Nursing Care of the pt w/ Child Birth Complications – Flashcards
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Complications of L&D
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Prolonged Pregnancy Prolapsed Umbilical Cord Shoulder Dystocia Cesarean Birth Uterine Rupture Amnioinfusion Dystocia Anaphylactoid Syndrome of Pregnancy Induction of Labor Precipitous labor Vaginal breech delivery Ineffective Uterine Force Multiple Gestation Fetal Presentation or Position
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Prolonged Pregnancy
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*Defined as those pregnancies lasting beyond the end of the 40-42nd week.* -Fetus at risk due to placental degeneration and loss of amniotic fluid (cord accidents). -Decreased amounts of vernix also allow the drying of the fetal skin, resulting in a dry, parchment like skin condition. *Dysmaturity syndrome: associated with uteroplacental insufficiency, meconium aspiration and short term neonatal complications.* *Neonatal complications: hypoglycemia seizures and respiratory distress*
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Nursing Assessment and Management
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-Directed toward ascertaining precise fetal gestational age and condition, and determining fetal ability to tolerate labor *Can be Induction of labor and possibly cesarean birth* (Placenta stops being healthy for the baby/decreased nutrition & O2 to the baby) (baby at risk for meconium aspiration)
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Assessment Findings
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-Measurements of fetal gestational age for fetal maturity -Biophysical profile-what are the different aspects you monitor and what is considered OK and when do you intervene....nursing 111.
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Nursing Interventions
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-Perform continual monitoring of maternal/fetal vital signs. -Support mother through all testing and labor. -Assist with amnio-infusion if ordered to increase cushion for cord or to minimize meconium aspirate syndrome (MAS).
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Amnioinfusion
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*Technique in which a volume of warmed, sterile, NS or LR is introduced into the uterus through an intrauterine pressure catheter to increase the volume of fluid (oligohydramnios) or thin the consistency of meconium.* +250-500 ml is administered using an infusion pump over 20-30 minutes *Risk? What nursing interventions would you do to minimize this risk? (rupture of the uterus from overextension)
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Nursing Management
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-Explain need -Assess contractions to identify over distention or inc uterine tone -Maternal VS -Strict I/O -FHR pattern to determine whether the amnioinfusion is improving the fetal status -Cesarean section if FHR does not improve
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Prolapsed Umbilical Cord
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*Is the Displacement of cord in a downward direction, near or ahead of the presenting part, or into the vagina.* -May occur when membranes rupture, or with ensuing contractions. *Associated with breech presentations, unengaged presentations, and premature labors.* *OB emergency: if compression of the cord occurs, fetal hypoxia may result in CNS damage or death*
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When ROM occurs, what is the first priority of the nurse?
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Assess FHR
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Assessment Findings of a Prolapsed Cord
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-Vaginal exam identifies cord prolapse into vagina -Sudden low or loss of fetal heart rate
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Nursing Interventions for Prolapsed Cord
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*Check fetal heart tones immediately when membranes rupture, and again after next contraction, or within 5 minutes, report decelerations.* -If fetal bradycardia, perform vaginal examination and check for prolapsed cord. -If cord prolapsed into vagina, exert (lift mom's bum) upward pressure against presenting part to lift part off cord, reducing pressure on cord.
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Nursing Interventions for Prolapsed Cord
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-Get help to move mother into a position where gravity assists in getting presenting part off cord. -Administer oxygen, and prepare for immediate cesarean birth. -If cord protrudes outside vagina, cover with sterile gauze moistened with sterile saline while carrying out above tasks. -Do not attempt to replace cord. -Notify physician.
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Fetal Distress
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-Insufficient oxygen supply to meet the demands of the fetus *Common contributing factors are: cord compression, uterine or placental rupture, placental abnormalities and preexisting maternal disease.*
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If fetus is in the complete breech position, what is a major concern for the fetus?
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Cord twisting around the fetus
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Assessment Findings for Fetal Distress
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*Change in fetal heart rate baseline* -Tachycardia: early sign of distress -Bradycardia: late sign of distress -Decrease or absence of variability of heart rate -Late deceleration pattern, severe variable deceleration pattern -*Meconium-stained amniotic fluid with a vertex presentation*
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Nursing Interventions for Fetal Distress
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*Check FHR on appropriate basis, institute fetal monitoring if not already in use.* -Conduct vaginal exam for presentation and position. -Place mother on left side, administer oxygen, check for prolapsed cord, notify physician. -Support mother and family. -Prepare for emergency birth if indicated.
