Gyne Finals

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 Abnormal or difficult labor

 Is often an indication of operative delivery with its associated complications.

 Shoulder dystocia TYPES ( 3 Ps)

a) Uterine Dystocia ( Power) - uterine contractions need to be strong, coordinated, rhythmic and intermittent to be effective b) Fetal Dystocia (Passenger) – malpresentation, malposition, or

other fetal factors such as macrosomia or shoulder dystocia. c) Pelvic Dystocia ( Passage) - fetus cannot enter or pass the bony

pelvis of the mother due to contractions of the pelvis. Types of Pelvic Contractions:

Inlet contractions Midpelvic contractions Outlet contractions

*A contracture in any of these can result in CPD.

CAUSES OF DYSTOCIA:

 Abnormalities of expulsive forces.  Abnormal presentation.

 Abnormalities of birth canal Risk Factors:

 Maternal Risks  Prolonged labor  Uterine rupture  Damage to soft tissue  Fetal Risks

 Cord prolapsed  Trauma to head Management

 Oxytocin administration if there is inadequate contractions.

 Cesarean delivery if there is abnormal fetal position. CEPHALOPELVIC DISPROPORTION

 implies disproportion between the head of the baby ('cephalus') and the mother's pelvis. Complications can occur if the fetal head is too large to pass through the mother's pelvis or birth canal.

 It is one of the commonest cause of different

complications in labor, including prolonged labor, fetal distress, and delayed second stage .

 Cephalo-pelvic disproportion (CPD) is very frequently diagnosed and is a very common indication of cesarian sections.

 But it is very difficult to diagnose CPD before a woman has started her labor pains since it is very difficult to anticipate how well the fetal head and the maternal pelvis will adjust and mould to each other.

CAUSES:

 Increased Fetal Weight:

 Very large baby due to hereditary reasons - a baby whose weight is estimated to be above 5 Kgs or 10 pounds.  Postmature baby - when the pregnancy goes above 42

weeks.

 Babies of women with diabetes usually tend to be big.  Babies of mothers who have had a number of children - each

succeeding baby tends to be larger and heavier.

 Fetal Position:

 Occipito-posterior position - In this position the fetus faces the mothers abdomen instead of her back.

 Brow presentation  Face presentation.  Problems with the Pelvis:

 Small pelvis.

 Abnormal shape of the pelvis due to diseases like rickets, osteomalacia or tuberculosis.

 Abnormal shape due to previous accidents.  Tumors of the bones.

 Childhood poliomyelitis affecting the shape of the hips.  Congenital dislocation of the hips.

 Congenital deformity of the sacrum or coccyx.  Problems with the Genital tract:

 Tumors like fibroids obstructing the birth passage.  Congenital rigidity of the cervix.

 Scarring of the cervix due to previous operations like conisation.

 Congenital vaginal septum. COMPLICATIONS:

 Dystocia  PROM

 Failure of the cervix to dilate or the fetus to descend  Extensive caput and molding

 Fetal intolerance

 Potential for birth injury related to a difficult and traumatic delivery

DIAGNOSTIC PROCEDURE:

 Clinical Pelvimetry: The assessment of the size of the pelvis is made manually by examining the pelvis and palpating the pelvic bones by vaginal examination. It is usually carried out after 37 weeks of pregnancy or at the time of the onset of labor.

 Radiological Pelvimetry: Xrays or CT scans are taken of the pelvis in different angles and views and the pelvic diameter measured. But this method is not done nowadays as it can cause radiation toxicity to the baby.

 Ultrasound: The estimation of the baby's size can be made by ultrasonogram and an assessment of potential CPD can be made when the results are compared with the clinical pelvimetry .

