Newberry College of Nursing OB checkpoint #4
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Factors Affecting Labor Progress
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¥ Passageway (birth canal) ¥ Passenger (fetus) ¥ Powers ¥ Position ¥ Psyche (mother)
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Passageway
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¥ True pelvis (space enclosed by the pelvic girdle and below the pelvic brim: between the pelvic inlet and the pelvic floor) Ð Inlet, midpelvis, outlet ¥ Four types Ð Gynecoid Ð Android Ð Anthropoid Ð Platypelloid ¥ Cervical changes Ð Dilation ♣ Widening of cervix during first stage; 0-10 centimeters Ð Effacement ♣ Stretching and thinning of the cervix; 0-100%
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Passenger--Fetal head
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Ð Two frontal bones, two parietal bones, and occipital bone Ð Sutures ¥ Membranous spaces b/n bones Ð Fontanelles ¥ Intersections of the cranial sutures ¥ Anterior: diamond shape ¥ Posterior: triangle shape Ð Molding ¥ Bones of fetal skull overlap to allow passage through birth canal ¥ Landmarks—mentum (chin), sinciput (brow), bregma (anterior fontanelle), occiput (back of head)
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Fetal Attitude
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Ð The relation of the fetal body parts to one another Ð Normal attitude is flexion
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Fetal Lie
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Ð The relationship of spinal column of the fetus to that of the mother Ð Longitudinal or transverse
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Fetal Presentation
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Ð Presenting part enters pelvic passage 1st ¥ Cephalic, Breech, Shoulder ¥ Cephalic broken down to vertex, sinciput, brow, face
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Engagement
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¥ Largest diameter of presenting part reaches level of ischial spines ¥ Determined by vaginal exam Engagement is based on how many fingers you can grasp the fetal head with.
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Station
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¥ Relationship of the presenting part to the ischial spines ¥ Ischial spines are zero station ¥ If presenting part above the ischial spine—negative number ¥ If presenting part below the ischial spine—positive number
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Fetal Position
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Ð Relationship of presenting part to maternal pelvis Ð Right (R) or left (L) side of the maternal pelvis Ð Landmark: occiput (O), mentum (M), sacrum (S), or acromion (scapula[Sc]) process (A) Ð Anterior (A), posterior (P), or transverse (T) Ð Determine by inspection/palpation of maternal abdomen or vaginal exam ********look this up for clarification******
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Powers
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¥ Primary forces—uterine muscular contractions Ð Involuntary Ð Contraction phases—increment, acme, decrement Ð Described with frequency, duration, and intensity Ð Braxton-Hicks: irregular and intermittent contractions; false labor ¥ Secondary forces—abdominal muscles used in pushing
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Position
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¥ Whatever is comfortable ¥ Allow mom to listen to her body ¥ NEVER supine!
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Psyche
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¥ Fears ¥ Anxieties ¥ Excitement level ¥ Feelings of joy and anticipation ¥ Level of social support
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Premonitory Signs of Labor
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¥ Lightening ¥ Braxton Hicks contractions ¥ Cervical changes (effacement, dilation, ripening) ¥ Bloody show ¥ Mucous plug released ¥ Rupture of membranes (ROM) ¥ Sudden burst of energy ¥ Weight loss ¥ Backache ¥ Nausea and vomiting ¥ Diarrhea
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True Labor
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¥ Progressive dilation and effacement ¥ Regular contractions increasing in frequency, duration, and intensity ¥ Pain usually starts in the back and radiates to the abdomen ¥ Pain is not relieved by ambulation or by resting
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False Labor
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¥ Lack of cervical effacement and dilatation ¥ Irregular contractions do not increase in frequency, duration, and intensity ¥ Contractions occur mainly in the lower abdomen and groin ¥ Pain may be relieved by ambulation, changes of position, resting, or a hot bath or shower
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STAGES OF LABOR FIRST STAGE
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- from beginning of labor to complete dilation and effacement of cervix ¥ Latent or early phase (0-3cm) ¥ Contractions every 10-30 min, lasting 30-40 seconds, mild ¥ Active phase (4-7cm) ¥ Contractions every 2-3 min, lasting 40-60 seconds, moderate to strong ¥ Transition phase (8-10cm) ¥ Contractions every 1 ½ - 2 min, lasting 60-90 seconds, strong
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Interventions for 1st stage labor
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¥ Complete Admission Assessment and Review History ¥ Assessment: Maternal VS, Response to Labor and Pain, FHR and UC, Cervical Changes, Membrane Status, Fetal Position and Descent ¥ Diet and Hydration: Clear Liquids ¥ Activity and Rest: Frequent Position Changes/Ambulation/Pad Pressure Points ¥ Elimination: Frequent Emptying, Perineal Care ¥ Comfort: Meds and Non-Pharmacologic Strategies, Warm or Cool Cloths, Oral Care, Fresh Bed Linen ¥ Support: Keep Family Involved; Decrease Anxiety ¥ Education: About Labor, Procedures, Policies ¥ Safety: Safe and Friendly Environment ¥ Documentation
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SECOND STAGE
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- begins with complete dilation of cervix and ends with birth of baby \"PUSHING\" ¥ S&Sx = sudden increase in bloody show, uncontrolled bearing down efforts, bulging of the perineum ¥ Contraction frequency 1 ½ - 2 min; duration 60 - 90 sec ¥ Crowning ¥ Episiotomy Ð Midline Ð Mediolateral
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Interventions for 2nd stage labor
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¥ Support and Encourage Spontaneous Pushing Efforts ¥ Monitor for Fetal Response to Pushing ¥ Provide Comfort Measures (Cool, warm cloths, sips of fluids or ice chips, change linens) ¥ Position Changes as needed ¥ Perineal Hygiene as needed ¥ Give Praise and Encouragement ¥ Encourage Rest between Contractions ¥ Teach Breathing Technique ¥ Teach Pushing Technique ¥ Meds as ordered ¥ Assist the Support Person ¥ Advocate on Woman's Behalf ¥ Documentation
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THIRD STAGE
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- begins with birth of the baby and ends with delivery of placenta ¥ Should deliver within 30 minutes ¥ Considered a \"retained placenta\" if greater than 30 mins. ¥ May need to remove manually
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Interventions for 3rd Stage
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¥ Maternal VS per protocol ¥ Encourage Breathing ¥ Encourage Rest ¥ Palpate Uterus ¥ Initial Newborn Care ¥ Encourage Bonding with Neonate ¥ Meds as ordered ¥ Documentation
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FOURTH STAGE
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- initial recovery time ¥ First 1-4 hours after delivery of placenta ¥ Expected amount of blood loss - 250 - 500 ml for vaginal delivery ¥ Essential for uterus to remain contracted ¥ Uterus should remain midline ¥ Uterus typically b/n symphysis pubis and umbilicus ¥ Priority problems during this stage ¥ -Risk for hemorrhage ¥ -Risk for hypotonic bladder/urinary retention
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Interventions for 4th stage
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¥ Maternal VS ¥ Assess Uterus Frequently: Position, Tone, Location ¥ Uterine Massage if needed ¥ Assess Lochia: Color, Amount, Clots ¥ Monitor Perineum for Swelling or Hematomas ¥ Meds as ordered ¥ Assist with Laceration/Episiotomy Repair ¥ Apply Ice to Perineum ¥ Monitor for Bladder Distention ¥ Promote Urinary Elimination ¥ Assess for motor-sensory function return if spinal or epidural used ¥ Encourage Bonding with Neonate ¥ May Eat and Drink Immediately if Vaginal Delivery ¥ Documentation
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Discharge to Postpartum Care
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¥ Discharge criteria Ð Stable vital signs Ð Stable bleeding Ð Undistended bladder Ð Firm fundus Ð Sensations fully recovered from any anesthetic agent received during birth
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Systemic Responses to Labor
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¥ Increased cardiac output ¥ Increased blood pressure, pulse ¥ Diaphoresis ¥ Hyperventilation ¥ Changes in acid-base balance ¥ Impaired blood and lymph drainage from base of bladder ¥ Reduced gastric motility and food absorption, and prolonged emptying time ¥ Increased WBCs (25,000-30,000) ¥ Decreased maternal blood glucose ¥ Pain
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Fetal Adaptations to labor
