Transcript Childbirth at Risk - Denver School of Nursing

Childbirth at Risk
The Perinatal and
Intrapartal Period
• Describe the mental illness that women
are at greatest risk for during the perinatal
period
• Critically assess and evaluate the cluster
of sx indicative of the most prevelant
mental illness in women
• Explore the nurse’s role
Flying Below the Radar Screen: Mental
Illness in the Perinatal Period
• Describe the mental illness that women
are at greatest risk for during the perinatal
period
• Critically assess and evaluate the cluster
of sx indicative of the most prevelant
mental illness in women
• Explore the nurse’s role
Care of the Woman at Risk Because of
Psychological Disorders
• Prevalence of psychological disorders of adults in the
U.S. is 26.2%
• 44 million women meet the diagnostic criteria for mental
illness in any given year.
• Represents 4 of the leading 10 causes of disability in
the U.S.
• Alteration in thinking, mood or behavior
PMAD
Perinatal mood and anxiety disorders
1. Depression
2. Anxiety or Panic Disorder
3. OCD
4. PTSD
5. Psychosis
6. Bipolar
These disorders can affect people at any time during their lives.
However, there is a marked increase in prevalence of these
disorders during pregnancy and the postpartum period.
Risk Factors for PMADs
• Previous PMADs: family history, personal
history, symptoms during pregnancy
• History of Mood Disorders: Personal or
family history of depression, anxiety,
bipolar disorder, eating disorders or OCD
• Significant Mood Reactions to hormonal
changes: puberty, PMS, hormonal BC,
fertililty treatment.
PMAD Risks
• Endocrine Dysfunction: hx of thyroid
imbalance, fertility issues, diabetes
• Social Factors: inadequate social, familial,
or financial support
• Teen pregnancy
It’s not all about Hormones….
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Biological/Physiological risks
Psychological risks
Social/Relationships
Myths of Motherhood
Myths of Motherhood
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Getting pregnant
Becoming a mother
Being pregnant
Labor & Delivery
Breastfeeding
The baby sleep all the time
Superwoman/wife/mother
Happy all the time
Media images
Postpartum Psychological &
Physiological Changes
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Focus on baby/forming attachment
Fatigue/sleep deprivation
Loss of freedom, control, and self-esteem
Hormonal changes
Birth not going as expected
Learning new skills
Role transitions
Dreams and expectations
Psychological and Physiological
Changes of Pregnancy
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All about the new mom
Hormonal changes
Prenatal classes
Preparing for parenthood
Dreams and expectations
Watching the “Baby Channel”
Not always happy, “glowing time”
Planned vs. unplanned
Why Moms Suffer in Silence
• Stigmas associated with mental illness
• Barriers to treatment
• Shame
Effect on Labor
• Unable to concentrate/process info from
healthcare team
• May begin labor fatigued or sleep deprived
• Labor process may overwhelm the woman
physically & emotionally-no energy
• May appear irritable or withdrawn due to
inability to articulate feelings of
hopelessness or “unworthiness of
motherhood”
Why should we care about
PMADs?
Tragic consequences Affecting Society:
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Marital problems/divorce
Disability/Unemployment
Child neglect & abuse
Developmental delays/behavioral problems
Infanticide/Homicide/Suicide
P. Boyce, University of Sydney Hospital, Nepean Hospital, Penrith
NSW Australia
Myths About Postpartum
Depression
• It’s only postpartum and it’s only depression
• It means I don’t love my baby/want to kill my
baby
• It’s all about crying
• Andre Yates drowned her 5 kids
• It’ll go away on its own
• Anxiety and depression don’t happen during
pregnancy
• Physical/Mental Illness
PMAD (Perinatal Mood and Anxiety Disorders)
• Depression and Anxiety Disorders can
occur anytime in pregnancy or the first
year postpartum
• PMAD is a new term replacing the narrow
definition of PPD.