MEDICAL MANAGEMENT:  Asses pelvic and fetal size  Sonography

 X-ray pelvimetry

 At the point of delivery in CPD, forceps delivery or vacuum suction – to assist delivering the fetus vaginally

UTERINE INERTIA

 failure of the mother`s expulsive effort during delivery  it may develop during the first or second stage of labor TYPES:

I. Primary Uterine Inertia

 most common of the two types

 degree of inertia range from complete failure of the uterus to normal delivery with retained placenta

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 excessively large fetus

 fatty infiltration of the myometrium

 ketosis – a metabolic disease related to fat body condition, it may combine with fatty uterus producing insufficient contractions  hypocalcemia  stress  uterine ruptures  uterine tortion MANAGEMENT:

 monitor contractions and FHR

 sedation in the form of short acting barbiturates ( to promote rest, relieve pain and abnormal uterine activity)  teach the patient proper muscle control

II. Secondary Uterine Inertia  direct result of dystocia CAUSES:

 malpresentation

 prolonged unproductive labor MANAGEMENT:

 Augment labor if no CPD (amniotomy and oxytocin)  If augmentation is used, the nurse should explain that

contraction are likely to be have rapid onset and very painful. Assurance should be given.

PRECIPITATE LABOR AND DELIVERY  Unusually rapid labor (<3 hours).

 It often occurs without the benefit of asepsis. CAUSES/PREDISPOSING FACTORS:  multiparity  previous amniotomy  oxytocin administration COMPLICATIONS:  Maternal  Infection  Laceration  Uterine atony  Hemorrhage  Abruption placenta  Neonatal  Intracranial hemorrhage  Aspiration of amniotic fluid  Infection

NURSING INTERVENTION:

 Give health teaching to those multiparas that labor will be shorter than before.

 Advice patient who have history of precipitate delivery that it may happen again.

 Patient who has history of precipitate delivery and those grand multiparas must be brought to D.R before full dilatation.

RUPTURED UTERUS

 A tear in the wall of the uterus, most often at the site of previous C- section.

TYPES:

a) Mild - it occurs without symptoms and do not cause problems for the mother or fetus.

b) Severe – laceration is large, hemorrhage may occur and require a blood transfusion.

 Uterus may not be repairable and may require removal.  Risk to baby`s life due to lack of oxygen.

 Risk to mother`s life due to excessive bleeding NURSING INTERVENTION:

 Nurse requires to be alert for changes that are either reassuring or non-reassuring in nature

 Emotional and educational support

 Assessment of cervical dilatation and fetal descent  Monitor progress of labor and FHT

 Immediately report sign of fetal distress UTERINE RUPTURE PREDISPOSING FACTORS:

 Scar from previous C- section

 Women who have other kind of uterine surgery  Multiple gestation

 Placenta accreta  Overdistended uterus  Unwise used of oxytocin  Dystocia

 Trauma to the uterus SIGNS AND SYMPTOMS:

 Severe localized pain, fetal distress

 Profuse vaginal bleeding, signs of hypovolemic shock  Changes in abdominal contour (Bandl`s Ring)

 Referred pain in the mother’s chest caused by irritation to the diaphragm from internal bleeding.

MANAGEMENT:  Emergency CS

 Laparotomy or Hysterectomy  Emergency fluid replacement

LACERATIONS  Tears of the birth canal TYPES:

a) 1st Degree Laceration - involves the vaginal mucous membrane and skin of the perineum to the fourchette b) 2nd Degree Laceration - involves vagina, perineal skin, fascia,

levator ani muscle and perineal body.

c) 3rd Degree Laceration - involves the entire perineum, and reaches the external sphincter of rectum.

d) 4th Degree Laceration – involves the vagina, perineum and internal sphincter of rectum. There is fistula between rectum and vagina.

CAUSES:

 Difficult or precipitate birth  Primigravida

 Macrosomia  Manual extraction MANAGEMENT:

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 promote hot sitz bath

UTERINE ATONY

 failure of the uterine muscle to contract normally following delivery of the baby and the placenta PREDISPOSING FACTORS:  Overdistended uterus  multiple gestation  hemorrhage  polyhydramnios  macrosomia

 prolonged labor, precipitous labor, augmented labor  grand multipara  MgSO4 treatment  chorioamnionitis  halogenated anesthetics  trauma  abruptio placenta SIGNS AND SYMPTOMS:

 excessive bleeding at the time of delivery  soft or relaxed uterus

MANAGEMENT  Uterine massage  fluid replacement

 put the baby on mothers breast  eliminate bladder distention

 find sources of bleeding ( lacerations, retained placental fragments and hematomas)

 oxytocin, methergine, prostaglandin  bimanual compression of uterus  uterine vessel ligation

 hysterectomy

DIC – DISSEMINATED INTRAVASCULAR COAGULATION  Acquired disorder of blood clotting associated with

trimester bleeding in pregnancy. SIGNS AND SYMPTOMS:

 easy bruising

 bleeding from IV site, uterus, nose  s/s of shock

CAUSES:

 premature separation of placenta  hypertension during pregnancy  amniotic fluid embolism  placental retention  septic abortion  retention of dead fetus PATHOPHYSIOLOGY:

