Labor & Postpartum Complications

Comprehensive Study Guide - Modules 7 & 8

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1. Premature Rupture of Membranes (PROM)

⚠️ Critical Point

Yellow or cloudy amniotic fluid = INFECTION (chorioamnionitis). This is your #1 concern!

Remember: Clear fluid ≠ No infection. Always assess comprehensively!

Classifications & Definitions

Type Definition Incidence Key Concerns
Term PROM ROM before labor onset at ≥37 weeks 8-10% of term pregnancies • 90% labor within 24h
• Infection risk increases after 18h
Preterm PROM (PPROM) ROM before 37 weeks 3% of all pregnancies • Accounts for 30% of preterm births
• Major cause of neonatal morbidity
Prolonged ROM ROM >18 hours before delivery Variable • Significant infection risk
• Requires antibiotic prophylaxis

Comprehensive Assessment Tools

Test Procedure Positive Result Clinical Pearls
Nitrazine Test Apply fluid to nitrazine paper Blue/Purple (pH 7.0-7.5) • False (+): Blood, semen, alkaline urine, BV
• False (-): Small leak, remote rupture
Ferning Test Dry fluid on slide, microscope exam Fern/tree branch pattern • Most specific test
• False (+): Fingerprints, cervical mucus
Visual Pooling Sterile speculum exam Fluid in posterior fornix • Ask patient to cough/bear down
• Look for fluid from cervical os
AmniSure® Immunoassay for PAMG-1 Two lines on test strip • 99% accurate
• Results in 10 minutes
• Not affected by blood/semen
Ultrasound Measure amniotic fluid index AFI <5 or MVP <2cm • Supportive, not diagnostic
• May be normal with small leak

Term PROM (≥37 weeks)

  • Expectant management: Up to 12-24 hours if GBS negative
  • Active management: Immediate induction if:
    • GBS positive or unknown
    • Signs of infection
    • Meconium-stained fluid
    • Patient preference
  • Antibiotics: Start if ROM >18 hours or GBS positive

Preterm PROM Management

Gestational Age Primary Goal Management
<24 weeks Counseling • Discuss poor prognosis
• Option for expectant management or termination
• Document thoroughly
24-31 weeks Prolong pregnancy • Antibiotics (7-day course)
• Corticosteroids
• Magnesium for neuroprotection
• Expectant management
32-33 weeks Balance risks • Corticosteroids if not given
• Consider delivery vs expectant
• Document lung maturity if available
34-36 weeks Delivery usually • Corticosteroids controversial
• GBS prophylaxis
• Most deliver within 24-48h

Antibiotic Protocols

Standard 7-Day Regimen for PPROM

IV × 48 hours:

  • Ampicillin 2g IV q6h AND
  • Erythromycin 250mg IV q6h

Then PO × 5 days:

  • Amoxicillin 250mg PO q8h AND
  • Erythromycin 333mg PO q8h

GBS Prophylaxis Protocol

Intrapartum GBS Prophylaxis

First choice: Penicillin G 5 million units IV load, then 2.5-3 million units IV q4h

Alternative: Ampicillin 2g IV load, then 1g IV q4h

PCN allergy (low risk): Cefazolin 2g IV load, then 1g IV q8h

PCN allergy (high risk): Clindamycin 900mg IV q8h OR Vancomycin 1g IV q12h

Chorioamnionitis Diagnostic Criteria

Clinical Diagnosis: Maternal fever PLUS one of:

  • Maternal WBC >15,000/mm³
  • Maternal tachycardia >100 bpm
  • Fetal tachycardia >160 bpm
  • Uterine tenderness
  • Foul-smelling amniotic fluid

Triple I Classification (2017)

Category Criteria Management
Isolated Maternal Fever Temp ≥39°C (102.2°F) once OR
38-38.9°C (100.4-102°F) twice 30min apart		 • Evaluate for sources
• Consider antibiotics
• Continue labor
Suspected Triple I Fever + ONE clinical sign • Start antibiotics
• Expedite delivery
• Notify pediatrics
Confirmed Triple I All criteria met OR positive amniotic fluid culture • Immediate antibiotics
• Delivery ASAP
• NICU team present

Monitoring Protocol

Q2H Assessment Includes:

  • Maternal temperature (oral or tympanic)
  • Maternal pulse and BP
  • FHR pattern and baseline
  • Uterine tenderness (between contractions)
  • Character of amniotic fluid
  • Maternal WBC if febrile

Cord Prolapse Risk

High-Risk Situations for Cord Prolapse with PROM:

  • Breech presentation
  • Transverse lie
  • Polyhydramnios
  • Unengaged presenting part
  • Multiple gestation

Prevention: Keep patient on bedrest until presenting part engaged

Pulmonary Hypoplasia Risk

GA at PPROM Risk Level Key Points
<16 weeks Very High • Lethal in most cases
• Counsel about prognosis
16-23 weeks High • Depends on fluid level
• Serial ultrasounds needed
24-28 weeks Moderate • Better prognosis
• Steroids crucial
>28 weeks Low • Rare complication
• Focus on infection prevention

Patient Education Points

Teaching Checklist

  • ✓ Signs of infection to report immediately
  • ✓ Importance of temperature monitoring
  • ✓ Activity restrictions (pelvic rest)
  • ✓ When to return to hospital
  • ✓ Pad count technique (weigh pads)
  • ✓ No tampons, douching, intercourse
  • ✓ Kick counts if appropriate GA
PROM Assessment: "COAST"

Color of fluid (clear, yellow, green, bloody)
Odor (foul = infection)
Amount (trickle vs gush)
Sterile speculum exam
Time of rupture

2. Preterm Labor

Definition & Impact

Preterm Labor: Regular contractions (≥4 in 20 min or ≥8 in 60 min) with cervical changes before 37 weeks

Impact: Accounts for 75% of neonatal mortality and 50% of long-term neurologic impairment

Risk Factor Assessment Tool

Risk Category Specific Factors Relative Risk Screening/Prevention
History • Previous preterm birth
• Previous 2nd trimester loss
• Uterine anomaly
• DES exposure		 2-4x increased • Serial cervical length
• Progesterone therapy
• Cerclage consideration
Current Pregnancy • Multiple gestation
• Polyhydramnios
• Vaginal bleeding
• Abdominal surgery		 2-3x increased • Increased surveillance
• Activity modification
• Corticosteroids ready
Maternal Factors • Age <17 or >35
• BMI <19
• Short interval (<6mo)
• Substance use		 1.5-2x increased • Nutritional counseling
• Smoking cessation
• Social support
Infections • UTI/pyelonephritis
• Bacterial vaginosis
• Periodontal disease
• STIs		 2x increased • Routine screening
• Prompt treatment
• Dental care
Preterm Labor Risk: "TEMP LABOR"

