ch 32 alterations in labor and birth, OB emergencies Flashcards
5 causes dystocia
-dysfunctional labor
-alterations in pelvic structure
-fetal causes
-position of woman
-psychological responses
risk factors for dystocia
-overweight
-short stature (<5 ft)
-uterine abnormalities
-fetal malpositions/presentations/CPD
-uterine overstimulation w/ oxytocin
-maternal fatigue, dehydration, electrolyte imbalance, fear
-early admin analgesic
-use of continuous epidural
-other (advanced maternal age, h/o infertility, h/o prior fetal version, masculine characteristic)
CPD
cephalopelvic disproportion
2 types dysfunctional labor
-protracted/prolonged: slower than expected
-arrest: progress stops
type of dysfunctional labor (stage 1, latent phase):
-frequent, painful, inefficient contractions
-Tx: therapeutic rest
hypertonic uterine dysfunction
type of dysfunctional labor (stage 2):
-normal progress initially, then stalls
-contractions become weak/inefficient or stop
-assess status, possible augmentation
hypotonic uterine dysfunction
fetal causes dystocia
-anomalies
-macrosomia/CPD
-malposition
-malpresentation
-multifetal gestation
3 complications dystocia
-maternal lacerations
-fetal injuries/fractures
-neonatal asphyxia
nursing interventions for dystocia
-positioning and movement
-pain and anxiety management
-labor support
-environmental control
-pt and family teaching
-open glottis pushing
-patient advocacy
labor that lasts <3 hours from onset of Cxs to time of birth
precipitous labor
what might precipitous labor be associated with
hypertonic uterine Cxs:
-placental abruption
-uterine tachysystole
-recent cocaine use
(increased risk trauma to mom and baby)
medical procedures for dystocia
-external cephalic version (before baby is engaged)
-operative vaginal birth (forceps, vacuum)
fetal risk with use of vacuum during birth
increased risk for jaundice due to blood buildup in head
how many times can a hcp try to use vacuum extraction if it pops off
3 times total
then switch to forceps or C/S
induction v augmentation of labor
induction: starting labor
augmentation: labor already started, helping it move along
how many weeks EGA does woman have to be to have elective induction
39 wks
maternal indications for medically indicated induction
-pregnancy complications (HTN)
-fetal death
-chorio
fetal indications for medically indicated induction
fetal jeopardy:
-maternal complications (DM, GDM, HTN)
-post term (42 wks EGA)
-IUGR
-Rh sensitization
-chorio
-term ROM without labor
contraindications for induction
-acute severe fetal distress (C/S)
-malpresentation
-floating presenting part (not engaged)
-uncontrolled hemorrhage
-previa
-some previous uterine incisions
relative contraindications for induction (with caution)
-grandmultiparity (G>5, increased risk PPH)
-multiple gestations
-suspected CPD
-breech
-inability to monitor FHR (obesity, previa)
purpose of bishop score
assess readiness of cervix prior to induction
what bishop score is considered successful, and equivalent to spontaneous labor
8+
what is evaluated in bishop score (5)
-dilation
-effacement
-station
-cervical consistency (firm, medium, soft)
-cervical position (posterior, midposition, anterior)
methods to facilitate cervical ripening (3 mechanical, 2 chemical)
MECHANICAL (stimulates cervix to release prostaglandins)
-balloon catheter
-hydroscopic dilator
-amniotic membrane stripping/sweeping (separates chorion from uterus)
CHEMICAL:
-misoprostol (cytotec)
-dinoprostone (prepidil gel, cervidil insert)
adverse effects of prostaglandins (misoprostol, dinoprostone)
-headache
-fever
-N/V/D
-hypoTN
-uterine tachysystole
-fetal passage meconium
absolute contraindication for use of cytotec
previous uterine scar
contraindications for use of dinoprostone (prepidil, cervidil)
-asthma
-glaucoma
-hypoTN/HTN
CAUTION WITH:
-cardiac/renal/hepatic disease
-anemia
-diabetes
-epilepsy
-GU infections
indications of use for oxytocin
-induction
-augmentation
-prophylaxis against PPH
-treat PPH
what does steady state of a med mean
max effect of med is reached
how long does it take for oxytocin to reach steady state
40 minutes
considerations for admin of oxytocin
given IVPB
always given at port closest to skin
documented in mIU/min
S+S uterine tachysystole
-5+ contractions in 10 mins
-contractions longer than 2 mins
-less than 1 minute resting time between Cxs
interventions for uterine tachysystole with oxytocin infusion for category 1 FHR
-side lying position
-IV fluid bolus LR
-decrease oxytocin by half if uterine activity not returned to normal after 10 mins
-discontinue oxytocin if not normal after another 10 mins
interventions for uterine tachysystole with oxytocin infusion for category 2 or 3 FHR
-discontinue oxytocin immediately
-side lying position
-IV fluid bolus LR
-O2 10L/min
-possibly give terbutaline
-notify hcp
guidelines before admin of oxytocin
-verify woman understands indications, risks and benefits
-verify order
-implement order
-comfort and position for woman
-fetal monitoring atleast 15 mins before
-bathroom before
goal for contractions with oxytocin infusion
-200-220 MVU (only can monitor if have IUPC)
-contraction q2-3min lasting 80-90 secs, strong
nursing considerations for oxytocin (assessments and frequency)
-EFM continuous
-VS q30-60mins and with dose change
-FHR and contraction pattern q15mins and with change in dose (2nd stage labor: q5mins)
-monitor I&O (limit IV to 1000 mL/8 hr)
side effect of oxytocin?