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¥ Early decelerations from head compression ¥ Decreased pH, anoxic periods ¥ Aware of sensations such as light, sound, touch, pressure
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Leopold's Maneuvers: Palpation of abdomen to determine fetal position
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¥ First maneuver Ð Which part occupies the fundus? Ð Am I feeling buttocks or head? ¥ Second maneuver Ð Where is the fetal back? Ð Where are the small parts or extremities? ¥ Third maneuver Ð What is in the inlet? Does it confirm what I found in the fundus? Ð Is the presenting part engaged? ¥ Fourth maneuver Ð Where is the cephalic prominence or brow? Ð Some practitioners may perform the fourth maneuver first to identify the fetal part in the pelvic inlet
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Nursing for Leopold's
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¥ Empty bladder ¥ Lie on back ¥ Positioning Ð Feet on bed Ð Knees bent
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Auscultation of FHR
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¥ Intermittent done with Doppler or fetoscope Ð Okay to count 30 seconds x2 Ð Count for full minute if tachycardia, bradycardia, or irregularities Ð Compare HR of mom and baby
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Frequency in low-risk women
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Ð Every 30 minutes in first stage Ð Every 15 minutes in second stage
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Frequency in high-risk women
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Ð Every 15 minutes in first stage Ð Every 5 minutes in second stage
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Systemic Analgesia
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¥ Goal is to provide maximum pain relief with minimal risk ¥ Alteration in maternal state affects fetus ¥ Affects the labor process
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Administration of Systemic Analgesia
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¥ When woman is uncomfortable ¥ Well-established labor pattern ¥ Contractions occurring regularly ¥ Significant duration of contractions ¥ Moderate to strong intensity
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Maternal Assessments Administration of Systemic Analgesia
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¥ The woman consents to receive medication after being advised ¥ Stable vital signs ¥ No contraindications
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Fetal Assessments Administration of Systemic Analgesia
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¥ Fetal heart rate between 110 and 160 beats/min ¥ No late decelerations or nonreassuring FHR patterns ¥ Variability is present ¥ Normal fetal movement ¥ Accelerations with fetal movement ¥ Term fetus
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Assessment of Labor Progress
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¥ Contraction pattern ¥ Cervical status Ð Position Ð Consistency Ð Effacement Ð Dilatation Ð Station
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Nursing Considerations Prior to Medication Administration
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¥ Assess for history of any medication reactions or allergies ¥ Provide information about the medication ¥ Document assessment data Ð Maternal vital signs Ð FHR Ð Contraction pattern Ð Pain level
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Nursing Considerations Following Medication Administration
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¥ Record the drug name, dose, route, and site on FHR strip and chart ¥ Record the woman's blood pressure and pulse on the FHR strip and chart ¥ Safety precautions Ð Raise side rails Ð Assess FHR
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Evaluation of Pharmacologic Effects
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¥ Assess and document data Ð Woman's pain level Ð Effectiveness of the medication Ð Adverse effects, if any
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Opioid Analgesics and Sedatives
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¥ Opioid analgesics Ð Used in early labor Ð Provide analgesic effect Ð Induce sedation
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Sedatives
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Ð Promote rest
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Opioid Analgesics
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¥ Butorphanol tartrate (Stadol) ¥ Nalbuphine hydrochloride (Nubain) ¥ Meperidine (Demerol) ¥ Sublimaze (Fentanyl) ¥ Sufenta (Sufentanil) ¥ Morphine (Astramorph)
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Analgesic Potentiators (ataractics)---enhance or increase effects of analgesics
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¥ Promethazine (Phenergan) ¥ Hydroxyzine (Vistaril) ¥ Metoclopramide (Reglan) ¥ Ondansetron (Zofran) ¥ Diphenhydramine (Benadryl) ¥ Main side effect: sedation
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Opiate Antagonist - Naloxone (Narcan)
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¥ Nurse must be proficient in basic airway management ¥ Personnel skilled in advanced resuscitative measures must be available
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Regional Anesthesia
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¥ Temporary and reversible loss of sensation ¥ Prevents initiation and transmission of nerve impulses ¥ Types Ð Epidural Ð Spinal Ð Combined epidural-spinal
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Epidural: Advantages
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¥ Produces good analgesia ¥ Woman is fully awake during labor and birth ¥ Continuous technique allows different blocking for each stage of labor ¥ Dose of anesthetic agent can be adjusted
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Epidural: Disadvantages
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¥ Hypotension ¥ Slowed fetal descent ¥ Prolonged labor ¥ Loss of bladder sensation may cause urine retention ¥ Low back pain
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Epidural: Contraindications
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¥ Patient refusal ¥ Infection at needle puncture site ¥ Maternal blood coagulopathies ¥ Increased intracranial pressure ¥ Allergy to anesthetic medication ¥ Hypovolemic shock
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Epidural - Patient Preparation
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¥ Confirm availability of obstetrician and ancillary staff ¥ Encourage woman to void urine ¥ Foley catheter insertion ¥ Assessment data Ð Maternal pain level, blood pressure (BP), pulse, respirations Ð Fetal heart rate (FHR) ¥ Continuous electronic fetal monitoring ¥ Assist with patient positioning ¥ Initiate intravenous infusion (18-gauge) Ð Bolus of 500 to 1000 mL of IV fluid
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Nursing Interventions During Epidural Anesthesia
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¥ Frequent assessment of maternal vital signs until block wears off ¥ Promote maternal side-lying position ¥ Frequent repositioning ¥ Assess sensorimotor ability every 30 minutes ¥ Assess for bladder distention ¥ Protect lower extremities from injury
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Recovery from Epidural Anesthesia
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¥ May take several hours Ð Dependent upon anesthetic agent and dose
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Potential side effects of epidural infusions:
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¥ Breakthrough pain Ð Hot Spots ¥ Sedation ¥ Nausea and vomiting Ð --Antiemetics ¥ Pruritus—severe itching of the skin Ð ----Benadryl ¥ Hypotension Ð ---Increase IVF rate, left uterine displacement, oxygen Ð ---If BP doesn't return in 1-2 minutes, give ephedrine 5-10 mg IV
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Epidural Opioid Analgesia
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¥ Provides analgesia for approximately 24 hours after delivery ¥ Works in 30-60 minutes ¥ Injection of opioid into epidural space following delivery ¥ Side effects include Ð Pruritus Ð Nausea and vomiting Ð Urinary retention
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Spinal Anesthesia: Advantages
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¥ Immediate onset of anesthesia ¥ Relative ease of administration ¥ Smaller drug volume ¥ Maternal compartmentalization of the drug
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Spinal Anesthesia: Disadvantages
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¥ High incidence of hypotension ¥ Greater potential for fetal hypoxia ¥ Uterine tone is maintained, making intrauterine manipulation difficult
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Spinal Anesthesia: Contraindications
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¥ Patient refusal ¥ Severe hypovolemia ¥ Central nervous system disease ¥ Infection over the puncture site ¥ Allergy to anesthetic agent ¥ Coagulation problems
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Spinal Anesthesia - Patient Preparation
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¥ Insert 16- to 18-gauge intravenous (IV) catheter ¥ Administer bolus of 500 to 1000 mL IV fluid ¥ Assess maternal vital signs, pain level, and FHR ¥ Position woman sitting or lateral
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Nursing Interventions During Spinal Anesthesia
