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Women's Health Test IV > Chapter 27: Intrapartum Complications > Flashcards

Chapter 27: Intrapartum Complications Flashcards

1
Q

what is dysfunctional labor?

A
  • lack of normal progress of cervical dilation, effacement, or descent
  • may result from problems with powers of labor, passenger, passage, psyche, or combination of these
  • often prolonged, but may be unusually short and intense
  • an operative birth may be needed if dysfunctional labor does not resolve or fetal or maternal compromise occurs
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2
Q

what is dystocia?

A
  • a general term to describe any difficult labor or birth
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3
Q

what are signs of compromise during a dysfunctional labor?

A
  • nonreassuring FHR
  • fetal acidosis
  • meconium passage
  • maternal exhaustion
  • maternal infection
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4
Q

problems of the powers that may result in dysfunctional labor

A
  • ineffective uterine contractions
  • ineffective maternal pushing
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5
Q

explain how ineffective contractions can be a problem for dysfunctional labor

A
  • good contractions are coordinated, strong, and frequent
  • causes of ineffective contractions:
    • fatigue
    • bedrest
    • electrolyte imbalance
    • hypoglycemia
    • excessive analgesia/anesthesia
    • overdistention of the uterus from multiple gestation or hydramnios
  • 2 patterns of ineffective uterine contractions:
    • hypotonic dysfunction
    • hypertonic dysfunction
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6
Q

hypotonic contractions

A
  • coordinated by too weak and infrequent to be effective
  • usually occurs during the active phase of labor, when progress normally quickens
  • uterine overdistention is assoc with this b/c the stretched uterine muscle contracts poorly
  • comfortable but frustrating to laboring woman
  • does not cause fetal hypoxia
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7
Q

mgmt of hypotonic contractions

A
  • administration of IV or oral fluids corrects maternal F&E imbalances or hypoglycemia
  • change positions, esp upright positions
  • stand or sit in warm shower
  • manage pain: epidural blocks
  • therapeutic communication to identify anxieties or beliefs about labor
  • amniotomy
  • oxytocin infusion
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8
Q

for moms with hypotonic contractions:

what are the main risks assoc with amniotomy?

what are the main risks assoc with oxytocin infusion?

A
  • amniotomy:
    • umbilical cord prolapse
    • infection
    • placental abruption
  • oxytocin infusion:
    • reduced placental perfusion caused by excessive contractions
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9
Q

hypertonic contractions

A
  • more often affect women in early labor w/ their first baby
  • contractions are uncoordinated and erratic, and they are painful but ineffective
  • uterine resting tone is high
    • dec oxygenation impacts fetus and causes constant cramping
  • woman becomes exhausted and anxious
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10
Q

mgmt of hypertonic contractions

A
  • warm shower: promotes relaxation and rest
  • systemic analgesics/low dose epidural
  • tocolytics: may reduce uterine resting tone and improve placental blood flow
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11
Q

what are the causes of ineffective pushing?

A
  • poor positioning
  • fear
  • no sensation or urge
  • exhaustion
  • analgesia or anesthesia
  • afraid to “let go” of baby
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12
Q

what are the interventions for ineffective pushing?

A
  • “laboring down”: delayed pushing, so encourage the woman to wait until she feels the reflexive urge to push
    • also do not limit the length of the 2nd stage of labor
  • upright positions
    • squatting
    • add gravity to the pushing effors
  • “runners stance”
  • education
  • less anesthesia
  • good coaching
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13
Q

problems of passenger that may cause dysfunctional labor

A
  • fetal size
  • fetal presentation or position
  • multifetal pregnancy
  • fetal anomalies
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14
Q

macrosomia

A
  • greater than 8 lb 13 oz or 4000 g
  • head or shoulders may not be able to adapt to the pelvis if they are too large: cephalopelvic disproportion (CPD)
  • also distention of the uterus by the large uterus reduces the strength of contractions during and after birth
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15
Q

