High-Risk Intrapartum

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High-Risk Intrapartum
2014-10-27 22:51:48
High Risk Intrapartum

High Risk Intrapartum
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  1. Onset of labor after 20 weeks gestation and before 37 weeks
    Preterm labor
  2. Gestational age or birth of more than 20 weeks gestation and less than 37 weeks
    Preterm Birth
  3. 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)
  4. Infant born between 34-36 weeks gestation
    Late Preterm Infant
  5. Infant born before 32 completed weeks of gestation
    Very preterm infant
  6. Infant weighing less than 2500 grams at delivery regardless of gestational age
    Low Birth Weight Infant (LBW)
  7. Infant weighing less than 1500 grams at birth
    Very low birth weight infant
  8. Infant weighing less than 1000 grams at birth
    Extremely low birth weight infant
  9. ____ is the number 1 cause of neonatal mortality
  10. 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)
  11. Factors leading to abnormal uterine distraction leading to Uterine Contraction/PROM
    • Multifetal Pregnancies
    • Polyhydramnios
    • Structural Uterine Anomalies
  12. Factors leading to Decidual Hemorrhage leading to Uterine Contraction/PROM
    • Abruption
    • Thrombin Activation
  13. Factors leading to Activation of HPA acis leading to Uterine Contraction/PROM
    • Prostaglandin production
    • Placental Estrogen production
    • Stress
  14. Factors leading to Infection leading to Uterine Contraction/PROM
    • Uterine Contractions
    • Breakdown of membranes and cervix
  15. 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
  16. 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
  17. In symptomatic women, a cervical length of ____ indicates a strong positive predictor of preterm labor/birth

    (30 mm reliably excludes preterm labor)
  18. 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)
  19. 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
  20. 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)
  21. Medications give to suppress uterine contractions in preterm labor
  22. Bed Rest complications:
    • Muscle Atrophy
    • Cardiovascular Deconditioning
    • Maternal Weight Loss
    • Stress for the woman and her family
  23. 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
  24. Contraindications to treating pre-term labor
    • Active Hemorrhage
    • Severe Maternal Disease
    • Fetal Compromise
    • Chorioamnionitis
    • Fetal Death
    • Previable Gestation and PROM
  25. 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
  26. Indication of Betamethasone (corticosteroids)
    Women at 24 and 34 weeks gestation with s/s of preterm labor or at risk to deliver preterm
  27. Adverse reactions of Betamethasone (corticosteroid)
    Raise Blood Sugar and may require temp insulin coverage to maintain levels in diabetic women
  28. Route/Dosage for Betamethasone in preterm pregnancies
    12mg IM every 24 hours for 2 doses
  29. 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
  30. 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
  31. Assessment of woman on tocolytics
    Monitor BP, Pulse, Auscultations

    (Look for SOB, Chest discomfort, cough, ox sat <90, increased RR/HR, Changes in behavior)
  32. WBC are _____ in women receiving corticosteroids

