Diabetes in Pregnancy

Client with diabetes and their infants are at risk for complication during pregnancy. Infants of diabetic mother tent to be large for gestational age. It is caused by glucose that crosses the placenta, whereas insulin does not, these infants tend to gain weight. The problem is that high glucose environment impedes lung development and although the infants are large for gestational age, they are often premature.

Complication of infants from maternal diabetes:

• Patent ductus arteriosus (PDA)
• Polyhydramnions
• Premature delivery
• Respiratory distress syndrome

Complications of mother with diabetes pregnancy:

• Hypertension
• Renal disease
• Ketoacidosis
• Vascular compromise
• Seizure activity related to hypoglycemia

Another problem in diabetes pregnancies is that the fluctuations in maternal blood sugar can result in fetal brain damage or sudden fetal death due to ketosis. That's why the client should be taught to check their blood glucose levels frequently during the day. Level over 120 mg/dL should be reported to the doctor for treatment.

Infants born to diabetic mothers might be delivered by cesarean section because of their large sizes and they should be assessed immediately after delivery for hypoglycemia by performing a dextrostix. The glucose level of 40 mg/dL or lower indicates hypoglycemia in the infant.

The blood is usually drawn from a heel stick and should be stuck on the lateral aspect of the heel. Blood test should be performed to detect hypocalcemia, hypokalemia and acidosis status.

Ectopic Pregnancy

Ectopic pregnancy is the condition in which the ovum implants in area other than the endometrial lining of the uterus. This pregnancy is not commonly successful since the areas outside of the uterus cannot sustain for a full-term pregnancy. It’s studied that it usually happens when there is a tubal blockage that prevents the fertilized ovum from passing through the fallopian tubes.

Ectopic pregnancy can be happened at abdominal, tubal, myometrial or cervical.

Ectopic pregnancy at abdomen:
The abdomen is usually unable to sustain for embryo growth

Ectopic pregnancy at tubal:
This is the most common site of ectopic pregnancy. It can causes mother at risk for tubal rupture that can be a life threatening condition.

Ectopic pregnancy at myometrial:
We cannot recognize it until delivery that usually requires a hysterectomy to stop bleeding. Sometime it is called as placenta accrete.

Ectopic pregnancy at cervical:
It has relation with placenta previa

Precipitating Factors:

1. Pelvic Inflammatory Disease
2. Previous tubal surgery or tubal pregnancy
3. Endometriosis, and
4. Congenital anomalies of the fallopian tubes

Sign and Symptoms:

1. Sharp one-sided pain
2. Tenderness of adnexal, area over ovary and tube
3. Vaginal bleeding (may or may not seen)
4. Hard and rigid abdomen and signs of circulatory collapse when tubal is ruptured.

How to care patient with ectopic pregnancy:

• Provide emotional support for whom undergoing surgical or medical treatment
• Provide emergency resuscitation and emergency surgery
• Teach mother about pre and post operative self care
• Consider to refer mother to a Fetal Demise Support Group

Anesthesia in Labor and Delivery

There are five types of anesthesia used in labor and delivery: local anesthesia, pudendal block, lumbar epidural block, subarachnoid (spinal) block, and general anesthesia.

Local Anesthesia:

• It is used for blocking pain during episiotomy
• It is administered just before the birth of the baby
• The anesthetic has no effect on fetus

Pudendal Block:

• It is administered just before the birth of the baby
• The anesthetic is injected into the pudental nerve through a transvaginal route
• It has effect last about 30 minutes
• It blocks the perineal area for episiotomy
• There is no effect on contraction or the fetus

Lumbar Epidural Block:

• The anesthetic relieves pain from contractions and numbs the vagina and perineum
• The anesthetic is injected in epidural space at L3 to L4 and may cause hypotension, so assess the maternal blood pressure
• The anesthetic is administered after labor is established or just before a scheduled casarean birth
• Keep mother in side-lying position or place a rolled blanket beneath the right hip to displace the uterus from the vena cava
• Administer IV fluids if prescribed
• Increase fluids if hypotension occurs

Subarachnoid (spinal) Block:

• The anesthetic is injected into the spinal subarachnoid space at L3 to L5 and administered just before the birth
• It relieves uterine and perineal pain and numbs the vagina, perineum, and lower extremities
• The anesthetic can cause maternal hypotension and postpartum headache
• Keep mother lie flat for 8 to 12 hours following spinal injection
• Administer IV fluids as prescribed

