2. Preeclampsia and eclampsia are associated with nulliparity, extremes of maternal age (teenagers and age >40 years), family history of preeclampsia, preeclampsia in a previous pregnancy, obesity, maternal low birth weight, chronic inflammatory conditions (lupus, rheumatologic disease), a history of gestational diabetes or type 1 diabetes mellitus, chronic hypertensive or renal disease, thrombophilias (factor V Leiden mutation, antiphospholipid syndrome), multifetal gestation, or large fetus. Other predisposing factors include poor outcomes in a previous pregnancy such as placental abruption, fetal death, and intrauterine growth restriction (IUGR) in previous pregnancies.

C. Clinical presentation.

2. Proteinuria (≥300 mg/dL in a 24-hour urine collection) due to decreased renal perfusion resulting in the development of glomerular capillary endotheliosis.

b. Cardiopulmonary failure and pulmonary edema.

c. Hepatic failure, hemorrhage or rupture.

d. Cerebrovascular accident.

e. Renal cortical necrosis.

f. Disseminated intravascular coagulation.

g. HELLP syndrome (i.e., hemolysis, elevated liver function test results, and low platelet count).

h. Retinal detachment.

i. Stroke or death (rare).

j. Long-term cardiovascular morbidity.

2. Placental/fetal.

b. Seizure precautions.

c. Placental–fetal function tests: continuous electronic fetal monitoring; fetal movement; ultrasonography to determine fetal age and detect IUGR; serial nonstress tests, biophysical profile, and/or umbilical artery Doppler studies; and amniocentesis to determine fetal lung maturity.

d. Medications.

(2) Use of antihypertensives is indicated when systolic BPs are greater than 160 mm Hg or diastolic BPs are greater than 110 mm Hg:

(b) Hydralazine (Apresoline). Should no longer be considered a first-line drug. Although effective in lowering BP, this drug has many side effects and alternative medications are preferred. Observe fetal heart rate for signs of hypoxia (tachycardia, bradycardia, or late decelerations), which can occur with a sudden decrease in maternal BP.

(3) Use of corticosteroids to increase fetal lung maturity when birth can be delayed for 24 to 48 hours and the woman is at less than 34 weeks of gestation. Infants born to mothers who are treated with antenatal steroid therapy are at decreased risk for respiratory distress syndrome, cerebrovascular hemorrhage, and death.

e. Delivery.

(2) Severe preeclampsia is not an indication for cesarean section, and the vaginal route is preferred.

b. Control of current seizure and prevention of recurrent seizures with administration of IV magnesium sulfate.

c. Control of severe hypertension with an antihypertensive (labetalol) to maintain the systolic BP between 140 and 160 mm Hg and the diastolic BP between 90 and 105 mm Hg.

d. Safety measures for woman during and after seizures to prevent injury.

e. Support of respirations with airway, oxygen, and suctioning, and the correction of hypoxemia and/or acidemia.

f. Observe fetal heart rate for transient bradycardia, rebound tachycardia, decreased variability, and late decelerations.

g. Continuous maternal assessment, including assessment for uterine contractions and signs of placental abruption.

h. Laboratory work: complete blood count (CBC), clot observation, serum creatinine, liver function tests, fibrinogen, arterial blood gases, and electrolytes.

i. Initiate the process of delivery according to the status of the maternal–placental–fetal complex. The mother must be stabilized before a cesarean section is performed.

j. Maternal emotional support.

3. Assessment of newborn infant for the following:

b. Preterm gestational age.

c. Hypoxia and acidosis.

d. Possible adverse drug effects on neonate:

B. Etiology and predisposing factors in gestational diabetes.

2. Risk factors for GDM include maternal obesity, previous history of gestational diabetes, a family history of diabetes, age greater than 25 years, member of an ethnic group at risk for diabetes (Native North American, Hispanic, African American, Pacific Islanders, and South or East Asian Americans), and prior obstetric history (infant weighing >4500 g, congenital anomaly, stillbirth, hydramnios).