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¥ Position woman supine with left uterine displacement Ð Rolled towel or blanket under right hip ¥ Monitor maternal blood pressure and pulse per protocol or physician's order ¥ If spinal block used during vaginal birth Ð Monitor uterine contractions Ð Instruct the woman to bear down during a contraction
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Recovery From Spinal Anesthesia
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¥ Cautious transfers from birthing bed (or operating room table) ¥ Bedrest for 6 to 12 hours following block ¥ Restoration of bladder control may take 8 to 12 hours Ð Urinary catheter may be needed if not already in place
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Combined Spinal-Epidural (CSE)
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¥ Can be used for labor analgesia and for cesarean birth ¥ Advantages Ð Faster onset than medications injected into epidural space Ð Medication can be added to increase effectiveness Ð Motor function preserved Ð Allows for ambulation with assistance
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Pudendal Block
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¥ Provides perineal anesthesia Ð Latter part of the first stage of labor Ð Second stage of labor Ð Birth Ð Episiotomy repair
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Pudendal Block: Advantages
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¥ Ease of administration ¥ Absence of maternal hypotension ¥ Pain reduction during use of low forceps or vacuum extraction
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Pudendal Block: Disadvantages
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¥ Possible complications Ð Broad ligament hematoma Ð Perforation of the rectum Ð Sciatic nerve injury ¥ May diminish urge to push
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General Anesthesia
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¥ Potential indications Ð Cesarean birth Ð Surgical intervention with some complications ¥ Used in less than 1% of all modern obstetric births
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Primary Dangers of General Anesthesia
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¥ Fetal depression Ð Most general anesthetic agents reach fetus in about 2 minutes Ð Fetal depression directly proportional to anesthetic depth and duration Ð Not advocated for high-risk fetus Ð Maternal general anesthesia associated with higher rate of neonatal respiratory depression than is maternal epidural anesthesia
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Premature Rupture of Membranes (PROM)
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¥ Spontaneous rupture of membranes before onset of labor ¥ Preterm PROM (PPROM): rupture of membranes before 37 weeks' gestation
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Risk Factors Associated With PROM / PPROM
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¥ Infection ¥ Previous history of PROM / PPROM ¥ Hydramnios ¥ Multiple pregnancy ¥ Urinary tract infection (UTI) ¥ Amniocentesis ¥ Placenta previa-- placenta partially or wholly blocks the neck of the uterus ¥ Abruptio placentae-- placental lining has separated from the uterus of the mother prior to delivery. ¥ Trauma ¥ Incompetent cervix ¥ History of laser conization or LEEP procedure ¥ Bleeding during pregnancy ¥ Maternal genital tract anomalies
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Maternal Risk of PROM
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¥ Related to infection Ð Specifically chorioamnionitis (intra-amniotic infection resulting from bacterial invasion before birth) and endometritis (PP infection of the endometrium) ¥ Abruptio placentae occurs more frequently in women with PROM ¥ Rare complications include retained placenta and hemorrhage, maternal sepsis, and maternal death
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Fetal/Newborn Implications
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¥ Risk of respiratory distress syndrome (with PPROM) ¥ Fetal sepsis ¥ Malpresentation ¥ Umbilical cord prolapse or compression ¥ Nonreassuring fetal heart rate tracings ¥ Premature birth ¥ Increased perinatal morbidity and mortality
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PROM - Nursing Care
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¥ Determine duration of the rupture of membranes ¥ Assess gestational age ¥ Monitor for infection ¥ Assess fetal heart rate ¥ Evaluate the woman and partner's childbirth preparation and coping abilities ¥ Assess uterine activity and fetal response to the labor Ð Vaginal exams only if necessary ¥ Provide comfort measures ¥ Maintain adequate hydration ¥ Encourage left lateral positioning ¥ If PPROM Ð Hospitalization, bed rest, monitored for infection, and assess fetal well-being ¥ Education
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Signs and Symptoms of PTL (preterm labor)
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¥ Uterine contractions that occur at least every 10 minutes Ð With or without pain ¥ Mild menstrual-like cramps felt low in the abdomen ¥ Constant or intermittent feelings of pelvic pressure ¥ Rupture of membranes ¥ Low, dull backache ¥ Change in the vaginal discharge ¥ Abdominal cramping
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Risk Factors of PTL
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¥ Multiple gestation ¥ Hydramnios ¥ Substance abuse ¥ Trauma ¥ Hypertension ¥ Obesity ¥ History of PTL ¥ Diabetes ¥ Cervical insufficiency
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Diagnosis of PTL
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¥ 20 to 37 weeks' gestation ¥ Documented uterine contractions Ð At least 4 in 20 minutes or 8 in one hour ¥ Cervical change or dilation >1 cm; effacement ≥ 80%
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Clinical Interventions for PTL
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¥ Maternal lateral positioning ¥ IV fluid infusion ¥ Maternal laboratory studies Ð CBC Ð C-reactive protein Ð Vaginal and urine cultures Ð Fetal fibronectin (fFN) ¥ Ultrasounds
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Tocolysis for PTL
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¥ Use of medication to stop labor Ð β-adrenergic agonists (β-mimetics) Ð Magnesium sulfate Ð Cyclooxygenase (prostaglandin synthetase) inhibitors Ð Calcium channel blockers ¥ (Brethine) and magnesium sulfate are most widely used tocolytics
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PTL - Community-Based Care
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¥ Teach signs and symptoms of PTL Ð Uterine contractions that occur every 10 min or less Ð Mild menstrual-like cramps low in the abdomen Ð Constant or intermittent feelings of pelvic pressure Ð Rupture of membranes Ð Constant or intermittent low, dull backache Ð Change in vaginal discharge Ð Abdominal cramping
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¥ Teach self-assessment and self-care
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Ð Evaluation of contraction activity once or twice daily for 1 hour Ð Ensure the woman knows when to report signs and symptoms Ð Reinforce to caregivers the need to take the woman's call seriously and treat her positively
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PTL - Hospital Care
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¥ Vital Signs ¥ Intake & Output ¥ Continuous FHR monitoring ¥ Continuous contraction monitoring ¥ Position on left side ¥ Administer medications ¥ If birth is inevitable, administer corticosteroids (Betamethasone, Dexamethasone) Ð Prevent RDS, IVH, NEC, death - especially b/n 24-34 weeks
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Placenta Previa
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¥ Placental implantation in the lower uterine segment ¥ As lower uterine segment contracts and dilates, placental villi are torn from uterine wall Ð Uterine sinuses exposed at placental site Ð Amount of bleeding may range from scanty to profuse
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¥ Placenta Previa: Four Degrees
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Ð Total (Internal os completely covered) Ð Partial (os partially covered) Ð Marginal (edge of placenta covered) Ð Low-lying (os not covered)
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Placenta Previa: Risk Factors
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¥ Women of African descent ¥ Prior cesarean birth ¥ High gravidity ¥ High parity ¥ Advanced maternal age ¥ Previous miscarriage ¥ Previous induced abortion ¥ Cigarette smoking ¥ Male fetus
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Placenta Previa - Fetal Prognosis
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¥ Depends on extent of placenta previa ¥ Profuse bleeding yields fetal compromise and hypoxia ¥ FHR monitoring is imperative upon maternal admission, particularly if vaginal birth is anticipated, as the presenting fetal part may obstruct the placental or umbilical cord blood flow
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Placenta Previa - Indications for Cesarean Birth
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¥ Nonreassuring fetal status ¥ Diagnosis of complete or partial previa
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Placenta Previa - Nursing Assessment
