Dystocia Dysfunctional Labor and Masectomy

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foxyt14
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Dystocia Dysfunctional Labor and Masectomy
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2014-05-13 19:06:56
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  1. Dystocia
    difficult labor or birth
  2. Dysfunctional Labor
    normal progress of dilation, effacement and descent is impeded....uterus simply isn't functioning as it should
  3. Signs that indicate a need for an operative birth
    • persistent non reassuring FHR patterns
    • fetal acidosis
    • meconium passage
  4. Problems of the powers
    ineffective contractions or ineffective maternal pushing efforts
  5. Normal labor progress once in active labor
    nullipara vs. multipara
    nulli= 1 cm/hr cervical dilation, likely to push 1-2 hrs

    multip=1.5cm/hr cervical dilation
  6. Purpose of contractions
    propelling the fetus past the resistance of the woman's bony pelvis and soft tissues
  7. Reasons for ineffective contractions
    • maternal fatigue and inactivity
    • F&E imbalance
    • dehydration
    • hypoglycemia
    • excessive analgesia
    • big head/small pelvis
    • abruption
    • catecholamines
  8. Hypotonic Labor Patterns
    define
    cause
    when occurs
    coordinated and regular but weak contractions

    hypoglycemia,fatigue, excessive analgesia, anesthesia, multiples

    occurs during active stage of labor
  9. How do you manage hypotonic labor patterns?
    • reposition to upright to help with fetus descent
    • hydration to correct F&E imbalances
    • Pitocin
    • effective pain management
    • assist with ROM
    • emotional comfort/therapeutic communicaiton
  10. If there is an overdistended uterus what do we need to watch for pp
    hemorrhage
  11. Hypertonic Labor Patterns
    define
    cause
    when occurs
    uncoordinated contractions with an erratic duration and intensity and they are painful

    • ineffective pushing techniques
    • fear of injury/pain/tearing
    • decreased/absent urge to push
    • maternal exhaustion
    • analgesia
    • unreadiness to let go of baby

    occurs during latent stage
  12. Nursing management for a woman with hypertonic labor patterns
    • #1 pain relief
    • warm showers to promote relaxation
    • STOP PITOCIN/DONT GIVE
    • Tocolytics to to reduce uterine resting tone
  13. Why is hypertonic labor pattern so painful?
    solution....
    because uterine resting tone between contractions is high, reducing uterine blood flow which decreases fetal O2 supply....which causes constant pain

    tocolytics
  14. What does secretion of catecholamines do?
    diverts blood from the uterus to muscles
  15. Examples of problems with the passenger
    fetus size and presentation
  16. macrosomia baby
    over 4000g or 8 lb 13 oz
  17. How do you manage problems with the passenger?
    • vacuum/forceps
    • McRoberts maneuver
    • supported squat
    • suprapubic pressure
    • check infants clavicles
    • c section
  18. What's McRoberts maneuver?
    when theres a problem with the passenger the mom is told to put her legs to her chest and apply pressure above the pubic bone
  19. Problems with fetal presentation hindering labor
    • OP and OT
    • any presentation other than vertex
  20. Nursing management when there are problems with presentation
    • position to hands and knees
    • pelvic rock to encourage rotation
    • side lying
    • sitting, kneeling, rocking, standing
    • birthing ball
    • lunge techniques
    • squatting to push open pelvis
  21. What position pushes open the pelvis
    squatting
  22. Sides to lye on for the following
    ROP
    LOP
    • rop=left side
    • lop= right side
  23. If baby is in a breech position then...
    cervical dilation and effacement will be slower
  24. Risks of multifetal gestation
    • uterine over distention (hypotonic dysfunction)
    • abnormal presentation of one/both fetus
    • great risk for cord compression/hypoxia
    • maternal pp hemorrhage from uterine atony
  25. What fetal anomalies can cause an unusual fetus presentation?
    • hydrocephalus
    • neural tube defect
    • omphalacele
  26. Problem of passage from soft tissue issue
    full bladder....mom needs to void q1-2 hrs
  27. Problems of psyche in labor
    • her perception of stress....more important thatn the actual existence of a threat
    • hx of sexual abuse
  28. How does stress interfere with labor
    • increased glucose consumption reduces energy supply
    • maternal catecholmines can impair labor by interfering with adequate uterine contractility
    • pain perception is increased and tolerance is decreased
  29. Nursing management for problems of passage
    • promote physical comfort/relaxation
    • establish trusting relationship
    • adjust light, noise and clean pt
  30. Describe Bishop Scoring System
    • predicts the inducibility by evaluating:
    • the position of the cervix as it relates to the vagina
    • cervical consistency
    • dilation
    • effacement
    • station of the presenting part

