High Risk L&D Flashcards
the majority of preterm deaths occurs in babies less than
32 weeks gestation
prevention of preterm labor
lifestyle changes
progesterone
prenatal care
only effective medication thought to prevent PTL
progesterone
given to women who have hx of PTL/short cervix
how does progesterone work
anti-inflammatory
supplements low progesterone
determining a short cervix
vaginal ultrasound - measures how many cm
vaginal exam
real dx of labor
dilation of the cervix
fetal fibronectin test
protein substance found between the maternal and fetal membranes (amniotic chorion)
vaginal swab test - must be done prior to vaginal exam to prevent false positive
should we treat a mom in preterm labor w/group b strep
yes- treat as if she does
norm test for group b strep 37-38 weeks
treatment for group b strep - preterm
ampicillin or penicillin
infections/fxrs contributing to preterm labor
stds chorio - infected membranes dental problems bladder/kidney infection - always do urinalysis cbc - wbc count pneumonia (systemic infections)
best treatment if mom is in preterm labor
betamethazone (injectable steroid) 12mg IM x2
stimulates baby lungs to produce surfactant
begins to work 24hrs after started - try to hold labor off
another benefit of betamethazone
decreases inner-ventricular hemorrhage
another drug routinely given in preterm labor
mag sulfate - loading dose
uterus cant contract (relax smooth muscle of the uterus) blocks calcium of the neuromuscular junction (wont allow acytlcholine to make jump between neuro and muscles)
while on mag sulfate check pt for
urine output
reflexes
watch fetus for depression (decreased variability/resp. depression)
if mag sulfate doesn’t work to stop preterm labor, what other meds can we try
All are off label medications
terbutaline
nifedipine
indomethicin
terbutaline s/e for mom
tremors tachy arythmias chest pain - may need ekg pulmonary edema esp. w/steroid use
nifedipine - action
anti-hypertensive
calcium channel blocker - like mag sulfate
indomethicin - action
anti prostoglandin
how is terbutaline given
injection - turn off mag sulfate
max amt of time terbutaline, nifedipine, indomethicin is given/used for
48-72 hours; they are too strong; too many adverse affects
gold standard med for preterm labor
mag sulfate
nifedipine s/e
BP - easy Hypertension
indomethicin s/e for fetus
can constrict the ductus arteriosis - they need that open while a fetus
cannot be given after 32 weeks - early preterm labor
what happens physiologically if you are on bed-rest
muscle atrophy
risk fxr for preterm labor
age
stressful job
poor nutrition
reduce/stop smoking
why would we want to induce labor
pre-eclampsia diabetes infection (chorionamnioitis) post term preg PROM (after 24 hours infection can start) fetal death
classification of post term pregnancy
42 weeks
who shouldn’t be induced
placenta previa
transverse lie
cord prolapse
herpes infection
a lot of times inductions lead to what
c-sections - as many as 2/3 of patients
determining readiness for induction
bishop score based on 13
what does the bishop score look at (5 things)
dilation effacement station cervical consistency cervical position
a bishop score of 8 or more
most likely succeed w/induction w/vaginal delivery
a bishop score of 6 or less
cervical ripening required prior to starting pitocin
which medication is used for induction
pitocin
what is cervical ripening
softening/thinning of cervix
medications used for cervical ripening
cytotec - prostoglanding agent (off label (gastric ulcers))
prepodil
mechanical means for cervical ripening
mechanical dilators
Cooks catheter w/balloon - irritates cervix to produce own prostoglandin & ripen cervix for dilation
can take pt to 5cm
why is cervical ripening done
low bishop score
firm, uneffaced, undialated cervix
how is cytotec given
a 100mg tablet broken into 4 pcs(25mg each) put into vagina next to cervix
causes cramping/contractions
may put pt into labor
very strong
how is prepodil given
gel inserted w/syringe(tube) onto cervix
works in the same way as cytotec, not as strong
mechanical means for inducing labor
Sweeping membranes - separates sac from wall of cervix - releases prostoglandins