max mainline IV infusion?
water retention
1000 mL/8hr
what is the low dose of oxytocin
-1 mu/min start
-increase 1-2 mu/min q30min
what is the high dose of oxytocin
-6 mu/min start
-increase 6 mu/min q15-20min
adverse effect high doses oxytocin
increased C/S rates due to fetal distress
alternative methods to induce labor
-herbals (black cohosh, evening primrose oil, blue cohosh, castor oil)
-acupuncture
*ask because she might have faster response to oxytocin induction
VBAC
vaginal birth after C/S
TOL/TOLAC
trial of labor (after C/S)
standard preop care for C/S
-NPO 8-12 hrs
-consent
-anesthesia preop
-IV
-foley
-preop meds (Abx, antacids)
-SCDs
intraop care for C/S: positioning
-tilt
-foley
-SCDs
-legs secured
-bovie pad
-blankets
intraop care for C/S: time out
-pt and procedure ID w/ indication
-consents
-preop meds
-blood if needed
-drug and food allergies
-neonatal team
2 types skin incisions for C/S
-transverse
-vertical
who can’t do TOLAC/VBAC (3)
woman who had previous C/S with:
-low vertical uterine incision
-J shape uterine extension
-T shape uterine extension
3 types uterine incisions for C/S
+2 extensions
-low transverse
-low vertical
-classical
extensions:
-J shape
-T shape
postpartum care for C/S mom
-pain management
-intestinal gas management
-diet
-ambulation, foley, SCDs
-peri care, breast care
-fundal and lochia assessments
possible causes meconium stained amniotic fluid (3)
-post term
-breech presentation
-hypoxia-induced peristalsis
intervention for meconium stained amniotic fluid before birth
-early recognition
-prep for neonatal resuscitation/intubation
intervention for meconium stained amniotic fluid immediately after birth
ASSESS
-good cry, tone, HR>100: wipe face and mouth, bulb suction
-depressed resps, decreased tone, HR<100: tracheal suction with ET tube
risk factors shoulder dystocia
-**diabetes (esp uncontrolled glucose during 2nd half pregnancy)
-prior macrosomia
-obesity
-AMA (>35 yo)
-excessive weight gain in pregnancy
-abnormal pelvis
-post term
S+S shoulder dystocia
-prolonged 2nd stage labor
-protracted/arrest of descent
-pronounced fetal head molding
-head delivers, shoulders don’t
-no external rotation
-“turtle sign” (head retracting back into pelvis)
dangers of shoulder dystocia
-fractures (esp humerus or clavicle)
-asphyxia
-brachial plexus damage
nursing intervention for shoulder dystocia
-McRoberts maneuver: legs onto chest, suprapubic pressure
-other positions: hands/knees, squatting
maternal complications shoulder dystocia
-uterine atony and PPH
-vaginal and perineal tears
-episiotomy with extension
-endometritis
nursing documentation for shoulder dystocia
-delivery time (time between head and shoulders)
-anesthesia
-all maneuvers in order they occurred
-consultants
-infant/maternal status at completion
OB emergency: occurs when cord lies below presenting part of fetus
prolapsed umbilical cord
contributing factors to prolapsed umbilical cord
-long cord (>100 cm)
-malpresentation (breech)
-transverse lie
-unengaged presenting part