    6-7 is a good score
  31. Consistency of Bishop Scoring
    • 0=firm
    • 1=medium
    • 2=soft
  32. Position in Bishop Scoring
    • 0= posterior
    • 1=mid
    • 2=anterior
  33. Effacement for Bishop Scoring
    • 0=0-30%
    • 1=40-50
    • 2=60-70
    • 3=80+
  34. Dilation for Bishop Scoring System
    • 0=0
    • 1=1-2
    • 2=3-4
    • 3=5-6
  35. When are meds given for women in pre term labor?
    after 20 weeks but before 37 weeks
  36. S/S of pre term labor
    • painful/pain free contractions coming every 15 min or less
    • feeling of fetus balling up
    • cramps similar to menstrual
    • constant dull low backache
    • pink/brown discharge
    • pelvic pressure....feeling like urinating frequently
    • feeling flu like
    • feeling "not right"
  37. Fetal Fibrinectin test
    fibrinectin isn't present between 22-35 weeks gestation....presence indicates a high likelihood of PTL
  38. How do you do the fetal fibrinectin test?
    sterile speculum is inserted and specimen is collected

    • no other exam done before or vaginal manipulation
    • no lubricating gels
  39. Sign that the cervix is thinning?
    <35 mm in length at 24 weeks
  40. How do you prevent the cervix from shortening?
    • stop smoking and using drugs!!!
    • early/constant pre natal care
    • good diet and healthy weight
    • prevent bladder infections
    • no stress
    • no infections
  41. Nursing management of a person whose cervix is shortening
    • 3 cm is the point of no return....
    • avoid sex/orgasm
    • avoid breast stimulation
    • bedrest with BRP
    • stay hydrated
    • fetal monitor
    • cerclage
  42. Meds to stop labor
    • magnesium sulfate IV
    • Terbutaline SQ or PO
    • Nifidepine
    • Indomethacin
  43. Betamethasone
    given at 24-34 weeks to prevent RDS.

    must start 24 hours before birth and within 7 days...so repeat after 7 days.

    given to mom IM and newborn ET
  44. PPROM
    rupture of the amniotic sac earlier than the end of the 37th week of gestation with or without contractions
  45. What causes PROM
    • infections
    • incompetent cervix
    • hydraminos
    • hormonal changes
    • weak amniotic sac
    • recent intercourse
    • maternal stress
    • ┬ánutritional deficiencies
  46. Risks from PROM
    • cord prolapse
    • infection
    • potential need for premature delivery
  47. Nursing considerations with PROM
    • no sex
    • no breast stimulation
    • bedrest with BRP
    • confirm rupture
    • prevent infection/temp q4h
    • iv antibiotics as ordered
    • monitor uterine contractions
    • no vaginal exams
  48. PROM and vaginal exams
    NO!!
  49. Dx for PROM
    • Nitrazine-pH sensitive....blue is positive
    • Ferning
    • LS ration 2:1
    • pH of vaginal fluid
    • vaginal culture
    • fetal fibrinectin
  50. Shoulder Dystocia
    failure of the shoulders to complete external rotation and is impacted above the maternal symphisis pubis

    turtle sign
  51. Complications of Shoulder Dystocia
    requires urgent attention by physician