PMADs : Underdiagnosed and
Under-treated
• Depression/Anxiety in Pregnancy: It is
estimated that 15-20% of pregnant women will
experience moderate to severe symptoms of depression
and/or anxiety
• Postpartum Depression: Approximately
15% (Marcus, 2009)
Exacerbating Factors for
PMADs
• Complications in pregnancy, birth, or
breastfeeding
• Age-related stressors: adolescence
perimenopause
• Climate Stressors: seasonal depression or
mania
• Perfectionism/high
expectations/”Superwoman syndrome”
Possible Exacerbating Factors
Pain
Lack of sleep
Abrupt discontinuation of breastfeeding
Childcare stress/Marital stress
Losses-miscarriage, neonatal death,
stillborn, selective termination, elective
abortion
History of childhood sexual abuse
Possible Exacerbating Factors
Culture shock – career vs motherhood
Who’s the dad?
Death of someone close
Building a new home or moving
Barriers to Treatment
• Distinguishing normal adjustment versus
depression
• Absence of education, screening, and
diagnosis
• Absence of professional education and
treatment knowledge
• Symptoms denied, ignored or minimized
More Barriers
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Social and cultural expectations
Stigma of mental illness
Myths of motherhood
Shame, embarassment
Lack of information and advocacy
Cost of treatment and medications
Fear of medications
Transportation
DENIAL
Depression
• More women are affected than men
• CNS imbalance in serotonin & other
neurotransmitters
• Unable to process information
• Unable to concentrate
• Fatigue, sleep deprivation
• Overwhelmed by labor process
• Unworthy of motherhood
• Hopelessness
Perinatal Depression Syndrome
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Sadness, crying
Suicidal thoughts
Appetite changes
Sleep disturbances
Poor concentration/focus
Irritability and anger
Hopelessness and helpless
Guilt and shame
Perinatal Depression – SX
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Anxiety
OVERWHEMED
Lack of feelings toward the baby
Inability to take care of self or family
Loss of interest, joy, or pleasure
“This doesn’t feel like me.”
Mood swings
Baby Blues: the Non-Disorder
• Affects 60-80% of new moms
• Symptoms include crying, feeling
overwhelmed with motherhood, being
uncertain
• Due to the extreme hormone fluctuations
at the time of birth
• Last no more than 2 days to 2 weeks
• Acute sleep deprivation
• Fatigue
Postpartum “blues”
Not a mild form of depression
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Features: tearfulness, lability, reactivity
Predominant mood: happiness
Peaks 3-5 days after delivery
Present in 50-80% of women, in diverse
cultures
• Unrelated to stress or psychiatric history
• Posited to be due to hormone withdrawal
and/or effects of maternal bonding
hormones
Anxious Depression
• High co-morbidity between depression and
anxiety symptoms in perinatal women.
(Moses-Kolko EL et al. JAMA 2005; 293: 2372-2383 & Anderson L et
al, American Journal Obstetrics & gynecology 2003; 189: 148-152)
Depression/Anxiety in
Pregnancy
• Rates vary by studies – up to 51% in low
SES women (average is 18%)
• Depression During Pregnancy, Overview Clinical Factors, Bennett,
H. et al., Clinical Drug Investigations 2004: 24 (3): 157-179
Anxiety Symptoms
• Agitated
• Excessive concern about baby’s or her
own health
• Appetite changes-often rapid weight loss
• Sleep disturbances (difficulty
falling/staying asleep)
• Constant worry
• Shortness of breath
• Heart palpitations
Anxiety Disorders
• Panic disorder, OCD,PTSD, generalized
anxiety disorder, phobias
• Cause a wide range of sx in the laboring
woman: terror, SOB, CP, weakness,
faintness, dizziness (exclude other dx)
• Labor may trigger flashbacks, avoidance
behavior, anxiety sx.
• Severe sx to vague feeling “something is
wrong”
Panic Symptoms
• Episodes of extreme anxiety
• Shortness of breath, CP, sensations of
choking or smothering, dizziness
• Hot or cold flashed, trembling, rapid heart
rate, numbness or tingling sensations
• Fear of going crazy, losing control or dying
• Beyond the Blues by Indman and Bennett (2006)
OCD: Classic Symptoms
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Cleaning
Checking
Counting
Ordering
Obsession with germs, cleanliness
Checking on baby
hypervigilence
OCD: Sx
• Intrusive, repetitive thought-ususally of harm
coming to baby
• Tremendous guilt and shame
• Horrified by these things
• Hypervigilence
• Moms engage in behjaviors to avoid harm or
minimize triggers.