shoulder dystocia

A
  • EMERGENCY!
  • delayed or difficult birth of the shoulders may occur as they become impacted above the maternal symphysis pubis
    • after the head is born, it retracts against the perineum: “turtle sign”
  • more likely to occur when the fetus is large or the mother has diabete
  • problem: head is born and chest is in vagina–>prevents breathing
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16
Q

mgmt for shoulder dystocia

A
  • try for vaginal delivery
    • but prepare for C/S
  • McRobert’s maneuver: woman flexes her thighs sharply against her abdomen, which straightens the pelvic curve somewhat
  • suprapubic pressure: push the anterior fetal shoulder downward to displace it from above the mother’s symphysis pubis
  • fundal pressure should NOT be used b/c we don’t want to push the shoulders even harder against the symphysis
  • once infant is born, check clavicles for crepitus, deformity, and bruising
  • timekeeper is essential
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17
Q

mnemonic for shoulder dystocia

A
  • H: call for Help
  • E: Evaluate for Episiotomy
  • L: Legs–McRobert’s Maneuver
  • P: suprapubic Pressure
  • E: Enter: rotational maneuvers
  • R: Remove the posterior arm
  • R: Roll the patient to her hands and knees
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18
Q

rotation abnormalities that may lead to dysfunctional labor

A
  • persistence of the fetus in occiput posterior (OP) or occiput transverse (OT)
    • these positions can prevent the cardinal movements of normal labor from occurring
  • most fetuses that begin in occiput posterior rotate spontaneously to the occiput anterior (OA)–>promotes normal extension and expulsion of the head
  • labor is longer or more uncomfortable if the fetus is in OP–>back pain b/c contractions is intense
  • mgmt:
    • counterpressure of the sacrum
    • hands and knees
    • side lying
      • 2 above both tend to rotate toward the anterior uterus
    • lunge positioning: widens the pelvis
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19
Q

deflexion abnormalities that may lead to dysfunctional labor

A
  • poorly flexed fetal head presents a larger diameter to the pelvis that if flexed with the chin on the chest
    • vertex presentation: head diameter is smallest
    • military and brow presentations: head diameter is largest
    • face presentations: head diameter is similar to the vertex presentation but the maternal pelvis can be transversed only if the fetal chin is anterior
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20
Q

breech presentation and how it may contribute to dysfunctional labor

A
  • dilation and effacement are slower in breech b/c the buttocks and feet do not form a smooth, round dilating wedge like the head
  • greatest risk: fetal head (largest part) is last to be born
    • by the time the lower body is born, the umbilical cord is well into the pelvis and may be compressed
      • shoulders, arms, and head must be delivered quickly so the infant can breathe
  • normally an external cephalic version is performed to try to position the infant in cephalic position or a C/S is performed if the baby can’t be turned
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21
Q

how does a multifetal pregnancy contribute to dysfunctional labor?

A
  • multifetal pregnancy may lead cause dysfunctional labor b/c of uterine overdistention (–>hypotonic contractions) and abnormal presentation of the fetuses
  • potential for fetal hypoxia is greater and risk of PPH is greater
  • almost always C/S: esp if 3 or more fetuses
  • monitor both babies FHR during labor and continue to monitor 2nd baby’s FHR once first baby is born (usually w/in 30 min of first)
  • equipment necessary for each baby: radiant warmers, resuscitation equipment, meds, blankets, hats, ID materials
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22
Q

fetal anomalies which can lead to dysfunctional labor

A
  • hydrocephalus
  • large fetal tumors
    • usually discovered by U/S
    • vaginal birth if possible but C/S is common
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23
Q

what are problems with the passage that may lead to dysfunctional labor?

A
  • small or abnormally shaped pelvis
  • maternal soft tissue obstructions: like full bladder
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24
Q

how can a woman’s psyche contribute to dysfunctional labor?