Twins or triplets
Early previous preterm
Maternal infection
Polyhydramnios

Low BMI
Abnormal uterus
Bleeding in pregnancy
Older or younger mom
Race (African American higher risk)

Initial Assessment Protocol

Triage Assessment Steps

  1. Continuous fetal monitoring × 1-2 hours
  2. Tocodynamometer to assess contractions
  3. Sterile speculum exam (look for pooling, cultures)
  4. Cervical exam (if membranes intact)
  5. Ultrasound for cervical length if available
  6. Laboratory tests as indicated

Diagnostic Tests

Test Purpose Interpretation Clinical Action
Fetal Fibronectin Predict delivery risk • Negative: <0.5% deliver in 7d, <1% in 14d
• Positive: 20% deliver in 2 weeks		 • Negative: Consider discharge
• Positive: Admit, steroids
Cervical Length Assess cervical competence • >30mm: Low risk
• 20-30mm: Moderate
• <20mm: High risk		 • <25mm: Consider cerclage
• <15mm: Hospital admission
Urinalysis Rule out UTI • Nitrites, WBC, bacteria • Treat if positive
• Can stop PTL
Vaginal Cultures Identify infections • GBS, BV, STIs • Targeted antibiotics
• Reduce PTL risk

Fetal Fibronectin Pre-test Requirements

  • ❌ NO vaginal exam in past 24 hours
  • ❌ NO intercourse in past 24 hours
  • ❌ NO transvaginal ultrasound in past 24 hours
  • ❌ NO significant vaginal bleeding
  • ✓ Gestational age 22-34 weeks
  • ✓ Intact membranes
  • ✓ Cervical dilation <3cm

Tocolytic Medications - Complete Guide

Magnesium Sulfate - First Line & Neuroprotection
Loading: 4-6g IV over 20-30 min | Maintenance: 2-3g/hour

Mechanism: Calcium channel blocker, decreases intracellular calcium

Neuroprotection: Given <32 weeks regardless of tocolysis need

Monitor:

  • DTRs q2h (loss = toxicity)
  • Respiratory rate >12/min
  • Urine output >30mL/hr (>100mL/4hr)
  • Serum Mg levels q6h (therapeutic 4-7 mg/dL)

Side Effects: Flushing, nausea, headache, muscle weakness

⚡ Toxicity Signs: Absent DTRs → Respiratory depression → Cardiac arrest
⚡ Antidote: Calcium gluconate 10% 10mL IV over 3 min
Terbutaline - Acute Tocolysis Only
0.25mg subQ q20min × 3 doses (max 0.5mg/hr)

Mechanism: Beta-2 agonist, relaxes smooth muscle

Monitor:

  • Maternal HR (keep <120)
  • Blood glucose (causes hyperglycemia)
  • Potassium levels (causes hypokalemia)
  • Fluid balance (risk of pulmonary edema)

Side Effects: Tachycardia, tremors, anxiety, hyperglycemia

❌ FDA Warning: Do NOT use >48-72 hours (maternal death/cardiac events)
❌ Contraindicated: Cardiac disease, hyperthyroidism, diabetes
Nifedipine - Oral Option
Loading: 20mg PO, then 10-20mg PO q4-6h

Mechanism: Calcium channel blocker

Advantages: Oral route, well tolerated, can use outpatient

Monitor:

  • Blood pressure q30min × 2hr after dose
  • Maternal heart rate
  • Signs of hypotension
⚠️ Caution: Do not use with magnesium (synergistic hypotension)
⚠️ Do not use sublingual (unpredictable absorption)
Indomethacin - Limited Use
Loading: 50mg PO/PR | Maintenance: 25mg PO q6h

Mechanism: Prostaglandin synthesis inhibitor

Strict Limitations:

  • ONLY use <32 weeks gestation
  • Maximum 48 hours total
  • Monitor amniotic fluid (causes oligohydramnios)
❌ Closes ductus arteriosus - risk increases >32 weeks
❌ Contraindicated: Renal disease, oligohydramnios, bleeding

Antenatal Corticosteroids - Critical for Outcomes

Benefits (24-34 weeks)

  • ↓ RDS by 50%
  • ↓ IVH by 46%
  • ↓ NEC by 54%
  • ↓ Neonatal death by 31%
Medication Dosing Notes
Betamethasone 12mg IM q24h × 2 doses • Preferred if time allows
• Full benefit after 48 hours
• Some benefit by 12 hours
Dexamethasone 6mg IM q12h × 4 doses • Use if delivery expected <24h
• Equivalent efficacy
• More doses required

Special Considerations

Late Preterm Steroids (34-36⁶/₇ weeks)

Criteria for administration:

  • No previous course of steroids
  • High risk of delivery within 7 days
  • Not in active labor

Benefits: ↓ respiratory morbidity by 20%

Risks: ↑ neonatal hypoglycemia

Rescue Course Considerations

  • May consider if >14 days since initial course
  • Gestational age <34 weeks
  • High risk of delivery within 7 days
  • Limited to ONE rescue course

22-23⁶/₇ Weeks

  • Perinatology & neonatology consultation
  • Detailed counseling on outcomes
  • Consider steroids if resuscitation planned
  • Magnesium for neuroprotection
  • Transfer to Level III/IV center

24-31⁶/₇ Weeks

  • Aggressive tocolysis
  • Corticosteroids (priority!)
  • Magnesium for neuroprotection
  • GBS prophylaxis if delivering
  • Prepare NICU team

32-33⁶/₇ Weeks

  • Corticosteroids if not previously given
  • Tocolysis for steroid benefit
  • Less aggressive management
  • NICU notification

34-36⁶/₇ Weeks

  • Consider late preterm steroids
  • GBS prophylaxis
  • May not require tocolysis
  • Prepare for late preterm complications

Nursing Care Priorities

Immediate Nursing Actions

  1. Position: Left lateral to improve placental perfusion
  2. IV Access: 18g or larger for medications/fluids
  3. Hydration: 500mL bolus then 125-150mL/hr (dehydration triggers contractions)
  4. Monitor: Continuous FHR and contractions
  5. Labs: CBC, urine C&S, fFN if appropriate
  6. Notify: Provider, pharmacy, NICU team

Patient Education Focus

  • Activity: Modified bedrest, bathroom privileges
  • Hydration: 2-3L fluid daily
  • Signs to report: Contractions, bleeding, fluid leaking, decreased fetal movement
  • Kick counts: If appropriate gestational age
  • Sexual activity: Pelvic rest typically recommended
  • Follow-up: Weekly visits minimum

3. Emergency Situations During Labor

Shoulder Dystocia

HELPERR Mnemonic - IMMEDIATE Actions

  1. H - Call for Help
  2. E - Evaluate for Episiotomy
  3. L - Legs (McRoberts position - knees to chest)
  4. P - Suprapubic Pressure (NOT fundal!)
  5. E - Enter maneuvers (Woods screw)
  6. R - Remove posterior arm
  7. R - Roll to all fours

🚫 NEVER DO

Fundal pressure - This worsens impaction!

