Onset of labor after 20 weeks gestation and before 37 weeks
Preterm labor
Gestational age or birth of more than 20 weeks gestation and less than 37 weeks
Preterm Birth
Possible reasons to have to have a pre-term birth
Hypertension, Preeclampsia, Hemorrhage, Intrauterine Growth Restriction (IUGR)
(any situation where early delivery would improve maternal or fetal status)
Infant born between 34-36 weeks gestation
Late Preterm Infant
Infant born before 32 completed weeks of gestation
Very preterm infant
Infant weighing less than 2500 grams at delivery regardless of gestational age
Low Birth Weight Infant (LBW)
Infant weighing less than 1500 grams at birth
Very low birth weight infant
Infant weighing less than 1000 grams at birth
Extremely low birth weight infant
____ is the number 1 cause of neonatal mortality
Prematurity
Possible factors contributing to spontaneous preterm birth
Uterine distention (prostaglandin stimulates uterus to contract...multiple gestations, polyhydramnios, uterine abnormalities)
Decidual Activation (Hemorrhage, Fetal-decidual paracrine system, Upper genital tract infection)
Premature activation of HPA axis
Inflammation/Infection of decidua (inflammatory cytokines or bacterial endotoxins can stimulate prostaglandin release resulting in cervical ripening)
Factors leading to abnormal uterine distraction leading to Uterine Contraction/PROM
Multifetal Pregnancies
Polyhydramnios
Structural Uterine Anomalies
Factors leading to Decidual Hemorrhage leading to Uterine Contraction/PROM
Abruption
Thrombin Activation
Factors leading to Activation of HPA acis leading to Uterine Contraction/PROM
Prostaglandin production
Placental Estrogen production
Stress
Factors leading to Infection leading to Uterine Contraction/PROM
Uterine Contractions
Breakdown of membranes and cervix
Common Risk Factors of Premature Labor/Birth
Prior Preterm Birth
Hx of 2nd Trimester Loss
Hx of Incompetent Cervix
Cerclage
IVF pregnancy
Multiple gestations
Uterine/Cervical abnormalities
Hydramnios or oligohydramnios
Infection
Pre-mature rupture of membranes
Short Pregnancy (<9 months)
HTN, DM, clotting disorders
Inadequate nutrition, low BMI
<17 years, >35 years
Late or no Prenatal Care
Obesity, high BMI
Working long hours, long periods of standing
African American
Unmarried status
Domestic Violence
Lack of social support
Smoking/Alcohol/Drugs
Lower Education/Poverty/Socioeconomic status
Tests for preterm birth prediction:
Biomarkers for decidual-membrane separation
(fetal fibronectin...negative predictor)
Proteomics to identify inflammatory activity
Genomics for susceptibility for preterm birth
Cervical Length
Bacterial Vaginosis
Presence of Fetal Fibronectin in Cervicovaginal fluid
In symptomatic women, a cervical length of ____ indicates a strong positive predictor of preterm labor/birth
<20mm
(30 mm reliably excludes preterm labor)
Dx of Preterm Labor (PTL)
Gestational age 20-37 weeks
Uterine Activity-- Regular UCs >6 hours
Positive Fetal Fibronectin Test (more of a neg test)
Progressive cervical change (effacement 80%, cervical dilation of >1cm)
What is a cerclage and why is it done/when is it removed
To hopefully prevent SPTL if mom has incompetent cervix...
Suture put in and removed at 37 weeks
Typically, management of pre-term labor is focused on:
Delaying delivery for several days to allow time to give glucocorticoids (corticosteroids) time to facilitate fetal lung maturity!
Treating GBS
(Tocalytic Drugs)
Medications give to suppress uterine contractions in preterm labor
Tocalytics
Bed Rest complications:
Muscle Atrophy
Cardiovascular Deconditioning
Maternal Weight Loss
Stress for the woman and her family
Management of Pre-Term Labor
Tocalytic Drugs (terbutaline)
Corticosteroids -- (betamethasone) lungs
Antibiotics -- GBS
Bed Rest (not effective)
Intravenous hydration
Progesterone (hx of spontaneous PTB)
Magnesium -- (12 hrs) reduce microcapillary brain hemorrhage of baby
Contraindications to treating pre-term labor
Active Hemorrhage
Severe Maternal Disease
Fetal Compromise
Chorioamnionitis
Fetal Death
Previable Gestation and PROM
General Contraindications for Tocolysis
Severe Preeclampsia
Placental Aburption
Intrauterine Infection
Lethal Congenital or Chromosomal Abnorm.
