Video 1: Treatment

Psychiatric Disorders in Pregnancy - ● Psychotherapy and SSRIs (works best

Obstetrics together)

POSTPARTUM BLUES POSTPARTUM PSYCHOSIS

Epidemiology Epidemiology
● 50-80% of pregnancies - < 1% of pregnancies
Symptoms Symptoms
● Guilt, crying, overwhelmed - Visual or auditory hallucinations
Onset Onset
● Birth - 2 weeks - 2 weeks - 1 year
Treatment Treatment
● Resolves spontaneously - Antipsychotics under care of a
psychiatrists
POSTPARTUM DEPRESSION Note: if any patients complain of homicidal or
Risk Factors: suicidal ideations, that patient needs to be
● Hx of depression or postpartum referred to the emergency room for immediate
depression hospitalization
● Poor social support
● If baby has health problems (or another
child has problems)
● Difficulty breastfeeding (this helps
against pp depression)
● Financial difficulties
Epidemiology
● 15-25% of pregnancies (but may be
higher, bc of poor diagnosis)
- Edinburgh Postnatal
depression scale to diagnose
from 2 weeks to a year;
self-administered
questionnaire; how well they
cope as a mom
Symptoms
● Inability to cope, disinterest in self or
child (and normal activities)
Onset
● 2 weeks - 1 year after delivery
Video 2:
Preeclampsia vs Eclampsia
PREECLAMPSIA
● Affects pregnant women
○ After 20 weeks gestation
○ Up to 6 weeks after delivery
● New onset Hypertension
● Proteinuria = markers of:
○ Kidney damage
○ Damage to other organs
○ Symptoms can be:
■ Mild
■ Life-threatening
● Risk factors:
○ 1st pregnancy
○ Multiple gestations
○ Mothers >35 yo
○ HPN
○ Diabetes
○ Obesity
○ Family hx
**PREECLAMPSIA + SEIZURES = ECLAMPSIA
Epidemiology:
● Exact cause is unclear
● key pathophysiologic feature is the
development of an abnormal placenta
○ Normally, the spiral arteries
dilate to 5-10 times their size
and develop into large
uteroplacental arteries
■ Delivers lots of blood to
the fetus
● preeclampsia, these spiral arteries
becomes fibrous > narrows > less blood
> poorly perfused placenta:
○ Intrauterine growth retardation
○ Fetal death
○ Releases proinflammatory
proteins w/c enters mother’s
circulation > her blood vessels
to become dysfunctional
(endothelial cell) >
vasoconstriction and kidneys
retain more salt = hypertension
Diagnosing:
Preeclampsia:
- Systolic = >140 mmHg
- Diastolic = >90 mmHg
Severe preeclampsia
- Systolic = >160 mmHg
- Diastolic = >110 mmHg
Theses can all lead:
hemorrhagic stroke or placental abruption
(placenta detaches from uterus prematurely)
Symptoms:
- Local vasospasm; reduced blood flow
to:
- kidneys > glomerular damage >
oliguria and proteinuria
- Retina > blurred vision or
seeing flashing lights and
scotoma (small part of visual
field has a low visual acuity)
- Liver > injury and swelling >
elevation of liver enzymes >
stretches capsules around liver
> right upper quadrant
pain/epigastric (cardinal
symptom of severe
preeclampsia)
 - Endothelial injury:
1. Formation of tiny thrombi (blood
clots)in the microvasculature; uses up
massive amounts of platelets
- Over time, RBCs slam
up against the clot and
get destroyed =
hemolysis
- Makes up the HELLP
syndrome:
- Hemolysis
- Elevated
- Liver enzymes
- Low
- Platelets
- HELLP: in 10-20% of
women with
preeclampsia or
eclampsia
2. Increases vascular permeability, allows water
to slip out of blood vessels and get into the
tissues
- Bc there's a loss of protein from blood
d/t proteinuria, even more fluid moves
from the blood vessels to the tissues
- Causes:
- Generalized edema: legs, face,
hands
