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