Advanced cervical dilation
Myasthenia Gravis
Concurrent Treatment with Nifedapine
Terbutaline use in previous 4 hours
Fetal Compromise or Placental Insufficiency
Indication of Betamethasone (corticosteroids)
Women at 24 and 34 weeks gestation with s/s of preterm labor or at risk to deliver preterm
Adverse reactions of Betamethasone (corticosteroid)
Raise Blood Sugar and may require temp insulin coverage to maintain levels in diabetic women
Route/Dosage for Betamethasone in preterm pregnancies
12mg IM every 24 hours for 2 doses
When are women moved from high risk of pre-term labor to a less intense unit
When uterine activity decreases (<5UCs/hr)
No further cervical change
Immediate Nursing Care of Woman in Pre-term labor
Review records for risk factors and establish gestational age through hx and ultrasound
Assess mom/baby for sx of:
Vaginal and Urinary infection
Rupture of Membranes (possible fern test)
Vaginal bleeding or discharge
Dehydration
Assess FHR and UCs
Report fetal tachycardia or increased UCs to health care provider
Obtain Vaginal and Urine Culters per orders
Obtain fFN per orders
**should be obtained BEFORE sterile vag exam...contraindicated if ROM, bleeding, sex, or prior collection in the last 24 hours
Maintain Strict I&O
Provide oral and IV hydration
Restrict to 3000mL/24hr if on tocolytics
Administer Tocalytic agent per protocol
Place pt on side for administration
Administer Glucocorticoids per orders
Assess V/S
Report to provider if BP over 140/90 or less than 90/50, HR > 120, Temp >100.4
Auscultate lungs
Assess cervical status (SVE)
Facilitate clear understanding of treatment plan and woman/family's involvement
Notify provider of all findings
Assessment of woman on tocolytics
Monitor BP, Pulse, Auscultations
(Look for SOB, Chest discomfort, cough, ox sat <90, increased RR/HR, Changes in behavior)
WBC are _____ in women receiving corticosteroids
higher
(not indication of infection)
Warning Signs of Preterm Labor/When to call doctor
Water Breaks
Baby stops moving
Many contractions in one hour
Low Bachache
Menstrual like cramps
Pelvic Pressure
Intestinal cramps (with/without diarrhea)
Increased discharge
Fever > 100.4
"Something isn't right"
Home care instructions for preterm labor
Baby Movements and Contractions
Lie on side for 1 hour and count movement
Activity Restrictions
Sexual Restrictions
Diet
Small meals and snacks, 8 glasses of fluid
Medication Sched (verify with MD)
Rupture of membranes with premature gestation
PPROM
Preterm Premature Rupture of Membranes
Rupture of membranes before the onset of labor but at term
PROM
Premature Rupture of Membranes
Time from membrane rupture to delivery
Latency
Rupture of membranes before 23-24 weeks
Previable PROM
ROM from 24-32 weeks gestation
Preterm PROM remote from term
ROM 31-36 weeks
Preterm PROM near term
Risk Factors for Preterm PROM
Previous PPROM or Preterm Delivery
Bleeding during Pregnancy
Hydramnios
Multiple Gestation
STIs
Cigarette Smoking
Risks r/t Preterm PROM for woman
Maternal Infection
Preterm labor/birth
Increased rates of C-Sections
Risks r/t Preterm PROM for Baby
Fetal/neonatal sepsis
(earlier the fetal gestation at ROM the greater the risk for infection...the membranes serve as protective barrier that separates the sterile fetus and fluid from the bacteria-laden vaginal canal)
Preterm Delivery/Complications of Prematurity
Hypoxia or Asphyxia bc of umbilical cord compression due to decreased fluid
Fetal deformities if preterm PROM before 26 weeks gestation
Assessment findings of PROM
Confirmed gestational age by pre-natal hx and ultrasound
Confirmed ROM with speculum exam and positive ferning test
Oligohydramnios on ultrasound may be seen but is not dx
Unless near term gestation premature PROM, management is aimed at:
Prolonging gestation for the woman who is not in labor, not infected, and not experiencing fetal compromise
PTs with PROM between 34-36 weeks should be managed:
as if they were at term with induction of labor and treatment for GBS
Pts with PROM before 32 weeks of gestation should be managed:
Expectantly until 33 completed weeks of gestation if no maternal/fetal contraindications exist....