Educate mom that thought does not equal action.
Perinatal PTSD
• An anxiety disorder after a terrifying event
or ordeal in which grave physical harm
occurred or was threatened.
“It’s in the eye of the beholder.”
Beck, CT (2004). Birth Trauma: In the Eye of the Beholder, Nursing
Research, 53, 28-35.
Postpartum PTSD Themes
• Perception of lack of caring
• Feeling abandoned
• Stripped of dignity
• Lack of support and reassurance
• Poor communication
• Moms feel invisible
• Feeling powerless
• Betrayal of trust
• Don’t feel protected by staff
• Do the ends justify the means?
• Healthy baby justifies traumatic delivery?
PPPTSD
Postpartum Hemorrhage
Emergency C/S
Any birth complication for mom or baby
Previous PTSD
Previous Sexual Abuse
PTSD: SX
• Intrusive re-experiencing of a past
traumatic event-anxiety attacks with
flashbacks
• “emotional numbing”
• Hyperarousal/hypervigilence
PTSD due to traumatic labor &
delivery
• Incidence
• Full PTSD in 0.2% - 3% of birth
• Partial symptoms in about 25% of birth
Creedy et al 2000: Czamocka et al 2000, Mounts K. Screening for
Maternal Depression in the Neonatal ICU. Clinical Perinatology
2009; 36: 137-152.
PTSD due to traumatic labor & delivery:
resultant problems
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Avoidance of aftercare
Impaired mother-infant bonding
PTSD in partner who witnessed birth
Sexual dysfunction
Avoidance of further pregnancies
Exacerbation in future pregnancies
Elective c/s in future pregnancies
PTSD in NICU moms
• Risk factors:
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Neonatal complications
Lower gestational age
Greater length of stay in NICU
Stillbirth
• Prominent symptoms:
• Intrusive memories of infant’s hospitalization
• Avoidance of reminders of childbirth
Perinatal Psychosis
• “It was the seventh deadly sin. My
children weren’t righteous. They stumbled
because I was evil. The way I was raising
them they could never be saved. The
were doomed to perish in the fires of hell.”
Andrea Yates, mother of
Noah, John, Luke, Paul and Mary
Psychosis: Prevalence
• 1-2 in 1,000 postpartum women will
develop PPP
• Of those women:
5% suicide
4% infanticide
Onset usually within first 3 weeks after
delivery
PPP: Sx
• Delusions (eg baby is possessed by a
demon)
• Hallucinations (eg. Seeing someone else’s
face instead of the baby’s face)
• Insomnia
• Rapid mood swings
• Waxing and waning (can appear and feel
normal for stretches of time between
psychotic symptoms
Bipolar Disorder
• Higher risk of suicide
• Women with a previous diagnosis of
bipolar depression are at greater risk for
developing a mood disorder in the
postpartum period
• Postpartum psychosis is more common in
women with bipolar disorder: 20 out of 30
postpartum women with bipolar disorder experience a psychotic
episode. 70% of women with bipolar disorder will relapse within the
first 6 months postpartum
Clinical Therapy
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Provide support
Decrease anxiety
Orient to reality
Sedatives/analgesia (decrease pain may
decrease psychological sx)
• Psychiatric support
Can PMADS Be Prevented
“…Prevention is the great challenge of
postnatal illness because this is one of the
few areas of psychiatry in which primary
prevention is feasible.”
Hamilton and Harberger (1992)
Primary Prevention Model
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Risk factors are known
Feasible to identify high-risk mothers
Screening is inexpensive and educational
Many risk factors are amenable to change
Known effective, reliable treatments exist
Does prevalence of perinatal
depression warrant screening?
YES !
By comparison:
4.8% have gestational diabetes
5% have hypertension in pregnancy
Who Should Screen?