    (not indication of infection)
  33. 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"
  34. 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)
  35. Rupture of membranes with premature gestation
    • PPROM
    • Preterm Premature Rupture of Membranes
  36. Rupture of membranes before the onset of labor but at term
    • PROM
    • Premature Rupture of Membranes
  37. Time from membrane rupture to delivery
  38. Rupture of membranes before 23-24 weeks
    Previable PROM
  39. ROM from 24-32 weeks gestation
    Preterm PROM remote from term
  40. ROM 31-36 weeks
    Preterm PROM near term
  41. Risk Factors for Preterm PROM
    • Previous PPROM or Preterm Delivery
    • Bleeding during Pregnancy
    • Hydramnios
    • Multiple Gestation
    • STIs
    • Cigarette Smoking
  42. Risks r/t Preterm PROM for woman
    • Maternal Infection
    • Preterm labor/birth
    • Increased rates of C-Sections
  43. 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
  44. 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
  45. 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
  46. PTs with PROM between 34-36 weeks should be managed:
    as if they were at term with induction of labor and treatment for GBS
  47. 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
  48. All women with preterm PROM should receive intrapartum _____ to prevent transmission of GBS
  49. Single course of _____ should be administered for woman preterm PROM before 32 weeks gestation
    antenatal corticosteroids
  50. Delivery is recommended when preterm PROM occurs:
    at or beyond 34 weeks gestation
  51. ____ should be avoided in pts with PROM unless they are in active labor or imminent delivery is anticipated
    Digital Cervical Examinations
  52. Previable PROM recommendations:
    • Pt counseling about risks to fetus
    • Expectant management/ Induction of labor
    • GBS is not recommended
    • Corticosteroids are not recommended
  53. 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)
  54. Mechanical defect in cervix that results in painless cervical dilation in 2nd Trimester that can progress to premature delivery
    Incompetent Cervix
  55. 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
  56. Cervical incompentence is associated with:
    Previous cervical trauma, cervical dilation and curettage/cauterization, Abnormal cervical development, Infection/Inflammation, Hormonal effects
  57. Risks to the Mom with incompetent cervix:
    • Repeated 2nd Tri births
    • Recurrent pregnancy losses
    • Preterm delivery
    • ROM/Infection
  58. Risks to Baby from incompetent cervix:
    Preterm birth and consequences of prematurity
  59. Assessment findings of Incompetent Cervix
    • Pelvic Pressure/Increased mucoid discharge
    • Shortened cervical length/funneling
    • Obstetrical hx
    • Live fetus/Intact membranes
  60. 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
  61. 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)
  62. Major causes of hemorrhage (antepartum)
    • placenta previa
    • plavental abruption
  63. 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)
  64. Complication of severe eclampsia

    • Hemolysis
    • Elevated Liver Enzymes
    • Low platelets
  65. Lab values of HELP syndrome in pre-eclamptic women
    • AST >70
    • ALT  >50

    Bilirubin >1.2

    LDH >600

    Platelets <100,000
  66. Risks for the mom in pre-eclampsia and HELLP syndrome
    • Abruptio Placenta
    • Renal Failure
    • Liver hematoma and possible rupture
    • Death
  67. Risks for baby during HELLP syndrome
    • Preterm birth
    • Death
  68. Management of HELLP syndrome
    • Delivery of baby and placenta
    • (resolution within 48 hours postpartum )

    Replacement of platelets
  69. 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
  70. When the placenta is totally covering the internal cervical os
    Complete (TOTAL) placenta previa
  71. When the placenta is 2.5 cm closer to the internal cervical os (partially covering internal os)
    Marginal (partial) placenta previa
  72. Hemorrhage is likely to happen with placenta previa during:
    3rd trimester (UCs)
  73. Placenta previa is dx usually by:
    ultrasound (before onset of bleeding)
  74. 4 classifications of placenta previa
    • Total
    • Partial
    • Marginal
    • Low-lying
  75. When the placenta is implanted in the lower uterine segment in close proximity to the internal cervical os
    Low-lying placenta
  76. 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)
  77. Things that cause endometrial scarring: (leading to placenta previa)
    Previous placenta previa

    Prior Csection


  78. Things that cause impeded endometrial vascularization (leading to placenta previa)
    • Advanced maternal Age (>35)
    • DM
    • HTN
    • Cigarrette Smoking
    • Uterine anomalies/fibroids/endometritis
  79. Things that cause Increased Placental Mass (leading to placenta previa)
    • Large placenta
    • Multiple gestations
  80. Never perform _____ with placenta previa pts
    SVE (you don't want to dislodge anything)
  81. Risks to mom when placenta previa occurs
    Hemorrhagic/Hypovolemic shock

    Maternal Exsanguination (10 mins)