A
  • if a woman’s perception of stress is high:
    • inc glucose consumption
    • inhibition of contractions
    • poor pushing as abdomen and pelvic muscles tighten
    • inc pain perception
  • nursing measures:
    • develop trusting relationship
    • make environment comfortable by adjusting temp/light
    • promoting physical comfort like cleanliness
    • provide accurate info
    • implement pain mgmt
25
Q

prolonged labor

A
  • guideline once in active labor:
    • 1.2 cm/hr dilation for nullipara
      • descend 1 cm/hr
    • 1.5 cm/hr dilation for parous woman
      • descend 2 cm/hr
  • risks of prolonged labor:
    • maternal or neonatal infection
    • maternal exhaustion–>ineffective pushing
    • high levels of anxiety/fear during subsequent labor
26
Q

nursing measures for prolonged labor

A
  • promote comfort, conservation of energy
  • emotional support
  • position changes that favor normal progress
  • assess for infection
  • observe fetus for signs of intrauterine infection or compromised fetal oxygenation
27
Q

precipitate labor

A
  • one in which birth occurs w/in 3 hrs of its onset
    • instense contractions have abrupt onset
  • risks:
    • placental abruption
    • fetal meconium
    • maternal cocaine use
    • PPH
    • low apgar scores for infant
    • fetal intracranial hemorrhage or nerve dmaage
    • fetal hypoxia
    • late decels and bradycardia
28
Q

nursing measures for precipitate labor

A
  • promote fetal oxygenation and maternal comfort
    • side lying position: enhance blood flow and reduce aortocaval compression
    • administer O2 to mom
    • IV fluids for blood volume
    • stop oxytocin if being given and begin tocolytic
    • epidural analgesia may not be possible
    • opioid analgesia given close to birth–>resp depression
    • breathing techniques for comfort
29
Q

precipitate birth

A
  • labor of any length that occurs when a trained attendant is not there to assist
  • unexpected, sudden birth
  • nurse should wear gloves and support infant’s body as it emerges
    • teach to pant b/w contractions
  • prepare for ROM
  • do not try to keep fetus from being delivered
  • apply gentle pressure to fetal head upward
  • infant: airway and warmth
30
Q

assessment for intrauterine infection

A
  • fetal tachycardia may be first sign
  • maternal temp: assess q2-4 h in normal labor and q2 h after membranes rupture
    • assess hourly if elevated over 100.4 deg F
  • maternal pulse rate, respirations, and BP
    • assess at least hourly to identify tachycardia or tachypnea
  • assess amniotic fluid for normal clear color and mild odor
    • yellow or cloudy color and foul odor–>infection
31
Q

interventions for intrauterine infection

A
  • wash hands before and after each contact w/ all pts to reduce transmission of organisms
  • limit vaginal exams
  • maintain aseptic technique
  • keep underpads as dry as possible to reduce the moist, warm environment that favors bacterial growth
  • clean excess secretions from the vaginal area in a front to back direction to limit fecal contamination and promote the mother’s comfort
32
Q

assessment for maternal exhaustion

A
  • many women begin labor w/ a sleep deficit b/c of fetal movement, frequent urination, and shortness of breath
    • as labor drags on, mother’s reserves are further depleted
  • signs of excessive fatigue:
    • verbal expression of tiredness, fatigue, or exhaustion
    • verbal expression of frustration w/ a prolonged, unproductive labor
    • ineffectiveness of or inability to use coping techniques (such as patterned breathing) that she previously used effectively
    • changes in her pule rate, respiration, and BP
33
Q

interventions for conserving maternal energy

A
  • reduce factors that interfere w/ a woman’s ability to relax:
    • lower lights
    • reduce noise
    • maintain a comfortable maternal temperature
  • position woman to maintain comfort, promote fetal descent, and enhance fetal oxygenation
    • support w/ pillows to reduce muscle strain
    • help change positions frequently, like q30 min, to reduce muscle tension
  • soothing back rub reduces muscle tension and dec fatigue
    • firm sacral pressure to reduce pain if the fetus is OP
    • use birthing ball or warmth
  • maintain IV fluids
    • assess I&O to identify dehydration
      • dehydration may cause maternal fever
    • if not contraindicated, provide juice, lollipops, frozen juice bars to moisten her mouth
34
Q