C. Clinical presentation and screening for gestational diabetes.

2. Women at high risk for GDM (severe obesity, strong family history of type 2 diabetes mellitus, previous history of gestational diabetes, impaired glucose metabolism, or glycosuria) should be screened at the first prenatal visit, because GDM may be asymptomatic or evidenced only by subtle changes. Screening should be repeated at 24 to 28 weeks of gestation, or when hyperglycemia is evident.

3. Women with average risk for GDM should be screened with a 1-hour glucose challenge test at 24 to 28 weeks of gestation, with further testing if values are abnormal.

4. Women who are low risk for GDM (ethnic group with a low prevalence of GDM, no known primary relative with diabetes mellitus, age <25 years, normal weight prior to pregnancy, no history of poor obstetric outcomes, no history of abnormal glucose metabolism) may not require glucose screening.

D. Potential complications.

b. Ketoacidosis in the second and third trimesters.

c. Progression of vasculopathy, nephropathy, and retinopathy with preexisting diabetes.

d. Hydramnios.

e. Gestational hypertension and preeclampsia.

f. Anemia.

g. Infections such as monilial vaginitis and urinary tract infections.

b. Glycosylated hemoglobin tests may be performed before conception and during the pregnancy to assess glucose control during the previous 1 to 2 months, with an acceptable hemoglobin A_1c goal of 5% to 6%.

c. Home blood glucose monitoring, diet, exercise, and either insulin pump therapy or several daily injections of insulin are prescribed to maintain euglycemia (60 to 120 mg/dL). Optimal control is associated with a decreased risk of macrosomia, respiratory distress syndrome, congenital anomalies, and perinatal death, as well as maternal urinary tract infection and preterm labor.

d. Women are evaluated early in pregnancy for evidence of diabetic retinopathy and nephropathy.

b. Self-monitoring of blood glucose is encouraged, with fasting and 2-hour postprandial glucose levels checked regularly; and

c. Nonstress testing begins at 28 to 32 weeks of gestation.

3. In the neonate:

b. Assess for:

(2) Hypoglycemia, hypocalcemia, and hypomagnesemia;

(3) Polycythemia and hyperviscosity;

(4) Complications resulting from decreased blood flow, erythrocyte hemolysis, and thrombosis;

(5) Congenital malformations; and

(6) Birth injuries: fractured clavicles, intracranial bleeding, facial nerve paralysis, brachial palsy, and skull fractures.

2. Low, dull, intermittent, or constant backache.

3. Intermittent or constant menstrual-like cramping.

4. Pelvic pressure.

5. Abdominal cramps, which may be accompanied by diarrhea.

6. Increased vaginal discharge, which may be mucoid, watery, or slightly bloody.

7. Spontaneous premature rupture of membranes.

8. A generalized feeling that something is wrong.

9. Progressive cervical effacement and dilatation.

b. Cervix 2 to 3 cm dilatation/<80% effaced: Preterm labor likely but not established.

c. Cervix <2 cm dilatation/<80% effaced: Diagnosis uncertain.

D. Potential complications.

b. Emotional stress and financial issues.

c. Complications from the mode of delivery, especially when a cesarean section is performed at less than 30 to 32 weeks of gestation as the lower uterine segment is poorly developed; there is a greater chance of infection, hemorrhage, and subsequent poor uterine function.

2. Fetal/neonatal.

b. Risks associated with prematurity, such as respiratory distress syndrome, necrotizing enterocolitis, intracranial hemorrhage, seizures, septicemia, and sequelae of IUGR.

c. Side effects from pharmacotherapeutics (tocolytic agents, antibiotics, corticosteroids).

E. Assessment and management.

2. Patient education should be provided to all pregnant women, including the symptoms of preterm labor and the actions to take if they occur (lie down on the left side and drink several glasses of fluid; report to the physician or midwife if contractions are still occurring after 1 hour).

3. Helping high-risk women modify their risk factors and take measures to prevent preterm labor (e.g., stop smoking, improve nutrition and hydration, treat infections, decrease work hours and stress, increase rest, and avoid nipple preparation or sexual activity that may initiate signs of preterm labor).

4. Although regular cervical examinations and ultrasonographic evaluation of the cervix are being performed by some providers, these methods have not been validated as predictors of preterm birth.