Normally platelets quickly form a seal over a point of bleeding to prevent further loss of blood. DIC occurs when there is extreme bleeding and so many platelets and fibrin from the general circulation rush to the site that there are not enough left for further clotting. The high thrombin level continues to encourage

anticoagulation, but throughout the rest of the system, bleeding defect exists.

MEDICAL MANAGEMENT:

 Heparin Therapy ( Anticoagulant) to halt the clotting; thus aid coagulation throughout the rest of the body

 Blood or Platelets Transfusion - it can be delayed until after heparin therapy so the new blood factors are also not consumed by the coagulation process.

NURSING MANAGEMENT:

 Explain her condition to the patient if she is unaware of it in order to instill and maintain confidence.

 Fetal assessment in order to evaluate the sufficiency of placental circulation.

 Referring to the physician all blood coagulation studies. NORMAL VALUES: CBC RBC= 4.2-5.4 cu/mm WBC=4500-11,000 cu/mm PLATELETS=150,000-350,000cu/mm PTT= 20-39 secs. 10-14 seconds PT= 9.5-12 secs. INR= 1.0

AMNIOTIC FLUID EMBOLISM

 a rare obstetric emergency in which the amniotic fluid, fetal cell, hair, or debris enter the maternal circulation causing cardio - respiratory collapse.

PREDISPOSING FACTORS:

 AFE is more likely in male fetus

 Condition is unpredictable unpreventable  Causes is unknown

OCCURRENCE:  During labor  During abortion

 During abdominal trauma  During amnioinfusion PATHOPHYSIOLOGY:

Amniotic fluid and fetal cells enter the maternal circulation→ this may trigger a massive anaphylactic reaction → activation of the complement cascade → progression occurs in 2 phases in phase 1 pulmonary artery vasospasm with pulmonary hypertension and elevated right ventricular pressure cause hypoxia → hypoxia causes myocardial capillary damage, left heart failure, and acute respiratory distress syndrome → death or women who survive this phase may enter phase II known as hemorrhagic phase characterized by massive hemorrhage with uterine atony and DIC.

SIGNS and SYMPTOMS:  Cough

 Hypotension - BP may drop significantly with loss of diastolic measurement

 Dyspnea – labored breathing and tachypnea may occurred  Seizure- patient may experience tonic clonic seizure  Cyanosis  Fetal bradycardia  Pulmonary edema  Cardiac arrest  Uterine atony COMPLICATIONS:

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 Left heart failure  DIC

LABORATORY STUDIES:

 ABG – changes consistent with hypoxia/hypoxemia Decreased ph levels ( Normal range 7.40-7.45) Decreased PO2 levels ( Normal range 104-108 mmHg) Increased PCO2 levels ( Normal 27-32 mmHg) Base excess increased

 CBC with platelets  HGB and HCT  PT, PTT  Blood typing  Other Test  ECG  Chest X-Ray MANAGEMENT:  treatment is supportive  oxygen and intubate if necessary

 CPR if patient arrested, perform perimortem CS if patient is not responding

 Treat hypotension

 Consider pulmonary artery catheterization in patient who are unstable

 Monitor the fetus

 Treat coagulopathy with FFP for prolonged PTT PLACENTA ACCRETA

 unusual deep attachment of the placenta to the uterine myometrium

 placenta cannot be loosen and deliver TYPES:

a) Placenta Accreta - invasion of the myometrium that does not penetrate the entire thickness of the muscle. It is the most common type.

b) Placenta Increta - the placenta extends into the muscles of the uterine wall

c) Placenta Pincreta – placenta penetrates the entire uterine wall. It can lead to the placenta attaching to other organs such as the bladder.

