mg/dl. Posted byUnknownat9:53 am66 comments: Email ThisBlogThis!Share to TwitterShare to FacebookShare to PinterestPre eclampsia
CLASSIFICATION OF HYPERTENSION IN PREGNANCY
HTN is the most common medical disorder in pregnancy occursin up to 22% of all pregnancies
A. Gestational hypertension: Without proteinuria orpathological edema
B. Preeclampsia: Hypertension and protenuria with orwithout pathological edema
C. Eclampsia : Pre eclampsia complicated with convulsionsor coma
D. Chronic hypertension
EssentialHypertension
ChronicRenal Disease
Coarctationof Aorta
Pheochromocytoma
Thyrotoxicosis
Connectivetissue disease-systemic lupic erthematous
E. Pre eclampsia or eclampsia superimposed on chronichypertension

PREECLAMPSIA
Definition
Preeclampsia is a multisysytem disorder of unknownetiology characterized by development of hypertension to the extent of 140/90mmHg or more with protenuria after the 20^th week in a previouslynormotensive and non-protenuric patient.
Etiology
Cause unknown: theories suggest vasospasm and ischemia, orabnormal immune system response. Arteriolar vasospasm causes endothelial celldamage, increases capillary permeability, and leads to edema
Risk Factors
Low socioeconomic class
Multiple foetuses, or hydatid
Maternal age 20 or 35yrs
Primipara
Gestational or pre-gestational DM
Renal disease
Family history- four times the risk
Pathophysiology
The normal endovascular invasion of cytotrophoblast into the spiral arteries fails to occur beyond deciduas-myometrial junctionThe musculo elastic media in the myometrial segment remains responsive to vasoconstrictor stimuli resulting in decreased blood flowAreas of ischaemia in tertiary villi of placentaMicrovilli from trophoblasts are shed into maternal vascular systemDamaged endothelial cells release vasoconstrictive agentsVasoconstrictve agents like Thromboxane, Endothelin are released, and vasospasm results i.e. hypertension occurs

Signs and Symptoms

Mild preeclampsia
SBP 140, DBP 90 taken 2 separate times 4-6 hrs apartProteinuria: 1+ protein with urine dipstick or 300 mg protein in 24-hr urine sampleSlight
Severe preeclampsia
SBP 160 or DBP 110 on 2 different occasions at least 4-6 hrs apart on bedrestProteinuria: 2+ on urine dipstick or 2g in 24 hr urine sample. Swollen glomerular capillaries result in stretched out capillary wallsalbumin/protein escapes into urineOliguria: urine output 500 mL in 24 hrsOther symptoms: cerebral/visual disturbances, hyperreflexia, NV, pulmonary edema, epigastric pain, thrombocytopenia

HELLP Syndrome

Complication of severe preeclampsia that involves hepaticdysfunction.
HELLP stands for:
H : Hemolysisof RBCs
EL : Elevatedliver enzymes
LP : Lowplatelets (1,00,000/mm3)

Similar to pre-eclampsia with
RUQ/ epigastric pain
N/V
Jaundice
Deranged LFT
Diagnosis of pre-eclampsia
Investigate all organ systems CVS, CNS, Resp.Haematological Platelets, haematocritRenal proteinuria, creatinnine, (uric acid)Hepatic ASTPlacenta Doppler U/S umbilical artery, fetal growth

MANAGEMENT
Rest:Admission in hospital and rest is helpful forcontinued evaluation and treatment of the patient. While in bed patientshould be in left lateral position as much as possible, to lessen the effectsof venacaval compression. Rest (1) increases the renal blood flow (2)increases the uterine blood flow improves the placental perfusion and (3)reduces the blood pressure.

Diet: The diet shouldcontain adequate of protein (about 100 gm). Usual salt intake is notrestricted. Fluids need not be restricted. Total calorie approximate 1600 cal /day.

Sedative: To cut down emotional factor, mild sedative may be givenorally as phenobarbitone 60 mg or diazepam 5 mg at bed time.

Diuretics: The diuretics should not be used injudiciously as theycause harm to the baby by diminishing placental perfusion and by electrolyteimbalance. The compelling reasons for its use are (1) cardiac failure (2)Pulmonary oedema (3) along with selective antihypertensive drug therapy (diazoxidegroup) where blood pressure reduction is associated with fluid retention. (4)Massive oedema, not relieved by rest and producing discomfort to the patient.The most potent diuretic commonly used is frusemide (Lasix) 40 mg givenorally after breakfast for 5 days in a week. In acute condition, IV route ispreferred.