- Pulmonary edema: causes
cough and shortness of breath
- Cerebral edema: headaches,
confusion and seizures
(eclampsia)
Treatments:
● Delivery of fetus and placenta
○ Depends on:
■ Gestational age of fetus
■ Severity of disease
● Manage symptoms after delivery
○ Symptoms subside on their
own
● Additional measures
○ Supplemental oxygen
○ Medications (for seizures,
placental abruption, strokes)
Video 3:
Postpartum Hemorrhage
● Significant blood loss after giving birth
● #1 reason for maternal morbidity and
death
● Losing 500mL after vaginal delivery; or
● Losing >1000mL after a CS delivery
*it is difficult to measure actual amount of
blood loss like internal bleeding, thus there are
more criteria:
- Decrease at least 10% of hematocrit
from baseline
- Changes in mother’s:
- Heart rate
- BP
- O2 sat
Primary postpartum hemorrhage: significant
bleeding w/in 24 hrs
Secondary or Late postpartum hemorrhage:
after 24 hours
Causes:
1. Tone
● Main cause of pp hemorrhage
● Lack of uterine tone (aka uterine atony)
○ Soft, spongy, boggy, uterus
○ Slow and steady loss of blood
● Uterus fails to contract after birth >
arteries don’t clamp down > excessive
bleeding
 ● Causes:
○ Related distention
■ Multiple pregnancies
■ Overstretching from
twins/triplets
○ Muscle fatigue from delivery
○ Unable to empty bladder
(pushes on uterus)
○ Obstetric medications
■ Anesthetics (ex:
halothane)
■ Magnesium sulfate,
nifedipine, terbutaline
● Treatment:
○ Final massage
■ Smooth muscles
contract
○ Urinate (or have catheter
placed)
○ Medications
○ Surgery
Normal:
*myometrium (smooth muscle) normally
contracts during labor to dilate and efface the
cervix to push out the fetus
*Myometrium continues to contract after
delivery and squeezes the placental arteries,
clamping them shut and reduces uterine
bleeding
2. Trauma
● Damage to genital structures (uterus
cervix vagina, perineum)
● From:
○ Incision from CS
○ From baby coming through
vaginal canal
■ Forceps
■ Vacuum extraction
■ Episiotomy
○ Hematoma formation
(mass/collection of blood) but
can be hard to diagnose in
spite of a firmly contracted
uterus
■ S/S: severe pain and
persistent bleeding
● Treated as an emergency
○ Site repaired right away
○ Apply pressure
○ Stitch lacerations
3. Tissue
● Placental fragments retained in uterine
cavity
● 1. Placenta accreta
○ Placenta invades myometrium
○ Does not easily separate
● 2. Traction on umbilical cord
○ Both retains placenta >
prevents contraction > uterine
atony
● Goal:
○ Make sure retained placenta
comes out intact
○ Remove retained tissue ASAP
Normal:
*the entire placenta separates from uterine wall
in 3rd stage of labor
4. Thrombin
● Has blood clotting condition
● Can be:
○ Genetic (ex: Von Willebrand
disease)
○ Obstetric (ex: eclampsia,
placental abruption)
 ● Can lead to Disseminated Intravascular
Coagulation (DIC)
○ Condition that prevents normal
clot formation
○ Can turn a tiny bleed to a
serious problem
● Treatment:
○ Specific to the underlying
cause
Postpartum hemorrhage
● = OB emergency
● Key: maintain adequate circulating
volume
○ IV
○ Blood products
● Most common cause of maternal
morbidity and mortality
● Cause: 4 T’s (tone, trauma, tissue,
thrombin)
○ Most common: uterine atony
(tone)
■ Fundal massage or
meds to contract
Video 4:
Shoulder Dystocia
SHOULDER DYSTOCIA
● Complication of vaginal delivery
● An obstetric emergency
● Occurs after a delivery of fetal head,
additional maneuvers are needed to
deliver the fetal shoulders
● Occurs in 1% of births
