Chapter 27: Intrapartum Complications Flashcards
Macrosomia is defined as
A fetal weight >8lbs 13 oz (4000 g) - 9lb 15 oz (4500 g)**
What are risks associated with macrosomia?
- Distention of uterus by large fetus reduces strength of contractions both during and after birth**
- Baby head/shoulder won’t fit -> shoulder dystocia.
- Most likely to get c/s
- Low blood sugar in baby (if mother has DM)
What can be done to help baby come out when the baby’s head/shoulder won’t fit?
- McRobert’s Maneuver
- If the first option doesn’t work, try SUPRAPUBIC PRESSURE to try to get baby out. (Fundal pressure is avoided)
- If that option doesn’t work, doctor can break clavicle -> need to get baby out ASAP.
McRobert’s Maneuver
Pull leg back to make room in pelvis to help baby come out
What are maternal complications associated with macrosomia?
- Tearing
- Hemorrhage
- Trauma down to fourth degree
- Hematomas
- Long labor
What are newborn complications associated with macrosomia?
- Head or shoulders may not be able to adapt to pelvis if they are too large (cephalopelvic disproportion)
- Bruising -> jaundice
- Broken clavicle**
Assessment for a baby with a broken clavicle
-Check for crepitus, deformity, Nursing that suggests fracture
What are risk factors for macrosomia?
- Diabetes
- Big baby or small pelvis
- Previous history of big babies
Abnormal Fetal Positioning
- May interfere with cervical dilation or fetal descent
- Presence of fetus in occiput posterior or occipital transverse can contribute to dysfunctional labor.
What is the most common fetal malposition?
Occiput posterior
What are maternal risks associated with abnormal fetal positioning?
- Labor is longer and uncomfortable when fetus remains in OT/OP position.
- Intense back or leg pain that may be poorly relieved with analgesia (makes coping with labor difficult)
- “Back labor”
- 4th degree lacerations; instrumentation
- C/S
Back Labor
- Aptly describes sensation when fetus is in the OP position. Continue to feel more pain in back or focus postpartum.
- Natural is more painful
What can be done to help discomfort in back labor?
Push up against their coccyx area to help their discomfort.
What is the nursing plan of care for abnormal fetal positioning?
- Maternal position changes
- Forceps or vaccum assist
- C/S may be needed if neither methods work.
Maternal position changes to assist in movement of the fetus into a more favorable position
- Hands and knees: rocking the pelvis back and forth while on hands and knees promotes rotation. Knees should be slightly behind hips in this position.
- Side-lying: on the opposite side of the fetal occiput
- Lunges
- Squatting or sitting on a slightly under inflated birth ball
- Sitting, kneeling or standing while leaning forward.
- Use of a birthing ball
Spontaneous Rupture or Membrane
Begins before onset of true labor.
>= 37 weeks
Preterm PROM
Rupture of membranes before term <37 weeks with or without contractions
What are causes of premature rupture of membranes?
- Chorioamnionitis
- Infection (asymptomatic possibly): GBS sometimes associated**
- Amniotic sac with a weak structure
- Previous preterm birth, esp. if preceded by PPROM
- Fetal abnormalities or malpresentation
- Incomplete cervix or short cervical length (<25 mm)
- Overdistention of uterus
- Maternal hormonal changes
- Recent sexual intercourse
- Maternal stress or low socioeconomic status
- Maternal nutritional deficiencies
- Periodontal disease which can affect all organs
- Multifetal pregnancy
- Frequent performances of digital examination of cervix.
What are the types of PROM?
- Spontaneous Rupture of Membranes
- Preterm Premature Rupture of Membranes
Nursing assessment for patient’s with PROM
- Maternal/fetal V/S changes, especially FHR
- Signs of infection: could odor, color of fluid (turning yellowish)
- BPP
- Whole CBC
- Fetal lung maturity
Nursing interventions for care of patients with PROM
- Good pericare
- If ruptured, make sure she stays clean and dry
- Preterm patient can stay for awhile with premature rupture - up to a couple weeks**
- Medications
- Hydrate! (Increased fluid to fetus)
Pharmacological management of PROM
- Check for more?