All healthcare professionals that have
contact with pregnant or postpartum
women
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Primary care providers
OB/GYN providers
Pediatricians
NPs, CNMs, CSWs
WIC programs
Hospitals
Key Points
• Provide privacy during screening
• Give brief explanation
• Edinburgh Postnatal Depression Scale
EDPS ( most thoroughly validated, free,
designed for perinatal use, easy to
administer & score)
Breastfeeding…to wean or not
to wean
The decision to breastfeed is not,
however, always so simple, especially for
women who suffer from depression and
are taking psychotropic medications.
3 Choices
1. Expose the baby to medicatoni through
the breast milk
2. Expose the baby to the adverse effects of
untreated depression in the mother
3. Take antidepressant medications and
don’t breastfeed the baby
Dad’s and Partner’s Role:
Education of Parnters important!!
 Often first to realize something is wrong
 Often required to intervene in an
emergency
 Best positioned to monitro treatment on a
daily basis
 Often required to assume more
responsibility for wellbeing of family
 Have the most at stake in her getting well
Dystocia
• Abnormal labor pattern
• Problem with the 3 Ps
• Most common problem is dysfunctional
uterine contractions resulting in prolonged
labor
• Friedman curve: 4cm in active labor1cm/hr for primips, 1.5 cm/hr for multips
• Variations: protracted labor & arrest of
labor (no change for 2 hours)
Hypertonic Labor Pattern
• Ineffectual uterine contractions of poor quality
occur in the latent phase and resting tone of the
myometrium increases
• Painful, ineffective contractions become more
frequent prolonging latent phase
• Management: bed rest and sedation to promote
relaxation and reducpain
• Nursing comfort measures: position change,
hydrotherapy, mouthcare, linen change,
relaxation exercises, education
Clinical Management
• Consider CPD (station) “out of the pelvis”
• If no CPD, consider amniotomy and
Pitocin augmentation
Active vs Expectant Management
• AMOL: amniotomy, timed cervical checks,
augmentation of labor with IV pitocin
• Expectant management: Labor considered
a normal process and allowed to progress
without automatic intervention
Nursing Care and Management
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VS
Labor pattern
Cervical progress
Fetal status
Vtx pressing down on cx without descent =
caput, caput increases with no progress
• Maternal hydration: I & O
• Monitor for infection
Precipitous Labor and Birth
• L & D occurs within 3 hours
• Maternal risks: abruptio placenta,
lacerations, PPH
• Fetal risks: oxygenation may be poormeconium stained AF may be aspirated,
low Apgar scores, trauma
• Know hx, assess laboring woman for rapid
dilatation
Postterm Pregnancy
• Extends beyond 42 completed weeks of
pregnancy
• 7% of all pregnancies in the U.S.
• Cause – unknown, wrong dates
• ? Dates: early sono
• Maternal risks: labor induced, LGA, macrosomia,
forceps, vacuum, perineal damage, hemorrhage,
c/s doubled (endometritis, hemorrhage,
thromboembolic disease)
Postterm Pregnancy
• Fetal risks: placental changes, increased
perinatal mortality, oligohydramnios, if
decreased placental perfusion-SGA;
• IF no compromise-LGA or macrosomic,
birth trauma, shoulder dystocia, prolonged
labor, hypoglycemia seizures, respiratory
distress, meconium staining-aspiration
Management of Postterm
Pregnancy
• Starting at 40 wks: NST, BPP, AF index +
NST usually twice weekly
• In labor, ongoing assessment, continuous
EFM, note AF,
Fetal Malposition - POP
• Early labor 15%, at birth 5%
• Maternal risk: intense back pain til rotation, 3rd or
4th degree laceration if born OP, higher
incidence of operative deliveries (60% of women
will have a c/s)
• Nursing assessment: back pain, abdominal
depression, protracted labor, FHR heard
laterally
• Nursing care: Position change! pelvic rocking
Face presentation. Mechanism of birth in mentoposterior
position. Fetal head is unable to extend farther. The face
becomes impacted.