5. The use of the fetal fibronectin test, performed on vaginal secretions in symptomatic women, may help prevent a false-positive diagnosis of preterm labor and prevent unnecessary and potentially harmful pharmacologic treatment.

b. Magnesium sulfate, given intravenously before 32 weeks of gestation, appears to have a neuroprotective effect and may decrease the incidence of cerebral palsy. It is recommended that its use be limited to between 24 and 32 weeks of gestation. Data do not support the use of this drug as a tocolytic, and research has not demonstrated that its use prolongs pregnancy. When maternal administration of high doses of magnesium sulfate occurs near the time of birth, the neonate should be monitored for respiratory depression, and neuromuscular depression, as evidenced by weakness, lethargy, hypotonia, flaccidity, and poor suck.

c. Prostaglandins (indomethacin) mediate contractions and are effective as tocolytics. Indomethacin is given prior to 32 weeks, orally, and use is restricted to 2 to 3 days. Maternal side effects include nausea, vomiting and dyspepsia. Contraindications to its use include fetal renal anomalies, oligohydramnios, IUGR, chorioamnionitis, ductal-dependent cardiac defects, and twin-to-twin transfusion syndrome. Fetal side effects include oligohydramnios, constriction of the ductus arteriosus, and neonatal pulmonary hypertension.

d. Terbutaline (Brethine), a β-mimetic, has commonly been used as a tocolytic, but due to potential side effects its use should be limited to a single 0.25-mg dose subcutaneously. This may be used while a therapy with a slower onset of action is being started, or to stop contractions during the initial evaluation of the patient to assist in the diagnosis of preterm labor. Data indicate that there are few side effects for a single dose.

9. Antibiotic therapy should be instituted to prevent neonatal group B streptococcal infection, or to treat specific conditions such as urinary tract infections.

10. If the measures noted above are not successful, and the cervix continues to efface and dilate, the following measures are important:

b. The head is delivered in a slow, controlled fashion.

c. Cesarean delivery is often suggested for the preterm fetus with a breech presentation because of the risk of cord prolapse and the potential risk of difficult birth of the head. There is no justification for elective cesarean delivery of all preterm infants.

In abruptio placentae, the placenta separates suddenly, prematurely, and in varying degrees from the uterine wall during pregnancy or labor. It is a common cause of bleeding in the second half of pregnancy.

b. Tachycardia.

c. Late or variable decelerations.

d. Decreased fetal heart rate variability.

B. Potential complications.

b. Hypovolemic shock.

c. Couvelaire uterus (blood forced between the muscle fibers of the uterus).

d. Disseminated intravascular coagulation.

e. Postpartum hemorrhage.

f. Fetomaternal hemorrhage.

g. End-organ damage.

h. Death.

2. Fetal/neonatal.

b. Preterm birth and sequelae associated with prematurity.

c. Hypoxemia.

d. Hypovolemia.

e. Greater risk for long-term neurobehavioral problems.

f. Risk for sudden infant death syndrome and ventricular leukomalacia.

g. IUGR.

h. Perinatal death (10-fold increase).

C. Assessment and management.

b. Pain.

c. Maternal vital signs.

d. Fetal condition.

e. Uterine contractions and tone.

4. Management if fetus is stable and maternal hematologic status can be maintained:

b. Bed rest in left lateral position, close assessment of abdomen for rigidity and pain, and close assessment of vaginal bleeding.

c. Monitoring of maternal vital signs and continuous monitoring of fetal heart for tachycardia, late decelerations, and decreasing baseline variability.

d. Insertion of large-gauge IV catheters (16- to 18-gauge) for possible administration of fluids and blood products.

e. CBC, coagulation studies, and type and cross-match for blood.

f. Possible collection of urine for drug screening if abuse is suspected.

g. Possible induction of labor and/or vaginal birth.

h. Notify the NICU and the neonatologist/pediatrician.

i. Emotional support of woman and family.

5. Preparation for cesarean birth if evidence of fetal compromise or severe hemorrhage occurs:

b. Notification of anesthesia department and NICU.

c. Laboratory tests as above.

d. Preparation of the abdomen for surgery (clipping of hair around incision site) and insertion of an indwelling urinary catheter.