    Potential Rh sensitization
  82. 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
  83. Classic presentation of placenta previa:
  84. 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!
  85. 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
  86. A C/S delivery is scheduled for ____ weeks gestation for partial or complete placenta previa
  87. Premature separation of a normally implanted placenta
    Placenta Abruption
  88. Two main types of abruptio placenta
    • Apparent or Concealed hemorrhage
    • (mild, moderate, severe grade)
  89. Abruptio placenta accounts for ____% of perinatal deaths for 1-200 deliveries
  90. <15% of placental separation with concealed hemorrhage
    Mild Grade Abruptio Placenta
  91. Up to 50% placenta separates with apparent hemorrhage
    Moderate Grade 2 Abruptio Placentae
  92. >50% placenta separates with concealed hemorrhage
    Severe Grade 3 abruptio placenta
  93. Less than 1/6 of placenta separates prematurely
    Mild: grade 1 abruptio placenta
  94. 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
  95. 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
  96. 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
  97. Grade of abruptio placenta:: Maternal V/S normal
    Milde: Grade 1
  98. Grade of abruptio placenta:: Maternal effects- mild shock, normal BP, Maternal tachycardia, narrowed pulse pressure, orthostatic hypotension, tachypnea
    Moderate: Grade 2
  99. Grade of abruptio placenta:: Maternal effects- moderate to profound shock, decreased BP, maternal tachycardia, severe orthostatic hypotension, significant tachypnea
    Severe: Grade 3
  100. Maternal Complications of Grade 1 Abruptio Placenta
    Normal fibrinogen 450 mg
  101. Maternal Complications of Grade 2 Abruptio Placenta
    Early signs of DIC

    Fibrinogen 150-300
  102. Maternal Complications of Grade 3 Abruptio Placenta
    DIC usually develops unless condition is treated immediately

    Fibrinogen <150
  103. Fetal/Neonate complications of Grade 1 abruptio placenta:
    Normal FHR pattern
  104. Fetal/Neonate complications of Grade 2 abruptio placenta:
    FHR shows significant signs of fetal compromise
  105. Fetal/Neonate complications of Grade 3 abruptio placenta:
    FHR shows signs of fetal compromise and death can occur
  106. 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
  107. 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!
  108. "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
  109. If maternal status is stable and fetus is immature, expectant management includes: (abruptio placenta)

    Monitoring of: FHR, UCs/Resting tone, Bleeding, Abdominal pain, Vaginal bleeding, Maternal labs, Coagulation studies

    Oxygen 8-10 L/min by mask


  110. Abnormality of implantation defined by degree of invasion into the uterine wall of trophoblast of placenta
    Placenta Accreta
  111. Associated with prior uterine surgery, TOLAC, abdominal trauma, and Oxytocin administration
    Uterine Rupture
  112. 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)
  113. Collaborative management of uterine rupture:
    • Initiate treatment for shock
    • Emergency operative delivery
    • Hysterectomy if uterus is too damaged
  114. 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
  115. 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
  116. 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
  117. 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


    Blood products as indicated if DIC develops

    Critical care nursing
  118. 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
  119. Dysfunctional Labor

    (prolonged, difficult labor and birth)
  120. 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
  121. Most common reason for primary C-Section
    Dystocia (difficult labor/birth)
  122. Dystocia usually indicates problems with:
    Powers, Pelvis (passage), Passenger, Psyche
  123. Hypertonic Uterine Dysfunction typically occurs in the _____ stage
    Latent Phast of the 1st stage of labor (<4cm dilation)...Prodromal Labor
  124. Frequent and painful (INEFFECTIVE to dilation and effacement) contractions
    Hypertonic Uterine Dysfunction
  125. Women in hypertonic uterine dysfunction are at greatest risk of ____ due to higher uterine resting tone
  126. Dangers of a high resting tone
    low oxygenation to the baby
  127. 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)
  128. Contributing factors of Hypertonic Uterine Dysfunction
    Uknown cause, most commonly seen in primigravidas with high anxiety
  129. 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)
  130. If pt is stressed with hypertonic dysfunction, ____ will be realeased in her body making things more painful
  131. Hypotonic Uterine dysfunction typically occurs during:
    Active phase of the 1st stage of labor (after 4 cm...little or no cervical change)
  132. ____ occurs when the pressure of the UC is insufficient to promote cervical dilation and effacement
    Hypotonic Uterine Dysfunction
  133. Contdaction characteristics during Hypotonic Uterine Dysfunction
    "Fizzling out"

    • Decreased frequency
    • (<2 contractions in 10 min)

    Decreased intensity
  134. Contributing factors of Hypotonic Uterine Dysfunction
    Fetal malpositions


    Cephalopelvic disproportion (CPD) -- baby's presenting part is too large to pass through pelvis

    Overdistended uterus (hydramnios)