PROM vs pPROM

A
  • PROM: rupture of amniotic sac before true labor
    • normal if it occurs at term
  • pPROM: preterm premature rupture of membranes (before 37 weeks)
  • greatest newborn risks occur when birth occurs before completion of 34 weeks of gestation
35
Q

conditions assoc with PROM:

A
  • chorioamniotis: fever and uterine tenderness
    • may be assoc with GBS, gonorrhea
  • vaginal or cervical infections: gonorrhea, chlamydia, trichomonas, GBS
  • weak amniotic sac
  • previous preterm births
  • fetal abnormalities or malpresentation
  • incompetent cervix
  • overdistention of the uterus
  • recent sexual intercourse
  • maternal stress
36
Q

complications of PROM

A
  • chorioamnionitis: weaken the membrane and lead to rupture
    • characterized by maternal fever and uterine tenderness
    • most likely to precede births in infants born before 34 weeks
    • frequent performance of vaginal exams inc risk of infection
  • oligohydramnios: membranes may continue to leak
    • umbilical cord compression, reduced lung volume, and deformities may result
  • RDS: if preterm birth occurs, the infant is more likely to have RDS
37
Q

mgmt of PROM

A
  • depends on gestation and whether evidence of infection or maternal/fetal compromise exists
  • for a woman at or near term (36 weeks or more of gestation), PROM may herald the the imminent onset of true labor
    • often the cervix is soft, with some dilation and effacement
  • if the fetus is less than 36 weeks or the woman’s cervix is not soft and favorable for labor induction, therapeutic mgmt is more complex
38
Q

how to determine the true membrane rupture

A
  • urinary incontnence, inc vaginal discharge, or loss of mucous plug can make a woman think that her membranes have ruptures when they have not
  • digital vaginal exam is avoided esp if gestation is preterm and no evidence of labor exists
    • instead, perform a sterile speculum exam to look for a pool of flui near the cervix and estimate dilation and effacement
    • pH swab or fern test may be done to verify fluid is amniotic
  • perform tests to assess fetal lung maturity
  • if near term, cervix is favorable, and & fetal lungs are mature, induce labor
    • if cervix is not favorable and no infection, start steroids and abx
  • if preterm, risk vs benefit:
    • look at gestational age, amt of amniotic fluid remaining, fetal lung maturity
    • cerclage may be placed to prevent premature dilation
    • if no evidence of infection and fetal lungs are immature, then observe for infection and onset of labor
      • daily NSTs are performed to watch for FHR nonreactivity
    • steroids and abx given
39
Q

nursing considerations for PROM

A
  • observe for signs of infection
  • at home:
    • avoid sexual intercourse or insertion of anything into vagina
    • avoid breast stimulation if preterm b/c can release oxytocin and stimulate contractions
    • take temp 4x per day: report anything over 100.4 deg F
    • maintain any activity restrictions
    • note and report uterine contractions or a foul odor to vaginal drainage
40
Q

preterm labor

A
  • 20th-37th week
  • ADRs of prematurity:
    • cerebral palsy
    • developmental delay
    • hearing and vision impairment
  • risk factors:
    • previous preterm delivery
    • multifetal pregnancy
    • use of assisted reproductive technology: including prematurity, C/S, infant disability
41
Q

associated factors of preterm labor

A
  • maternal medical conditions: UTIs, infection of reproductive organs, dental disorders, preexisting and gestational diabetes,connective tissue disorders, chronic HTN, drug abuse
  • conceptions enhanced by assisted reproductive technology
  • present and past obstetrical conditions: short cervical length, multifetal gestation, preterm membrane rupture, preeclampsoa, bleeding disorders, or problems with placental implantation
  • fetal conditions: growth retardation, inadequate amniotic fluid
  • social and environmental factors: absent prenatal care, domestic violence, maternal smoking
42
Q

symptoms of preterm labor

A
  • uterine contractions
  • sensation that the baby is frequently “balling up”
  • cramps similar to menstrual cramps
  • constant low backaches
  • sensation of pelvic pressure or feeling the baby is pushing down
  • pain, discomfort, or pressure in vagina
  • change or inc in vaginal discharge
  • abdominal cramps w/ or w/o diarrhea
  • sense of just feeling bad
43
Q