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¥ Maternal assessment for painless, bright-red vaginal bleeding Ð Most accurate diagnostic sign of placenta previa Ð If this sign develops during the last 3 months of pregnancy, placenta previa should always be considered until ruled out by ultrasound examination ¥ Bleeding usually begins as scant and becomes more profuse ¥ Uterus remains soft ¥ Anticipate unengaged fetal presenting part ¥ Transverse lie is common ¥ Assessment of fetal status Ð FHR - continuous external fetal monitoring Ð Electronic monitor tracing ¥ Anticipate need for blood transfusion ¥ Assess maternal vital signs Ð Every 15 minutes if no hemorrhage Ð Every 5 minutes with active hemorrhage ¥ External tocodynamometer-- Electronic external monitoring of uterine contractions ¥ No vaginal exams when bleeding present ¥ Intake and output ¥ IV line
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Placenta Previa - Nursing Care During Active Bleeding
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¥ Assessments and management directed toward physical support ¥ Address emotional aspects simultaneously Ð Explain assessments and treatment measures Ð Provide time for questions Ð Advocate for the family Ð Stay with the family Ð Therapeutic Touch
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Placenta Previa - Newborn Care
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¥ Promote neonatal physiologic adaptation ¥ Immediate laboratory assessment and monitoring Ð Hemoglobin, cell volume, and erythrocyte count ¥ Anticipate potential need for oxygen, blood administration, and admission to special care nursery
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Abruptio Placentae
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¥ Premature separation of a normally implanted placenta from the uterine wall ¥ Cause is largely unknown ¥ Uterus is hard on palpation
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Abruptio Placentae - Associated Risk Factors
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¥ Increased maternal age (over 35) ¥ Increased parity ¥ Cigarette smoking ¥ Cocaine abuse ¥ Trauma ¥ Maternal hypertension ¥ Rapid uterine decompression associated with hydramnios and multiple gestation ¥ Preterm premature rupture of the membranes (PPROM) ¥ Previous placental abruption ¥ Uterine malformations or fibroids ¥ Placental anomalies ¥ Amniocentesis ¥ Retroplacental fibromyoma ¥ Shortened umbilical cord ¥ Subchorionic hematoma ¥ Elevated alpha fetoprotein—(Levels of the protein can be measured to detect certain congenital defects such as spina bifida and Down syndrome.) in second trimester ¥ Inherited thrombophilia-- blood has an increased tendency to form clots
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Three Types of Placental Separation
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¥ Marginal (separates at the edges) Ð Blood passes between the fetal membranes and the uterine wall and escapes vaginally ¥ Central (separates centrally) Ð Blood is trapped between the placenta and uterine wall with concealed bleeding ¥ Complete Ð Total separation and massive bleeding
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Abruptio Placentae - Implications
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¥ Maternal Ð Risk of hemorrhage, shock, and DIC ¥ Fetal Ð Neonatal outcomes depend on degree of abruption Ð Low incidence of fetal death ♣ Typically depends upon the degree of placental separation Ð Fetal complications include preterm labor, anemia, and hypoxia
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Abruptio Placentae - Assessment and Monitoring
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¥ Electronic monitoring of uterine contractions and resting tone between contractions Ð Provides information about the labor pattern and effectiveness of oxytocin induction ¥ Hourly abdominal girth measurements
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Monitor for DIC
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Ð Coagulation tests (Fibrinogen and platelets decrease; PT and PTT WNL to prolonged) Ð Levels of fibrin-degradation products (rise with DIC) ( pregnancy complications including the following: (1) acute peripartum hemorrhage (uterine atony, cervical and vaginal lacerations, and uterine rupture); (2) placental abruption; (3) preeclampsia/eclampsia/hemolysis, elevated liver enzymes, and low platelet count)
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Abruptio Placentae - Clinical Therapy
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¥ Immediate priorities are maintaining maternal cardiovascular status and developing a birth plan ¥ Cesarean birth is often the safest option ¥ Induction of labor may be indicated
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Abruptio Placentae - Decreasing the Risk of DIC
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¥ Type and crossmatch for blood transfusions (at least three units) ¥ Evaluate clotting mechanism ¥ Administer intravenous fluids
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Abruptio Placentae - Moderate to Severe Separation
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¥ Cesarean birth follows treatment of hypofibrinogenemia ¥ Vaginal birth impossible with a Couvelaire uterus—( is a life-threatening condition in which loosening of the placenta (abruptio placentae) causes bleeding that penetrates into the uterine myometrium forcing its way into the peritoneal cavity.) Ð Lack of proper uterine contraction in labor Ð Hysterectomy often needed
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Abruptio Placentae - Fluid Volume Status
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¥ Hypovolemia associated with severe abruptio placentae is life threatening Ð Requires administration of whole blood ¥ If fetus is alive but experiencing stress Ð Emergency cesarean is method of choice ¥ If fetus is stillborn Ð Vaginal birth is preferable if bleeding has stabilized, unless maternal shock from hemorrhage is uncontrollable ¥ Administer intravenous fluids ¥ Hourly central venous pressure (CVP) monitoring ¥ Laboratory testing Ð Includes hemoglobin, hematocrit, and coagulation status ¥ Hematocrit maintained at 30% through administration of packed red blood cells or whole blood
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Third-Trimester Bleeding - Overview of Nursing Care
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¥ Frequent monitoring of vital signs ¥ Assess for signs of shock ¥ Estimate blood loss ¥ Monitor FHR ¥ Electronically monitor contractions ¥ Administer blood as needed ¥ Monitor urine output ¥ Facilitate and monitor diagnostic tests and results ¥ Support and educate the woman and her family
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Cervical Insufficiency
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¥ Formerly called incompetent cervix ¥ Painless dilatation of the cervix without contractions due to a structural or functional defect of the cervix ¥ Woman is usually unaware of contractions and presents with advanced effacement and dilatation and, possibly, bulging membranes
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Cervical Insufficiency - Risk Factors
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¥ Multiple gestations ¥ Repetitive second-trimester losses ¥ Previous preterm birth ¥ Progressively earlier births with each subsequent pregnancy ¥ Short labors ¥ Previous elective abortion or cervical manipulation ¥ Diethylstilbestrol (DES) exposure--- a powerful synthetic estrogen used in hormone therapy, as a postcoital contraceptive ¥ Other uterine anomaly
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Cervical Insufficiency - Caring for Women at Risk
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¥ Close surveillance of cervical length Ð Transvaginal ultrasound beginning between 16 and 24 weeks' gestation ¥ Education early in pregnancy Ð Warning signs of impending birth Ð Lower back pain, pelvic pressure, and changes in vaginal discharge
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Cervical Insufficiency - Medical Therapies
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¥ Serial cervical ultrasound assessments ¥ Bed rest ¥ Progesterone supplementation ¥ Antibiotics ¥ Anti-inflammatory drugs
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Cervical Insufficiency - Surgical Therapies
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¥ Cerclage- Ð Surgical procedure in which a stitch is placed in the cervix to prevent spontaneous abortion or premature birth ¥ Elective cerclage- Ð May be placed late in first trimester or early in second trimester Ð 80% to 90% success rate in preventing fetal loss and premature labor and birth ¥ Emergent cerclage- Ð Placed when dilatation and effacement have already occurred Ð 40% to 60% success rate ¥ Abdominal cerclage- Ð Indicated for congenitally short or amputated cervix, cervical defects, a cervix previously scarred, or unhealed lacerations or subacute cervicitis
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Discovery of Unexpected Cervical Dilation
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¥ Attempt may be made to \"rescue\" pregnancy through cerclage placement after advanced cervical dilatation ¥ May require decompression of bulging amniotic sac Ð Preoperative evaluation for infection, ruptured membranes, and uterine activity may be prudent ¥ Perioperative and ongoing treatment Ð Tocolytics (drugs that stop labor) Ð Broad-spectrum antibiotics Ð Anti-inflammatory agents
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Cerclage - Hospitalization and Postoperative Plan
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¥ Uncomplicated elective cerclage Ð May be outpatient procedure Ð May require hospitalization with discharge after 24 to 48 hours ¥ Emergency cerclage Ð Requires hospitalization for > 5 to 7 days ¥ After 37 completed weeks' gestation, suture may be cut and vaginal birth permitted, or the suture may be left in place and a cesarean birth performed