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Membranes must for ruptured for?
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Insertion of an internal fetal heart monitor
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For admin of Pitocin
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a good assessment of fetal contraction strength and intensity must be done. (use internal FHR monitor to do this if appropriate)
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Fetal Presentation or Position
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Some presentations and positions that can be problematic include: -Occipitoposterior position (OP) -Breech presentation -Face presentation -Transverse lie and brow presentation.
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Version
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*Turning of fetus artificially from one presentation to another, externally or internally* 1) External cephalic version 2)Internal version *version is still done when the baby is battlotable*
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External Cephalic Version
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version turn fetus from a breech or shoulder to vertex
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Internal Version
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fetus turned by inserting a hand into the uterus and changes the presentation to cephalic
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Transverse Presentation
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can't be delivered vaginally. Results in C/S
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Face Presentation
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can be vaginal delivery but could be prolonged *avoid head entrapment*
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MAPS
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*are interventions for shoulder dystocia* 1) McRoberts 2) Anterior Shoulder 3) Posterior Shoulder 4) Salvage (contains 3 sub-types)
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Salvage Maneuver
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a) Posterior Axillary Maneuver b) Zavaneli Maneuver c) Fracture of the clavicles
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What is a major risk for Breech delivery?
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prolapsed cord
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Nursing Assessment for Version
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-Ultrasound scanning to determine fetal position, locate cord etc... -Non-stress test to confirm fetal well being -Tocolytic agent such as terbutaline is given to relax the uterus -Ultrasound scanning and fetal monitoring done to ensure fetal well being during procedure
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Multiple Gestation
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-Additional personnel are needed for the birth -Possibly immature neonates -Twins-depends on position for delivery -3 or more-c/sec-to decrease the risk of anoxia to a subsequent fetus, inc incidence of cord entanglement and premature separation of the placenta. (*Twin A needs to be vertex & Twin B needs to be transverse in order to have 1 bag delivery & 1 c/s)
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Shoulder Dystocia
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(An obstetric emergency resulting from difficulty or inability to deliver the shoulders) *Maternal risks: lacerations and tears of birth canal and postpartum hemorrhage* *Neonatal risks: hypoxia, fractures of clavicle, and injury to neck and head* (nerve damage r/t fractured shoulders)
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Interventions
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-Turtle sign (isn't actually an intervention, is a sign that shoulder dystocia is present/crinkling of the fetal face ; head popping in ; out of vaginal opening during delivery) -McRobert's Maneuver (*1st intervention for getting shoulders out) -Suprapubic Pressure (*RN performs this duty not practitioner*) -Wood Screw Maneuver
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Risk factors associated with External Version
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-increased chance of cord prolapse -increased chance of uterine rupture
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Injuries to newborn
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-*Check for crepitus, deformity, and bruising, each of which suggest fracture* -Brachial plexus stretching -*Erb's Palsy refers to an injury of the upper brachial plexus nerves leading to loss of motion around the shoulder and ability to flex the elbow.* -*Klumpke's palsy refers to an injury of the lower brachial plexus leading to loss of motion in the wrist and hand.*
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Erb's Palsy
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refers to an injury of the upper brachial plexus nerves leading to loss of motion around the shoulder and ability to flex the elbow
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Klumpke's palsy
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refers to an injury of the lower brachial plexus leading to loss of motion in the wrist and hand
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Dystocia (Difficult Labor)
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-Any labor/delivery that is prolonged or difficult. -Usually results from a change in the interrelationships among the "Ps". *Dysfunctional uterine contractions:* contractions may be too weak, too short, too far apart, ineffectual. (Progress of labor is affected, progressive dilation, effacement, and descent do not occur in the expected pattern.)
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Dystocia
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Frequently seen causes include: -disproportion between fetal presentation and maternal pelvis (cephalopelvic disproprotion (CPD). -If disproportion is minimal, vaginal birth may be attempted if fetal injuries can be minimized or eliminated or cesarean birth needed if disproportion is great.
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Dystocia
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*Problems with presentation:* any presentation unfavorable for delivery, posterior presentation that does not rotate, or cannot be rotated with ease, cesarean birth is the usual intervention.
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Dystocia
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*Problems with maternal soft tissue:* a full bladder may impede the progress of labor, cervical edema, scar tissue, and congenital abnormalities. Emptying the bladder may allow labor to continue, the other conditions may necessitate caesarean birth.