48 hr IV course of ampicillin and erythromycin followed by 5days treatment with amoxicillin and erythromycin
All women with preterm PROM should receive intrapartum _____ to prevent transmission of GBS
chemoprophylaxis
Single course of _____ should be administered for woman preterm PROM before 32 weeks gestation
antenatal corticosteroids
Delivery is recommended when preterm PROM occurs:
at or beyond 34 weeks gestation
____ should be avoided in pts with PROM unless they are in active labor or imminent delivery is anticipated
Digital Cervical Examinations
Previable PROM recommendations:
Pt counseling about risks to fetus
Expectant management/ Induction of labor
GBS is not recommended
Corticosteroids are not recommended
Nursing Actions for PROM
Assess FHR and Uterine contractions
Assess sx of infection (100.4 temp, tachycardia, uterine tenderness, malodorous fluid)
Monitor for labor/fetal compromise
Provide antenatal testing (non-stress test and BPPs)
Mechanical defect in cervix that results in painless cervical dilation in 2nd Trimester that can progress to premature delivery
Incompetent Cervix
Process of pre-mature cervical ripening, and the notion of cervical competency existing of reproductive performance on a continuum rather than all or none, competent vs incompetent
Cervical Insufficiency
Cervical incompentence is associated with:
Previous cervical trauma, cervical dilation and curettage/cauterization, Abnormal cervical development, Infection/Inflammation, Hormonal effects
Risks to the Mom with incompetent cervix:
Repeated 2nd Tri births
Recurrent pregnancy losses
Preterm delivery
ROM/Infection
Risks to Baby from incompetent cervix:
Preterm birth and consequences of prematurity
Assessment findings of Incompetent Cervix
Pelvic Pressure/Increased mucoid discharge
Shortened cervical length/funneling
Obstetrical hx
Live fetus/Intact membranes
Medical Management of Incompetent Cervix:
Obtain transcervical ultrasound to evaluate cervix for length and funneling (not dx)
Cervical cultures for chlamydia, gonorrhea, cervical infections
Cerclage -suture placed to reinforce weak cervix (between 12-16 weeks gestation)
Administer antibiotics/tocolytics
Remove sutures if membranes rupture, infection occurs, or labor onset
Post-Op Nursing Care for Incompetent Cervix
Monitor Uterine activity
Monitor for vaginal bleed/leaking fluid/ROM
Monitor for Infection (fever, tenderness)
Administer Tocolytics to suppress UC
Discharge Teaching (s/s of UC, ROM, Bleeding, Infection...Modify activity and pelvic rest for a week)
Major causes of hemorrhage (antepartum)
placenta previa
plavental abruption
Basic principles of immediate care of antepartum woman hemorrhaging:
Assessment of mom/baby
Prompt maternal resuscitation if required
Consideration of early delivery if evidence of fetal distress (and if baby is of sufficient maturity to be potentially capable of survival)
Complication of severe eclampsia
HELLP SYNDROME
Hemolysis
Elevated Liver Enzymes
Low platelets
Lab values of HELP syndrome in pre-eclamptic women
AST >70
ALT >50
Bilirubin >1.2
LDH >600
Platelets <100,000
Risks for the mom in pre-eclampsia and HELLP syndrome
Abruptio Placenta
Renal Failure
Liver hematoma and possible rupture
Death
Risks for baby during HELLP syndrome
Preterm birth
Death
Management of HELLP syndrome
Delivery of baby and placenta
(resolution within 48 hours postpartum )
Replacement of platelets
When the placenta is implanted in the lower uterine segment of the uterus, near/over the internal cervical os instead of in the body or fundus of the uterus
Placenta Previa
When the placenta is totally covering the internal cervical os
Complete (TOTAL) placenta previa
When the placenta is 2.5 cm closer to the internal cervical os (partially covering internal os)
Marginal (partial) placenta previa
Hemorrhage is likely to happen with placenta previa during:
3rd trimester (UCs)
Placenta previa is dx usually by:
ultrasound (before onset of bleeding)