PREDISPOSING FACTORS:  placenta previa  previous CS delivery  advance maternal age

 placental location overlying previous uterine scar  previous multiple pregnancies

 previous uterine surgery  previous D&C

 rate of incidence is higher when the fetus is female according to studies COMPLICATION:  rupture uterus MANAGEMENT:  bedrest  curettage

 oversewing of placenta bed

 occluding the blood vessel that supply the pelvis

 scheduled delivery by CS

 Methotrexate –to destroy the still attached tissue  Hysterectomy

CAESAREAN DELIVERY TYPES:

a) Classical Caesarean section involves a midline longitudinal incision which allows a larger space to deliver the baby. However, it is rarely performed today as it is more prone to complication.

b) Lower uterine segment section is the procedure most commonly used today; it involves a transverse cut just above the edge of the bladder and results in less blood loss and is easier to repair.

c) Emergency Caesarean section is a Caesarean performed once labor has commenced.

d) Crash Caesarean section is a Caesarean performed in an obstetric emergency, where complications of pregnancy onset suddenly during the process of labor, and swift action is required to prevent the deaths of mother, child(ren) or both.

e) Caesarean hysterectomy consists of a Caesarean section followed by the removal of the uterus. This may be done in cases of intractable bleeding or when the placenta cannot be separated from the uterus. Traditionally other forms of Caesarean section have been used, such as extraperitoneal Caesarean section or Porro Caesarean section.

f) Repeat Caesarean section is done when a patient had a previous Caesarean section. Typically it is performed through the old scar

DILATATION AND CURETTAGE (D & C)

 a gynecological procedure in which the cervix is dilated (expanded) and the lining of the uterus (endometrium) is scraped away.

 used to diagnose and treat heavy or irregular bleeding from the uterus.

PUERPERIAL INFECTION

 an infection that may be acquired during labor and delivery but signs and symptoms are manifested during post partal period.

PREDISPOSING FACTORS:  PROM

 retained placental fragment tissue necroses and serves as an excellent bed for bacterial growth

 trauma during labor  anemia

 prolonged and difficult labor

 contaminated internal fetal heart monitor  local vaginal infection present at the time of birth  manual exploration

 break in aseptic technique (most common)  Coitus at the latter period of pregnancy PRIMARY SOURCE OF INFECTION:

 Endogenous - bacteria inside the normal flora becomes virulent

 Exogenous - pathogens was introduced by excessive obstetric manipulation

Anaerobic Streptococci- organism usually found at the site of infection

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 pain heat and pressure at the perineum  inflammation of the suture line with pus  with or without elevated temperature  foul smelling vaginal discharge  thrombophlebitis COMPLICATIONS:  pulmonary abscess  pelvic cellulites  generalized peritonitis PREVENTION:

 well balanced diet

 avoid coitus in late pregnancy

 separation of infected patient from non- infected patients  strict aseptic technique

 proper perineal care

 good handwashing technique to prevent cross- contamination

NURSING MANAGEMENT:

 remove the suture to drain the area  antibiotic therapy as ordered  hot sitz bath or warm compress

 instruct the mother to observe for problem in their infant (such as oral candida) This occur due to portion of maternal antibiotic passes into breast

 Milk and can cause the overgrowth of fungal organism in an infant

ENDOMETRIOSIS  from endo, "inside", and metra, "womb"

 is a medical condition in females in which endometrial like cells appear and flourish in areas outside the uterine cavity, most commonly on the ovaries.

 The uterine cavity is lined by endometrial cells, which are under the influence of female hormones. These

endometrial-like cells in areas outside the uterus (endometriosis) are influenced by hormonal changes and respond similarly as do those cells found inside the uterus. Symptoms often worsen in time with the menstrual cycle. SIGNS AND SYMPTOMS:

 Pelvic pain

dysmenorrhea – painful, sometimes disabling cramps; pain may get worse over time (progressive pain), also lower back pains linked to the pelvis

chronic pelvic pain – typically accompanied by lower back pain or abdominal pain

dyspareunia – painful sex

dyschezia – painful bowel movements

dysuria – urinary urgency, frequency, and sometimes painful voiding

 Infertility

 nausea, vomiting, fainting, dizzy spells, vertigo or diarrhea— particularly just prior to or during the period or after  frequent or constant menses flow

 chronic fatigue

 heavy or long uncontrollable menstrual periods with small or large blood clots

 some women may also suffer mood swings

 extreme pain in legs and thighs  back pain

 mild to extreme pain during intercourse  extreme pain from frequentovarian cysts

 pain from adhesions which may bind an ovary to the side of the pelvic wall, or they may extend between the bladder and the bowel,uterus, etc

 extreme pain with or without the presence of menses  mild to severe constipation [5]

 premenstrual spotting  mild to severe fever COMPLICATIONS:

