Programs, Trends, and Issues in Maternal Health Introduction Maternal mortality trends are unacceptable, but not insurmountable

e because the major causes are known and avoidable Nearly 2/3 of maternal deaths are due: Hemorrhage Obstructed labor Pregnancy-induced hypertension Sepsis/infection Complications of unsafe abortion Interventions can be made available even in resource-poor settings

1987 Safe Motherhood Initiative 1990 World Summit for Children 1994 International Conference on Populations and Development th 1995 4 World Conference on Women 2000 Millennium Summit/Declaration

Why aim for maternal survival? 1. Moral imperative The death of a woman during pregnancy or childbirth is a violation of her rights to life and health. Governments must promote dignity and equity for women within the health-care system. Social implications Maternal death or disability can plunge families into poverty and deeper despair; surviving children esp. those < 5 years old are at risk of dying since no one will attend to their needs The loss may reverberate throughout an entire community

2.

Maternal death The death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes. Ways in measuring progress in reducing maternal mortality Maternal Mortality Ratio refers to the number of maternal deaths during a given time period per 100,000 live births during the same time period. Maternal Mortality Rate refers to the number of maternal deaths in a given time period per 100,000 women of reproductive age during the same time period. Adult Lifetime Risk of Maternal Death refers to the probability of dying from a maternal cause during a womans reproductive lifespan. Methodological issues in measuring maternal mortality 1. 2. 3. It is a rare event and therefore its number may not be large enough to detect statistically significant changes over time. Underreporting especially if most occur outside of health facilities (in the absence of health personnel to report them). Misreporting because of the complicated definition requiring also its cause and timing OR sometimes done intentionally to avoid legal action.

Lessons learned : Most maternal deaths and disabilities would be averted if... All pregnancies are wanted and planned. All pregnancies are adequately managed throughout its course. All births are attended by skilled health professionals (ideally facility-based). All complications are managed in adequately-staffed and equipped facilities offering emergency obstetric care.

Strategies to reduce maternal mortality 1. 2. Universal access to contraceptive services to reduce unintended pregnancies. Skilled attendance at all births.

Nursing Care of the High Risk Pregnant Client High Risk Pregnancy - One in which a concurrent disorder, pregnancy related complications or external factor jeopardize the health of the woman, the fetus or both. Risk Factors Physiologic -

Physiological Socio demographic Psychological Environmental

Concurrent illness Malnutrition Physically challenged Frequent pregnancies

Socio Demographic Poverty Unemployment Lack of education Age Poor access to transportation for care Lack of support people Psychological Factor Cognitively challenge Single / Separated mothers Victims of Abuse, domestic violence, rape, incest Mental Retardation Environmental factors Exposure to Teratogens due to employment Environmental contaminants at home Poor Housing

CARING FOR A WOMAN WHO DEVELOPS A COMPLICATION OF PREGNANCY Assessment Provide enough time for a thorough health history. Problems such as headache, blurred vision, vaginal spotting should be discovered and investigated thoroughly. Common Nursing Diagnosis Anxiety related to guarded pregnancy outcome. Risk for infection related to incomplete miscarriage. Deficient knowledge related to signs and symptoms of possible complications. Risk for ineffective tissue perfusion related to pregnancy-induced hypertension. Ineffective role performance related to increasing level of daily restrictions secondary to chronic illness and pregnancy. Implementation interventions for woman experiencing a complication of pregnancy include measures to maintain number of different areas. Continued healthy fetal growth. A womans and family s psychological health. Continuation of the pregnancy as long as possible. Evaluation Clients BP is maintained within acceptable parameters Couple state they feel able to cope with anxiety associated with the pregnancy complication Client accurately verbalizes crucial signs and symptoms to report to the health care provider immediately.

SUDDEN PREGNANCY COMPLICATION In few women, unexpected deviations or complications from the normal course of pregnancy happens. Sudden Pregnancy Complications Bleeding during pregnancy Ectopic pregnancy Gestational trophoblastic disease Premature cervical dilatation Placenta previa Abruptio placenta Disseminated intravascular coagulation

Bleeding during pregnancy is always a deviation from the normal.