Placenta previa is a placenta that is implanted in the lower part of the uterus near the cervix (marginal) or in varying degrees (partial or total) over the cervix. Cervical dilatation at or near term is accompanied by bleeding from the placenta. Placenta previa is a common cause of bleeding in the second half of pregnancy, when the lower uterine segment stretches and thins.

2. Other associated and predisposing factors include previous placenta previa, increasing parity or maternal age, prior cesarean birth, living in higher altitudes, cigarette smoking, maternal race (Asian women have the highest incidence), multifetal gestation, and prior curettage.

2. Uterine contractions occur in 10% to 20% of cases, but otherwise the uterus is usually soft and nontender.

3. If an ultrasound is performed at less than 20 weeks of gestation, a low-lying placenta may be noted. However, at this gestational age, the lower uterine segment is not yet fully developed and this is not diagnostic of a placenta previa.

4. Failure of presenting part of fetus to become engaged. Fetus may lie transversely or be in a breech position.

D. Potential complications.

b. Hypovolemic shock.

c. Endometritis.

d. Decreased contractile strength of the lower uterine segment, which can lead to postpartum hemorrhage and need for hysterectomy.

e. Abnormal placental implantation (placenta accreta, percreta, and increta).

f. Air embolism.

2. Fetal/neonatal.

b. Fetal anemia.

c. Malpresentation.

d. IUGR.

e. Prematurity and subsequent sequelae.

E. Assessment and management.

b. No vaginal examinations.

c. Activity restrictions at home or in the hospital determined by clinical presentation.

d. Nutritional supplements and dietary management to prevent anemia.

e. Antenatal corticosteroid therapy may be considered.

f. Avoidance of intercourse and orgasm, which can cause uterine contractions.

g. Time of delivery is based on the clinical picture but generally recommended at 37 weeks when fetal lung maturity is documented.

b. Frequent assessment of maternal vital signs and fetal heart tones, and palpation of abdomen.

c. Laboratory work: CBC, type and cross-match for possible blood transfusion.

d. With significant bleeding, placement of IV lines with 16- to 18-gauge catheters for blood administration.

e. Cesarean section is the preferred mode of delivery for a partial or complete placenta previa. Timing is dependent on the clinical picture.

Umbilical cord prolapse is an event that is life threatening to the fetus and requires immediate and effective management by the nurse. It occurs when the cord falls below the presenting part or is compressed between the presenting part and the pelvis or cervix.

2. In an occult prolapse, cord is not visible or palpable but is located between the presenting part and the pelvis or cervix.

3. More commonly occurs with a high station of presenting part, and membranes are often ruptured.

4. Fetal heart rate changes observed may include an abrupt occurrence of persistent, severe variable decelerations or bradycardia.

D. Potential complications.

b. If general anesthesia is used for surgery, may result in uterine atony with subsequent postpartum bleeding.

c. Blood loss from cesarean birth.

d. Emotional distress.

2. Fetal/neonatal.

b. Fetal anoxia leading to long-range neurologic complications.

c. Fetal death.

E. Assessment and management.

b. Dilation of cervix.

c. Status of membranes.

d. Estimation of fetal weight and fetal heart rate.

2. Assessment for presence of polyhydramnios or lack of engagement of presenting part. Ambulation during labor and artificial rupture of membranes may be contraindicated if either of the above is present.

3. Assessment after artificial or spontaneous rupture of membranes.

b. Perform vaginal examination to detect prolapse if indicated.

b. Monitor fetal heart rate continuously and palpate cord lightly for continued pulsation. Administration of oxygen, insertion of IV lines if not already present, and notification of the anesthesia and neonatology departments.

c. An alternative measure is to insert an indwelling catheter to fill the mother’s bladder with sterile saline solution in order to elevate the fetal presenting part so that it is off the cord.

Shoulder dystocia is an acute emergency in which the physician or midwife is unable to deliver the shoulders of the infant by the usual maneuvers (downward traction) after birth of the head.

2. Prolonged second stage of labor (>2 hours).

3. After birth of the head, it recoils against the perineum and restitution does not occur (“turtling”). The usual traction from below is not successful in delivering the neonate.