Types of cephalic presentations. A, The occiput is the presenting part
because the head is flexed and the fetal chin is against the chest. The
largest anteroposterior (AP) diameter that presents B, Military (sinciput)
presentation. C, Brow presentation.D, Face presentation.
Breech
• Overall incidence 4%, directly related to
gestational age
• Frank breech most common 50-70%(term)
• Single or double footling breech 10-30%
(preterm)
• Complete breech 5%
Frank breech
Incomplete (footling) breech
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Complete breech
On vaginal examination, the nurse may feel the anal
sphincter. The tissue of the fetal buttocks feels soft.
Breech
• Associated with: placenta previa, oligo,
hydrocephaly, anencephaly,multiples
• Higher incidence of cord prolapse,
neonatal & infant mortality, mec aspiration
• Entrapment, head trauma, spinal injury
• ECV (external cephalic version) attempted
at 37- 38 weeks
• Passage of mec normal in vag breech
Transverse Lie
Common in mutliples
More common in multips
Many convert to cephalic or breech by term
If still transverse ECV may be done
Persistent transverse lie requires a c/s after
determining fetal lung maturity
Transverse lie. Shoulder presentation
Macrosomia
• More than 4500 g. (differs according to
ethnic group)
• Obese women 3-4 times more likely
• Association with pregestational and
gestational diabetes
• Distention of uterus, overstretching leads
to dysfunctional labor & increased PPH
• Increased risk perineal trauma, PPH,
infections, forceps, vacuum
Shoulder Dystocia
• ID macrosomic infant infant in labor
• McRoberts maneuver, lower mom’s head,
apply suprapubic pressure
• Recognize: slow descent, turtle sign,
excessive molding
• After the birth: examine for
cephalhematoma, Erb’s palsy, fractured
clavicle. Neuro/cerebral damage
McRoberts maneuver. A, The woman flexes her
thighs up onto her abdomen
B, The angle of the maternal pelvis before McRoberts
maneuver. C, The angle of the pelvis with McRoberts
maneuver.
Multiples
• Twins 3.2% of all pregnancies
• Triplets and higher 1.8%
• 33% monozygotic twins: genetically
identical-highest risk for fetal demise, cord
entanglement, twin-to-twin transfusion
• 25% of all twins are lost before the end of
the first trimester
• Higher incidence of preterm birth
Complications Common with
Multiples
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Spontaneous abortion
Gestational diabetes
Hypertension or preeclampsia 2.6x
HELLP
Acute fatty liver (severe coagulopathy, hypoglycemia, hyperammonemia
Pulmonary embolism 6x
Maternal anemia
Hydramnios
PROM, incompetent cx, IUGR
Labor cx: PTL, uterine dysfunction, abn presentations,
operative delivery (forceps, c/s) PPH
Management
• Goals: promote normal fetal development,
prevent maternal complication, prevent PTD, diminish
fetal trauma
• US: frequent surveillance
• PTL prevention: cervical checks start at 28 wks &
cervical measurements, fetal fibronectin equivocal. Bed
rest and hospitalization to prevent PTL not supported by
EBP
• Expect fundal height greater than wks gestation
• Auscultate 2 heart beats
• Wt gain 35-44#
• Diet 135g protein & 1mg folic acid
Labor Management of Multiples
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c/s if presenting twin is not vertex
External monitor A & B
Internal monitor A & external monitor B
Correctly identify A & B
Anticipate PPH
Nonreassuring Fetal Status
• O2 supply insufficient to meet
physiological demands of fetus
• Causes: cord compression, uteroplacental
insufficiency, maternal/fetal disease
• Most common initial signs=meconium
stained AF (vertex) changes in FHR( late,
severe variable decelerations; rising
baseline)
Interventions
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Change mother’s position
Increase rate of IV infusion
O2 via mask at 6-10 L/min
Continuous EFM
D/C pitocin if running
Provide emotional support to woman, her
partner, family-explanations: unexpected
c/s
Placental Problems
• Abruptio placenta
• Placenta previa
• Accreta
Abruptio Placentae
• Premature separation of a normally implanted placenta:
0.5%-2%
• Risk factors: smoking, PROM, HTN, previous
abruptio=10x higher risk
• Cause unknown: maternal HTN(44%), trauma ( 210%),fibroids, cocaine, high parity, short cord
• Marginal, Central (concealed bleeding), Complete
• Retroplacental clot, blood invades myometrium, uterus
turns blue couvelaire uterus- hysterectomy
• Large amts of thromboplastin are released triggering
DIC, fibrinogen plummets
Abruptio placentae. A, Marginal abruption with external
hemorrhage. B, Central abruption with concealed
hemorrhage. C, Complete separation
Management
• Risk of DIC- evaluate coagulation profile
• In DIC fibrinogen and platelet counts are decreased, PT
and PTT are normal to prolonged, fibrin split produces
rise with DIC
• IV access (16 or 18 gauge), continuous EFM, c/s usually
safest, T and X-M at least 3 units of blood, treat
hypofibrinogenemia with cryo or FFP before surgery,
may need CVP monitoring.