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Assessment Findings for Dystocia
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-Progress of labor slower than expected rate of dilation, effacement, descent for specific client. -Length of labor prolonged. -Maternal exhaustion/distress. -Fetal distress.
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Nursing Interventions for Dystocia
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-Individualized as to cause. -Provide comfort measures for client. -Provide clear, supportive descriptions of all actions taken. -Practitioner may decide to use vacuum, forceps, and/or episiotomy to assist delivery -Administer analgesia if ordered/indicated. -Prepare oxytocin infusion for induction if ordered. -Monitor mother/fetus continuously. -Prepare for cesarean birth if needed. -Vacuum Extraction -Forceps -Episotomy
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Risks for Vacuum-Assisted Birth
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*Newborn: cephalhematoma, scalp laceration and subdermal hematoma* *Maternal: uncommon but perineal, vaginal and cervical lacerations and soft-tissue hematomas*
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Risks for Forcep-Assisted Birth
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-Maternal: vaginal and cervical laceration, hematoma formation. -Newborn: bruising and abrasions, facial palsy resulting form pressure of the blades on the facial nerve and subdural hematoma.
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Precipitous Labor and Delivery
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-Labor of less than 3 hours -Emergency delivery without patient's physician or midwife-
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Assessment Findings for Precipitous L;D
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-As labor progressing quickly, assessment may need to be done rapidly -Patient may have history of previous precipitous -Desire to push -Observe status of membranes, perineal area for bulging and for signs of bleeding
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Nursing Interventions for Precipitous L;D
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-Assess the patient's affect and ability to understand directions -Stay with patient at all times!! -Do not prevent birth of baby -Maintain sterile environment (if possible) -Rupture membrane (if necessary) -Support baby's head as it emerges, preventing too rapid delivery with gentle pressure -Check for nuchal cord, slip over head if possible -Deliver shoulders after external rotation, asking mother to push if needed -Provide support for baby's body as it is delivered -Hold baby in head down position to facilitate drainage of secretions -Promote cry by gently rubbing over back and soles of feet -Dry to prevent heat loss
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Nursing Interventions for Precipitous L&D
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-Place baby on mother's abdomen -Check for signs of placental separation -Check mother for excess bleeding, massage uterus prn -Hold placenta as it is delivered -Cut cord when pulsations cease, if cord clamp is available, if no clamps available, leave intact, tie both ends -Wrap baby in dry blanket, give to mother, put to breast if possible -Check mother for fundal firmness and excess bleeding -Record all pertinent data -Comfort mother and family as needed -Now Breathe!
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Anaphylactoid syndrome of pregnancy (ASP)
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*Causes Amniotic Fluid Embolism (AFE)* -ASP occurs when amniotic fluid containing particles of debris enters the maternal circulation and obstructs pulmonary vessels, causing respiratory distress and circulatory collapse. *Obstetric emergency, may be fatal to the mother and to the baby*
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Assessment Findings of ASP
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-Sudden onset of respiratory distress, hypotension, chest pain, signs of shock -Bleeding -Cyanosis -Pulmonary edema
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Nursing Interventions for ASP
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-Initiate emergency life support activities for mother -Administer oxygen -Correction of hypotension -Establish IV line for blood transfusion -Administer medications to control bleeding as ordered -Prepare for emergency birth of baby -Keep patient/family informed as possible
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Induction of Labor
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Deliberate stimulation of uterine contractions before the normal occurrence of labor
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Assessment Findings for Induction of Labor
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Indications for use: postmature pregnancy, preeclampsia/eclampsia, diabetes, premature rupture of membranes *Condition of fetus: mature, engaged vertex fetus in no distress* *Condition of mother: cervix "ripe" for induction, no CPD*
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Nursing Interventions for Induction of Labor
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-Explain all procedures to the patient -Prepare appropriate equipment and medications -Explain sensations to patient -Check FHR immediately before and after procedure, marked changes may indicate prolapsed cord or nuchal cord -Additional care as for woman with prom
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Cervical Ripeness and Labor Induction
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1) Either Ripe cervix-shortened, anterior, softened and partially dilated 2) Or Unripe-long, closed, posterior and firm -Various scoring-Bishop Score is most common. Murray: Table: 16-1, pg. 307 -Dilation, Effacement, Station, Cervical consistency and Cervical position *Scoring: a woman with previous birth, successful is over 5, a woman having her first baby is most successful if her score is 7 or higher.*
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Nursing and OB Management
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-Amniotomy -Oxytocins (usually Pitocin) -Prostaglandin in gel/suppository form -Misoprostil -Non pharmacologic Methods