● Anterior:
○ More common
○ Caused by impaction at
maternal pubic symphysis
● Posterior:
○ Less common
○ Caused by impaction at
maternal sacral promontory
● Risk factors:
○ Maternal DM
○ Suspected macrosomia
○ Gestational age >42 weeks
○ Previous shoulder dystocia
○ Operative delivery
● Over 50% of cases are not predictable
or have no risk factors
Diagnosis:
● Routine practice of gentle downward
traction of the fetal head fails to deliver
the anterior shoulder
● Diagnose it as soon as it occurs
Goal of management:
● Deliver the infant before asphyxia from
umbilical cord compression occurs, w/o
causing any fetal/maternal trauma
Management: (ALARMER)
A - ask for help
● Pull alarm bell or ask a team member
to call for more staff
L - legs hyperflexed
● McRoberts maneuver: px legs flexed
all the way back so her thighs are
against her abdomen
● This rotates the pubis symphysis and
flattens the sacrum to relieve
obstruction up to 42% of pxs
A - apply suprapubic pressure and anterior - it is possible for shoulder dystocia resolves
shoulder disimpaction after the 1st step
● A team member stands on a stool and - only move onto next step if doesn’t resolve
then uses their palm or fist to apply - each step becomes more invasive and
requires more skill
downward and lateral pressure
suprapubicly
Last Resort Options (increases morbidity)
● This adducts and rotates the fetal
● Fracture of the fetal clavicle
shoulders to disimpact the anterior
● Zavanelli Maneuver (returning fetal
shoulder
head and attempting CS delivery)
● Another way to disimpact the anterior
● Symphysiotomy (separation of the
shoulder is the Rubin maneuver
maternal pubic bones)
○ Place 1 hand into the vagina
and on the back surface of the
Key Points
posterior fetal shoulder and
1. Shoulder dystocia is an obstetrical
rotating it anteriorly to
emergency
disimpact the anterior shoulder
2. diagnosis : routine downward traction
R - release the posterior shoulder
of fetal head fails to deliver anterior
● 1 hand in vagina after finding the fetal
shoulder
arm, flex the elbow across the chest to
3. ALARMER acronym to remember
grasp the forearm or hand and pull it
management of dystocia
out of the vagina
● If you can’t deliver the fetal arm, it may
Video 5:
be possible to deliver the shoulder
Fetal Positions
M - maneuver of woods
● Aka ‘Screw Maneuver’ bc you try to
*these positions can be predicted by a
rotate the fetus or unscrew it by putting
thorough abdominal examination
pressure on the clavicle of the posterior
shoulder and rotating it until it
Longitudinal presentation
becomes anterior
↳ Breech
E - episiotomy
↳ Cephalic (moves clockwise)
● Surgical cut at the opening of the
1. Right occipito-anterior
vagina to allow more room and better
2. Right occipito-transverse
access to the posterior arm
3. Right occipito-posterior
R - roll onto all fours
4. Occipito-posterior
● Px is onto her hands and knees in an
5. Left occipito-posterior
effort to take advantage of gravity to
6. Left occipito-transverse
facilitate delivery
7. Left occipito-anterior
8. Occipito-anterior
 ↳ Transverse FETAL PRESENTATION
1. Right transverse - The fetal body part that occupies the
2. Left transverse lower bowl of the uterus and thereby
↳ Oblique enters the pelvic passage first
1. Right oblique - This is determined by fetal lie
2. Left oblique - 3 types:
1. Vertex presentation (cephalic)
Video 6: 2. Breech presentation (podalic)
Fetal Lie, Position and Presentation 3. Shoulder presentation (shoulder)