    • umbilical cord compression
    • clavicles crepitus, deformity, bruising
    • nerve injury to brachial plexus
  52. Erbs Palsy
    nerve injury to brachial plexus causing flaccid muscle tone....most resolve without intervention a few weeks pp
  53. Major dangers of shoulder dystocia
    • entrapment of cord
    • inability of childs chest to expand properly
    • severe brain damage or death if child not delivered within minutes
  54. Management of shoulder dystocia
    McRoberts maneuver....sharply flexing the legs upon the maternal abdomen causing the pubic symphysis to rotate and the sacrum to straighten out
  55. Fibroadenoma
    fibrous, glandular breast tissue....

    usually one lump that palpates as firm, moveable and rubber.

    seen in teens and 20yo

    treatment is follow up mammograms, sometimes excision
  56. Fibrocystic Breast Changes
    fibrosis or thickening of normal breast tissue with cystic enlargement of the glands

    multiple, smooth, tender, cystic feeling

    pain and tenderness associated with menstrual cycle
  57. Treatment for fibrocystic breast changes
    • fine needle aspiration or open biopsy
    • decrease fat, caffeine, sodium, chocolate
  58. Ductal Ectasia
    breast problems seen in women approaching menopause

    dilation of collecting ducts with inflammation
  59. Intraductal papilloma
    occurs just before or during menopause
  60. S/S of breast tumors
    • nipple discharge
    • nipple retraction
    • nipple ulceration
    • edema
    • palpable lump
    • **all require dx mammogram, stereotactic needle biopsy and possibly surgery
  61. Primary task when caring for a mastectomy patient
    • teaching....
    • how to care for drain
    • change dressings
    • pain management
    • how to handle sensory alterations (numbness, burning, phantom pain)
    • how to avoid restricted range of motion
  62. When is the ideal time to teach a breast cancer patient?
    prior to surgery....with reinforcement of teachings after the procedure is complete and she is awake and alert
  63. Drain care after breast removal
    • keep it clear
    • show her how to empty and decompress the JP drain....also strip the tube to keep it clot free
  64. Post op pain management after a masectomy
    • oral opioids or ibuprofen/acetamoniphen
    • PCA sometimes
  65. Problems after a woman has an axillary lymph node procedure
    sensory alterations like numbness and burning in her chest and arm....refer to a pain management Dr.
  66. Movement and post mastectomy patient
    keep on moving and do your arm exercises....go to PT
  67. Complications after a masectomy
    hematoma....look for pooling of blood under the skin, hard and swollen, tender to touch

    flap necrosis-dark purple or black skin

    infection-red, warm purulent drainage
  68. Lymphedema
    occurs with removal of lymph nodes
  69. Advising the mastectomy patient on how to reduce her risks for lymphedema
    Avoid saying never and say "when possible"....

    • BP and blood draws on opposite arm
    • nothing tight
    • use electric shaver for under arms
    • wear heavy duty mit for cooking
    • SPF 15 at least
    • sleep on back or non surgical side
    • minimize carrying heavy things with that side
  70. S/S of lymphedema
    • surgical side feels heavy/full
    • tight feeling skin on surgical side
    • less movement in surgical sides hand/wrist
    • larger surgical side....cant fit in to sleeve
    • tight wring or watch on surgical side, but hasn't gained weight
  71. Ways to decrease lymphedema once she has it
    • prop arm up with small pillow
    • squeeze a small ball
  72. S/S of cellulitus after masectomy
    • swelling lasting longer than 1 week
    • redness
    • heat
    • fever
    • swollen lymph nodes
  73. Breast prosthesis and mastectomy bras
    • covered by insurance
    • can be warn once drains are removed
    • fitted for at 6 weeks after surgery and is well healed

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