Umbilical Cord Prolapse

IMMEDIATE Action Sequence

  1. Call for help - STAT cesarean
  2. INSERT HAND - elevate presenting part OFF cord
  3. Trendelenburg or knee-chest position
  4. DO NOT attempt to replace cord
  5. Cover exposed cord with warm saline gauze
  6. Continuous fetal monitoring
  7. Prepare for immediate cesarean

✓ Remember

Student nurses CAN perform emergency interventions to save lives!

Amniotic Fluid Embolism

Recognition Triad

  1. Sudden respiratory distress
  2. Cardiovascular collapse
  3. DIC/Coagulopathy

Mortality Rate: 80% - IMMEDIATE action required!

9. Postpartum Hemorrhage (PPH) - The #1 Killer

NEW Definition (ACOG 2017) - Know This!

PPH: Cumulative blood loss ≥1000mL OR bleeding with signs/symptoms of hypovolemia within 24 hours

Why changed: 500mL is average loss, not pathologic

Clinical focus: Watch for SYMPTOMS, not just numbers!

The 4 T's - Causes in Order of Frequency

1. TONE (Uterine Atony) - 70% of PPH

Recognition in 10 Seconds

  • Feel: Boggy, soft, "doughy" fundus
  • See: Steady flow of blood, large clots
  • Location: Fundus above umbilicus or deviated
  • Response: Firms with massage then relaxes
Risk Factors - "GRAND MULTIPARA PLUS"

Grand multipara (>5 deliveries)
Rapid labor (<3 hours)
Amnionitis (infection)
Neonatal macrosomia (>4000g)
Distended bladder

Multiple gestation
Uterine overdistention (polyhydramnios)
Labor augmentation (Pitocin)
Tocolytics (MgSO4 = relaxed uterus)
Induction of labor
Precipitous delivery
Amnionitis
Retained placental fragments
Abruption history

PLUS: Prolonged labor, full bladder, fibroids, general anesthesia

IMMEDIATE Action Sequence - "MASSAGE FIRST!"

  1. Massage fundus vigorously
    • Support lower segment with other hand
    • Circular motion with firm pressure
    • Express clots gently after firming
    • Continue until firm and contracted
  2. Call for help WHILE massaging
    • State "POSTPARTUM HEMORRHAGE"
    • Request hemorrhage cart
    • Need 2-3 nurses immediately
  3. Empty bladder
    • Full bladder prevents contraction
    • Insert Foley if not voiding
    • Note urine amount/color
  4. Establish second large-bore IV
    • 18g or larger
    • Start LR or NS wide open
    • Draw labs with insertion
  5. Increase oxytocin infusion
    • If already running: increase to max
    • If not: 40 units in 1L, run 500mL/30min

Medication Administration - Master This Sequence!

Order Medication Dose & Route Mechanism Contraindications Key Points
1st Oxytocin
(Pitocin)		 • IV: 10-40 units in 1L
• IM: 10 units
• Rate: 200-500mL/hr		 Stimulates uterine contractions None in PPH • Never IV push
• Can cause hypotension
• Water intoxication risk
2nd Methylergonovine
(Methergine)		 0.2mg IM only
May repeat q2-4h
Max: 5 doses		 Ergot alkaloid, tetanic contractions ❌ Hypertension
❌ Preeclampsia
❌ Cardiac disease		 • Check BP first!
• Causes N/V
• Painful cramping
3rd Carboprost
(Hemabate)		 250mcg IM
q15-90min
Max: 8 doses (2mg)		 Prostaglandin F2α ❌ Asthma
❌ Active cardiac
❌ Pulmonary disease		 • Causes diarrhea (90%)
• Fever common
• Can give intramyometrial
4th Misoprostol
(Cytotec)		 800-1000mcg
Rectally
Single dose		 Prostaglandin E1 None significant • Onset 3 min
• Peak 30 min
• Fever/shivering
Adjunct Tranexamic Acid
(TXA)		 1g IV over 10min
Repeat × 1 if needed		 Antifibrinolytic Active thrombus • Give within 3hr
• ↓ Death by 30%
• New recommendation

Progressive Interventions

Bimanual Compression

  • One hand in vagina, fist in anterior fornix
  • Other hand on abdomen, compress fundus down
  • Compress uterus between hands
  • Hold until bleeding stops
  • Very painful - consider pain meds

Uterine Tamponade Options

Method Technique Success Rate
Bakri Balloon • Insert, inflate with 300-500mL saline
• Leave 24 hours
• Antibiotics while in place		 87%
Uterine Packing • Kerlix gauze, pack tightly
• Start at fundus
• Remove in 24-48hr		 Variable
Condom Catheter • Foley + condom
• Inflate with 250-500mL
• Low-cost option		 80%

Surgical Options

  1. B-Lynch Suture: Compression sutures
  2. O'Leary Sutures: Uterine artery ligation
  3. Hypogastric Artery Ligation: Reduces pulse pressure
  4. Uterine Artery Embolization: IR if available
  5. Hysterectomy: Last resort, definitive

2. TRAUMA - 20% of PPH

Key Recognition Point

Bleeding with FIRM, CONTRACTED uterus = Think TRAUMA!