Mechanism of Labor: The Journey 1. Types of Cephalic Presentation

● Occiput or vertex presentation
Basic Obstetric Terminology ○ Occiput is the presenting part
FETAL LIE ○ 3 types:
- the relationship of the cephalo-caudal ■ Occiput transverse
axis or long axis (spinal column) of the presentation (left or
fetus to the long axis of the centralized right)
or maternal spine ■ Occiput anterior
- 3 types: presentation (left or
1. Longitudinal right)
- Both fetal and maternal long ● The sagittal
axis are parallel to each other sutures lie in 1
- Can be wither cephalic or of the oblique
breech diameters of
2. Transverse the pelvic inlet
- Fetal and maternal long axis
are perpendicular to each other
3. Oblique
- Fetal and maternal long axis
cross each other at an angle of
45 degrees
- Usually unstable and becomes
longitudinal or transverse
during the course of labor
■ Occiput posterior
presentation (left or
right)
● Brow presentation
● Face presentation
 ● Sinciput presentation
*depends on the degree of flexion of the fetal
head
2. Types of Breech Presentation
● Complete Breech: buttocks presented
first with flexed hips and flexed knees,
feet are not below the buttocks
● Footling: one or both feet present at the
birth canal as both hips and knees in
extended position
● Frank Breech: buttocks present first
with flexed hips and legs are extended
on the abdomen
3. Types of Shoulder Presentation
- transverse lie is an abnormal fetal
presentation in which the fetus lies
transversely with the shoulders
presenting in the lower pole of the
uterus; long axis of the fetus is
perpendicular to maternal spine
● Presenting part is the fetal shoulder
● The denominator is the fetal scapula
depending on whether the position of
fetal scapula is anterior, posterior,
superior or inferior
● 2 positions are possible:
1. Dorsoanterior position
- Most common position
- Fetal scapula lies
anteriorly
2. Dorsoposterior position
- Fetal scapula lies
posteriorly
3. Dorso Superior position
- Fetal scapula is
directed superiorly
4. Dorso Inferior position
- Fetal back is directed
inferiorly depending on
the position of the fetal
head; fetal position can
be described as right or
left
PRERECORDING 1: Therapeutic Management:
ANTENATAL COMPLICATIONS - Immediately an EMERGENCY
SITUATION
PLACENTA PREVIA - Fluid replacement
- A condition in pregnancy in which the - Oxygen by mask
placenta is implanted abnormally in - Keep client in a lateral position
the lower part of the uterus - Do not perform vaginal or abdominal
- A sonogram can be used to detect it exam
during the FIRST trimester - Perform surgery: Hysterectomy if case
is severe
S/Sx:
- Low lying placenta detected on GESTATIONAL HYPERTENSION
sonogram - Is a condition in which vasospasm
- Abrupt, painless, bright red bleeding occurs in both small and large arteries
during pregnancy, causing signs of
Therapeutic Management: increased blood pressure, proteinuria,
- Inspect the perineum for bleeding and and edema
estimate the rate of blood loss
- Weigh perineal pads before and after S/Sx:
use - High blood pressure
- Obtain baseline vital signs and assess - Proteinuria
blood pressure every 5-15 minutes - Edema
- Administer IVF as prescribed - Blurry vision
- Headache

ABRUPTIO PLACENTAE
- The premature separation of the CLASSIFICATION:
placenta that generally occurs late in - Preeclampsia
pregnancy - Severe preeclampsia
- Identified 3rd trimester - Eclampsia

S/Sx: Therapeutic Management:

- Sharp, stabbing pain in the uterine - Promote bed rest
fundus - Promote good nutrition
- Tenderness in the uterine fundus upon - Provide emotional support
palpation - Monitor fetal well-being
- Tense, rigid uterus - Administer medications as prescribed
GESTATIONAL DIABETES PRERECORDING 2:
- Is a diabetes during pregnancy which INTRANATAL COMPLICATIONS
causes high blood sugar that can affect
pregnancy and the baby’s health PROBLEMS WITH FETAL POSITION,
PRESENTATION, AND SIZE
S/Sx:
- Increased thirst Occipitoposterior Position
- Frequent urination ● The position is posterior rather than
- Hyperglycemia anterior
- Dizziness if hypoglycemic ● The occiput is directed diagonally and
posteriorly

