CH 21 Flashcards
Dystocia
difficult birth, typically caused by a large or awkwardly positioned fetus, by smallness of the maternal pelvis, or by failure of the uterus and cervix to contract and expand normally
Risk Factors for Dystocia
-epidural analgesia / excessive analgesia
-multiple gestation
-hydramnios
-maternal exhaustion
-ineffective maternal pushing technique
-occiput posterior position - sunny side up
- longer 1st stage of labor
- nulliparity - no previous births
-short maternal stature
-fetal birth weight over 8.8 lbs
-abnormal fetal presentation/ position
-fetal anomalies
-shoulder dystocia
-maternal age over 35 yrs
-high caffeine intake
-overweight
-gestational age over 41 weeks
-chorioamnionitis - infection in the amniotic sac
-ineffective uterine contractions
-high fetal station at complete cervical dilation
McRoberts Maneuver
opens up the cervix
Suprapubic Pressure Maneuver
push right above it, pushing the shoulders
2 Manuvers we do
- McRoberts
- Suprapubic Pressure
Causes of Dystocia: Problems w/ Powers
- hypertonic uterine dysfunction - contracting TOO MUCH
- hypotonic uterine dysfunction - not contracting enough
- arrest disorders - just STOPS
Causes of Dystocia: Problems w/ Passageway
- pelvic contraction - not enough room to get thru
- obstructions in maternal birth canal - fibroids
Causes of Dystocia: Problems w/ Passenger
- occiput posterior position
- breech presentation
- multifetal pregnancy
- macrosomia and CPD
- structural abnormalities - baby may not be able to come out
Causes of Dystocia: Problems w/ Psyche
psychological distress
What are the P’s affecting labor and birth?
Powers
Passageway
Passenger (positions?)
Psyche
What is Preterm Labor?
-regular uterine contractions w/ cervical effacement and dilation between 20 - 37 weeks gestation
-one of the most common obstetric complications
Preterm Labor Meds:
-tocolytic drugs: no clear first line drugs to manage preterm labor. May prolong pregnancy for 2-7 days while steroids can be given for fetal lung maturity
-give mag sulfate and then give steroids.
-betamethosome shot every 24hrs for lungs.
-Nefedipine (CCB)- tries to relax the uterus but need to be careful if moms BP is already low
-antibiotic prophylaxis for women w/ group B streptococcus (test not done until 36 wks)
Subtle Signs of Preterm Labor
cramping, bleeding, pressure
Contraction Patterns of Preterm Labor
-more than 6 an hr = too much and mom needs to come in
-4 contractions every 20 min
Preterm Labor Labs
- CBC
- urinalysis - UTI = can push mom into prelabor
- amniotic fluid analysis
- fetal fibronectin
- cervical length via transvaginal ultrasound
- home uterine activity monitoring
More Preterm Labor MEDS
- terbutaline (not used much anymore)- SQ, PO
- Magnesium sulfate (not used much anymore) - relaxes uterine muscle, uncomfy side effects for mom, IV
- Indomethacin - NSAID, prostaglandin inhibitor, fetal SE= PDA. Slows the cervix down.
- Procardia - CCB - inhibits muscle contractions, less SE, but hypotension
**most common one*** - steroid admin - - betamethasone
Postterm Labor is pregnancy continuing past end of ______ weeks gestation
42
Postterm Labor Maternal Risks:
c-section birth
dystocia
birth trauma
post-partum hemorrhage
infection
Postterm Labor Fetal Risks:
macrosomia
shoulder dystocia
brachial plexus injuries
low Apgar scores
postmaturity syndrome
cephalopelvic disproportion
Postterm Assessment:
-estimated date of birth
-daily fetal movement counts - do at the most active time of day. Mom should lay down and see how long it takes to have 10 movements and then check the next day and next. If it takes longer each time = concerning .
-nonstress test 2x weekly- tells us baby is good for at least 4 days. When baby is not good = induce.
-amniotic fluid analysis
-weekly cervical exams
-client understanding
-anxiety and coping ability
Postterm Nursing Management:
-fetal surveillance
-decision for labor induction
-support, education
-intrapartal care
Labor Induction
stimulating contractions via medical or surgical means
Labor Augmentation
enhancing ineffective contractions after labor has begun
Labor Induction & Augmentation Indications:
-prolonged gestation
-prolonged premature rupture of the membranes
-gestational hypertension
-cardiac disease
-renal disease
-chorioamnionitis
-dystocia
-intrauterine fetal demise
-isoimmunization
-diabetes
Labor Induction Therapeutic Management
- cervical ripening (Bishop score = docs dont want it written on chart, says how dilated, effaced, etc - it can say baby doesnt need to be induced buy doc would want to induce anyways)
- herbal agents
- Castor oil - makes mom miserable and doesnt work. N/V, dirrhea., NO hot baths - dont want to heat up baby. Enemas
- sexual intercourse w/ breast stimulation. Nipple stim may work.
