Adhesions following cesarean delivery: a review of their occurrence, consequences and preventative management using adhesion barriers.

The objective of this article is to provide a comprehensive review of the occurrence and consequences of postoperative adhesions following cesarean delivery (CD), and an overview of the published clinical data on prevention in this setting using adhesion barriers. Adhesions occur frequently after CD and the incidence increases with each subsequent CD. Repeat CDs are complicated by adhesions, which increase operating time, time to delivery and risk of bladder injury. Clinical data on the efficacy of adhesion prevention strategies specific to the setting of CD are limited. Two small, nonrandomized studies found that the use of absorbable anti-adhesion barriers was associated with a significant reduction in adhesion formation and a shorter time to delivery at repeat CD, compared with no barrier use. Implications for practice and research are discussed. There is a significant need for well-controlled, randomized clinical studies investigating adhesion prevention in the labor and delivery setting.

Acute pulmonary edema in pregnancy.

Pulmonary edema is a secondary disease process characterized by an excess accumulation of fluid in the pulmonary interstitial and alveolar spaces, preventing adequate diffusion of both oxygen and carbon dioxide. The excess fluid accumulation interferes with maternal oxygenation and, if not identified and corrected, can lead to maternal and fetal hypoxemia. The purpose of this article is to review principles of oxygen transport and the pathophysiology, diagnosis, management, and nursing implications of acute pulmonary edema in pregnancy.

Multiorgan dysfunction in the perinatal patient.

MODS is a rare but potentially lethal complication of pregnancy. Pregnancy induces physiologic changes in all major maternal organ systems that mimic early changes seen in SIRS and MODS. When a potentially life-threatening event occurs, such as hemorrhage,sepsis, or severe preeclampsia, the perinatal nurse must monitor subtle changes in maternal and fetal status and intervene to optimize maternal status.

Maternal mortality--a review of current trends.

Pregnancy-related maternal deaths, although rare,are higher than the public health goal of no more than 3 per 100000 live births [5,6]. Achievement of this goal mandates complete and consistent reporting of all maternal deaths to identify causes of death accurately and correct underreporting [2]. Racial disparity between white and African American women must be reduced. Further research is needed to identify the factors contributing to the higher mortality rates in the African American population. Risk factors currently identified with adverse perinatal outcomes do not explain the differences in mortality rates adequately. Perinatal nurses and primary care providers should take an active role in identifying current trends in causes of matemal mortality. The population of women encountered daily in perinatal units is changing, with an increasing number of pregnancies complicated by preexisting and pregnancy-related medical conditions. Caring for these women within the framework that pregnancy is a normal, physiologic state can lead to complacency and increase the probability of missing early signs of maternal decompensation from an undiagnosed cardiac lesion, because shortness of breath and decreased exercise tolerance are considered normal changes as the pregnancy advances. Common complaints of pregnancy often mimic early signs of cardiopulmonary compromise, delaying an accurate diagnosis. The perinatal nurse must be aware of the early signs of an impending cardiopulmonary arrest. If recognized. subtle changes in levels of mentation, increasing pulse and respiratory rates, and changes in blood pressure lead to earlier interventions to correct maternal hemodynamic status and possibly prevent cardiopulmonary collapse. To further complicate the issue, the mindset in perinatal units often is, "It can't happen here" or "We don't have codes in obstetrics."Perinatal units should practice emergency drills, including management of eclampsia, hemorrhage, and cardiopulmonary arrest. Rehearsal of the emergency situation helps decrease anxiety for the staff and increase response times. The goal of the irreducible minimum for prevent-able maternal deaths is one to strive for in today's perinatal practice. Active surveillance to identify causes of maternal mortality allows for initiation of early interventions to minimize maternal compromise, thereby decreasing preventable deaths.

Analgesia and anesthesia during labor and birth: implications for mother and fetus.

Labor and birth, although viewed as a normal physiological process, can produce significant pain, requiring appropriate pain management. Systemic analgesia and regional analgesia/anesthesia have become less common, whereas the use of newer neuraxial techniques, with minimal motor blockade, have become more popular. Low- and ultra-low-dose epidural analgesia, spinal analgesia, and combination spinal-epidural analgesia have replaced the once traditional epidural for labor. The shift from regional anesthesia during labor, in which the woman became a passive participant during the labor and birth, to a collaborative approach for pain management, in which the woman becomes an active participant, has resulted in a new philosophy of labor analgesia. This article provides a review of the current systemic analgesics and regional and neuraxial analgesia/anesthesia techniques for pain management in labor and birth. Also addressed are implications for perinatal nurses who participate in pain management choices during labor and birth.

Neuraxial analgesia for labor and birth: implications for mother and fetus.

Women are better educated today on issues related to labor and childbirth. Pain management options for the woman in labor have changed dramatically over the last decade. Systemic analgesia and dense-motor-blockade regional analgesia/anesthesia have become less common for childbirth while the use of newer neuraxial and regional techniques, with minimal motor blockade, have become more popular. The shift from regional anesthesia with significant motor-blockade during labor, where the woman is a passive participant during the labor and birth, to a collaborative approach for pain management, where the woman becomes an active participant, has resulted in a new philosophy of analgesia for labor and birth. This article provides a review of current neuraxial analgesia/anesthesia techniques used for pain management in labor and birth and their implications for the perinatal nurse.

Thalassemia and pregnancy.

Thalassemia syndromes, hemoglobinopathies characterized by anemia secondary to genetic defects of hemoglobin, are the most common of the genetic blood disorders. The prevalence and severity of the thalassemia syndromes are population dependent, with the type of thalassemia seen dependent on racial background. The health care provider must recognize the woman at highest risk for thalassemia and initiate appropriate screening and diagnostic testing. The specific thalassemia dictates the potential maternal, fetal, and neonatal consequences of anemia, red blood cell dysfunction, and systemic oxygenation issues. This article discusses normal globin chain synthesis, diagnostic testing for thalassemia, plan of management, and implications for the woman and fetus.

Renal disease in pregnancy.

Anatomic and physiologic adaptations within the renal system during pregnancy are significant. Alterations are seen in renal blood flow and glomerular filtration, resulting in changes in normal renal laboratory values. When these normal renal adaptations are coupled with pregnancy-induced complications or preexisting renal dysfunction, the woman may demonstrate a reduction of renal function leading to an increased risk of perinatal morbidity and mortality. This article will review normal pregnancy adaptations of the renal system and discuss common pregnancy-related renal complications.