Summary of Primary Causes of Bleeding during Pregnancy Time type cause Assess-ment cautions

1 trimester

st

Threatened miscarriage Imminenent miscarriage

Unknown, possibly chromosomal uterine abnormalities

Vaginal spotting perhaps slight Cramping Vaginal spotting, cramping, cervical dilatation Vaginal spotting, perhaps slight cramping; no apparent loss of Pregnancy Vaginal spotting, cramping ,cervical dilatation, but incomplete expulsion of uterine contents Complete expulsion of uterine contents

Disseminated intra-vascular coagu-lation associated with missed mis carriage

Missed miscarriage Incomplete miscarriage Complete miscarriage

2nd trimester

1. Ectopic pregnancy

Implan-tation of zygote at site other than the uterus

Sudden uni-lateral lower abdominal quadrant pain, minimal vaginal bleeding, possible signs og shock or hemorrhage Overgrowth of uterus, highly positive HCG, no fetus on ultrasound,bleeding from vagina Painless bleeeding leading to expulsion of fetus

May have repeat ectopic pregnancy in future if tubal scarring is bilateral

Hydatidi-form mole Premature cervical dilatation

Abnormal proliferation of trophoblast cells,ferti-lization or division defect Cervix begins to dilate and pregnancy is lost at about 20 weeks

Retained trophoblast tissue malignant Can have cervical sutures placed to ensure a second pregnancy

Time

Type

Cause

Assess-ment

cautions

3 trimester

rd

Placenta previa Abruptio placenta

Low implan-tation of placents possibly because of uterine abnorma-lity Unknown cause, placenta separates from uterus Trauma, substance abuse,PIH, cervicitis, increased chance in multiple gestation ,maternal illness

Painless bleeding at beginning of cervical dilatation Sharp abdominal pain followed by uterine tenderness, vaginal bleeding Show accompanied by uterine contract-ions becoming regular and effective

No vaginal examina-tions Disse-minated intra-vascular coagulation

Pre-term labor

Preterm labor may be halted if the cervix is less than 4 cm dilated and the membranes are intact

Abortion - Medical term for any interruption of a pregnancy before a fetus is viable. Spontaneous Miscarriage th Early miscarriage if it occurs before 16 week Late between 16-24 weeks CAUSES: Terratogenic factor Chromosomal abberations/abnormal fetal development Implantation abnormalities Failure to produce enough Progesterone Infection Presenting Symptom Vaginal bleeding/spotting. Should consult attending Obstetrician so that instructions may be given. Threatened Miscarriage Vaginal bleeding,scant, bright red usually, slight cramping No cervical dilatation Mgt: Fetal heart assessment Utz hCG determination Avoid strenuous activity

 Coitus usually restricted for 2 weeks Spotting usually stops within 24-48 hours Imminent (inevitable) Miscarriage Uterine contractions and cervical dilatation occurs. Loss of product of conception cannot be halted. If no FHT and UTZ reveals empty uterus-dilatation and evacuation may be performed. Complete Miscarriage - entire products of conception are expelled spontaneously without assistance. Incomplete miscarriage Part of the conceptus is expelled, but the membrane or placenta is retained. Mgt. Dilatation and curettage or suction curettage. Recurrent Pregnancy Loss Women who had 3 spontaneous miscarriages Defective spermatozoa or ova Endocrine factors Deviations of the uterus Uterine infections Autoimmune disorders Complications of miscarriage Hemorrhage Infection Risk for isoimmunization Process of Shock because of Blood Loss 1. Blood loss 2. Decreased intravascular volume 3. Increased heart rate, vasoconstriction,increased RR, feeling of apprehension 4. Cold ,clammy skin,decreased uterine perfusion,blood pressure falls 5. Reduced renal,uterine and brain perfusion 6. Lethargy,coma,decreased renal output---renal failure----maternal and fetal death Signs and Symptoms of Hypovolemic Shock ASSESSMENT SIGNIFICANCECOLD

INCREASED PULSE RATE DECREASED BP INCREASED RR

Heart is attempting to compensate to increase BV Less peripheral resistance Increase gas exchange to oxygenate decreased RBC volume