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Amniotomy
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Cervical hook or cervical finger cot *Promotes pressure of the presenting part on the cervix and stimulates inc in the activity of prostaglandins* Risks (infection for mom ; baby)
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Cervical Ripening
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(Three:) 1) Prostaglandin gel [Dinoprostone (Prepidil)] 2) Vaginal insert [Dinoprostone (Cervidil)] 3) Misoprostol (Cytotec). Know these, yes open the book, table 16-2, pg. 308..... Advantages Disadvantages
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Ineffective Uterine Force
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-Although effective labor can become ineffective at any time, there are 2 general types: primary and secondary -Complications d/t ineffective uterine force can impede the natural course of labor. These complications include: (*hypertonic, hypotonic and uncoordinated.*)
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Oxytocin Administration
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-IV administration, "piggybacked" to main line -Usually dilution 30mU/500 ml fluid, delivered via infusion pump for greatest accuracy in controlling dosage -1mu=1cc
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Oxytocin Administration
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-Usual administration rate is .5-1 mu/min increased no more than 1-2 mu/min at 40-60 intervals until regular pattern of appropriate contractions is established -Know that continuous monitoring and accurate assessments are essential
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Oxytocin Administration
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-Apply external continuous fetal monitoring equipment -Monitor maternal condition on a continuous basis: blood pressure q30 min or with rate change of pitocin, pulse, progress of labor -Discontinue pitocin infusion when fetal distress is noted, hypertonic contractions occur, signs of other ob complications and notify physician of any untoward reactions
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Oxytocin Administration
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*Maternal contraindictations: severe preeclampsia-eclampsia, risk for uterine rupture, CPD, malpresenation, preterm, rigid, unripe cervix or total placenta previa and presence of nonreassuring FHR.* -Maternal side effects: hyperstimulation of uterus, rapid labor and birth, hypotension, and water intoxication (see book, page 309 for more details) *Fetus-newborn effects: hypercontactility decreasing oxygen, trauma from rapid birth*
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Non pharmacologic Methods
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Herbal agents Sexual intercourse with breast stimulation Walking
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Vaginal Breech Delivery
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-Maternal risks -Prolonged labor -Forceps delivery -Trauma to birth canal during delivery form manipulation and forceps to free the fetal head -Intrapartum or postpartum hemorrhage
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Fetal Risks for Breech Delivery
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-Compression or prolapse of the umbilical cord -Entrapment of the fetal head in incompletely dilated cervix -Aspiration and asphyxia at birth -Birth trauma from manipulation and forceps to free the fetal head
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Vaginal Breech Delivery
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-Fetal body may pass though an incompletely dilated cervix entrapping the lager fetal head that follows -Delivery of fetal head must be done quickly to avoid hypoxia -Piper (long handle) forceps may be applied to the after-coming fetal head
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Cesarean Section
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*Major indications for cesarean delivery: dystocia or CPD, fetal distress, breech presentation and previous birth* -Maternal risks: aspiration, hemorrhage, infection, injury to bowel or bladder, thrombophlebitis, or pulmonary embolism -Fetal risks: prematurity or injury at birth
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Uterine Rupture
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*Tearing open or separation of uterine wall* Most common causes: -Separation of scar tissue from previous c/sec -Uterine trauma
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Common Causes of Uterine Rupture
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-Intense uterine contractions -Overstimulation of labor with oxytocin -Difficult forceps-assisted birth -External cephalic or internal version -Drug use
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Planning and Implementation for Uterine Rupture
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*Prevention is best* -Identify patients at risk -Avoid hyperstimulation of the uterus during induction
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Nursing Assessment for Uterine Rupture
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-Signs of shock or hemorrhage -Report of "ripping or tearing" sensation or sharp uterine pain -Abrupt cessation of contractions -Abrupt onset of fetal distress -Fetus, lying outside the uterus may be palpated more easily than before -Blood is often concealed
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Management
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-Prevention is the best -Management depends on severity.... *Nursing role: starting IV, monitoring FHR, administering oxygen as ordered, transfusing blood products, and preparing for immediate surgery.*
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Nursing Diagnoses for childbirth complications
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-Risk for maternal or fetal injury related to interventions implemented for dystocia -Powerlessness related to loss of control -Risk for infection -Ineffective individual coping related to exhaustion -Pain related to procedures