 Internal scarring  Adhesions  Pelvic cysts

 Chocolate cyst of ovarys  Ruptured cyst

 Blocked bowel/bowel obstruction TREATMENT:

Hormonal medication

 Progesterone or Progestins: Progesterone counteracts estrogen and inhibits the growth of the endometrium. Such therapy can reduce or eliminate menstruation in a controlled and reversible fashion. Progestins are chemical variants of natural progesterone.

 Avoiding products with xenoestrogens, which have a similar effect to naturally produced estrogen and can increase growth of the endometrium.

 Hormone contraception therapy: Oral contraceptives reduce the menstrual pain associated with endometriosis. They may function by reducing or eliminating menstrual flow and providing estrogen support. Typically, it is a long-term approach.

 Danazol (Danocrine) and gestrinone are suppressive steroids with some androgenic activity. Both agents inhibit the growth of endometriosis but their use remains limited as they may cause hirsutism and voice changes.

 Gonadotropin Releasing Hormone (GnRH) agonist: These agents work by increasing the levels of GnRH. Consistent stimulation of the GnRH receptors results in downregulation, inducing a profound hypoestrogenism by decreasing FSH and LH levels. While effective in some patients, they induce unpleasant menopausal symptoms, and over time may lead to osteoporosis. To counteract such side effects some estrogen may have to be given back (add-back therapy). These drugs can only be used for six months at a time.  Lupron depo shot is a GnRH agonist and is used to lower the

hormone levels in the woman's body to prevent or reduce growth of endometriosis. The injection is given in 2 different doses a once a month for 3 month shot with the dosage of (11.25 mg) or a once a month for 6 month shot with the dosage of (3.75 mg).

 Aromatase inhibitors are medications that block the formation of estrogen and have become of interest for researchers who are treating endometriosis.

VAGINAL FISTULA

 an abnormal passage that connects the vagina to other organs, such as the bladder or rectum, resulting in leakage of urine or feces into the vagina.

 could also be described as a hole in the vagina that allows stool or urine to pass through the vagina.

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 Vesicovaginal fistulas, also called bladder fistulas, occur between the vagina and urinary bladder. This is the most common type of vaginal fistula.

 Uterovaginal fistulas occur between the vagina and distal ureter (ureters are ducts that carry urine from the kidney to the bladder)

 Urethrovaginal fistulas, also called urethral fistulas, occur between the vagina and urethra (tube that carries urine out of the body)

 Rectovaginal fistulas, also called rectal fistulas, occur between the vagina and the rectum

CAUSES:

 Childbirth  Prolonged labor  Pelvic surgery

 Pelvic radiotherapy - such as for pelvic cancer ENDOMETRITIS

 A scant, serosanguineous discharge with a foul odor can result from bacterial invasion of the endometrium. Associated findings include fever, lower back and abdominal pain, abdominal muscle spasm, malaise, dysmenorrhea, and an enlarged uterus.

URINARY TRACT INFECTION ( UTI )  infection that begins in urinary system

 serious consequences can occur if infection spreads to kidneys (Pyelonephritis)

 women are most at risk of developing UTI due to short urethra

 antibiotic are the typical treatment SIGNS AND SYMPTOMS:

 a strong persistent urge to urinate  a burning sensation when urinating  passing frequent, small amount of urine

 blood in the urine, or cloudy, strong smelling urine

Acute Pyelonephritis - kidney infection characterized by upper back and flank pain, high fever, shaking chills, and nausea and vomiting. Cystitis - inflammation of the bladder characterized by pelvic pressure, lower abdomen discomfort, frequent painful urination and strong smelling urine

Urethritis - inflammation of the urethra leads to burning with urination

CAUSES:

 bacteriuria- bacteria enter the urinary tract through the urethra and begin to multiply in the bladder.

 cystitis may occur in women after sexual intercourse  proximity of the anus to the urethra