Type Location Recognition Management
Cervical Cervix (3 & 9 o'clock common) • Bright red bleeding
• Firm fundus
• Steady flow		 • Visualize with speculum
• Suture required
• Ring forceps help
Vaginal Sidewalls, sulci • Bleeding despite firm uterus
• May be hidden		 • Good lighting
• Systematic inspection
• Suture carefully
Perineal 1st-4th degree tears • Visible trauma
• Active bleeding		 • Layer closure
• Don't miss apex
• Consider OR if 4th
Periurethral Around urethra • Very vascular
• Bleeds heavily		 • Pressure first
• Careful suturing
• Foley × 24hr

Hematomas - The Hidden Hemorrhage

Cardinal Signs of Hematoma

  • Pain: Out of proportion, rectal pressure
  • Unable to void: Pressure on urethra
  • Vital sign changes: Without visible bleeding
  • Falling H&H: Despite firm fundus
Type Location Size Management
Vulvar Labia, visible <4cm: Observe
>4cm: Surgery		 • Ice × 24hr
• I&D if large
• Pack if needed
Vaginal Upper vagina Can be massive • OR for evacuation
• Pack after drainage
• May need embolization
Retroperitoneal Above fascia Can hold 3-4L • CT diagnosis
• IR embolization
• Surgical if unstable

3. TISSUE (Retained Placenta) - 9% of PPH

Prevention is Key

  • Inspect EVERY placenta - both sides
  • Check for intact membranes
  • Count cotyledons
  • Note if succenturiate lobe present
  • Document: "Placenta appears complete"

4. THROMBIN (Coagulopathy) - 1% of PPH

Recognition

  • Oozing from IV sites, episiotomy
  • Bleeding despite interventions
  • No clot formation
  • Petechiae, ecchymoses

Associated with: Abruption, AFE, severe preeclampsia, sepsis, IUFD

Quantifying Blood Loss (QBL)

New Standard: Quantify Don't Estimate!

Visual estimation: Underestimates by 33-50%!

Use calibrated drapes, weigh materials, measure suction

Item Dry Weight Calculation
Lap sponge 10g Weight - Dry weight = mL blood
(1g = 1mL)
4×4 gauze 4g
Chux pad 50g
Peri pad 15g

Massive Transfusion Protocol

  • Activate when: 4+ units PRBCs needed
  • Ratio: 1:1:1 (RBC:FFP:Platelets)
  • Labs: CBC, coags, fibrinogen q30-60min
  • Warm all products: Prevent hypothermia
  • Consider: TXA, cryo, rFVIIa

10. Postpartum Infections - The Silent Threat

Official Definition - Must Know!

Puerperal Infection: Temperature ≥100.4°F (38°C) on ANY 2 of the first 10 days postpartum, exclusive of the first 24 hours

Why exclude first 24h? Dehydration, exertion can cause temp elevation

Incidence: 5-7% of all deliveries; higher after cesarean (15-20%)

A. ENDOMETRITIS - Most Common PP Infection

Polymicrobial Nature

Common organisms:

  • Aerobes: GBS, enterococci, E. coli, Klebsiella
  • Anaerobes: Bacteroides, Peptostreptococcus
  • Others: Gardnerella, Mycoplasma, Chlamydia

Clinical pearl: Broad-spectrum coverage essential!

Risk Factors - "LABOR CAMP FAILED"

Long labor (>24 hours)
Amnionitis during labor
Bacterial vaginosis
Operative delivery (C/S, forceps)
Ruptured membranes >18hr

Chorioamnionitis
Anemia (Hgb <9)
Multiple vaginal exams (>4)
Poor prenatal care

Failure to progress
Age extremes
Internal monitors
Low socioeconomic status
Emergent cesarean
Diabetes

Clinical Presentation Timeline

Day PP Typical Findings Severity Action
1-2 • Low fever (100.4-101°F)
• Mild uterine tenderness
• Slight ↑ in lochia		 Early/Mild • Cultures
• Start antibiotics
• Monitor closely
2-3 • Higher fever (101-103°F)
• Moderate pain
• Foul lochia develops		 Moderate • Broad spectrum ABX
• R/O abscess
• Check WBC trend
3-5 • High fever (>103°F)
• Severe pain
• Purulent lochia
• Ileus possible		 Severe • IV antibiotics
• Imaging for abscess
• Surgical consult
>5 • Persistent fever
• Possible abscess
• Septic picture		 Complicated • Change antibiotics
• Drain collections
• ICU if septic

Physical Examination Findings

System Finding Significance
Vital Signs • Fever >100.4°F
• Tachycardia >100
• Tachypnea >20		 SIRS criteria - consider sepsis
Uterus • Tender to palpation
• Subinvolution
• Lateral fornix pain		 Parametritis if lateral
Lochia • Foul odor
• Purulent
• Increased amount		 Classic triad with fever & pain
Abdomen • Distention
• Absent bowel sounds
• Guarding		 Ileus or peritonitis

Laboratory Findings

  • WBC: >20,000 concerning (normal PP up to 25,000)
  • Blood cultures: Positive in 10% only
  • Endometrial culture: Gold standard but invasive
  • Urinalysis: R/O concurrent UTI
  • CRP/ESR: Elevated but nonspecific

Antibiotic Treatment Protocols

First-Line: Clindamycin + Gentamicin
Clindamycin 900mg IV q8h + Gentamicin 5mg/kg IV q24h

Coverage: Excellent anaerobic + gram-negative

Duration: Until afebrile 24-48 hours

Switch to PO: Not recommended - complete IV course

⚠️ Monitor: Gentamicin levels, renal function
Alternative: Single Agent
Ampicillin/Sulbactam 3g IV q6h OR Cefoxitin 2g IV q6h

Advantages: Single drug, less monitoring

Disadvantages: May miss resistant organisms

Add if No Response in 48h
Ampicillin 2g IV q6h (for enterococcus)

Consider also: Metronidazole if C. diff risk

Image if persistent: CT for abscess/septic pelvic thrombophlebitis

B. WOUND INFECTIONS

Timing Tells the Tale

  • Days 1-2: Group A Strep (severe, spreading)
  • Days 4-7: Mixed flora (most common)
  • Days 7-14: MRSA increasingly likely
  • >2 weeks: Consider deep infection, foreign body

REEDA Assessment - Document Daily!

Component 0 Points 1 Point 2 Points 3 Points
Redness None <0.25cm 0.25-0.5cm >0.5cm
Edema None <1cm 1-2cm >2cm
Ecchymosis None <0.25cm 0.25-1cm >1cm
Drainage None Serous Serosanguinous Purulent
Approximation Closed Gaping <3mm Gaping 3mm Gaping >3mm

Score Interpretation

  • 0-3: Normal healing
  • 4-6: Mild infection - oral antibiotics
  • 7-10: Moderate - IV antibiotics, possible I&D
  • >10: Severe - surgical evaluation needed

Cesarean Wound Infection Management

Step-by-Step Approach

  1. Assess depth - Probe gently with Q-tip
  2. Culture - Aerobic, anaerobic, fungal if chronic
  3. Open if needed - Remove skin staples/sutures over affected area
  4. Irrigate - Saline irrigation, remove debris
  5. Pack if deep - Wet-to-dry dressings
  6. Antibiotics - Based on severity and culture
  7. Daily care - Dressing changes, reassess

Necrotizing Fasciitis - EMERGENCY!