COLD,CLAMMY SKIN

Vasoconstriction occurs to maintain blood volume in central body core Decrease blood supply in the kidneys Inadequate blood is reaching the cerebru, Decreased venous return

DECREASED URINE OUTPUT DIZZINESS DECREASED CVP

Ectopic Pregnancy Implantation occurs outside the uterine cavity. Ovary or cervix. Most common is fallopian tube. Due to fallopian tube scarring that slow the travel of the zygote. Woman still experiences the signs of pregnancy. Missed period. Signs and symptoms of pregnancy is experienced by the woman. (+) pregnancy test. Ruptured Ectopic Pregnancy Sharp stabbing pain in lower abdominal quadrant. Vaginal spotting. Amount of bleeding not evident. May lead to shock. Falling hcg level. Utz provides clear cut picture. If the woman does not seek help at once Cullens sign Dull, vaginal abdominal pain Movement of cervix cause excruciating pain Pain in shoulders Management: Unruptured methotrexate followed by leucovorin, mifepristone (abortifacient). Ruptured emergency situation. Laparoscopy-ligate the bleeding vessels and remove/repair fallopian tube. Complete Blood Count Administration of fluids Abdominal Pregnancy Woman may report sudden lower quadrant pain. Fetal outline is easily palpable. Danger is infiltration of large blood vessel,bowel perforation, poor nutrient supply to the fetus.

 Infant must be born through laparotomy. Rate of survival is 60%. Gestational Trophoblastic Disease (Hydatidiform Mole) Abnormal proliferation and then degeneration of the trophoblastic villi Cells become filled with fluid and appears as fluid filled grape sized vesicles 1 in every 1500 pregnancies Two types: Complete mole all trophoblastic villi swell and become cystic. Partial mole - some of the villi form normally. Assessment Uterus tends to expand faster. Strong (+) result of hCG- 1 to 2 M IU compared to a normal of 400,000IU. th Symptoms of pregnancy induced hypertension may appear before the 20 week. Ultrasound-no fetal growth and fetal heart sound. Marked nausea and vomiting. Dark brown blood, profuse flesh flow(16 weeks) with clear fluid filled vessicles. Therapeutic Management Suction curettage Post surgery: Pelvic examination, chest radiograph,hCG level HCG monitoring Half of woman positive at 3 weeks positive result at 40 days Assess every 2 weeks until normal Every 4 weeks for the next 6 to 12 months Should use reliable contraceptive method Plan pregnancy at 12 months if hcg is normal Prophylaxis Methotrexate Dactinomycin Premature Cervical Dilatation Old name-Incompetent cervix. Cervix that dilate prematurely,cannot hold a fetus until term. Painless st Pink-stained vaginal discharge(1 symptom) Followed by Rupture of membrane, discharge of amniotic fluid. Uterine contractions-birth of the fetus. Associated with: Increased maternal age. Congenital structured defect.

 Trauma to cervix. Management: Cervical cerclage-purse-string sutures are placed in the cervix by vaginal route. McDonald Procedure - Nylon sutures are placed vertically and horizontally across the cervix and pulled tight to reduce the cervical canal. Shirodkar - Sterile tape is threaded in a purse string manner under the submucous layer of the cervix. Placenta Previa - Placenta is implanted abnormally in the uterus. Most common cause of painless bleeding in the third trimester of pregnancy. Occurs in 4 degrees: Low lying- implantation in the lower rather than in the upper portion of the uterus. Marginal the placenta edge approaches that of the cervical os. Partial - implantation that totally obstructs the cervical os. Total placenta previa - totally obstructs the cervical os. Assessment Bleeding is abrupt, painless , bright red and sudden. Immediate care measures: Place the woman immediately on bedrest in a side lying position Associated with: Increased parity Advanced maternal age Past CS Past uterine curettage Multiple gestation Male fetus Assess:

Duration of pregnancy Time the bleeding began Estimate amt of blood loss Accompanying pain Color of the blood What has she done Prior episodes of bleeding Prior cervical surgery

Therapeutic Management Never attempt a pelvic or rectal examination with painless bleeding late in pregnancy Obtain baseline VS IVF therapy I and O monitoring External monitoring equipment Complete blood count Blood typing and crossmatching Fetal delivery depends on the percentage of previa and the condition of the pregnancy.