D. Complications.

b. Postpartum hemorrhage.

c. Vaginal and cervical lacerations.

d. Ruptured uterus.

e. Bladder atony.

2. Fetal/neonatal.

b. Hypoxia.

c. Permanent brain injury.

d. Intrapartum or neonatal death.

2. Anticipate shoulder dystocia if descent of the head is slow and estimated weight is large. Make sure the woman’s bladder is empty before birth occurs.

3. If shoulder dystocia occurs, the physician or midwife will:

b. Apply suprapubic pressure to attempt to release the anterior shoulder; the pressure may be directly downward or lateral.

c. Turn the woman onto her side or pull the hips off the bed to free the sacrum.

d. Turn the woman on “all fours” facing downward to widen the pelvic outlet if this can be easily accomplished (Gaskin’s maneuver).

e. Manually rotate the shoulders from the anteroposterior to the oblique diameter.

f. Use the Woods’ corkscrew maneuver, in which both hands are inserted internally to rotate the posterior shoulder to the anterior position for delivery under the pubic bone, with the maneuver repeated for the other side.

g. Deliver the posterior arm.

h. The expulsive efforts of the mother, as opposed to traction by the provider, are of the utmost importance.

b. Uterine abnormalities (e.g., bicornuate uterus).

c. Contracted pelvis.

d. Use of anticonvulsant medications or alcohol abuse.

2. Placental/fetal.

b. Multifetal gestation.

c. IUGR or fetal anomalies, especially those related to CNS problems.

d. Short cord.

e. Preterm fetus.

C. Clinical presentation.

2. Fetal heart sounds are heard loudest above the umbilicus.

3. Use of Leopold’s maneuvers indicates head is in the fundal area and the breech is in the pelvis.

4. On vaginal examination, it is found that the presenting part is soft, no fontanelles are felt, and the genitalia may be identified.

D. Assessment and management.

b. Report clinical findings immediately to the physician or midwife.

4. Ultrasonography may be ordered to confirm breech presentation, determine degree of flexion of fetal head, evaluate size of fetal head, estimate fetal weight, diagnose fetal anomalies, and locate placenta.

b. A continuation of the frank breech position for a period of time after the birth.

E. Complications.

b. Asphyxia from slow birth of fetal head or from compression of umbilical cord between pelvis and head during birth.

c. Aspiration of amniotic fluid with potential for meconium aspiration syndrome.

d. Genital damage in the male infant.

e. CNS injuries such as intracranial hemorrhage, brachial plexus injury, and severed spinal cord, especially if fetal head is hyperextended.

f. Damage to the nose and pharynx.

b. Nausea and vomiting.

c. Hypotension.

d. Drowsiness and dizziness.

e. Clammy skin and sweating.

2. Fetal/neonatal.

b. Neonatal respiratory depression.

B. Assessment and management.

2. Administer IV analgesics slowly; give during a uterine contraction to minimize amount of drug the fetus receives.

3. Observe the woman for side effects and monitor the fetal heart rate with the electronic fetal monitor or via intermittent auscultation.

4. With maternal hypotension, turn the woman onto her left side, increase IV infusion of fluids, and closely monitor the fetal heart rate and maternal BP.

5. Have naloxone (Narcan), oxygen, and ventilatory equipment available to manage potential newborn respiratory depression.

6. Document use of analgesic and transmit this information to the nursery nurse.

7. Observe the neonate for side effects of maternal analgesia.

Several types of anesthesia are used with women in labor and delivery. General anesthesia is used primarily for emergency cesarean and complicated vaginal births when it is not possible to have immediate and effective regional anesthesia. Regional anesthesia includes continuous lumbar epidural, spinal, and pudendal block. Local anesthesia involves perineal infiltration prior to episiotomy, birth, and/or perineal repair.

b. Respiratory depression.

c. Hypotension or hypertension.

d. Tachycardia.

e. Laryngospasm.

f. Uterine atony.

2. Fetal/neonatal.

b. Fetal depression in proportion to the amount of anesthesia.