4 classifications of placenta previa
Total
Partial
Marginal
Low-lying
When the placenta is implanted in the lower uterine segment in close proximity to the internal cervical os
Low-lying placenta
Risk factors for placenta previa
Endometrial Scarring (previous placenta previa, prior c-section, abortion, multiparity)
Impeded endometrial vascularization (advanced maternal age, DM, HTN, Cigarrette smoking, uterine anomalies/fibroids/endometritis)
Increased placental mass (large placenta, multiple gestation)
Things that cause endometrial scarring: (leading to placenta previa)
Previous placenta previa
Prior Csection
Abortion
Multiparity
Things that cause impeded endometrial vascularization (leading to placenta previa)
Advanced maternal Age (>35)
DM
HTN
Cigarrette Smoking
Uterine anomalies/fibroids/endometritis
Things that cause Increased Placental Mass (leading to placenta previa)
Large placenta
Multiple gestations
Never perform _____ with placenta previa pts
SVE (you don't want to dislodge anything)
Risks to mom when placenta previa occurs
Hemorrhagic/Hypovolemic shock
Maternal Exsanguination (10 mins)
Anemia
Potential Rh sensitization
Risks to baby when placenta previa occurs:
Disruption of bloodflow -- affects fetal status
Blood loss, Hypoxia, Anoxia, Death (related to maternal hemorrhage)
Fetal Anemia
Neonatal morbidity
Classic presentation of placenta previa:
PAINLESS BLEEDING!!!!
When can a vaginal delivery be done with placenta previa
It may be attempted in a low-lying placenta if one can proceed to emergency CSection if needed!
Nursing Interventions for Placenta Previa (relating to fetal status and maternal bleeding)
Perform initial assessment (bleeding, ultrasound, fetal well being, V/S-- every 5-15 minutes)
Notify the physician of:
-onset or increase in vaginal bleeding
-BP less than 90/60, Pulse less than 60
-Resp less than 14 or more than 26
-Temp >100.4
-Urine output <30 ml
-Ox < 95%
-Decreased LOC
-Increased uterine activity
-Cat 2 or 3 FHR pattern
Assess abdominal pain, uterine tenderness, irritability, and contractions
Initiate bed rest with bathroom priv.
Maintain IV access with large-bore IV in case blood replacement therapy is needed
Ensure availability of "hold" clot and blood
Assess FHR/UCs
Give corticosteroids to accelerate lungs
Monitor lab values
Inform pt and family about fetal status
Anticipate csection if pt is unstable
If delivered and mother is RH neg, administer RhoGAM
A C/S delivery is scheduled for ____ weeks gestation for partial or complete placenta previa
38
Premature separation of a normally implanted placenta
Placenta Abruption
Two main types of abruptio placenta
Apparent or Concealed hemorrhage
(mild, moderate, severe grade)
Abruptio placenta accounts for ____% of perinatal deaths for 1-200 deliveries
10-15%
<15% of placental separation with concealed hemorrhage
Mild Grade Abruptio Placenta
Up to 50% placenta separates with apparent hemorrhage
Moderate Grade 2 Abruptio Placentae
>50% placenta separates with concealed hemorrhage
Severe Grade 3 abruptio placenta
Less than 1/6 of placenta separates prematurely
Mild: grade 1 abruptio placenta
Grade of abruptio placenta:: Total blood loss <500 mL, Dark vaginal bleeding, vague lower abdominal or back discomfort, no uterine tenderness, no uterine irribility
Mild: Grade 1
Grade of abruptio placenta:: Total blood loss 1000-1500 mL, 15-30% blood volume, Dark vaginal bleeding, gradual or abrupt onset of abdominal pain, uterine tenderness, Uterine tone increased
Moderate: Grade 2
Grade of abruptio placenta:: Total blood loss >1500 mL, more than 30% of total blood volume, dark vaginal bleeding, abrupt onset of pain (tearing, knife-like)
Severe: Grade 3
Grade of abruptio placenta:: Maternal V/S normal
Milde: Grade 1
Grade of abruptio placenta:: Maternal effects- mild shock, normal BP, Maternal tachycardia, narrowed pulse pressure, orthostatic hypotension, tachypnea
Moderate: Grade 2