- mechanical methods (Cook balloon, foley) Two balloons = one in cervix then pull against cervix and pull tension and tape it to moms abdomen. slowly pulls on cervix and causes it to open up.
- pharm agents — dinoprostone, misoprostol, oxytocin.
Dinoprostone = looks like a tampon, flat. Goes up and around the back of cervix and sits there releasing prost ripening the cervix. Sits there for 12 hrs and can come out if she is dilating. If still thich then keep in for another 12 hrs.
Oxytocin = start w/ very little and titrate up until good labor.
VBAC (vaginal birth after cesarean)
-controversy related to risk of uterine rupture & hemorrhage
-where the scar is from a c section has a risk of opening up during labor and some babies can die. No circulation going to the baby. 17 min to get the baby out
-any type of surgery that has gone through the uterus = NO VBAC (fibroids, classical incision)
-Focus on: consent, documentation, surveillance, readiness for emergency
Nurses as advocates for pts: expertise in reading fetal monitoring tracings to identify nonreassuring pattern and instituting measures for emergency delivery
Amnioinfusion
Indications:
1. severe variable decelerations due to cord compression
2. oligohydramnios due to placental insufficiency
3. thick meconium fluid = but no longer done
Nursing management: teaching, maternal and fetal assessment, preparation for possible c-section
Will weigh chux to see how much fluid is coming out.
Intrauterine Fetal Demise
Causes: cord accident, clot, abruption, etc
RN Assessment: inability to obtain fetal heart sounds, ultrasound to confirm absence of fetal activity, labor induction
RN Management: assistance w/ grieving process, referrals
Umbilical Cord Prolapse
-emergency
-happens with partial or total occlusion of cord w/ rapid fetal deterioration
-umbilical cord comes thru the cervix before the baby is born
-can’t cut off that cord
-want to keep baby’s head up against the cervix
-c section
Umbilical Cord Prolapse (Assessment/Management):
-prevention; risk factors
-continuous assessment of pt and fetus
-prompt recognition
-measure to relieve compression
Placental Abruption
-emergency involving premature separation
-management dependent on: gestational age, extent of hemorrhage, meaternal-fetal oxygenation perfusion
-maintenance of maternal cardiovascular status
-prompt delivery of fetus
-csection birth if fetus is still alive; vaginal birth if fetal demise
Uterine Rupture
-emergency - onset marked by sudden fetal bradycardia
RN assess: risk factors, onset of sudden fetal distress
-bleeding, variable decels, go down and do not come back up
RN management: prepare for c-section, continuous maternal and fetal monitoring
Anaphylactoid Syndrome of Pregnancy (Amniotic Fluid Embolism)
-emergency
-allergic reaction that mom has to the pregnancy
-sudden onset. Basically a blood clot that goes to the lung - all the particles that are in the amniotic fluid goes into the maternal circulation. Goes fast and mom can die very quickly. Depending on where it is, it can slow down so it’s not so quick and sudden. Can happen at any time during pregnancy.
-Only way we really know what it was is in the autopsy.
Anaphylactoid Syndrome Onset of & Assessment:
- hypotension
- hypoxia
- coagulopathy due to breakage in barrier between maternal circulation and amniotic fluid
Assess for: difficulty breathing, hypotension, cyanosis, seizures, tachycardia, coagulation failure, DIC, pulmonary edema, uterine atony w/ subsequent hemorrhage, ARDS, cardiac arrest
Anaphylactoid Syndrome RN Management:
-supportive measures to maintain oxygenation
-hemodynamic function
-correct coagulopathy
-critical care monitoring
Forceps or Vacuum Assisted Birth
-application of traction to fetal head
INDICATIONS: prolonged 2nd stage of labor(pushing/delivery) , nonreassuring FHR pattern, failure of presenting part to fully rotate and descend, limited sensation or inability to push effectively, presumed fetal jeopardy or fetal distress, maternal heart disease, acute pulmonary edema, intrapartum infection, maternal fatigue, infection
Risk: of tissue trauma to mother and newborn. Can damage baby’s head. Can cause cephalohematoma to baby’s head.
-Pump up during contraction, let go during contraction. 10 minutes of pumped time OR 3 pop offs and that’s it.
Prevention is key
Cesarean Birth
- classic or low transverse incision. Want LOW TRANSVERSE incision.
-major surgical procedure
Cesarean Birth Preoperative Care:
-only clip, no shaving bc of infection
-consent
-foley catheter
-abdominal prep
-surgical checklist
-education
Cesarean Birth Posoperative Care:
-recovery
-pain relief
-post surgical assessments
-education