Premature Separation of the Placenta/Abruptio Placenta Placenta appears to be implanted correctly Begins to separate and bleeding results Cause is unknown Predisposing Factors: High parity Advanced maternal age Short umbilical cord Chronic hypertensive disease Pregnancy induced hypertension Direct trauma Vasoconstriction Autoimmune antibodies Chorioamnionitis Assessment Sharp stabbing pain high in the uterine fundus. If labor begins, each contraction will be accompanied by pain over and above the pain of contraction. Heavy bleeding-evident if separation occurs at the edges. Couvelaire uterus(uteroplacental apoplexy)-hard board like uterus with no apparent bleeding. DIC may occur. Therapeutic Management Emergency situation Large gauge IV catheter Oxygen by mask FHT and maternal VS monitoring Lateral position No abdominal, pelvic or vaginal examination Unless separation is minimal, pregnancy must be TERMINATED. Degress of Premature Placental Separation Grade Criteria

0 1

No symptoms apparent,diagnosis made after birth Minimal separation, but enough to cause vaginal bleeding and changes in maternal VS,no fetal distress Moderate separation,there is evidence of fetal distress, uterus tense and painful Extreme separation, maternal shock and fetal death may occur

2 3

Disseminated Intravascular Coagulation Acquired disorder of blood clotting, fibrinogen level falls to below effective limits Conditions asscociated with its development: Premature separation of placenta PIH Amniotic fluid embolism Placental retention Septic abortion Retention of dead fetus Extreme bleeding causes many platelets and fibrin from the general circulation rush to the site, not enough are left for the rest of the body. Test Clotting Time Test tube-clot must form Platelet assessment-less than or equal to 100,000/uL Prothrombin low Thrombin-elevated Fibrinogen less than 150 mg/dL Management Halt the underlying insult IV administration of of Heparin Blood or platelet transfusion Way to Predict which Pregnancy will End Early: Analyze change in vaginal mucus. Presence of fetal fibronectin-preterm contractions are ready to occur. Absence- labor will not occur at least 14 days. Therapeutic Management Woman usually admitted Bed rest IV fluids Tocolytic agent-halt labor (terbutaline) Advised to limit strenuous activities Fetal assessment-count to 10 test Administration of Terbutaline Mixed with lactated Ringers Piggy back Microdrip Check blood pressure and pulse rate If contractions are halt, oral terbutaline may be given. Drug Administration Steroid( betamethasone)-to hasten lung maturity. Effects after 24 hours and lasts 7 days.

Labor that cannot be Halted Membranes have ruptured. Cervix more than 50% effaced and 3-4 cm dilated. If fetus is very immature - CS. Method of Delivery If very immature - CS. Cord is clamped immediately. Preterm Rupture of the Membranes Rupture of fetal membranes with loss of amniotic fluid during pregnancy before 37 weeks. Threats to fetus: Uterine and fetal infections. Increased pressure on the umbilical cord(cord prolapse). Potter like syndrome-distorted facial features and pulmonary hypoplasia. Assessment Sudden gush of clear fluid from vagina. Test with nitrazine paper-turns blue (alkaline). Therapeutic Management If labor does not begin, fetus is at point of viability: Woman is placed on bed rest and receives corticosteroid. Administration of broad spectrum antibiotics. Membranes resealed by fibrin based commercial sealant. Pregnancy Induced Hypertension Vasospasm occurs during pregnancy in both small and large arteries Used to be called toxemia Occurs most frequently in women: Of color Multiple pregnancy Primiparas younger than 20 years or older than 40 years Low socioeconomic backgrounds Who have had five or more pregnancies Hydramnios Underlying disease Classifications: Gestational hypertension Mild eclampsia Severe eclampsia Eclampsia Assessment Hypertension Proteinuria Edema

Symptoms of Pregnancy Induced Hypertension Hypertension type Symptoms

Gestational HPN

BP 140/40 or SBP elevated 30 mm Hg or DBP elevated 15 mm above pre pregnancy level; no proteinuria or edema,BP returns to normal after birth BP 140/90 or SBP elevated 30 mm or DPB elevated 15 mm above pre pregnancy nd level;proteinuria of 1-2 + on a random sample, weight gain over 2 lbs /week in 2 rd trimester and 1lb/wk on the 3 trimester, mild edema in upper extremities or face.