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Physical Discomfort Associated with Multiple Gestation
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¥ Shortness of breath ¥ Dyspnea on exertion ¥ Backaches and musculoskeletal disorders ¥ Pedal edema
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Problems Associated with Multiple Gestation
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¥ Urinary tract infections ¥ Threatened abortion ¥ Anemia ¥ Gestational hypertension and preeclampsia ¥ Preterm labor and birth ¥ Premature rupture of membranes ¥ Thromboembolism ¥ Placenta disorders (previa, abruption)
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Complications During Labor for Women with Multiple Gestation
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¥ Abnormal fetal presentations ¥ Uterine dysfunction ¥ Prolapsed cord ¥ Hemorrhage at birth or shortly after
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Multiple Gestation - Fetal/Neonatal Implications
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¥ Higher mortality rate than for single fetus ¥ Decreased intrauterine growth rate ¥ Increased incidence of fetal anomalies ¥ Increased risk of prematurity ¥ Abnormal presentations ¥ Increase in cord accidents ¥ Increase in cerebral palsy
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Multiple Gestation - Clinical Therapy
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¥ Prenatal visits more frequent than for mothers with single gestation ¥ Maternal education Ð Nutritional implications Ð Assessment of fetal activity Ð Signs of preterm labor Ð Danger signs of pregnancy ¥ Serial ultrasounds Ð No risk factors present: every 3-4 weeks to assess growth Ð Identified risk factors present: every 2-3 weeks
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Multiple Gestation - Third-Trimester Testing
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¥ Usually begins at 32 to 34 weeks' gestation ¥ May include nonstress test (NST) or biophysical profile (BPP)
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Multiple Gestation - Intrapartum Management
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¥ Insertion of large-bore IV in mother ¥ Anesthesia and crossmatched blood readily available ¥ Continuous dual electronic fetal monitoring of twins ¥ Method of birth might not be chosen until labor begins ¥ Cesarean birth may be indicated if complications
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Multiple Gestation - Maternal Dietary Counseling
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¥ Prenatal vitamins ¥ Daily intake of 1 mg of folic acid ¥ Recommended total weight gain of 40 to 45 lb, with a 24-lb gain by 24 weeks
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Multiple Gestation - Maternal Activity Counseling
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¥ Frequent rest periods Ð Side-lying position with her lower legs and feet elevated to reduce edema ¥ Relief of back discomfort Ð Pelvic rocking Ð Good posture Ð Pregnancy belt Ð Good body mechanics
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Multiple Gestation - Labor Care
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¥ Continuous FHR monitoring ¥ Most multiple gestations are now delivered via cesarean birth
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Multiple Gestation - Postdelivery Care
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¥ Duplicate all necessary supplies ¥ Additional staff members should be available ¥ Special precautions to ensure correct identification of newborns
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Amniotic Fluid Complications
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¥ Hydramnios (polyhydramnios) >2000 mL ¥ Oligohydramnios <500 mL
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Hydramnios Hydramnios—Risk Factors
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¥ Multiple gestation ¥ Diabetes ¥ Rh sensitization ¥ Infections (syphilis, toxoplasmosis, CMV, herpes, rubella) ¥ Fetal malformations—swallowing or neurologic disorders
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Hydramnios - Diagnosis
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¥ Fundal height increases out of proportion to gestational age ¥ Difficult to palpate fetus and auscultate FHR ¥ Severe cases: abdomen tense and tight, ultrasound shows large spaces between fetus and uterine wall
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Hydramnios - Nursing Care
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¥ Supportive care unless distress or symptoms of pain and dyspnea ¥ May need to remove fluid either vaginally or through amniocentesis Ð Maintenance of sterile technique during amniocentesis ¥ Psychologic support for the family
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Hydramnios - Maternal Implications
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¥ Rapid fluid removal could lead to abruptio placentae ¥ Risk of postpartum hemorrhage
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Fetal/Neonatal Implications with Hydramnios
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¥ Malformations ¥ Preterm labor/preterm birth ¥ Prolapsed cord ¥ Malpresentation ¥ Cesarean section
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Oligohydramnios Oligohydramnios - Risk Factors
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¥ Intrauterine growth restriction (IUGR) ¥ Fetal conditions—renal malformations ¥ Post-maturity ¥ Maternal HTN
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Oligohydramnios - Diagnosis
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¥ Largest vertical pocket of fluid measure 5 cm (2 inches) or less on ultrasound ¥ Uterus does not increase in size with dates ¥ Easily palpated fetus ¥ Not ballottable—meaning floating or unengaged
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Oligohydramnios - Maternal Implications
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¥ Dysfunctional labor, slow progress
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Oligohydramnios − Fetal Risks
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¥ Fetal skin and skeletal abnormalities ¥ Pulmonary hypoplasia--- incomplete development of the lungs ¥ Cord compression ¥ Fetal head compression
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Oligohydramnios − Clinical Therapy
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¥ Fetal assessment Ð Biophysical profiles (BPPs)-- measures your baby's heart rate, muscle tone, movement, breathing, and the amount of amniotic fluid around your baby.—(may include NSTs, ultrasound, and EFM) Ð Nonstress tests (NSTs) goal of the test is to measure the heart rate of the fetus in response to its own movements Ð Serial ultrasounds Ð Continuous EFM to detect cord compression ¥ Induction of labor when fetus at term ¥ Possible amnioinfusion
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Tachysystolic Labor
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more than 5 contractions in 10 minutes, over a 30 min period
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Oligohydramnios − Nursing Care During Labor and Birth
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¥ Evaluate continuous EFM for nonreassuring signs ¥ Maternal repositioning if variable decelerations noted Ð Notify physician/CNM Ð Nonreassuring tracing may warrant cesarean ¥ Assess newborn for signs of congenital anomalies, pulmonary hypoplasia, and postmaturity
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Tachysystolic (hypertonic) Labor Patterns
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need at least a 30 sec. break and this does not allow that to happen ¥ Ineffective uterine contractions in latent phase (the first of stage 1) of labor ¥ Increased myometrial resting tone—not getting break, so tone stays hard ¥ May develop prolonged latent phase Ð --Fetal hypoxia can result
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Risks of Tachysystolic Labor Patterns
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¥ Increased discomfort and fatigue ¥ Frustration and stress ¥ Dehydration ¥ Increased risk of infection ¥ Nonreassuring fetal status-because blood flow is diminished. ¥ Prolonged pressure on fetal head—could cause injury
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Clinical Therapy for Tachysystolic Labor
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¥ Bed rest and sedation ¥ If tachysystolic pattern continues and prolonged latent phase develops Ð Oxytocin (Pitocin)-(make contractions more effective) infusion or amniotomy (artificially rupture the membranes) may be considered to start a more natural progression ¥ If vaginal birth impossible—if baby is too big, or in a malposition Ð -No stimulation of labor Ð ---Cesarean section
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Care of Patient with Tachysystolic Contractions
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¥ Assess contractions, vitals, and FHR ¥ Provide comfort and support measures ¥ Change positions, provide back rubs, quiet environment ¥ Warm showers, tub baths ¥ Sedation, pain medication ¥ Client education
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Hypotonic Labor Patterns
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¥ Usually develop in active phase of labor ¥ Characterized by fewer than two to three contractions in a 10-minute period ¥ Contractions may be of low intensity and are minimally uncomfortable
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Hypotonic Labor Patterns - Associated Factors