RISK FACTOR:

 women who are sexually active- sexual intercourse can irritate the urethra

 women who use diaphragms for birth control  women who use spermicidal agent

 after menopause- tissue of the vagina, urethra and the base of the bladder become thinner and fragile due to loss of estrogen

 diabetes and other chronic illnesses that may impair the immune system

 chronic cortisone therapy or chemotherapy- it lowers immunity

 prolonged use of tubes in the bladder (catheters) SCREENING AND DIAGNOSIS:

 Urinalysis - to determine if pus, red blood cells or bacteria are present

 Urine Culture- can reveal if there is an infection CHLAMIDIAL INFECTION

 causes a yellow, mucopurulent, odorless, or acrid vaginal discharge. Other findings include dysuria, dyspareunia, and vaginal bleeding after douching or coitus, especially following menses. Many women remain asymptomatic. CHANCROID

 a rare but highly contagious sexually transmitted disease — produces a mucopurulent, foul-smelling discharge and vulvar lesions that are initially erythematous and later ulcerated. Within 2 to 3 weeks, inguinal lymph nodes (usually unilateral) may become

 tender and enlarged, with pruritus, suppuration, and spontaneous drainage of nodes. Headache, malaise, and fever to 102.2° F (39° C) are common.

ATROPHIC VAGINITIS

 a thin, scant, watery white vaginal discharge may be accompanied by pruritus, burning, tenderness, and bloody spotting after coitus or douching. Sparse pubic hair, a pale vagina with decreased rugae and small hemorrhagic spots, clitoral atrophy, and shrinking of the labia minora may also occur.

BACTERIAL VAGINOSIS

 formerly called Gardnerella vaginalis and Haemophilus vaginalis

 results from an ecozogic disturbance of the vaginal flora. Causing a thin, foul-smelling, green or gray-white discharge, it adheres to the vaginal walls and can be easily wiped away, leaving healthy-looking tissue.

 Pruritus, redness, and other signs of vaginal irritation may occur but are usually minimal.

CANDIDIASIS

 Infection with Candida albicans causes a profuse, white, curdlike discharge with a yeasty, sweet odor. Onset is abrupt, usually just before menses or during a course of antibiotics. Exudate may be lightly attached to the labia and vaginal walls and is commonly accompanied by vulvar redness and edema. The inner thighs may be covered with a fine, red dermatitis and weeping erosions. Intense labial itching and burning may also occur. Some patients experience external dysuria.

HERPES SIMPLESX (genital)

 A copious mucoid discharge results from herpes simplex, but the initial complaint is painful, indurated vesicles and ulcerations on the labia, vagina, cervix, anus, thighs, or

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lymph nodes may occur with fever, malaise, and dysuria. GENITAL WARTS

 are mosaic, papular vulvar lesions that can cause a profuse, mucopurulent vaginal discharge, which may be foul-smelling if the warts are infected.

 Patients frequently complain of burning or paresthesia in the vaginal introitus.

GONORRHEA

 Although 80% of women with gonorrhea are asymptomatic, others have a yellow or green, foul-smelling discharge that can be expressed from Bartholin’s or Skene’s ducts.

 Other findings include dysuria, urinary frequency and incontinence, bleeding, and vaginal redness and swelling. Severe pelvic and lower abdominal pain and fever may develop.

TRICHOMONIASIS

 can cause a foul-smelling discharge, which may be frothy, green-yellow, and profuse or thin, white, and scant.  Other findings include pruritus; a red, inflamed vagina with

tiny petechiae; dysuria and urinary frequency; and dyspareunia, postcoital spotting, menorrhagia, or dysmenorrhea.

 About 70% of patients are asymptomatic. GYNECOLOGIC CANCER

 Endometrial or cervical cancer produces a chronic, watery, bloody or purulent vaginal discharge that may be foul-smelling.

 Other findings include abnormal vaginal bleeding and, later, weight loss; pelvic, back, and leg pain; fatigue; urinary frequency; and abdominal distention. INFERTILITY

 Refers to biological inability of a person to contribute to conception

 Also a state of a woman who is unable to carry pregnancy to full term CAUSES:  Genetic factor  General Factor  Diabetes  Thyroid disorder  Adrenal disease

 Hypothalamic- pituitary factor  Environmental Factor  smoking  Toxins  Causes Female  Hormonal imbalance  Ovulation problems  Endometriosis  Age related factor  Previous tubal ligation  Over or underweight  Tubal blockage