Recognition in Minutes Saves Lives

  • Pain: Out of proportion to exam
  • Rapid spread: Mark edges - spreads past marks
  • Systemic toxicity: High fever, altered mental status
  • Skin changes: Dusky → purple → black
  • Crepitus: Gas in tissues

ACTION: Immediate surgical debridement + broad antibiotics!

C. MASTITIS - The Breastfeeding Challenge

Key Message: CONTINUE BREASTFEEDING!

Stopping breastfeeding worsens mastitis and can lead to abscess formation

Feature Engorgement Plugged Duct Mastitis Abscess
Onset Day 3-5 PP Any time Week 2-4 usually After mastitis
Location Bilateral One area Wedge-shaped Fluctuant mass
Systemic No fever No fever Fever, flu-like High fever
Treatment • Frequent feeds
• Ice packs
• Cabbage leaves		 • Massage
• Heat
• Position baby		 • Antibiotics
• HEAT protocol
• Rest		 • I&D
• Antibiotics
• May stop BF
Mastitis Management - "HEAT FEEDS"

Heat before nursing
Empty breast completely
Antibiotics (dicloxacillin 500mg QID × 10-14d)
Tylenol/ibuprofen for comfort

Frequent feeding
Ensure good latch
Express if too painful
Different positions
Support bra (not tight!)

D. URINARY TRACT INFECTIONS

Why Postpartum Women Are at Risk

  • Bladder trauma: From fetal head descent
  • Catheterization: During labor/cesarean
  • Overdistention: From epidural, unable to void
  • Residual urine: Hypotonic bladder
  • Perineal contamination: Proximity to rectum
Type Symptoms Diagnosis Treatment
Cystitis • Dysuria
• Frequency
• Urgency
• Suprapubic pain		 • UA: WBC, bacteria
• Culture >100K		 • Nitrofurantoin 100mg BID × 5d
• Cephalexin 500mg QID × 7d
Pyelonephritis • High fever
• Chills
• CVA tenderness
• N/V		 • UA + culture
• Blood cultures
• CBC		 • Admit if severe
• IV ceftriaxone
• Switch to PO when afebrile

E. SEPTIC PELVIC THROMBOPHLEBITIS - The Diagnosis of Exclusion

Classic Presentation

  • Persistent fever: Despite 48-72h appropriate antibiotics
  • "Picket fence" pattern: Fever spikes then normal
  • Tachycardia: Out of proportion to fever
  • Abdominal/pelvic pain: May have palpable "rope"
  • Normal WBC: Unlike other infections

Diagnostic & Treatment Approach

  1. Suspect when: Endometritis treatment failing
  2. Image: CT or MRI pelvis with contrast
  3. Finding: Ovarian vein thrombosis (R>L)
  4. Treatment:
    • Continue antibiotics
    • Add heparin anticoagulation
    • Dramatic response in 48h
    • Anticoagulate 7-10 days minimum

7. Postpartum Mood Disorders

Universal Screening is Essential

Use Edinburgh Postnatal Depression Scale (EPDS) at:

  • First prenatal visit (baseline)
  • At least once in pregnancy
  • 6 weeks postpartum
  • Well-child visits through 6 months

Score ≥10 requires further evaluation

Comparison of Postpartum Mood Disorders

Disorder Incidence Onset Duration Key Features Management
Baby Blues 50-80% Days 3-5 <2 weeks Crying, mood swings, overwhelmed Support, reassurance, rest
PPD 10-20% Any time 1st year >2 weeks Can't function, no joy, guilt Therapy, SSRIs, support groups
PP Anxiety 10-15% Birth-6 months Variable Racing thoughts, panic, OCD CBT, medications, relaxation
PP Psychosis 0.1-0.2% First 2 weeks Variable Hallucinations, delusions EMERGENCY - hospitalize

A. Baby Blues - Normal but Needs Support

Key Teaching Points

  • "This is your hormones adjusting - it's temporary"
  • "Most mothers experience this"
  • "It should improve by 2 weeks"
  • "Call if it gets worse instead of better"

Support strategies: Sleep when baby sleeps, accept help, lower expectations, stay hydrated

B. Postpartum Depression - Beyond Baby Blues

Clinical Recognition - The Mother Who...

  • Can't sleep even when baby is sleeping
  • Finds no joy in anything, including baby
  • Has excessive guilt about "failing" as a mother
  • Can't make simple decisions
  • Has thoughts of self-harm (NOT harming baby)
  • Isolates from family/friends
  • Changes in appetite (over/under eating)

Edinburgh Postnatal Depression Scale (EPDS)

  • Score 0-9: Low risk
  • Score 10-12: Possible depression, monitor closely
  • Score ≥13: Likely depression, refer immediately
  • Question 10 positive: (Self-harm) IMMEDIATE evaluation

Treatment Options

Intervention Details Effectiveness
Psychotherapy CBT or IPT weekly × 12 weeks 60-80% response
Antidepressants SSRIs first-line (sertraline, paroxetine) 60-70% response
Support Groups Peer-led or professional Adjunct therapy
Exercise 30 min moderate × 3-5 days/week Mild-moderate PPD

Breastfeeding & Antidepressants

Preferred in breastfeeding:

  • Sertraline (Zoloft) - lowest milk levels
  • Paroxetine (Paxil) - short half-life
  • Nortriptyline - if SSRI fails

Benefits of treatment outweigh risks - untreated PPD harms both mother and baby

C. Postpartum Psychosis - TRUE EMERGENCY

Recognition - MEDICAL EMERGENCY

Classic presentation: Previously well woman with rapid onset (hours to days) of:

  • Hallucinations (auditory > visual)
  • Delusions (baby is evil, changed, or dead)
  • Confusion/disorientation
  • Rapid mood swings (mania to severe depression)
  • Not sleeping for days
  • Bizarre behavior

IMMEDIATE Actions

  1. Never leave alone with baby
  2. Call psychiatry STAT
  3. 1:1 observation
  4. Remove potential weapons
  5. Calm, safe environment
  6. Support person to stay
  7. Document exact statements

Risk Factors for PP Psychosis

  • Bipolar disorder (30-50% risk!)
  • Previous PP psychosis (50-90% recurrence)
  • Family history of bipolar/psychosis
  • First pregnancy
  • Sleep deprivation
  • Discontinued psych meds in pregnancy

D. Postpartum Anxiety Disorders

Type Key Features Treatment
Generalized Anxiety • Excessive worry
• Can't relax
• Physical symptoms		 • CBT
• SSRIs
• Relaxation
Panic Disorder • Sudden attacks
• Fear of dying
• Chest pain, SOB		 • CBT crucial
• SSRIs
• Benzos short-term
OCD • Intrusive thoughts
• Compulsive checking
• Knows irrational		 • ERP therapy
• Higher SSRI doses
• Family education
PTSD • Birth trauma
• Flashbacks
• Avoidance		 • Trauma therapy
• EMDR
• Prazosin for nightmares
Supporting Moms: "LISTEN"

Let her express feelings without judgment
Identify support systems
Screen at every contact
Treatment saves lives
Educate about normalcy of seeking help
Never minimize her experience

Why This Matters - Leading Cause of Maternal Death

Incidence: 1-2 per 1000 pregnancies (5× higher than non-pregnant)

Mortality: PE causes 10% of all maternal deaths

Timing: Highest risk first 6 weeks postpartum

Key fact: 50% of DVTs are asymptomatic!