- Bethametasone or selestone (24 hours apart, up to 72 hours for them to work)
What are maternal risks associated with PROM?
- Postpartum infection
- Chorioamnionitis: maternal fever, uterine tenderness
- Oligohydramnios if continued leaking.
- Umbilical cord compression
- Reduced lung volume
- Deformities d/t cord compression, even worse if 23 weeks.
Fetal-newborn risks associated with PROM
- Infection
- Neonatal sepsis
- Repository distress syndrome
- Greatest risk for hazards of prematurity before 34 weeks of gestation, esp if no steroids.
When does the risk for chorioamnionitis increase after rupture?
- Increases after 24 hours of rupture.
- More likely to precede preterm birth in infant born before 34 weeks.
What should the nurse teach the patient who has PROM?
- Teach mom to avoid sexual intercourse, orgasm, or insertion in vagina cause of increased risk for infection caused by ascending organisms. (Can stimulate contractions)
- Avoid breast stimulation if gestation is preterm because it may cause release of oxytocin from posterior pituitary gland and thus stimulates contractions.
Nursing Implications when caring for mothers with PROM
- Take temperature at least 4 times a day. Report anything higher than 100 (37.8 C)**
- Maintain any activity restrictions
- Note and report uterine contractions or any foul odor to vaginal drainage.
What is the first step to interventions for mothers with PROM?
Determine true membrane rupture.
- Urinary Incontinence
- Vaginal discharge
- Loss of mucous plug
What should the nurse avoid in a mother with PROM if no evidence of labor exists and preterm?
-Avoid digital vaginal examination
Nursing Interventions for PROM: Maternal
- pH swab or fern test done on fluid to verify that it is amniotic fluid.
- Transvaginal ultrasound examination performed to measure cervical length
- Induction of labor if other factors are favorable.
- ABT given during labor
- GBS drugs
Short cervix (<25 mm) is more likely to
Continue effacement and dilation even if gestation is far from term.
Labor induction in woman with PROM
- Delayed for 24 hours if not given antibiotics (GBS) and allow cervical softening
- Consider gestational age, amount of amniotic fluid remaining, fetal lung maturity and any signs of fetal compromise.
Cerclage**
To prevent premature cervical dilation.
*look up more info??
PROM: ABT given during labor
- Can delay the onset of labor and allowing fetus to mature.
- Ampicillin, amoxicillin and erythromycin.
What fetal heart patterns can you expect in a baby with PROM?
Variable decelerations
Desired outcomes in mothers with PROM
- Absence of infection
- Get her as close to term as possible (w/ steroids and antibiotics)
When does preterm labor begin?
Begins after the 20th week but before the end of 36.6th week of pregnancy.
Preterm labor can increase the risk for
- Increased risk for ill equipped infant if <32 weeks gestation.
- Can result in cerebral palsy, developmental delay, vision/hearing impairment
Preterm Labor
Not sure what these numbers represent but look it up.
4x in 20 min or 8 in an hour; concern if she is dilating (IT IS ABNORMAL)
Risk factor for Preterm Labor include
- History of previous preterm infant**
- Dehydration**
- Overdistention of uterus (i.e multifetal pregnancy, hydramnios, macrosomia)**
- Infection**
- Use of assisted reproductive technology -> c/s, prematurity, infant disability/death.
- Over half do not show known risk.
- Maternal medical conditions (UTI, reproductive organs, systemic organs; dental disorder like periodontal disease, preexisting or GDM, connective tissue disorder, chronic HTN, drug abuse.
- Conception with assisted reproductive technology
- Present/past OB conditions such as short cervical length.
- Fetal conditions such as growth retardation, inadequate amniotic fluid volume and chromosomal abnormalities.
- Social/environmental factors (maternal smoking, etc.)
- Demographics (race, age of parents, etc.)
Why is dehydration a risk factor for preterm labor?
Stimulates posterior pituitary gland -> releases oxytocin -> preterm contractions
When does a mother with preterm labor show characteristics of typical term labor?
Only when labor reaches the active phase