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¥ Overstretched uterus (twin gestation) ¥ Large fetus ¥ Hydramnios ¥ Grand multiparity ¥ Bladder or bowel distention ¥ CPD—cephalopelvic disproportion---baby too big for pelvis
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Risks of Hypotonic Contractions
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¥ Maternal exhaustion ¥ Stress ¥ Postpartum hemorrhage—if uterus does not contract, can bleed after delivery ¥ Intrauterine infection ¥ Nonreassuring fetal status ¥ Fetal sepsis
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Hypotonic Contractions - Goals of Therapy
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¥ Improve uterine contraction quality ¥ Ensure safe maternal and fetal outcome ¥ Uterine contractions may be stimulated Ð Pitocin, amniotomy (artificially stimulate labor), or stimulation of the nipples (releases oxytocin)
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Hypotonic Contractions - Active Management of Labor (AMOL)
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¥ Labor managed from beginning with amniotomy, timed cervical exams, augmentation of labor with IV Pitocin ¥ May be instituted for treatment ¥ Goals of AMOL include cervical exam changes and more active labor pattern ¥ If improvement not significant, cesarean birth may be indicated
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Care of Patient with Hypertonic Contractions
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¥ Assess contractions, vitals, and FHR ¥ Verify adequacy of the pelvic measurements ¥ Rule out malpresentation ¥ Maintain adequate hydration ¥ Monitor for signs of infection ¥ Stimulation of uterine contractions
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Postterm Pregnancy - after 42 weeks Postterm Pregnancy - Maternal Risks
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¥ Labor induction ¥ Dystocia—abnormal labor ¥ Large-for-gestational-age (LGA) infant ¥ Forceps-assisted or vacuum-assisted birth ¥ Increased psychologic stress ¥ Infection—especially if membranes ruptured ¥ Severe perineal trauma related to macrosomia ¥ Double the risk of cesarean birth ¥ Hemorrhage—uterus has been distended for so long and can lead to bleeding
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Postterm Pregnancy - Fetal Risks
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¥ Decreased placental perfusion—kinda starts to breakdown ¥ Oligohydramnios—soon there may be not enough fluid ¥ Meconium aspiration---during birth baby ends up swallowing its own poop. ¥ Low Apgar score—because they were compromised in utero ¥ Orthopedic or neurologic injury—some type of trauma during birth leads to this
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Growth Beyond 42 Weeks - Fetal Risks
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¥ Macrosomia Ð Shoulder dystocia—may break clavicle if not careful ¥ Intrauterine growth restriction (IUGR) / Small for gestational age (SGA)—without fluid, this may result Ð Postmaturity or dysmaturity syndrome—loss of muscle mass and subcutaneous fat ¥ Small-for-gestational-age (SGA)
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Postterm Pregnancy - Clinical Therapy After 40 Weeks' Gestation
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¥ Biweekly assessments of fetal well-being Ð Nonstress test (NST), biophysical profile (BPP), modified BPP, or contraction stress test (CST) as assessment tools Ð Nonreassuring results may suggest need for delivery
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Community-Based Nursing Care
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¥ Teach the woman to perform daily assessment of fetal movement ¥ Education about post-term pregnancy ¥ Provide opportunities for the woman and her partner to ask questions and seek clarification
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Hospital-Based Nursing Care
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¥ Careful assessment and evaluation Ð Fetal response to labor Ð FHR tracing Ð Labor progress ¥ Emotional support ¥ Encouragement and support ¥ Acknowledgement of the woman's anxiety
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Fetal Macrosomia
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¥ Weight of more than 4500 g at birth Ð Some sources cite weights up to 4000 g ¥ Increased maternal risks Cephalopelvic disproportion (CPD), dysfunctional labor, prolonged
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Macrosomia - Risk Factors
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¥ Obesity ¥ Excessive weight gain ¥ Diabetes ¥ History of macrosomia ¥ Male fetus ¥ Grand multiparity ¥ Prolonged gestation ¥ Hispanic descent
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Macrosomia - Fetal Complications
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¥ Shoulder dystocia ¥ Upper brachial plexus injury ¥ Fractured clavicle ¥ Meconium aspiration ¥ Asphyxia ¥ Hypoglycemia ¥ Polycythemia ¥ Hyperbilirubinemia ¥ Obesity in childhood and adolescence ¥ Diabetes in later life
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Identification of Macrosomia Before Labor Onset
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¥ May reduce the occurrence of associated maternal and fetal problems ¥ Evaluation of maternal pelvis if large fetus suspected ¥ Estimation of fetal size ¥ Ultrasonography may be indicated
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Macrosomia - Method of Birth
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¥ Cesarean if weight estimated > 4500 g ¥ Vaginal delivery Ð Unexpected shoulder dystocia is critical problem Ð Nurse may be asked to assist woman into McRoberts maneuver or to apply suprapubic pressure in an attempt to aid in the birth of the fetal shoulders Ð Application of fundal pressure contraindicated b/c can further wedge shoulder under symphysis pubis
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Dystocia
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: abnormal or difficult labor—ends up being a prolonged labor ¥ Most common cause is dysfunctional or uncoordinated contractions; irregular in strength, timing, or both
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Nursing Care of the Laboring Woman with Fetal Risk for Macrosomia
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¥ Help identify women who are at risk for carrying a large fetus or those who exhibit signs of macrosomia ¥ Frequent assessment of FHR for indications of nonreassuring fetal status ¥ Evaluation of rates of cervical dilatation and fetal descent
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Nursing Care of the Fetus with Macrosomia During Labor
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¥ Continuous fetal monitoring Ð Early decels could be disproportion at the bony inlet ¥ Report any sign of labor dysfunction or nonreassuring fetal status to physician/ CNM Ð Lack of fetal descent should raise suspicion that infant may be too large for vaginal birth ¥ Support and inform laboring woman and her partner
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Neonatal Assessment of the Infant with Macrosomia
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¥ Nurse inspects newborn for cephalohematoma (bruising on head), Erb's palsy (paralysis of the arm caused by injury to the upper group of the arm's main nerves), and fractured clavicles ¥ Inform nursery staff of any problems ¥ Ensure close monitoring for cerebral, neurologic, and motor problems
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Postpartum Care of the Woman who Delivers Infant with Macrosomia
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¥ Anticipate excessive uterine stretching leading to contracting issues during labor and postpartum ¥ Expect uterine atony and boggy (soft) uterus ¥ Monitor for and treat uterine hemorrhage Ð Fundal massage Ð IV or IM Pitocin may be needed ¥ Closely monitor maternal vital signs for development of shock ¥ Electronic fetal monitoring - can tell if pressure relieved
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Umbilical Cord Prolapse - Cord precedes the presenting part causing compression
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Umbilical Cord Prolapse ¥ Relieve compression with gloved fingers-- ¥ Position for gravity to help relieve compression (knee chest; Trendelenburg) ¥ Oxygen via mask ¥ Cesarean birth if cervix not complete and pelvic measurements are not adequate
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Umbilical Cord Prolapse - Prevention
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¥ Keep horizontal after ROM until head well engaged ¥ If SROM or amniotomy - FHR auscultated for 1 minute at beginning and end of contraction for several contractions ¥ If fetal bradycardia - perform vaginal exam to rule out prolapse
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Umbilical Cord Prolapse - Symptoms
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¥ EFM will show severe, moderate, or prolonged variable decels with baseline bradycardia
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Amniotic Fluid Embolism
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¥ Currently known as anaphylactoid syndrome of pregnancy ¥ Small tear in amnion or chorion high in the uterus; small amount of amniotic fluid may leak into chorionic plate and enter maternal system; can enter at areas of placental separation or cervical tears; the uterus contracts, pushes fluid embolism into maternal circulation and into maternal lungs ¥ Occurs during or after the birth when the woman has had a difficult, rapid labor
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Amniotic Fluid Embolism - Risk Factors