Virchow's Triad in Pregnancy/Postpartum

Component Pregnancy Changes Postpartum Factors Clinical Impact
Venous Stasis • Uterine compression of IVC
• ↓ Venous return
• Progesterone vasodilation
• ↓ Velocity 50%		 • Bedrest post-cesarean
• Immobility with epidural
• Leg edema
• Varicosities		 Blood pools in legs, especially left (iliac compression)
Hypercoagulation • ↑ Factors I, VII, VIII, X
• ↑ Fibrinogen 50%
• ↓ Protein S
• ↓ Fibrinolysis		 • Peak at delivery
• Persists 6-8 weeks
• Tissue factor release
• Inflammation		 Clotting 5× faster than normal
Vessel Injury • Venous distention
• Previous DVT damage		 • Vaginal delivery trauma
• Cesarean surgery
• Forceps/vacuum
• Manual placenta removal		 Endothelial damage triggers cascade

Risk Stratification - Know Your Patient!

High Risk (>3% risk) - Prophylaxis Required

Moderate Risk (1-3%) - Consider Prophylaxis

SUPERFICIAL VENOUS THROMBOSIS (SVT)

Feature Finding Management
Appearance • Red, cord-like vein
• Can trace path
• Warm, tender
• Usually saphenous		 • Warm compresses
• NSAIDs (if not contraindicated)
• Compression stockings
• Ambulation
Size • <5cm from SFJ/SPJ
• >5cm length		 • Consider anticoagulation
• US to r/o DVT
• May progress
Follow-up • Monitor progression
• 10-20% develop DVT		 • Repeat exam 7-10 days
• US if worsening

DEEP VENOUS THROMBOSIS - The Hidden Danger

Clinical Diagnosis - Modified Wells Score

Criteria Points
Active cancer +1
Paralysis/recent cast +1
Recently bedridden >3 days OR surgery +1
Tenderness along vein +1
Entire leg swollen +1
Calf >3cm larger +1
Pitting edema (greater in symptomatic) +1
Collateral superficial veins +1
Previous DVT +1
Alternative diagnosis likely -2

Score: 0-1 = Low risk | 2 = Moderate | ≥3 = High risk

Compression Ultrasound - First Line

  • Sensitivity: 95% for proximal DVT
  • Technique: Non-compressible vein = thrombus
  • Limitation: Poor for calf veins, pelvic veins
  • Pregnancy note: Left lateral position for IVC compression

When Ultrasound Is Negative but High Suspicion

  1. Repeat US in 7 days - Clot may propagate
  2. MR venography - For iliac/IVC clots
  3. CT venography - If PE suspected too
  4. Consider empiric treatment - If very high risk

D-dimer - Limited Use in Pregnancy

Problem: Elevated throughout pregnancy/postpartum

Normal values by trimester:

  • 1st trimester: <750 ng/mL
  • 2nd trimester: <1000 ng/mL
  • 3rd trimester: <1500 ng/mL
  • Postpartum: Variable, not useful

DVT Treatment - Act Fast!

Initial: Low Molecular Weight Heparin (LMWH)
Enoxaparin 1mg/kg subQ q12h OR 1.5mg/kg q24h

Advantages: No monitoring needed, outpatient possible

Duration: Throughout pregnancy + 6 weeks postpartum minimum

Breastfeeding: Safe - does not enter milk

⚠️ Hold 24h before delivery if possible
Alternative: Unfractionated Heparin
Initial: 80 units/kg bolus, then 18 units/kg/hr

Monitor: PTT q6h until therapeutic (1.5-2.5× normal)

Use when: Delivery imminent, renal failure, need reversal ability

⚡ Antidote: Protamine sulfate
Postpartum Transition: Warfarin
Start 5-10mg daily, adjust to INR 2-3

Overlap: With heparin × 5 days AND INR therapeutic × 24h

Duration: 3-6 months total therapy

Breastfeeding: Safe - minimal transfer

❌ Contraindicated during pregnancy (teratogenic)

PULMONARY EMBOLISM - Every Second Counts!

Classic Presentation - "Can't Breathe!"

IMMEDIATE PE Response - "O2 FIRST"

  1. O2 - High flow 10-15L non-rebreather
  2. 2 large bore IVs - Prepare for hemodynamic support
  3. Full monitoring - Continuous pulse ox, cardiac
  4. Imaging STAT - CTA or V/Q scan
  5. Rapid response team - May need ICU
  6. Start anticoagulation - Don't wait for confirmation if high suspicion
  7. Thrombolytics ready - If massive PE

Initial Tests

Test Finding Significance
ABG • ↓ PO2
• ↑ A-a gradient
• Respiratory alkalosis		 Hypoxemia despite tachypnea
ECG • Sinus tachycardia
• S1Q3T3 pattern
• Right heart strain		 Classic but rare S1Q3T3
Chest X-ray • Often normal
• Hampton hump
• Westermark sign		 Rule out other causes
Troponin/BNP • Elevated if RV strain Prognostic value

Definitive Imaging

CT Pulmonary Angiography (CTPA)

  • Gold standard - 95% sensitive
  • Radiation: 3-5 mGy to fetus (safe)
  • Contrast: Risk of reaction
  • Findings: Filling defects in pulmonary arteries

V/Q Scan Alternative

  • Use if: Contrast allergy, normal CXR
  • Less radiation to breast tissue
  • Interpretation: High probability = treat
  • Limitation: Indeterminate results common

Prevention Strategies - Save Lives!