measures to prevent preterm labor

A
  • reduce barriers and improve access to care
  • assess for risk factors
  • promote adequate nutrition
  • promote smoking cessation
  • teach women and their partners about subtle signs of preterm labor and ways in which they differ from normal pregnancy changes
  • empower women and their partners to take an active approach to seeking care:
    • they should know the S/S of preterm labor
44
Q

how to predict preterm birth

A
  • cervical length: <25 mm–>may allow organisms easier access to the uterus and may weaken membranes and cause rupture
  • PPROM in previous birth
  • fetal fibronectin (fFn): protein present in fetal tissues
    • normally found in cervical and vaginal secretions from 16-20 wks and again at or near term
    • if it appears to early, it suggests that labor may begin early
    • maternal or fetal infection may be present if the fFn is positive during midpregnancy
  • maternal illness or infection
45
Q

stopping preterm labor

A
  • first determine if any problems exist that contraindicate continuing the pregnancy including HTN, hypovolemia, cardiac dz, pyelonephritis, nonreassuring FHR
  • identify and tx infections
    • amniocentesis can be done to obtain amniotic fluid for culture if chorioamnionitis is suspected b/c this infection would contraindicate stopping labor
    • cultures: require 24-48 hr to complete, so antiinfectives started as soon as cultures obtained
  • limit activity: help them relax
  • hydrate: dehydration can contribute to uterine irritability in some women
  • tocolytics administered
  • corticosteroids given to accelerate fetal lung maturity if birth before 34 weeks seems inevitable
    • can reduce incidence and severity of RDS and IVH in preterm infants
    • try to delay birth for 24 hr after start of corticosteroid therapy
46
Q

Magnesium sulfate

A
  • tocolytic and used to manage pregnancy assoc HTN to prevent seizures
  • loading dose: 4-6 g over 30 min
    • maintenance tocolysis: 1-4 g/hr
  • nursing care:
    • assessment of DTRs
    • monitor that urine output is >30 mL/hr
    • monitor RR b/c can depress RR
    • EFM b/c reduce variability is common
    • monitor bowel sounds q4-8 hr b/c of smooth muscle in intestinal tract is relaxed as uterus is relaxed
    • SEs: lethargy, flushing, dizziness, visual blurring, nausea, weakness, sensation of heat
    • calcium gluconate is antidote
47
Q

corticosteroids

A
  • beta/dexamethasone
    • betamethasone: 6 mg q12H times 4 doses
    • dexamethasone: IM 12 mg, 2 doses 24 hr apart
  • delay birth 24 hr
  • accelerates fetal lung maturity
    • indicated if gestation is b/w 24-34 weeks b/c of high incidence of RDS
  • increase maternal glucose
  • monitor V/S: fever and tachycardia may indicate infection assoc with steroid administration
    • assess lung sounds b/c steroids can cause fluid retention
    • assess for pain and burning on urination (UTI)
48
Q

Nursing Actions to care for early term and late preterm infants

A
  • assess frequently for resp difficulty
  • observe for feeding difficulties
  • monitor frequently for temp instability
  • educate parents
49
Q

post term

A
  • lasts longer than 42 weeks
  • cause of prolonged labor: miscalculation of estimated delivery date b/c woman has irregular periods or miscalculated her LMP
  • complications:
    • placenta aging–>placental insufficiency (dec supply of O2 and nutrients to baby)
      • calcification and abruption can occur
      • may start to notice late decels or dec variability
    • oligohydramnios
      • cord compression can result from reduced fluid
    • passage of meconium–>RDS if aspirated
    • late growth retardation
    • loss of weight
    • large babies are a birthing risk: dysfunctional labor, PPH, shoulder dystocia
50
Q