Grade of abruptio placenta:: Maternal effects- moderate to profound shock, decreased BP, maternal tachycardia, severe orthostatic hypotension, significant tachypnea
Severe: Grade 3
Maternal Complications of Grade 1 Abruptio Placenta
Normal fibrinogen 450 mg
Maternal Complications of Grade 2 Abruptio Placenta
Early signs of DIC
Fibrinogen 150-300
Maternal Complications of Grade 3 Abruptio Placenta
DIC usually develops unless condition is treated immediately
Fibrinogen <150
Fetal/Neonate complications of Grade 1 abruptio placenta:
Normal FHR pattern
Fetal/Neonate complications of Grade 2 abruptio placenta:
FHR shows significant signs of fetal compromise
Fetal/Neonate complications of Grade 3 abruptio placenta:
FHR shows signs of fetal compromise and death can occur
Risk factors of Abruptio Placenta
Preeclampsia
Chronic HTN
Renal disease
Trauma
Short Umbilical Cord
Cocaine use
Cigarrette Smoking
**risks to mother and fetus correlates to the placental surface area involved
Classic S/S of complete abruption
Very painful, rigid abdomen (board-like)
Dark vaginal bleed
Uterine tenderness
Persistent tetanic UCs
Moderate - profound shock
DIC if not treated immediately!
"Expectant" Medical management of Abruptio Placenta if pt is <34 weeks and if the woman and baby are stable:
Immediate birth (if mod- severe bleeding)
IV line (2 large bore)
V/S
Hemodynamic monitoring
Blood transfusion may be necessary
Foley catheter
Lab, Hct, Hgb, Clotting studies
If maternal status is stable and fetus is immature, expectant management includes: (abruptio placenta)
Hospitalization
Monitoring of: FHR, UCs/Resting tone, Bleeding, Abdominal pain, Vaginal bleeding, Maternal labs, Coagulation studies
Oxygen 8-10 L/min by mask
Corticosteroids
Tocolysis
Abnormality of implantation defined by degree of invasion into the uterine wall of trophoblast of placenta
Placenta Accreta
Associated with prior uterine surgery, TOLAC, abdominal trauma, and Oxytocin administration
Uterine Rupture
Signs of Rupture:
Sudden, sharp, abdominal pain with referred shoulder pain
Sudden cessation of uterine contractions
Sudden, severe fetal distress and maternal shock (internal hemorrhage)
Collaborative management of uterine rupture:
Initiate treatment for shock
Emergency operative delivery
Hysterectomy if uterus is too damaged
Amniotic Fluid Embolism leads to: Anaphylactoid Syndrome
Amniotic fluid is drawn into maternal circulation
Fluid and debris travel to lungs/obstruct pulmonary vessels
Rapid respiratory
< Cardiac function
Circulatory collapse
Thromboplastin in amniotic fluid leads to DIC
Prognosis of Amniotic Fluid Embolism (anaphylactoid syndrome)
50-80% maternal mortality rate
(survivors have neuro damage 80% of time)
...if rupture occurs during labor, 50% mortality
Process of Amniotic Fluid Embolism
Amniotic fluid and fetal tissue gain access to the maternal circulation via a defect in the placenta
The uterine veins and inferior vena cava carry the material up to the mother's heart and out the lungs bilaterally
The fetal material makes its way through the lungs and returns to the heart where it is pumped out to entire body
Amniotic Fluid Embolism Management:
Advanced Cardiac life support
Tilt pregnant woman 30 degress to side if before birth
O2 (8-10L), Intubation
Volume expansions (Fluid, Plasma, Blood)
Central line placement
Hemodynamic monitoring
Vasopressors
Blood products as indicated if DIC develops
Critical care nursing
Test after trauma or bleeding disorder to see if there has been any mixing of the fetal/maternal blood:
KB (Kleihauer-Betke) Test
**Make sure mom has Rhogam shot if it is a positive test
Dysfunctional Labor
Dystocia
(prolonged, difficult labor and birth)
Clinical indicators of Dystocia:
alteration in expected characteristics of contractions for the stage/phase of labor
lack of progress in rate of effacement & cervical dilation (could be related to passage– pelvis)
lack of progress in fetal descent and expulsion
Most common reason for primary C-Section
Dystocia (difficult labor/birth)
