high risk L&D Flashcards
incompetent cervix
cervical insufficiency; dilatation of the cervix (prematurely) without pain or contractions
- this can be d/t congenital, acquired, or hormonal problems
what does an incompetent cervix put her at risk for?
- early delivery
- miscarriage
- loss of pregnancy
cerclage
stitch is place in cervix with the goal of maintaining a pregnancy
what are the risks of a cerclage?
- ROM
- stimulation to cervix = put her in labor = some bleeding
nursing considerations for a cerclage
- monitor for s/sx of labor
- monitor for infection
premature ROM (PROM)
- ROM prior to onset of labor
- after 38 weeks
preterm premature ROM (PPROM)
- ROM prior to onset of labor
- before 37 completed weeks
prolonged ROM
ROM for > 24 hours prior to delivery
what are the maternal concerns for a premature ROM?
- infection
- chorioamnionitis (infection of chorion)
- endometritis (infection of lining of uterus)
what are the fetal concerns for a premature ROM?
- preterm delivery (lung development = issue)
- infection
- risk for cord prolapse
- oligohydramnios
how can we assess for fetal infection while in utero?
- assess fluid might be leaking –> foul smelling
- FHR (tachy)
what do we do is ROM is suspected?
nitirizine test
management of PROM/PPROM patient:
- monitor for infection
- monitor for cx
- bed rest (prevent cord prolapse)
- fetal assessment (FHR, quickening)
- corticosteroids (helps mature fetal lungs)
- possible antibiotics
preterm labor
labor after 20 weeks and prior to 38 weeks
fetal fibronectin (FFN)
vaginal swab that tests for presence of fetal fibronectin
what does a negative FFN indicate?
woman will likely not deliver in the next 14 days
what does a positive FFN indicate?
doesn’t tell us much; it could be positive d/t vaginal manipulation (vag exam, sex)
maternal risks of preterm labor
- underlying cause of PTL (bleeding, trauma, infection)
- DVT
- emotional concerns
- S/E from meds used to treat PTL
fetal risks for preterm labor
- mortality
- immature body systems and lungs
if a baby born at ___ weeks (earliest a baby can survive) –> it has a ___% chance of acquiring respiratory distress syndrome and ___% survival rate.
24 weeks; 70%; 40%
management of preterm labor
- pt education
- tocolysis (tocolytic meds used to stop labor)
- ritodrine
- mag sulfate
- CCB
- prostaglandin synthetase inhibitors
what is the typical dosage of magnesium sulfate?
bolus: 4-6 g/20-30 min
maintenance: 2 g/hr
a patient presents with symptoms of visual changes, hot/flushed, and lethargic –> what do we do?
these are the expected symptoms of being on a magnesium drip
keep monitoring the patient
a patient on magnesium seems to have diminished reflexes upon her mag assessment –> what do we do?
we are concerned for mag toxicity, have the antidote on hand
antidote for magnesium sulfate
calcium gluconate
what do calcium channel blockers do in management of preterm labor?
reduce Ca from entering smooth muscle = prevent smooth muscles from contracting
what do prostaglandin inhibitors do in management of preterm labor?
prevent Ca from entering smooth muscles = prevent smooth muscles from contracting
what is a concern in contraction monitoring of management of preterm labor
concern if > 6 contractions/hr
placental abruption
separation of the placenta from the uterine wall
move toward emergent c/s!
how does a placental abruption affect the fetus?
isn’t getting blood, O2 & nutrients that it needs
how does a placental abruption affect the mother?
losing blood or could be hemorrhaging
marginal placental abruption
blood passes b/w fetal membranes and uterine wall and escapes vaginally = vaginal bleeding
central abruption placenta
separates centrally –> bleeding would be entrapped
complete abruption
most concerning!
massive vaginal bleeding, almost total separation –> fetus in tremendous amount of stress d/t not getting any nutrients or O2
how do we expect mom to look in a severe case of a placental abruption?
she will complain of rigid painful abdomen that can be enlarging
placental previa
placenta improperly implants over the lower portion of the uterus and may cover the cervix
indication for c/s
what is mom at risk for with a placental previa?
could be a hemorrhage situation = fetal distress
nursing considerations for placental previa
- no vag exams if bleeding
- draw labs to see extent of blood loss
- pad counts and frequency of which she’s saturating them
previa vs. abruption
previa: bleeding!
abruption: painful! maybe, maybe not bleeding
oligohydramnios
less than normal amount of amniotic fluid
what is the fetus at risk for with olighydramnios?
- practice breathing may be compromised = lung compliance issue
- fluid is cushion for cord so if no cushion = variable decels
polyhydramnios
great amount of amniotic fluid
what does polyhydramnios put the pregnancy at risk for?