• Consider 2 IV lines, watch I & O, worrisome if output
below 30 mL/hour
• Clot observation test at bedside (red top tube) if clot fails
to form in 6 minutes fibrinogen level of less than 150
mg/dL is suspected, clot not formed in 30 minutes
fibrinogen less than 100 possible
Placenta Previa
• The placenta is improperly implanted in
the lower uterine segment. Implantation
may be on a portion of the lower uterine
segment or over the internal os.
• As the lower uterine segment contracts
and dilates in the later weeks of
pregnancy, the placental villae are torn
from the uterine wall. Bleeding
Previa
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Cause: unknown; 1:200 preganacies
Risk factors: multiparity,increasing age,
accreta, prior c/s, smoking, recent abortion
spontaneous or induced, large placenta
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Total placenta previa: internal os covered completely
Partial placenta previa: internal os partly covered
Marginal placenta previa: edge of placenta is at the margin of the
os
Low-lying placenta: implanted in the lower segment but does not
reach the os
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Placenta previa. A, Low placental implantation. B, Partial
placenta previa. C, Total placenta previa
Management
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Vasa previa: fetal vessels course thru the amniotic membranes and are
present at the cervical os
• Women present with bleeding, review records, get us,
no vag exams (unless double set-up), consider
cervical bleeding
• If less than 37 weeks & first bleeding episode-expectant
management:
No vag exams
Bed rest with BRP
Monitor bleeding, pain , UC, vs, FHR
Labs: Rh, h&h urinalysis
IV
2 units blood available
Betamethasone to facilitate fetal lung maturity
Prolapsed Cord
• An umbilical cord that precedes the fetal
presenting part; cord falls or is washed
down thru the cervix into the vagina and
becomes trapped between the presenting
part and the maternal pelvis
• Usually occult cord prolapse
• Risks: breech, shoulder presentations,
LBW, multips with 5 or more births,
multiples, amniotomy
Prolapse of the umbilical cord
Prolapsed Cord
• Mom: c/s, fetal death
• Fetus: bradycardia, variable decel
• Relieve the pressure by pushing back the
presenting part, O2, EFM, IV, fill bladder,
Trendelenberg,knee-chest, delivery
• Women at risk: not engaged & SROM or
AROM, bed rest if ROM and not engaged
AFE
• Occurs when a bolus of amniotic fluid
enters the maternal circulation and then
the maternal lungs
• Cause unknown
• Mortality 60-80%
• 10% of all maternal deaths in the U.S.
“Vigorous contractions in a woman having her first baby can led to
circumstances in which AFE is likely to develop.”
-Williams Obstetrics
• Cytotec causes unusually strong
contractions, AFE is a known risk of using
cytotec on a pregnant woman
AFE
• WE know that the rate of women dying
around the time of birth has been
increasing in the US for 25 years
• What about the rate of AFE?
• Evidence suggests that AFE related
deaths are increasing as well with a clear
connection with increasing use of uterine
stimulant drugs
WHY?
• “Wild West” medicine
• Maternal mortality going up
• Slight decrease in perinatal mortality due
not to a decrease in % of babies who die
before they are born but rather to a slight
decrease in the rate of babies who die
shortly after birth owing to our Neonatal
intensive care.