Dystocia usually indicates problems with:
Powers, Pelvis (passage), Passenger, Psyche
Hypertonic Uterine Dysfunction typically occurs in the _____ stage
Latent Phast of the 1st stage of labor (<4cm dilation)...Prodromal Labor
Frequent and painful (INEFFECTIVE to dilation and effacement) contractions
Hypertonic Uterine Dysfunction
Women in hypertonic uterine dysfunction are at greatest risk of ____ due to higher uterine resting tone
Exhaustion
Dangers of a high resting tone
low oxygenation to the baby
If a mother is experiencing Hypertonic Uterine dysfunction, advise her (or medicate) to try to ____
sleep!!! (this has a lot to do with mother's psyche...but always assess, perform sterile vaginal exam)
Contributing factors of Hypertonic Uterine Dysfunction
Uknown cause, most commonly seen in primigravidas with high anxiety
Management of Hypertonic Dysfunction
Assess UCs and FHR (cat 2 or 3)
Evaluate cause
Light sedation to promote rest
Hydration(to improve uterine perfusion)
Relaxation techniques: Exercises, tub baths, showers
Pain Relief: Morphine sulfate, IM or IV
Evaluate labor process (dilation/effacement)
GIVE MOM AND FAMILY EMOTIONAL SUPPORT (explain interventions and let her know what is going on)
If pt is stressed with hypertonic dysfunction, ____ will be realeased in her body making things more painful
Cortisol
Hypotonic Uterine dysfunction typically occurs during:
Active phase of the 1st stage of labor (after 4 cm...little or no cervical change)
____ occurs when the pressure of the UC is insufficient to promote cervical dilation and effacement
Hypotonic Uterine Dysfunction
Contdaction characteristics during Hypotonic Uterine Dysfunction
"Fizzling out"
Decreased frequency
(<2 contractions in 10 min)
Decreased intensity
Contributing factors of Hypotonic Uterine Dysfunction
Fetal malpositions
Fatigue
Cephalopelvic disproportion (CPD) -- baby's presenting part is too large to pass through pelvis
Overdistended uterus (hydramnios)
Epidural anesthesia
Narcotic analgesia (epidural)
Management of Hypotonic Uterine dysfunction
Evaluate labor process
-Assess UCs, FHR, SVE
-Rule out CPD (C-Section needed if so)
-Augment labor with Pitocin (if no CPD)
-Ambulation/Position changes
-AROM (check FHR)
-IV fluids/PO fluids
-Provide emotional support (always!)
Labor of less than 3 hours from onset to birth
Precipitous labor
Risk factors contributing to precipitous labor:
Grand multiparity, previous precipitous birth
Cause of precipitous labor:
may be related to decrease maternal tissue resistance (we really don't know)
Risks to mom during precipitous labor:
Uterine rupture
Vaginal lacerations
PP hemorrage secondary to uterine atony
Fetus risks from precipitous labor
hypoxia (potential for FHR Category 1 or 2)
intracranial hemorrhage
Management of precipitous birth
Assess UC's, FHR every 15 minutes!
SVE!
Provide Emotional Support
Anticipate/Prepare for complications such as pp hemorrhage, lacerations
Potential fetal comlications
Prepare for birth (stay in room with woman!!!)
Have NICU team in the room and be on the look out for hypoxia
Occur in the second stage of labor when the woman is not able to push or bear down
Inadequate expulsive forces
Risk factors of inadequate expulsive forces
Maternal exhaustion, epidural anesthesia
Medical management of inadequate expulsive forces:
augment with pitocin
assist with vacuum or forceps
Nursing actions for inadequate expulsive forces
Assess fetal descent, coach in pushing, use non-directed approach
Occurs when decreased diameters of the inlet, midplane, or outlet prevent normal fetal descent through the maternal pelvis
Pelvic Dystocia (problem with passage)
Most common pelvic dystocia
Narrow midplane transverse diameter-- level of ischial spines resulting in transverse arrest of the fetal head and "failure to progress"
Management of pelvic dystocia
If patient gets to complete dilation and +2 station, forceps delivery/vacuum may be needed
If CPD or forceps/vacuum fail, the C-Section!