Antihypertensives: Antihypertensive drugs have limited value incontrolling blood pressure due to pre- eclampsia. The compelling indications ofits use are: (1) Persistent rise of blood pressure specially where thediastolic pressure is over 110 mm Hg. The use is more urgent if associated withproteinuria. (2) In severe pre-eclampsia to bring down the blood pressureduring continued pregnancy and during the period of induction of labour. Thecommon oral drugs used are

Drug Mode of action Dose Methyl dopa Labetalol Nifedipine Hydralazine Central and peripheral and adrenergic actionAdrenoceptor antagonist (α and β blocker) Calcium channel blockerVascular smooth muscle relaxant 250 500 mg tid or qid250 mg tid or qid10 20 mg bid10 25 mg bid

In hypertensive crisis: Any of the drugs is helpful by intravenousinfusion till the diastolic pressure comes down to 110 mm Hg.
(1) Labetalol (200 mg of normalsaline) at the rate of 20 mg/hr t be doubled every 30 minutes. (2) Hydralazine5 mg I.V. bolus to be followed by infusion 25 mg in 200 ml normal saline, therate being 2.5 mg / hour to be doubled every 30 minutes.
(3) Nitroglycerin 5 μg/mins. I.V.or Sodium nitroprusside 0.25 5 μg/min I.V.
Progress chart: Theeffect of treatment should be evaluated by maintaining a chart which recordsthe following:
(1) Blood Pressure at leastfour times a day.
(2) State of oedema and daily weight.
(3) Fluid intake and urinaryoutput.
(4) Urine examination onadmission and to be repeated, if necessary.
(7) Fetal well being assessment

DURATION OF TREATMENT: The definitive treatment of pre-eclampsia istermination of pregnancy. The aim of the treatment is to continue the pregnancy,until the fetus becomes mature enough to survive in extra-uterine environment.Thus, the duration of treatment depends on (1) severity of pre-eclampsia, (2)duration of pregnancy and (3) response to treatment.

Group A : If the duration of pregnancy is remote from term, thepatient may be discharged with advice to attend the antenatal clinic after oneweek. If the patient is near term, she should be kept foe a few days tillcompletion of 37^th week. Thereafter, decision is to be taken eitherto terminate pregnancy or to wait for spontaneous onset of labour by the due date.It is not wise to allow the pregnancy to continue beyond the expected date.
Group B: If the pregnancy is beyond 37 completed weeks,termination is to be considered without delay. If less than 37 weeks, expectanttreatment may be extended judiciously at least up to 34 weeks. Careful maternaland fetal well being are to be monitored during the period with the availableparameters.
Group C: The couple is counseled. Termination of pregnancy isconsidered irrespective of duration of gestation. Seizure prophylaxis(magnesium sulphate) should be started. Steroid therapy is considered if theduration of pregnancy is 34 weeks. It prevents neonatal RDS, IVH andmaternal thrombocytopenia.

METHODS OF TERMINATION:

Induction of labour
Indications:
(1) Aggravation of thepre-eclamptic features in spite of medical treatment and / or appearance ofnewer symptoms such as epigastric pain.
(2) Hypertension persists inspite of medical treatment with pregnancy reaching 37 weeks or more.
(3) Acute fulminatingpre-eclampsia irrespective of the period of gestation.
(4) Tendency of pregnancy tooverrun the expected date.

Methods: If the cervix is ripe, surgical induction by low ruptureof the membrane is the method of choice. Oxytocin infusion may be added toaccelerate the process in selected cases. Raised blood pressure alone is not acontraindication to oxytoin infusion, if the cervix is unripe and thetermination is not an urgent one, prostaglandin (PGE₂₎ gel 500 μgintercervical or 1-2 mg in the posterior fornix is inserted to make the cervixripe when low rapture of the membranes can be performed.
Caesarean section
Indications:
(1)When an urgent termination isindicated but the cervix is unfavorable (unripe and closed) for surgicalinduction.
(2)Severe pre-eclampsia with atendency to prolong the induction delivery interval.
(3)Associated complicatingfactors such as elderly primigravide, contracted pelvis, malpresentation etc.

MANAGEMENT DURING LABOUR:
Blood pressure tends to rise during labour and convulsions may occur (intra-partum eclampsia). The patient should be in bed. Liberal sedatives should be given in the form of pethidine 75-100 mg intramuscularly and to be repeated at intervals. Antihypertensive drugs may be given if the blood pressure becomes high. Blood pressure and urinary output are to be noted regularly so as to detect imminent eclampsia. Careful monitoring of the fetal well being is mandatory.Labour duration is curtailed by low rupture of the membranes in the first stage; and forceps or ventouse in second stage. Intravenous ergometrine following the delivery of the anterior shoulder is withheld as it may cause further rise of blood pressure. The patient should be sedated immediately following the delivery of the baby with intramuscular morphine 15 mg to prevent postpartum eclampsia and to keep the patient under close observation for several hours.

PUERPERIUM: The patient is to be watched closely for at least 48hours, the period during which convulsions usually occur. Tab phenobarbitone60mg in repeated doses can produce effective sedation. The patient is to bekept in the hospital, till the blood pressure is brought down to a safe leveland proteinuria disappears.

Nursing Management
Nursing management focuses on prompt diagnosis, prevention of complications, and delivery of an uncompromised fetusMonitor BP, proteinuria, and edema: edema in face, hands, abdominal area vs. dependent edema which is normal during pregnancyObserve for these symptoms: HA, visual disturbances, epigastric pain, RUQ pain, hyperreflexia, clonusAuscultate lungs for crackles or diminished lung sounds that might indicate pulmonary edemaSigns of impending seizure (eclampsia): hyperreflexia, severe epigastric pain, , vomiting. Protecting the patient is key side rails up and padded, suction accessible, O2 availableFetal surveillanceLab studies: CBC, clotting studies, liver enzymestype screen or crossmatch
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