Risk Level Prophylaxis Duration
Low Risk • Early ambulation
• Hydration
• Compression stockings		 Until fully mobile
Moderate Risk • Pneumatic compression
• Consider LMWH
• Stockings		 Until discharge
High Risk • LMWH prophylaxis
• Enoxaparin 40mg daily
• Mechanical + pharmacologic		 6 weeks postpartum
Very High Risk • Therapeutic anticoagulation
• LMWH bid dosing
• Consider filter if contraindication		 3-6 months minimum
DVT Prevention: "CLOTS AWAY"

Compression stockings
Leg exercises hourly
Out of bed early
Turn q2h if bedbound
Stay hydrated

Anticoagulation if indicated
Walk in hallways
Assess calves daily
Yield to any symptoms

12. Special Populations - Unique Challenges

A. SUBSTANCE ABUSE IN PREGNANCY

Approach with Compassion - Addiction is a Disease

Incidence: 15-20% use substances during pregnancy

Barriers to care: Shame, fear of legal consequences, lack of treatment

Your role: Build trust, provide care, protect newborn

Universal Screening Tools

CAGE-AID Questions (Adapted to Include Drugs)

  • Cut down: Have you felt you should cut down on drinking/drug use?
  • Annoyed: Have people annoyed you by criticizing your use?
  • Guilty: Have you felt guilty about your use?
  • Eye-opener: Have you used first thing in the morning?

Scoring: ≥2 positive = high risk for substance disorder

Substance Maternal Effects Fetal/Neonatal Effects Labor Considerations
Tobacco • Vasoconstriction
• ↑ Abruption risk
• ↑ Previa risk		 • IUGR
• ↑ SIDS risk 3×
• Preterm birth		 • Monitor for abruption
• SGA baby likely
Alcohol • Withdrawal seizures
• Hepatic dysfunction
• Nutritional deficits		 • FAS spectrum
• Facial features
• CNS damage
• Growth restriction		 • Monitor for withdrawal
• Thiamine supplement
• Seizure precautions
Cocaine • HTN/stroke
• MI risk
• Abruption (8×)
• Seizures		 • IUGR
• Microcephaly
• GU anomalies
• Neurobehavioral		 • EMERGENCY if HTN
• Precipitous delivery
• Abruption watch
Opioids • Withdrawal risk
• Poor nutrition
• Infections (IV use)		 • NAS (60-90%)
• IUGR
• Preterm birth
• SIDS risk		 • Pain control difficult
• Higher doses needed
• Withdrawal signs
Meth • Dental decay
• Psychosis
• HTN
• Hyperthermia		 • SGA
• Neurodevelopmental
• Cardiac defects
• Agitation		 • Paranoia/violence
• HTN crisis
• Poor pain tolerance
Marijuana • Respiratory
• Tachycardia
• Anxiety		 • Controversial
• ? ADHD
• ? Low birth weight		 • May affect pain perception
• Drug interactions

Recognition: Recent Cocaine + Labor = DANGER

Classic presentation: HTN, tachycardia, chest pain, agitation

IMMEDIATE Actions

  1. Position left lateral - Reduce aortocaval compression
  2. Notify MD STAT - High risk for stroke/MI/abruption
  3. Continuous monitoring - Maternal cardiac + fetal
  4. IV access × 2 - Prepare for emergency
  5. Side rails UP - Seizure risk
  6. Avoid beta-blockers - Unopposed alpha → worse HTN
  7. Benzodiazepines ready - For agitation/seizures

Complications to Anticipate

  • Abruption: Sudden pain, tetanic uterus, bleeding
  • Precipitous delivery: Can go 0-10cm rapidly
  • Stroke: Severe HA, neuro changes
  • Fetal compromise: Late decels, bradycardia

Neonatal Abstinence Syndrome (NAS)

Peak Withdrawal Timing by Drug

  • Heroin: 24-48 hours
  • Methadone: 48-72 hours (longer half-life)
  • Buprenorphine: 36-60 hours
  • May be delayed: Up to 5-7 days
System Signs Nursing Interventions
CNS • High-pitched cry
• Tremors
• Hyperreflexia
• Seizures		 • Low stimulation
• Swaddle tightly
• Vertical rocking
GI • Poor feeding
• Vomiting
• Diarrhea
• Poor weight gain		 • Small frequent feeds
• High-calorie formula
• Assess suck
Autonomic • Sweating
• Fever
• Yawning
• Sneezing		 • Monitor temp
• Frequent clothing changes
• Skin care
Respiratory • Tachypnea
• Nasal flaring
• Retractions		 • Monitor RR
• Suction PRN
• O2 if needed

Finnegan Scoring System

Frequency: q3-4h after birth

Treatment threshold: Score ≥8 on 2 consecutive OR ≥12 once

Medications: Morphine or methadone, wean slowly

Length of stay: Often 2-4 weeks

B. BIRTH OF INFANT WITH CONGENITAL ANOMALIES

The Golden Hour - First Response Matters

How parents are told and supported in the first hour impacts their entire grief and attachment process

What NOT to Say - Ever!

Harmful Phrases to Avoid

  • ❌ "At least you have other children"
  • ❌ "Everything happens for a reason"
  • ❌ "God gives special babies to special people"
  • ❌ "It could be worse"
  • ❌ "I know how you feel"
  • ❌ "You can have another baby"

Helpful Responses

  • ✓ "I'm here with you"
  • ✓ "Your baby is beautiful"
  • ✓ "What is your baby's name?"
  • ✓ "Would you like to hold your baby?"
  • ✓ "This must be overwhelming"
  • ✓ "What questions do you have?"

Visible Anomalies (Cleft lip, limb differences)

  • Parents see immediately - address quickly
  • Point out normal features too
  • Show before/after surgery photos if available
  • Immediate referral to specialists
  • Connect with support groups same day

Life-Threatening (Complex cardiac, severe neural tube)

  • Balance hope with honesty
  • Involve palliative care early if appropriate
  • Support ANY decision parents make
  • Facilitate family visits/photos
  • Baptism/blessing if desired

Chromosomal (Down syndrome, Trisomy 13/18)

  • Avoid outdated terms (mongoloid)
  • Emphasize baby's potential
  • Current life expectancy info
  • Early intervention referrals
  • Sibling preparation resources

C. PERINATAL LOSS

Types & Unique Challenges

Type Definition Unique Aspects
Miscarriage <20 weeks Often minimized, no rituals
Stillbirth ≥20 weeks Full L&D, milk comes in
Neonatal death Live birth, dies <28 days Had hopes, NICU trauma
Selective reduction Multiples reduced Chosen loss, guilt

Creating Memories - If Parents Want

  1. Photos - Professional if available, multiple poses
  2. Footprints/handprints - Clay molds, ink, plaster
  3. Lock of hair - If present
  4. Weight/length - Record officially
  5. Blanket/outfit - That touched baby
  6. Blessing/baptism - Any denomination
  7. Family time - Unlimited, private
  8. Sibling visits - Age-appropriate
Perinatal Loss Care: "COMFORT"