Amniotomy - ruptured membranes - always check fetal hearts
if pressure on the cord what will we see on fetal monitoring
bradychardia
variables
what is labor augmentation
stimulation of labor after it begins, due to slowing/stopping
methods to initiate labor augmentations
amniotomy - rupture membranes
nipple stimulation - every 2-3 min
oxytocin
nurs considerations for induction/augmentation
uterine tachysystole - contractions more than 5-10 min; contracting every 1-2 minutes lasting a min
nurs mgmt for uterine tachysystole
reduce/discontinue pitocin (esp non-reassuring FHR) iv fluid bolus turn mom on left side 8-10 L of oxygen terbutaline (given for preterm labor)
dysfunctional labors are
long, difficult, abnormal labor
dysfunctional labor classifications
powers - dysfunctional labor pattern (contractions not strong/long enough)
passage - small pelvic diameters, full bladder (baby can’t come down)
passenger - unusually lg baby (maternal diabetes), Mal-presentation, multi-fetal (twins, multiples)
dysfunctional labor patterns
hypo-tonic (subnormal frequency)
hypo-tonic (subnormal intensity)
hypertonic
tachysystole
norm contraction pattern classification
contractions 2-3 min lasting 60 sec.
pressure 75mmHg
hypo-tonic (subnormal intensity) classification
hypo-tonic (subnormal frequency) classification
contractions not measuring much
hyptertonic classification
Latent phase
uncoordinated contractions
give morphine-give her rest-wake up in nice labor pattern
tachysystole classification
contractions too close together
uterus is over stimulated
stop pitocin
in extreme cases will give terbutaline
never give morphine in active labor t or f
true
operative delivery consists of
Forceps
Vacuum extraction - can damage blood vessels in babies head; can get a hemorrhage
shortens 2nd stage
can be used w/moms who have cardiac problems
can cause trauma after delivery
operative delivery methods nurs mgmt
membranes must be ruptured prior to implementing
MUST HAVE EMPTY BLADDER
protocol for vacuum extraction
do not allow more than 3 pop offs
c-section (operative delivery) indications
non-reassuring strip (baby looking acidotic)
CPD - cephalo pelvic disproportion
active herpes infection
type of c-section incisions
classical - vertical incision (skin/uterus)
pfannestial (bikini) horizontal incision (skin) w/low vertical uterine incision
pfannestial (bikini) horizontal incision (skin) w/low transverse (horizontal) uterine incision
majority of c-sections today
pfannestial with horizontal through the uterus
which incisions are likely to open up if a women goes into labor after a c-section
vertical uterine incisions
important nursing consideration post c-section
parent/baby bonding
VBAC candidacy
2 or less previous low transverse c-sections w/no other uterine scars
risk of VBAC
uterine rupture
what happens in uterine rupture
fetus comes out of uterus and goes into abdomen
placenta detaches
mom hemorrhages
what is shoulder dystocia
shoulder gets stuck behind moms pubic bone
shoulder dystocia risk to fetus
asphyxia - emergency
injured/broken clavicle
palsy (may never fully heal)
shoulder dystocia risk to mom
increased vaginal bleeding
2 signs of shoulder dystocia
double chin - sucked back in
turtle sign - head coming in/out
nursing interventions for shoulder dystocia
push moms feet as far back as possible to open outlet
place fist above pubic bone, push down to “unlock” shoulder
what is a prolapsed cord
cord slips through presenting part and the cervix
babies head comes down and blocks it
sometimes it hidden; sometimes its evident
treatment priority for prolapsed cord
position change (all fours)
relieve pressure on the cord
manually hold head off cord
stat c-section
what is uterine inversion
the uterus turns inside out
risk of uterine inversion
maternal hemorrhage - must give a lot of blood products
trt for uterine inversion
manually replace the inverted uterus
what is anaphylactoid syndrome of pregnancy
amniotic fluid gets into maternal blood stream
anaphylactoid syndrome of pregnancy can cause
severe respiratory distress
pulmonary collapse
rt/lt sided HF
clotting/hemorrhage