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¥ Tumultuous labor ¥ Placental abruption ¥ Trauma ¥ Induction of labor ¥ Eclampsia ¥ Operative vaginal birth ¥ Cesarean section ¥ Multiple gestation
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Amniotic Fluid Embolism - Maternal Implications
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¥ Sudden onset of respiratory distress, circulatory collapse, acute hemorrhage, and cor pulmonale (failure of the right ventricle) ¥ Immediate birth may be required to obtain a live newborn ¥ Signs and symptoms include dyspnea and cyanosis progressing to hemorrhage, shock, and death
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Amniotic Fluid Embolism - Clinical Therapy
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¥ Monitor woman for signs and symptoms Ð Chest pain, dyspnea, cyanosis, frothy sputum, tachycardia, hypotension, and massive hemorrhage ¥ Implementation of immediate life-saving efforts by healthcare team ¥ Medical interventions are supportive Cesarean birth if necessary
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Cephalopelvic Disproportion (CPD)
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¥ Fetus is larger than passageway ¥ Causes of passageway contractures (narrowed diameter) Ð Narrowed pelvis or soft-tissue dystocia (fibroids, Bandl's ring, stool, full bladder) Ð Reproductive tract anomalies can also impact birthing ability
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CPD - Maternal Implications
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¥ Prolonged labor ¥ Rupture of membranes ¥ Increased risk of uterine rupture ¥ Maternal soft tissue necrosis ¥ Difficult, forceps-assisted birth
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CPD - Fetal/Neonatal Implications
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¥ Danger of cord prolapse ¥ Excessive cranial molding ¥ Bruising ¥ Nerve trauma ¥ Eye socket damage
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CPD - Clinical Therapy
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¥ Assessment of fetopelvic relationships Ð Compare pelvic measurements obtained by manual exam before labor ¥ Estimate weight of the fetus with ultrasound Ð Can be obtained by ultrasound measurements ¥ Trial of Labor (TOL) if pelvic diameters borderline Ð Frequently assess dilation and fetal descent
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Nursing Care of the Woman with Suspected CPD
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¥ Assess adequacy of maternal pelvis for vaginal birth both during and before labor ¥ Intrapartum assessment of fetal size, presentation, position, and lie ¥ Suspect CPD when labor is prolonged, cervical dilatation and effacement are slow, and engagement of the presenting part is delayed ¥ Support couple in coping
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¥ Nursing actions during TOL
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Ð Similar to care during any labor except that cervical dilatation and fetal descent are assessed more frequently ¥ Continuous monitoring of contractions and fetus ¥ Report signs of nonreassuring fetal status ¥ Assist mother with positioning to increase diameters - sitting, squatting, changing from side to side, hands and knees
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Third- and Fourth-Stage Complications
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¥ Retained placenta—beyond 30 mins after birth ¥ Lacerations ¥ Placental adherence
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Retained Placenta
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Ð Retention of the placenta beyond 30 minutes after birth Ð Bleeding can be excessive Ð May require manual removal of placenta Ð If no epidural, potential IV sedation Ð If manual removal fails, surgical removal with curettage (scraping it out)
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Cervical or Vaginal Lacerations
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Ð Suspected when bright red vaginal bleeding persists despite well-contracted uterus Ð Factors associated with increased incidence: ♣ Nullipara, epidural anesthesia, forceps-assisted or vacuum-assisted birth, episiotomy, birth weight greater than 3634 grams, macrosomia
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Degrees of Laceration---at least one test question here!!!
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¥ First-Degree Ð Laceration limited to the perineal skin, and vaginal mucous membrane ¥ Second-Degree Ð Perineal skin, vaginal mucous membrane, underlying fascia, and muscles of the perineal body; may extend upward on one or both sides of the vagina ¥ Third-Degree Ð Extends through the perineal skin, vaginal mucous membranes, and perineal body and involves the anal sphincter; it may extend up the anterior wall of the rectum ¥ Fourth-Degree Ð Same as third but extends through the rectal mucosa to the lumen of the rectum
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¥ Placenta accreta
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Ð Chorionic villi attach directly to the uterine myometrium (the smooth muscle tissue of the uterus.) Ð Associated with maternal hemorrhage and failed placental separation after birth Ð High incidence of abdominal hysterectomy
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¥ Placenta increta
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Ð Myometrium is invaded
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Placenta percreta
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¥ Ð Myometrium is penetrated
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Perinatal Loss
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- death of a fetus or infant from time of conception through the end of the newborn period 28 days after birth; Also referred to as intrauterine fetal death, stillbirth, fetal demise
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Perinatal Loss - Potential Causes Fetal
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¥ Chromosomal disorders ¥ Birth defects ¥ Exposure to teratogens ¥ Infections ¥ Complications of multiple gestation ¥ Fetal growth restriction
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Perinatal Loss - Potential Causes Maternal
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¥ Chronic HTN ¥ Preeclampsia & Eclampsia ¥ Diabetes ¥ Advanced maternal age ¥ Rh incompatibility ¥ Uterine rupture ¥ Ascending maternal infection ¥ Placenta previa ¥ Abruptio placentae ¥ Cord problem
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Perinatal Loss - Confirmation
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¥ Absence of heart action on ultrasound
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Perinatal Loss - Removal
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¥ Prolonged retention of dead fetus increases risk of DIC and infection ¥ Most women have spontaneous labor 2 weeks after death ¥ Want a vaginal expulsion if possible ¥ Will use prostaglandin agents to ripen and dilate the cervix ¥ Former c/s may require removal by c/s due to risk of uterine rupture
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Grief
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Ð An individual's total response to a loss, including physical symptoms, thoughts, feelings, functional limitations, and spiritual reactions Ð Manifestations may include certain behaviors and rituals of mourning, such as weeping or visiting a gravesite, which help the person experience, accept, and adjust to the loss
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Bereavement
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Ð Period of adjustment to loss
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Stages of Grief
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¥ Denial ¥ Anger ¥ Bargaining ¥ Depression ¥ Acceptance
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External Version
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¥ Physician applies external manipulation to maternal abdomen ¥ May be done after 36 weeks' gestation to change breech or shoulder presentation to cephalic presentation ¥ Fetal presenting part must not be engaged ¥ Reactive NST performed to establish fetal well-being—done first ¥ Before procedure, ultrasound to check position, placenta ¥ Tocolytic (terbutaline) given during procedure to relax the uterus ¥ Nursing assessment Ð Mom: IV line, BP, HR, Pain Ð Baby: EFM before, during, after at least 30 min
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Internal Version
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¥ Physician reaches into uterus and grabs feet of fetus and pulls them down through cervix ¥ Tocolytic given during procedure to relax uterus
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Podalic version
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¥ Used to turn second twin during vaginal birth ¥ Used only if second fetus does not descend readily and heartbeat is not assuring
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Amniotomy - artificial rupture of membranes (AROM)
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¥ Use of amnihook or gloved finger ¥ Need at least 2cm of dilation ¥ Fetal head should be engaged (dropped down into true pelvis) to avoid cord prolapse
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Purpose of Amniotomy
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¥ Stimulate or induce labor ¥ Apply internal fetal or contraction monitors ¥ Obtain fetal scalp blood sample for pH monitoring ¥ Assess amniotic fluid (consistency, color, amount, odor, meconium or blood present)
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Nursing Care for amniotomy