Create memories if desired
Offer options, follow their lead
Mother's physical needs too
Family involvement as wished
Ongoing support planned
Respect cultural practices
Time - no rushing

D. ADOLESCENT MOTHERS - Developmental Considerations

Age Group Developmental Stage Nursing Approach
Early (10-14) • Concrete thinking
• Egocentric
• Present-focused		 • Very simple language
• Demonstrate everything
• Involve trusted adult
Middle (15-17) • Peer-focused
• Risk-taking
• Identity forming		 • Peer support groups
• Maintain independence
• Non-judgmental
Late (18-19) • Future orientation
• Abstract thinking
• Goal-setting		 • Include in decisions
• Education/career planning
• Adult resources

Success Strategies for Teen Moms

  • Flexible scheduling: After school appointments
  • Transportation: Vouchers, mobile clinics
  • Child care: During appointments
  • Text reminders: Preferred communication
  • Peer mentors: Teen moms who succeeded
  • School coordination: Homework during long waits
  • Grandparent inclusion: With teen's permission

Comparison Chart

Disorder Incidence Onset Duration Key Features Management
Baby Blues 50-80% Days 3-5 <2 weeks Crying, mood swings Support, reassurance
PPD 10-20% Any time 1st year >2 weeks Can't function, no joy Therapy, SSRIs
PP Psychosis 0.1-0.2% First 2 weeks Variable Hallucinations, delusions EMERGENCY - hospitalize

Postpartum Psychosis - IMMEDIATE Actions

  1. Never leave alone with baby
  2. Call psychiatry STAT
  3. Likely needs admission
  4. Remove potential weapons
  5. Maintain calm environment
  6. Document exact words/behaviors

Interactive Knowledge Check - Test Your Understanding

Question 1: A woman at 35 weeks gestation reports a sudden gush of fluid. The fluid appears yellow-tinged. What is your PRIMARY concern?
  • Chorioamnionitis (infection)
  • Imminent delivery
  • Cord prolapse
  • Placental abruption
Question 2: A postpartum patient is bleeding heavily. Her fundus is boggy and displaced to the right. What is your FIRST action?
  • Call for help
  • Massage the fundus
  • Check vital signs
  • Increase IV oxytocin
Question 3: During delivery, the baby's head delivers but the shoulders do not follow. What should you NEVER do?
  • Apply suprapubic pressure
  • Apply fundal pressure
  • Call for help
  • Position mother in McRoberts
Question 4: A patient receiving magnesium sulfate for preterm labor has absent DTRs. What is your priority action?
  • Check serum magnesium level
  • Stop the magnesium infusion
  • Notify the physician
  • Administer calcium gluconate
Question 5: Which medication is contraindicated for a postpartum patient with asthma who is experiencing hemorrhage?
  • Oxytocin
  • Methylergonovine
  • Carboprost (Hemabate)
  • Misoprostol
Question 6: A laboring woman who admitted to recent cocaine use has BP 160/95, pulse 88, irregular respirations. What is the priority intervention?
  • Position her on her right side
  • Elevate the head of bed 90 degrees
  • Maintain side rails up at all times
  • Keep overhead lights on
Question 7: Which finding indicates chorioamnionitis in a patient with PROM?
  • Clear amniotic fluid
  • Maternal temperature 99.8°F
  • Fetal tachycardia >160 bpm baseline
  • Decreased fetal movement
Question 8: A postpartum day 3 patient reports unilateral breast pain, redness in a wedge pattern, and fever of 101.5°F. What is the MOST important teaching?
  • Stop breastfeeding immediately
  • Continue breastfeeding from affected breast
  • Apply ice packs before feeding
  • Pump and discard milk from affected side
Question 9: You notice the umbilical cord protruding from the vagina. What is your FIRST action?
  • Call for help
  • Insert hand and elevate presenting part
  • Place patient in Trendelenburg
  • Cover cord with warm saline gauze
Question 10: A postpartum patient has been on antibiotics for endometritis for 48 hours but continues to spike fevers in a "picket fence" pattern. What should you suspect?
  • Resistant organism
  • Wound infection
  • Septic pelvic thrombophlebitis
  • Drug fever
Quiz Progress: 0/10

Answer Explanations

Q1: Yellow or cloudy amniotic fluid indicates infection (chorioamnionitis), which is the primary concern with PROM as it can lead to maternal and fetal sepsis.

Q2: With a boggy fundus (indicating uterine atony - 70% of PPH), immediate fundal massage is the first action. You can call for help while massaging.

Q3: Fundal pressure during shoulder dystocia worsens the impaction and can cause uterine rupture. Use HELPERR maneuvers instead.

Q4: Absent DTRs indicate magnesium toxicity. Stop the infusion immediately before checking levels or giving antidote.

Q5: Carboprost (Hemabate) is contraindicated in asthma as it can cause severe bronchospasm.

Q6: Recent cocaine use + hypertension = high seizure risk. Side rails up is the priority safety measure.

Q7: Fetal tachycardia >160 bpm is a key sign of chorioamnionitis, indicating fetal response to infection.

Q8: Continuing breastfeeding is essential in mastitis - stopping can lead to abscess formation. The milk is safe for baby.

Q9: Immediate manual elevation of the presenting part off the cord is critical to prevent cord compression and fetal hypoxia.

Q10: "Picket fence" fever pattern despite appropriate antibiotics is classic for septic pelvic thrombophlebitis.

Quick Reference Summary

Emergency Phone Triage Rules

NEVER: Diagnose over phone, recommend medications, tell them to wait

ALWAYS: "Come to hospital for evaluation"

Priority Framework

  1. Life-threatening emergencies (AFE, severe PPH, PE)
  2. Threats to maternal stability (sepsis, DIC)
  3. Threats to fetal well-being
  4. Pain/comfort (unless affecting VS)
  5. Teaching needs

Critical Recognition Patterns

• "Board-like abdomen" → Abruption
• "Turtle sign" → Shoulder dystocia
• "Ripping sensation" → Uterine rupture
• "Can't catch breath after delivery" → AFE or PE
• "Gush of fluid, baby won't come down" → Cord prolapse
• "Oozing from everywhere" → DIC
• "Sweet fruity breath" → DKA
• "Picket fence fever" → Septic pelvic thrombophlebitis

Final Success Strategy: "PREPARE"

Prioritize by severity
Recognize patterns quickly
Emergencies need immediate action
Prevent complications
Assess continuously
Report and document
Educate for safety