Round, cylindric pelvis shape...wide pubic arch
Gynecoid (GOOD!)
Long narrow pelvis with narrow pelvic arch
Anthropoid (OC position)
Heart/Triangular shaped pelvis, Narrow everywhere
Android (male)
Flattened, wide, short, oval pelvis shape....
Platypelloid (least favorable)
Most common malpresentation
Breech (3-4%)
Risks with Breech presentation
Umbilical cord prolapse when membranes rupture
Head entrapment in lower uterine segment or pelvic outlet (feet and legs come out)
Management (approaches) for fetal malpresentations:
External cephalic version (manipulation of the fetus through maternal abdominal wall by provider)
C-Section delivery
Things that need to be done prior to version:
Locate placenta with Ultrasound
Baseline FM tracing
Baseline maternal v/s
Primary IV line started
SubQ terbutaline given (tocalytic)
Tocalytics are normally given:
between 24-28 weeks gestation...2 doses... between 24 hours to produce surfactant
Post- version nursing interventions:
Electronic FHR monitoring
Electronic uterine contraction
Discharge instructions (s/s of labor, leaking of fluid, etc...)
Mom may need _____ before version
pain medication
Most common malposition
Occiput posterior (LOP, ROP)
Women with babies in OP position usually experience
Back Pain
Nursing interventions for a mom with OP baby
Countersacral pressure with contractions
Lateral positioning to the opposite side
Lunging toward opposite side
Hands-Knees position
Medical interventions for mom with OP baby
Forceps or Vacuum extraction (risk for fetal injury, risk for 3rd and 4th degree lacerations)
Key warning sign of shoulder dystocia
Fetal Macrosomia
(fetal weight > 4,000-4,500 g)
Contributing factors of shoulder dystocia
post dates, poorly controlled diabetes, excessive weight gain in pregnancy, advanced maternal age, multiparity
Shoulder Dystocia is _____
an obstetrical emergency
Turtle sign
Baby's head comes out and goes back in (retraction)....SHOULDER DYSTOCIA!!!!
Fetal risks from fetal macrosomia/dystocia
Infection (most common sequela)
Asphyxia
fractured clavicle (assess as soon as infant is stable)
Erb's palsey (brachial plexus injury)
Maternal risks from fetal macrosomia
Infection-- Most common sequela
Increased pain, fatigue, anxiety
Vaginal trauma
Episiotomy extension OR intentional 4th degree episiotomy
Nursing responsibility with fetal macrosomia/ shoulder dystocia
McRobert's position (pts legs all the way up)
Suprapubic pressure (never fundal pressure )
Stay calm
Explain to pt/family
Instruct mom not to push
Call for help (anesthesia, NICU, everyone!)
Prepare for neonatal resuscitation
Multifetal pregnancies are at risk for:
preterm labor and c-sections
Multifetal pregnancies usually deliver:
between 34-35 weeks (late preterm!)
C-Section unless vertex/vertex
Patient's first abdominal delivery or pt has had at least 1 previous C/S, or for fetal malposition
Scheduled C-Section
Unscheduled C-Sections are divided into:
Emergent (immediate need to deliver...prolapsed cord, rupture of uterus)
Urgent (need for rapid delivery, fetal malposition or mild placenta previa)
Non-Urgent (failure to progress or lack of fetal descent with normal FHR, category 1)
Fetal risks to C-Section
Increased risk for newborn respiratory distress (babies delivered vaginally get fluid squeezed out of their lungs)
Trauma
Maternal risks/complications from C-Section
Anesthesia risks
Intra-operative complications
Post-op complications, hemorrhage, thromboembolic disease, atelectasis, infection, abdominal wound dehiscence, UTI, amniotic fluid embolism, maternal death
Psychosocial complications of a C-Section
Delayed mother-infant bonding (especially if unplanned C/S)
Preop for C-Section:
*Family centered care
maternal vs
lab work
FHR monitoring until completely prepped
IV started
skin prep
foley cath inserted before IV
prophylactic antibiotics
epidural or morphine PCA
emotional support
Post-op care for CSection
VS q 15 minutes
ABCs
Incision
Fundus
Lochia
Oxytocin
Pain
Assess DVT, paralytic ileus
Turn/Cough/Deep Breath