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¥ Check FHR before procedure and immediately after ¥ Assess for cord prolapse ¥ Assess amniotic fluid ¥ Limit vaginal exams -limit exposure and prevent infections ¥ Check temperature every 2 hours—assessing for infection ¥ Clean perineum as needed ¥ Change perineal pads as needed
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Amnioinfusion
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¥ Used to increase volume of fluid with oligohydramnios--<500mL ¥ Potentially used in preterm labor with premature rupture of membranes ¥ Transcervical instillation through IUPC of 250 mL sterile NS or LR at a continuous rate of 100-200 mL/hr ¥ Administered at room temperature
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Nursing Care for amnioinfusion
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¥ Help administer fluid ¥ Maternal VS ¥ Monitor contractions ¥ Continuous EFM ¥ Maintain bedrest ¥ Pericare/Change pads ¥ Intake and output (count pads)
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Labor Induction
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- stimulation of uterine contractions before the spontaneous onset of labor, with or without ruptured membranes for the purpose of accomplishing birth ¥ Indications: Diabetes, preeclampsia, eclampsia, PROM, chorioamnionitis, postterm, intrauterine fetal death, IUGR, alloimmunization, nonreassuring antepartum testing ¥ Any contraindication to spontaneous labor or vaginal birth are contraindications of labor induction ¥ Labor readiness: o Assess gestational age, amniotic fluid studies to determine lung maturity, Bishop score
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Cervical Ripening
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¥ Consists of effacement and softening of the cervix ¥ May be used at or near term to enhance success of and reduce time needed for labor induction when continuing pregnancy is undesirable ¥ May hasten beginning of labor or shorten course of labor ¥ Bishop score done to determine favorability of cervix for labor Ð 9 spontaneous labor likely—no need to induce ¥ May cause hyperstimulation of uterus—at risk for rupture ¥ Pharmacologic agents include Cytotec and prostaglandin agents (Prepidil, Cervidil) given intracervically or intravaginally Ð Can cause uterine stimulation after insertion
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Nursing Care for cervical ripening
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¥ Maternal VS ¥ EFM ¥ Lie supine with right hip wedge or left side for at least 1 hour ¥ Monitor for uterine hyperstimulation, nonreassuring FHR for at least 2 hours Ð If seen, insert should be removed
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Stripping of the Membranes ¥ Mechanical method
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Ð Gloved finger inserted into internal os and rotated 360 degrees twice ♣ Separating amniotic membranes lying against lower uterine segment Ð Releases prostaglandins to stimulate contractions Ð Does not require monitoring or other assessments ♣ Often done as outpatient service Ð May not induce labor ♣ If labor is initiated, it typically begins within 48 hours Ð May cause bleeding
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Mechanical Dilatation with Intracervical Catheter
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¥ Foley balloon inserted into cervix and inflated to stretch cervix without fetal side effects ¥ Disadvantages: difficulty with placement; failure to maintain placement; limited ambulation
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Pitocin Infusion
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¥ Usually effective at producing contractions or enhancing ineffective contractions Ð May cause hyperstimulation of the uterus, uterine rupture, water intoxication, fetal hypoxia, fetal death ¥ Goal: stable contractions every 2-3 minutes, lasting 40-60 seconds, strong intensity ¥ Progress is determined by checking effacement, dilation, and fetal station ¥ Requires small, precise dosage; MUST use infusion pump Ð Run as a secondary infusion (piggybacked into the primary line of 1000 mL of LR) Ð Start with 10 units Pitocin = 1 milliunit/min = 6 mL/hour ¥ Maximum rate and dosing interval based on facility protocol, clinician order, individual situation, and maternal-fetal response ¥ Palpating uterus essential, unless IUPC in place—MVU's to assess intensity of contractions ¥ May initially decrease blood pressure
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Episiotomy
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¥ Surgical incision of perineal body to enlarge outlet during 2nd stage of labor Ð Commonly used to avoid spontaneous laceration ¥ usually performed with regional or local anesthesia Complications: increased risk of 4th degree laceration, blood loss, infection, pain
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Episiotomy--two types
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Ð Midline ♣ Incision begins at bottom center of perineal body and extends straight down midline to fibers of rectal sphincter Ð Mediolateral ♣ Incision begins in midline of posterior fourchette and extends at 45 degree angle downward to the right or left
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Nursing Care for episiotomy
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¥ During procedure, provide mother with support and comfort ¥ Use distraction if needed Ð If procedure is uncomfortable, act as advocate for mother ¥ Document type of episiotomy in records and report to subsequent caregivers ¥ After procedure, provide comfort and apply ice pack (on for 20-30 min; off for 20 min) ¥ Assess perineal area frequently Ð Inspect every 15 minutes during first hour after birth for redness, edema, tenderness, ecchymosis, and hematomas ¥ Instruct mother in perineal hygiene and comfort measures
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Forceps-Assisted Birth
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Indications ¥ Any condition that threatens the mother or fetus relieved by birth ¥ Can assist in pushing efforts of the woman
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Forceps-Assisted Birth risks for baby
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¥ Newborn may experience Ð Bruising Ð Edema Ð Facial lacerations Ð Cephalohematoma/Caput Succedaneum Ð Brachial plexus injury Ð Transient facial paralysis Ð Cerebral hemorrhage, brain damage
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Forceps-Assisted Birth risks
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¥ Woman may experience Ð Vaginal or perineal lacerations Ð Infection secondary to lacerations Ð Increased bleeding Ð Bruising Ð Perineal edema Ð Anal incontinence
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Vacuum Extractor
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¥ Assists birth by applying suction to fetal head ¥ Should be progressive descent with first two pulls, procedure should be limited to prevent cephalohematoma Ð Risk increases if birth not within six minutes
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C/S indications
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¥ Most common indications for cesarean birth-- Ð Fetal distress Ð Active genital herpes Ð Multiple gestation (three or more fetuses) Ð Umbilical cord prolapse Ð Lack of labor progression (\"failure to progress\") Ð Pelvic size disproportion Ð Placenta previa---( placenta partially or wholly blocks the neck of the uterus, thus interfering with normal delivery of a baby.) Ð Placental abruption—( separation of the placenta from the wall of the uterus) Ð Previous cesarean section
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¥ Preparation for cesarean birth requires
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Ð Establishing IV lines Ð Placing indwelling catheter Ð Performing abdominal/perineal prep Ð NPO except antacids 30 min prior—due to spinal anesthesia, to prevent aspiration of stomach contents Ð Maternal VS Ð EFM
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C/S incisions
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¥ Skin - Vertical (b/n navel and symphysis pubis); Transverse (below pubic hairline) ¥ Uterus - Transverse (upper or lower uterine segment); Classical (vertical in upper uterine segment)—typically used in emergency situation. If this type of C/S is done, will always have a C/S with future pregnancies.
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Nursing Care for C/S
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¥ Vital Signs Ð Every 5 min til stable Ð Every 15 min for 2 hours Ð Every 4 hours until transferred to postpartum ¥ Check dressing and perineal pads every 15 min for 1 hour ¥ Numbness/sensation checked every 15 min until full feeling returns ¥ Intake and output ¥ Monitor IV Pitocin if given ¥ Assess fundus
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Vaginal Birth After Cesarean (VBAC) OR Trial of Labor (TOL)
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¥ Can occur after trial of labor in cases of nonrecurring indications for cesarean birth ¥ Most common risks are: Ð Uterine rupture Ð Hemorrhage Ð Surgical injuries Ð Infant death or neurological complications
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Nursing Care for VBAC
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¥ Continuous EFM ¥ Internal Monitoring ¥ IV fluids ¥ Avoid Pitocin if at all possible ¥ Classic or T uterine incision is contraindication to VBAC ¥ Important for nurse to support couple, explore their feelings, and provide information throughout labor