B. Assessment and management with general anesthesia.

2. Note the time of her last meal.

3. Physician may order 30 mL of clear antacid to be administered before general anesthesia to increase the pH of the stomach contents in case of aspiration.

4. Endotracheal tube and cricoid pressure are techniques used by the anesthesiologist to prevent aspiration.

5. Place a wedge under the right hip to cause displacement of the uterus from the aorta and vena cava and to prevent supine hypotensive syndrome during surgery.

6. Monitor the woman’s cardiorespiratory status during and after surgery, and uterine bleeding postoperatively.

7. Monitor the newborn infant after surgery for complications.

C. Potential complications with regional anesthetics.

(2) Allergic reaction to the injected anesthetic.

(3) Toxic reaction to overdose or intravascular injection, with seizure activity.

(4) Respiratory paralysis from inadvertent high spinal anesthesia.

(5) Postdural puncture headache.

(6) Failure of anesthetic to be effective.

(7) Urinary retention during labor and in the postpartum period.

(8) Formation of a hematoma that compresses the spinal cord, with potential for permanent damage.

(9) Paralysis (rare).

b. With epidural anesthesia:

(2) Bladder distention.

(3) Prolonged second stage and subsequent increase in instrumented vaginal delivery (forceps and vacuum-assisted).

(2) Perforated rectum.

(3) Anesthetic toxicity.

(4) Broad-ligament hematoma.

2. Fetal/neonatal.

b. Fetal compromise with prolonged maternal hypotension, as evidenced by late decelerations, bradycardia, and either increased or decreased variability.

D. Assessment and management with regional anesthetics.

2. Prehydrate with 500 to 1000 mL IV fluid before spinal or epidural anesthesia to minimize hypotensive effects from sympathetic blockade.

3. Position and reassure woman during administration of anesthetic. To prevent supine hypotension, a small roll may be placed under the right hip.

4. Monitor the woman’s BP after administration of spinal or epidural anesthetic; monitor fetal heart rate after any type of regional anesthesia.

5. Monitor bladder distention and catheterize if necessary.

6. Complications and their management.

(b) Dizziness or affected vision.

(c) Nausea and vomiting.

(2) Management.

(b) Displace uterus from aorta and vena cava.

(c) Administer oxygen and IV ephedrine as ordered.

(d) Monitor the fetal heart rate for evidence of compromise, and the fetus/newborn for side effects of ephedrine (tachycardia, jitteriness, and increased muscular activity).

b. High spinal.

(b) Sensation of inability to breathe.

(c) Respiratory arrest.

(2) Management.

(b) Maintain airway and ventilation.

(c) Observe fetal heart rate for signs of compromise.

c. Toxic reaction.

(b) Ringing in ears.

(c) Slurring of speech.

(d) Numbness of tongue and mouth.

(e) Seizures.

(f) Cardiovascular and respiratory depression.

(2) Management.

(b) Drugs to control seizures.

(c) Monitor the newborn infant for seizures, bradycardia, apnea, and hypotonia.

d. Allergic reaction.

(b) Laryngeal edema.

(c) Urticaria.

(2) Management: use of IV antihistamine such as diphenhydramine (Benadryl).

b. Cephalopelvic disproportion.

c. Dystocia (inadequate progress in labor).

d. Maternal medical conditions.

2. Placental.

b. Placenta previa.

c. Placental insufficiency.

3. Fetal.

b. Breech or other malpresentation.

c. Multifetal gestation.

d. Congenital anomalies such as myelomeningocele and anterior abdominal wall defects.

C. Potential complications.

b. Anemia.

c. Hemorrhage.

d. Morbidity and death from anesthesia.

e. Inadvertent operative injuries.

f. Pulmonary embolus and atelectasis.

g. Thrombophlebitis.

2. Fetal/neonatal.

b. Iatrogenic preterm birth.

c. Respiratory distress syndrome caused by retained fluid in the lungs.

2. Notify neonatology and pediatrician.

3. Give an antacid if ordered.

4. Remove fetal scalp electrode before surgery if present.

5. Place wedge under woman’s right hip to displace the uterus to the left to avoid supine hypotension and fetal hypoxia.

6. Follow Neonatal Resuscitation Program protocols for neonatal care following birth.