placental abnormalities

A
  • women w/ placental abnormalities may experience hemorrhage
    • placenta previa (abnormal implantation in lower uterine segment) is sometimes assoc with an abnormally adherent placenta (placenta accreta)
  • strongest risk for placenta accreta is previous uterine surgery
    • may cause intrapartum hemorrhage or hemorrhage immediately after birth b/c the placenta does not separate cleanly, often leaving fragments behind that prevent full contraction
  • placenta increta: placenta penetrates uterine muscle itself
  • placenta percreta: placenta penetrates through entire uterine wall
  • hysterectomy may be required if large portion of placenta is abnormally adherent
51
Q

causes of prolapsed cord

A
  • high station with ROM
  • small fetus
  • breech presentation: esp footling breech
  • transverse lie
  • hydramnios
52
Q

nursing care w/ a prolapsed cord

A
  • priority:
    • to relieve pressure on the cord
    • to inc fetal oxygenation
    • prompt delivery of the fetus
  • get help
  • steps:
    • position woman’s hips heigher than head: knee chest, trendelenberg, hips elevated w/ pillows in side lying position
    • maintain vaginal elevation while woman is transferred to OR: minimize cord compression from the hand that is elevating the presenting part
      • use a gloved hand to push the fetus up and off the cord
    • avoid or minimize manual palpation or handing of cord
      • do not try to replace cord or manipulate cord
    • U/S exam to confirm presence of FHR before C/S
    • while prepping for C/S, give woman 8-10 L/min of O2 by face mask
      • may use a tocolytic to inhibit contractions to inc placental blood flow and reduce pressure on fetus
      • warm, saline moistened towels slow cooling and drying of the cord
53
Q

3 variations of uterine rupture

A
  • complete: direct communication exists b/w uterine and peritoneal cavities
  • incomplete: rupture into peritoneum covering the uterus or into the broad ligament but not the peritoneal cavity
  • dehiscence: partial separation of an old uterine scar
    • little or no bleeding may occur
    • rupture or “window” may be found incidentally in a subsequent C/S or surgery
54
Q

clinical manifestations of uterine rupture

A
  • abdominal pain and tenderness: can be excruciating or it may not be severe if at the peak of contraction
    • feels as if something “ripped”
  • labor progress may stop b/c the open area prevents efficient expulsion of the fetus
  • chest pain, pain b/w scapulae, pain on inspiration
  • hypovolemic shock caused by hemorrhage: tachycardia, tachypnea, hypoTN, pallor, cool/clammy skin
  • rigid abdomen
  • signs of impaired fetal oxygenation: late decels, reduced variability, tachy/bradycardia
  • absent FHR
  • fetus palpated outside the uterus–>fetus likely dead
55
Q

risk factors for uterine rupture

A
  • high parity
  • blunt abdominal trauma
  • intense contractions
  • cephalopelvic disproportion
  • previous uterine surgery or C/S
56
Q

nursing care for uterine rupture

A
  • monitor maternal and fetal V/S
  • administer uterine stimulant drugs cautiously to reduce risk of excessive contractions
  • prepare client for C/S
  • provide emotional support for client and partner
  • treat shock: replace fluids/blood
57
Q

anaphylactoid syndrome

A
  • AKA amniotic fluid embolism
  • occurs when amniotic fluid is drawn into the maternal circulation and carried to the woman’s lungs
    • fetal particulate matter (skin cells, vernix, hair, meconium) obstructs pulmonary vessels
    • abrupt respiratory distress, depressed cardiac function, circulatory collapse, DIC, and usually death result
      • can also cause sepsis, preeclampsia, and cardiac dz
  • more likely if labor is very strong and high intrauterine pressure forces amniotic fluid into open uterine/cervical veins
  • presents like a PE
58
Q

therapeutic mgmt of anaphylactoid syndrome

A
  • CPR and support
  • O2 with mechanical ventilation
  • correction of hypoTN
  • blood component therapy (ie fibrinogen, packed RBCs, platelets, FFP) to correct coagulation defects
59
Q

maternal cardiac arrest

A
  • CPR in pregnancy:
    • left tilt or manual uterine displacement
    • compression placement elevated
    • AED use is the same, but remove fetal monitors
  • perimortem C/S: 4 min after arrest

Women's Health Test IV (5 decks)

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