Mild pre eclampsia

Severe pre eclampsia Eclampsia

BP of 160/110, proteinuria 3-4+ on a random sample and and 5g on a 24 hr sample, oliguria,cerebral or visual disturbances, pulmonary or cardiac involvement, extensive peripheral edema,heaptic dysfunction, thrombocytopenia, epigastric pain Seizure or coma accompanied by signs and symptoms of pre eclampsia

Management for Mild Pre-eclampsia Promote bed rest. Anti platelet therapy. Promote good nutrition. Provide emotional support. Management for Severe Pre-eclampsia Support bed rest. Monitor maternal well being. Monitor fetal well being. Support nutritious diet. Administer medications to prevent eclampsia. Management of Eclampsia Tonic-clonic seizures. Maintain patent airway. Administer oxygen. Turn to side. Administer Magnesium sulfate or diazepam (Valium). Assess FHT. Check for vaginal bleeding. HELLP SYNDROME Variation of PIH H-emolysis EL-evated liver enzymes L-ow P-latelet count Increased BP, edema, proteinuria+ Nausea, epigastric pain,general malaise,RUQ tenderness Management Improve platelet count by transfusion of fresh frozen plasma or platelets.

Multiple Pregnancy A womans body must adjust to the effects of more than one fetus. MONOZYGOTIC TWINS: Single ovum and spermatozoon,zygote divides into two identical individuals One placenta,one chorion,2 amnions, 2 umbilical cords. DIZYGOTIC(FRATERNAL/NONIDENTICAL Double ova-2 placentas,2 chorions, 2 amnions, 2 umbilical cord. Assessment Uterus increase in size at a rate faster than usual. Alpha-fetoprotein levels elevated. Quickening-flurries of action at different portions of abdomen. Reveals by ultrasound. Therapeutic Management Closer prenatal supervisions. Hydramnios Normal amniotic fluid volume-500-1000mL Fluid index above 24 cm or more than 2000 mL Suggests difficulty with the fetus ability to swallow Unusual enlargement of uterus Difficult to auscultate FHT Shortness of breath Increase weight gain Hemorrhoid Varicosities Management Bed rest Assess VS and edema NSAID Amniocentesis- almost daily Oligohydramnios Pregnancy with less than the average amount of amniotic fluid Caused by bladder or renal disorder Fetus is cramped for space Uterus fails to meey expected growth rate Mgt: Amniotransfusion Post Term Pregnancy Pregnancy that exceeds 42 weeks. If there is evidence of placental unsufficiency. Common in receiving salicylates. Mgt: oxytocin to initiate labor or CS is performed. Isoimmunization Occur when an Rh negative mother carries a fetus with an Rh positive blood (D antigen). Maternal antibodies may cross the placenta causing hemolytic disease of the newborn or erythroblastosis fetalis.

Assessment st Anti D antibody titer-done at 1 pregnancy visit. th If normal (0) or minimal (below 1:8)-test repeated in the 28 week. If normal-no therapy. If elevated (1:16) fetal condition monitored every 2 weeks. Therapeutic Management Passive Rh (D) antibodies against the Rh factor is administered to women who are Rh-negative at 28 weeks. st Given in the 1 72 hours after birth. Cord blood is tested-if Rh positive (coombs negative)-mother will receive RhIg injection. If Rh negative-injection not necessary. Intrauterine Transfusion Injection of RBC directly into the vessel of the fetal cord or deposting them in the fetal abdomen. Fetal Death If labor does not begin, it will be induced by a combination of prostagalndin gel such as misoprostol (Cytotec) and oxytocin.