General Anesthesia:

• General anesthesia may be used for some surgical interventions
• It might cause a danger of respiratory depression and vomiting
• The mother is not awake

STAGES OF LABOR – Stage IV

LAST STAGE

• Last stage of labor begins with delivery of placenta and ends with postpartum stabilization
• Duration: usually 1-2 hours after delivery (primipara or multipara)
• Blood pressure returns to the pre-labor level
• Pulse is slightly lower than during labor
• Fundus remains contracted, in the midline, 1-2 fingerbeadths below the umbilicus

Nursing Interventions:

• Maternal assessment every 15 minutes for 1 hours, every 30 minutes for 1 hours, and hourly for 2 hours
• Administer oxytocin product if ordered
• Assess fundus every 15 minutes, if soft, massage with side of hand
• Assess lochia, checking peripad and under lower back
• Assess bladder for distention because full bladder will prevent contractions and increase bleeding
• Assess episiotomy for intactness and possible bleeding

STAGES OF LABOR – Stage III

THIRD STAGE

• Third stage of labor begins with delivery of infant and ends with delivery of placenta
• Duration: up to 20 minutes (primipara or multipara)
• Contractions occur until the placenta is born
• Placental separation and expulsion occur
• Birth of placenta occurs 5-30 minutes after birth the baby

Nursing Interventions:

• Assess maternal signs and uterine status
• Observe for placental separation
• Observe mother for signs of altered LOC or altered respiration (indicate aneurysm or emboli)
• Allow maternal-infant interaction as soon as possible

STAGES OF LABOR – Stage II

SECOND STAGE

• Second stage of labor begins with complete dilation and ends with delivery of infant
• Duration: 30-90 minutes in primipara and 15-20 minutes in multipara
• Cervical dilation complete
• Uterine contractions occur every 2-3 minutes, lasting 60-75 seconds and the intensity is strong
• Increase in bloody show
• Mother feels urge to bear down

Nursing Interventions:

• Assess fetal well-being continuously
• Monitor maternal vital signs
• Encourage pushing
• Encourage deep-full breath (not to hold breath longer than 5 seconds when pushing)
• Commend mother’s effort

STAGES OF LABOR – Stage I

First Stage

The first stage consists of three phases: latent, active, and transition. This stage begins with the first true contraction and ends with complete effacement and dilation to 10 cm.

Latent Phase (Early Labor):

• Duration: 10-12 hours in primipara and 8-10 hours in multipara
• Cervical dilation is 1 to 4 cm
• Uterine contractions occur every 15-30 minutes and are 15-30 seconds in duration and mild intensity
• Mother is talk active
• Encourage mother and partner to participate in care
• Change position and ambulation to comfort mother
• Offer fluids an ice chips
• Inform the progress to mother and partner
• Encourage voiding every 1-2 hours

Active Phase:

• Duration: 2-4 hours in primipara and 2-4 in multipara
• Cervical dilation is 4-7 cm
• Uterine contractions occur every 3-5 minutes and are 30-60 seconds in duration and of moderate intensity
• Mother becomes restless and anxious as contractions become stronger
• Mother may experience feeling of helplessness
• Encourage mother in maintenance of effective breathing
• Provide a quiet environment
• Inform the progress to mother and partner
• Backrubs, sacral pressure, pillow support and position changes to promote comfort
• Offer fluids and ice chips
• Instruct partner in effleurage
• Encourage voiding every 1-2 hours

Transition Phase:

• Duration: 2-4 hours in primipara and 1-2 in multipara
• Cervical dilation is 8-10 cm
• Uterine contractions occur every 2-3 minutes and are 45-90 seconds in duration and strong intensity
• Mother may becomes tired, restless, irritable, and feels out of control
• Encourage rest between contraction
• Inform the progress to mother and partner
• Provide privacy
• Offer fluids and ice chips
• Encourage voiding every 1-2 hours

Special Nursing Interventions First Stage:

• Monitor vital signs
• Monitor fetal heart rate via ultrasound Doppler, fetoscope or electronic fetal monitor
• Assess fetal heart rate before, during and after a contraction (normal FHR is 120-160 beats per minute)
• Monitor uterine contractions by palpating, determining frequency, duration, and intensity of contraction
• Assess status of cervical dilation and effacement
• Assess fetal station presentation and position by Leopold’s maneuver
• Assess the color of the amniotic fluid if the membranes have ruptured because meconium-stained fluid can indicate fetal distress