HX
DES
DES
• DES approved by FDA without testing
• 1947-1971 “wonder drug” 5 million US
women take DES
• Popular regime 125 mg = 700 bcps
• 1962 declared ineffective for preg but used
as a morning after pill
• 1971 alarming rates of vaginal cancer
seen in DES daughters
cytotec
• “off-label”
• Not approved by…
Letter from Searle Warning Doctors Against Cytotec Birth Inductions
August 23, 2000
Important drug warning concerning unapproved use of intravaginal or oral
misoprostal in pregnant women for induction of labor or abortion
Dear Health Care Provider:
The purpose of this letter is to remind you that Cytotec administration by
any route is contraindicated in women who are pregnant because it can
cause abortion. Cytotec is not approved for the induction of labor or abortion.
Cytotec is indicated for the prevention of NSAID (nonsteroidal antiinflammatory drugs, including aspirin)-induced gastric ulcers in patients at
high risk of complications from gastric ulcer, e.g., the elderly and patients
with concomitant debilitating disease, as well as patients at high risk of
developing gastric ulceration, such as patients with a history of ulcer.
The uterotonic effect of Cytotec is an inherent property of prostaglandin
E1(PGE1), of which Cytotec is stable, orally active, synthetic analog. Searle has
become aware of some instances where Cytotec, outside of its approved indication,
was used as a cervical ripening agent prior to termination of pregnancy, or for
induction of labor, in spite of the specific contraindications to its use during
pregnancy.
Serious adverse events reported following off-label use of Cytotec in
pregnant women include maternal or fetal death; uterine hyperstimulation,
rupture or perforation requiring uterine surgical repair, hysterectomy or
salpingo-oophorectomy; amniotic fluid embolism; severe vaginal bleeding,
retained placenta, shock, fetal bradycardia and pelvic pain.
Searle has not conducted research concerning the use of Cytotec for
cervical ripening prior to termination of pregnancy or for induction of labor,
nor does Searle intend to study or support these uses. Therefore, Searle is
unable to provide complete risk information for Cytotec when it is used for
such purposes. In addition to the known and unknown acute risks to the
mother and fetus, the effect of Cytotec on the later growth, development
and functional maturation of the child when Cytotec is used for induction of
labor or cervical ripening has not been established
Searle promotes the use of Cytotec only for its approved indication.
Further information may be obtained by calling 1-800-323-4204.
Michael Cullen, MD
Medical Director, U.S.
Searle
Hydramnios
• Polyhydramnios
• Over 2000mL of amniotic fluid
• Often occurs in cases of major congenital
anomalies, malformations that affect
swallowing, anencephaly
• Diabetes, Rh sensitization, infections
(syphilis, toxoplasmosis, cytomegalovirus,
herpes, rubella)
Oligohydramnios
• Largest pocket of amniotic fluid is 5 cm or
less on ultrasound
• Postmaturity, IUGR, renal malformations
in the fetus
CPD
• Cephalopelvic Disproportion
• Contracture of the bony pelvis or the
maternal soft tissues
• Contractures of the inlet, outlet, midpelvis
• Labor is prolonged and protracted
Retained Placenta
• Retention of the placenta beyond 30
minutes after birth of the baby
• Manual removal
Lacerations
•
•
Bright red bleeding: cx, vagina
Risks: nullip, epidural, forcps, VAD, epis
1.
First–degree: limited to fourchette, perineal skin and
vaginal mucous membrane
Second-degree: perineal skin, vaginal mucous
membrane, fascia, muscles of the perineal body
Third-degree: involves anal sphincter and may extend
up the anterior wall of the rectum
Fourth-degree: extends thru the rectal mucosa to the
lumen of the rectum.
2.
3.
4.
Placenta Accreta
• Chorionic villi attach directly to the
myometrium of the uterus
• Increta: myometrium is invaded
• Percreta: myometrium is penetrated
• Causes maternal hemorrhage
• Tx may be abdominal hysterectomy