    Epidural anesthesia

    Narcotic analgesia (epidural)
  135. 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!)
  136. Labor of less than 3 hours from onset to birth
    Precipitous labor
  137. Risk factors contributing to precipitous labor:
    Grand multiparity, previous precipitous birth
  138. Cause of precipitous labor:
    may be related to decrease maternal tissue resistance (we really don't know)
  139. Risks to mom during precipitous labor:
    • Uterine rupture
    • Vaginal lacerations
    • PP hemorrage secondary to uterine atony
  140. Fetus risks from precipitous labor
    • hypoxia (potential for FHR Category 1 or 2)
    • intracranial hemorrhage
  141. 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
  142. Occur in the second stage of labor when the woman is not able to push or bear down
    Inadequate expulsive forces
  143. Risk factors of inadequate expulsive forces
    Maternal exhaustion, epidural anesthesia
  144. Medical management of inadequate expulsive forces:
    augment with pitocin

    assist with vacuum or forceps
  145. Nursing actions for inadequate expulsive forces
    Assess fetal descent, coach in pushing, use non-directed approach
  146. Occurs when decreased diameters of the inlet, midplane, or outlet prevent normal fetal descent through the maternal pelvis
    Pelvic Dystocia (problem with passage)
  147. Most common pelvic dystocia
    Narrow midplane transverse diameter-- level of ischial spines resulting in transverse arrest of the fetal head and "failure to progress"
  148. 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!
  149. Round, cylindric pelvis shape...wide pubic arch
    Gynecoid (GOOD!)
  150. Long narrow pelvis with narrow pelvic arch
    Anthropoid (OC position)
  151. Heart/Triangular shaped pelvis, Narrow everywhere
    Android (male)
  152. Flattened, wide, short, oval pelvis shape....
    Platypelloid (least favorable)
  153. Most common malpresentation
    Breech (3-4%)
  154. Risks with Breech presentation
    Umbilical cord prolapse when membranes rupture

    Head entrapment in lower uterine segment or pelvic outlet (feet and legs come out)
  155. Management (approaches) for fetal malpresentations:
    External cephalic version (manipulation of the fetus through maternal abdominal wall by provider)

    C-Section delivery
  156. 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)
  157. Tocalytics are normally given:
    between 24-28 weeks gestation...2 doses... between 24 hours to produce surfactant
  158. Post- version nursing interventions:
    • Electronic FHR monitoring
    • Electronic uterine contraction
    • Discharge instructions (s/s of labor, leaking of fluid, etc...)
  159. Mom may need _____ before version
    pain medication
  160. Most common malposition
    Occiput posterior (LOP, ROP)
  161. Women with babies in OP position usually experience
    Back Pain
  162. 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
  163. Medical interventions for mom with OP baby
    Forceps or Vacuum extraction (risk for fetal injury, risk for 3rd and 4th degree lacerations)
  164. Key warning sign of shoulder dystocia
    • Fetal Macrosomia
    • (fetal weight > 4,000-4,500 g)
  165. Contributing factors of shoulder dystocia
    post dates, poorly controlled diabetes, excessive weight gain in pregnancy, advanced maternal age, multiparity
  166. Shoulder Dystocia is _____
    an obstetrical emergency
  167. Turtle sign
    Baby's head comes out and goes back in (retraction)....SHOULDER DYSTOCIA!!!!
  168. 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)
  169. Maternal risks from fetal macrosomia
    • Infection-- Most common sequela 
    • Increased pain, fatigue, anxiety
    • Vaginal trauma
    • Episiotomy extension OR intentional 4th degree episiotomy
  170. 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
  171. Multifetal pregnancies are at risk for:
    preterm labor and c-sections
  172. Multifetal pregnancies usually deliver:
    between 34-35 weeks (late preterm!)

    C-Section unless vertex/vertex
  173. Patient's first abdominal delivery or pt has had at least 1 previous C/S, or for fetal malposition
    Scheduled C-Section
  174. 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)
  175. Fetal risks to C-Section
    Increased risk for newborn respiratory distress (babies delivered vaginally get fluid squeezed out of their lungs)

  176. 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
  177. Psychosocial complications of a C-Section
    Delayed mother-infant bonding (especially if unplanned C/S)
  178. 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
  179. Post-op care for CSection
    • VS q 15 minutes
    • ABCs
    • Incision
    • Fundus
    • Lochia
    • Oxytocin
    • Pain
    • Assess DVT, paralytic ileus
    • Turn/Cough/Deep Breath