Therapeutic Management: Breech Presentation

- Keep glucose level near normal ● Is when the fetus is lying longitudinally
- Administer insulin and its buttocks
- Close fetal monitoring → especially for ● Frank, footling, or complete
hypothermia
- Lifestyle changes Face Presentation
- Proper diet ● Potentially dangerous fetal
presentation in which the baby is likely
PRETERM LABOR to enter the birth canal face first
- Labor that occurs before the end of
week 37 of gestation Brow Presentation
- PROM → before labor; PPROM → ● Rare presentation, has the chin
before 37 wks untucked and the neck is extended
slightly backward
S/Sx:
- Constant, low, dull back pain Transverse Lie
- Sensation of lower abdominal pressure ● Occurs in women with pendulous
- Vaginal spotting or light bleeding abdomen or with hydramnios; it may
also occur in prematurity if the infant
Therapeutic Management: has room for free movement or in
- Administer tocolytic medications as multiple gestations
prescribed
- Complete bed rest
- Monitor fetal well-being
- Administer IVF for hydration
- DOC: Magnesium Sulfate → relax
uterine muscles
Macrosomia ➢ Management:
● Fetus who weighs more than 1. Attempt fundal
4,000-4,500 grams massage
● If the baby is oversized, he/she cannot 2. Administer medication
be born vaginally; a CS birth becomes as prescribed
the birth method of choice 3. Elevate lower
extremities to improve
Prolapse of the Umbilical Cord circulation
● A loop of the cord slips down in front of 4. Administer oxygen by
the presenting fetal part face mask
● May occur at any time after the 5. Obtain vitals and assess
membrane rupture if the presenting for decreasing BP and
part is not fitted firmly into the cervix rising pulse rate →
assess for signs of
Therapeutic Management: shock
- Relieve cord compression 2. Lacerations
- Place client in knee-chest or ➢ Small lacerations may be
trendelenburg considered a normal
- Administer oxygen by face mask consequence; large lacerations
- Tocolytic agent as prescribed however, can be sources of
- Cover exposed portion with a sterile infection or hemorrhage
saline compress
➢ Types:
PRE RECORDING 3: 1. Cervical laceration
POSTNATAL COMPLICATIONS 2. Vaginal lacerations
3. Perineal lacerations
Postpartum Hemorrhages
● One of the primary causes of maternal ➢ Management:
mortality associated with childbearing 1. Lacerations are sutured
● A major threat during pregnancy, and repaired
throughout labor and continuing into 2. Proper diet and good
postpartum period nutrition
3. Perineal care to prevent
Causes: infection
1. Uterine Atony 4. Encourage ambulation
➢ Known as the relaxation of the to hasten wound
uterus; the most frequent healing
cause of postpartum
hemorrhage
3. Retained Placental Fragments
➢ When placenta does not detach
in its entirety so fragments of it
separate and are left still
attached to the uterus
➢ Management:
1. Removal of retained
fragment is necessary
to stop bleeding
2. Medication may be
prescribed to destroy
the retained fragment
→ Oxytocin
3. Observe for change of
color of lochial
discharge → main
indicator for retained
placental fragments
4. Assess for presence of
profuse bleeding
➢ Management:
1. The underlying
condition must be
identified and
corrected
2. Transfuse platelet and
clotting factors to
replace depleted blood
component and stop
bleeding
3. Administer blood
thinner to prevent
blood clotting

4. Disseminated Intravascular
Coagulation
➢ A deficiency in clotting ability
caused by vascular injury
➢ May occur in the postpartal
period, but usually associated
with premature separation of
the placenta, early miscarriage,
or fetal death in utero