- higher % of malpresentation or fetal presentations that are not vertex
- if water breaks –> cord might prolapse = set up for lack of O2 to cord
dystocia
abnormal labor pattern r/t cx, expulsion, fetal size, position, presentation, or size of the pelvis
hypotonic labor patterns
hypotonic cx (lack tone)
- irregular cx
- lack intensity
- < 1 cm dilatation/hr
interventions for hypotonic labor patterns
- pitocin augmentation
- amniotomy (AROM)
- active management of labor
tachysystole labor pattern
uterine hyperstimulation: > 5 cx per 10 min & not effective on dilation and effacement
can be very painful for moms
management of tachysystole labor patterns
- fetal assessment (ensure fetus isn’t stressed)
- pain managment
- pitocin (increases effect of cx)
- amniotomy
precipitous labor and delivery
entire labor and birthing process occurs within 3 hrs (cervix from being closed to delivering baby in 3 hrs)
what can cause a precipitous labor and delivery?
- low resistance of maternal soft tissues
- abnormally strong cx
maternal risks in precipitous labor and delivery
- fear (little time for pain management)
- lacerations
- bleeding
fetal risks in precipitous labor and delivery
- hypoxia & fetal distress
- meconium
- injuries
- low APGAR scores
post dates pregnancy
pregnancy that lasts longer than 42 full weeks, beginning of 43 weeks
risks of post dates pregnancy
- induction
- LGA
- macrosomia
- c/s
- oligohydramnios
- dysmaturity syndrome
dysmaturity syndrome
associated with utero placental insufficiency; resembles IUGR
- may be meconium aspiration
- may be low blood sugar or seizures r/t low blood sugar
- resp. distress
macrosomia
fetal weight of more than 4000g
what can contribute to macrosomia?
- maternal obesity
- diabetes
- post term
- multiparity
maternal/fetal risks of macrosomia
- dysfunctional labor
- > chance of lacerations/episiotomy
- > chance of instrumental delivery
- bleeding
- infection
- shoulder dystocia
what are the risks with a cord prolapse?
lack of blood flow = hypoxemia, bradycardia
interventions of non-reassuring fetal status
- 5 turns
- scalp stimulation
- internal monitors
cord prolapse
umbilical cord falls into the vagina prior to delivery and becomes trapped b/w the pelvis and presenting part, interfering with blood flow
what are the emergent interventions for a cord prolapse?
- relieve cord compression
- knee/chest position
- prepare for c/s
what causes a cord prolapse?
when the presenting part is not well applied
retained placenta
30 minutes or more after delivery, the placenta has not delivered
manual removal or D&C (dilation & curettage surgery)
placenta accreta
placental chorionic villi attach to the myometrium instead of endometrial lining
placenta increta
placenta invades the myometrium
placenta percreta
placenta penetrates the myometrium
external version
manual movement of the fetus from breech or transverse to cephalic presentation
when is an external version done?
done after 36 weeks
criteria for an external version
- must be adequate amniotic fluid and reassuring non-stress test and FHR
- would not be done in high risk situations
cervical ripening
softening and effacing the cervix prior to induction of labor
medications for cervical ripening
- cytotec
- cervidil
mechanical methods for cervical ripening
pressure from balloon on cervix
labor induction
stimulation of cx prior to spontaneous labor
labor augmentation
stimulation of cx in addition to spontaneously occurring cx
bishop score
score of 9 is favorable
- < 9 is associated with long labor and higher c/s rates
membrane stripping
manual separation of amniotic membranes
- thought to release prostaglandins and initiate labor b/w 24-48 hrs following
oxytocin/pitocin infusion
goal is stimulate adequate cx that lead to dilatation
nursing assessment following AROM
- FHR and pattern
- amount
- color or fluid (abnormal: yellow, bloody, or green)
amnioinfusion
administration of warmed sterile fluid into the uterus through an intrauterine pressure catheter
what is the goal of an amnioinfusion
increase fluid volume to decrease umbilical cord compression or dilute meconium
what are the risks associated with using forceps?
trauma to mom
- 3rd-4th degree lacerations
- more perineal pain PP
trauma to fetus
- small bruise/edema
- facial paralysis
- low APGAR score
risks associated with using vacuum extraction
- mom at increased risk for 3rd-4th degree laceration
- fetus can have swelling, bruising to head = skin integrity issues
vaginal birth after cesarean (VBAC)
viable and safe alternative for subsequent delivery if the prior indication is not recurring
how successful are VBACs and what are their risks?
- 60-80% successful (contraindicated in those with previous classical incision or uterine rupture)
- risks: uterine rupture (RARE)
