Intrapartum Flashcards
Precipitous Delivery
Rapid intense contractions
Labor less than 3 hrs
Dystocia
Long, difficult, or abnormal labor
As a result of
Powers
Passenger
Passageway
Dysfunctional Labor Pattern
Hypertonic
Hypertonic
Strong, painful, ineffective contractions
Contributing factor: maternal anxiety
Occiput-posterior malposition of fetus
Dysfunctional Labor Pattern
Hypotonic
Hypotonic
Contractions decrease in frequency, intensity
Maternal and fetal factors that produce excessive uterine stretching
Structural Dystocia (4)
Shoulder Dystocia McRoberts Maneuver
Cephalo-Pelvic Disproportion (CPD)
Fetal Anomalies
IDM or LGA
Uterus Complications
Uterine inversion – uterus follows the placenta out
Surgical repair
Uterine rupture - complete separation vs. small tear
Obstetric emergency
Sharp referred pain -> between scapula
Increased risk during VBAC = vaginal birth after C-section
Umbilical Cord
Umbilical cord complications
Nuchal cord
“loose vs. tight” “knots”
“how many loops”
Umbilical cord prolapse
Obstetric emergency
-> c/s
Placenta Complications
5
Placenta irregularities:
Implantation
Circumvellate,Succenturiate
Adherence
Accreta, Increta, Percreta
Insertion of cord
Battledore, Velamentous
Infarcts
Substances – cocaine
Insufficiency
Smoking
Amniotic Fluid Complications (5)
Oligohydramnios -> less amniotic fluid, amniofusion, kidney problems of baby not urinating
Polyhydramnios –> too much amniotic fluid, tracheoesophageal atresia
Amniotic Fluid Emboli –> amniotic fluid and fetal tissue in moms blood supply, fast death
Meconium –> Meconium-stained; seizure, stress on baby
Pea soup – thick and under a lot of stress –> aspiration and pneumonia
Infection – Chorioamnionitis
Intrapartal Infections
Chorioamnionitis “chorio”
7 symptoms
Maternal fever (100.4 F)
Plus WBC > 15,000 Maternal tachycardia (> 100 bpm) Fetal tachycardia (> 160 bpm) Foul or strong-smelling amniotic fluid Cloudy or yellow amniotic fluid Tender uterus
Tocolytics are contraindicated in the presence of symptomatic Amniotic Fluid Infection.
Perineal Trauma (8)
Lacerations
1st degree to 4th degree
Birth weight > 4 kg Persistent occipitoposterior position Nulliparity Induction of labor Epidural analgesia Prolonged second stage > 1 hr Midline episiotomy Forceps delivery
Intrapartum Assessment
Maternal and fetal well-being
Analyze labor status
Monitor for symptoms of complications
Facilitate progression of labor
Ensure safety of patient and fetus/newborn
Fetal Assessment
Changes in Fetal HR
Tachycardia (9)
Bradycardia (8)
Changes in Fetal Heart Rate
Tachycardia > 160 bpm maternal fever or infection maternal dehydration maternal anemia maternal anxiety maternal medications or illicit drugs prolonged fetal stimulation compensatory response to transient fetal hypoxemia chorioamnionitis fetal anemia
Bradycardia maternal supine positioning mom hypotension mom meds/illicit drugs mom hypothermia mom hypoglycemia umbilical cord prolapse decompensating fetus prolonged PSNS
Fetal Assessment
–> C-Section HR STATS
Fetal heart rate
Baseline FHR
Tachycardia
> 160 bpm x 10 mins
Bradycardia
Interpret FHR, EFM Tracing
What are you looking for
Contractions
Frequency and Intensity
FHR Pattern
Reassuring
Non-reassuring
EFM Assessment
Baseline FHR Presence of... Variability Accelerations Decelerations Early Variable Late
Acceleration
Abrupt increase in HR from baseline
Can occur at any time during labor
Reassuring sign of fetal well being
Variable deceleration
Abrupt decrease in HR from baseline
Onset varies with contractions
Extremely common, present in 83% of labors
Late Decelerations
Gradual, symmetrical, decrease in HR
HR returns to baseline after contraction ends
Onset occurs at peak of contraction
May indicate fetal distress if repetitive or severe
Early vs. Late Decelerations
And Variable
Early decelerations caused by head compression
Late decelerations caused by uteroplacental Insufficiency
Variable decelerations caused by cord compression
VEAL CHOP
variable - cord
early - head
acceleration - ok
late - placenta
Nursing Interventions
FHR decelerations
Early vs. variable and late (6)
Early: no action
Variable and Late Discontinue oxytocin Lateral position change Increase IVF rate Oxygen per face mask Palpate for hyperstimulation Notify HCP
Obstetric interventions (4) for labor
Induction of Labor
Labor is started artificially
Labor Augmentation
Assisting labor which has started spontaneously but is ineffective
Instrument Assisted Labor
Vacuum Extraction
Forceps
Cesarean Section
Post term pregnancy
Time
Management
Post-term—extends beyond 42 wks
Risk for fetal/neonatal problems
Increased maternal risk
Management—labor induction
Indications for induction (6)
Post term pregnancy
Premature Rupture of Membranes (PROM)
Chorioamnionitis
HTN: Chronic, Gestational, or Preeclampsia (mild)
Maternal co-morbidities
Diabetes
Cardiac or Respiratory
Psychosocial (including hx precipitous or rapid labor & distance to hospital )
Fetal compromise Intrauterine growth restriction (IUGR) Oligohydramnios Isoimmunization Fetal demise
Induction and the Cervix
Mechanical vs. Medication
Mechanical
Amniotomy = AROM
Membrane Stripping
Medication Cervical Ripening dinoprostone insert or gel misoprostol (off-label) laminaria Synthetic Oxytocin IV
Augmentation of Labor
Mechanical
Medication
Prolonged labor
“failure to progress”
Mechanical
AROM
Membrane Stripping
Medication
Synthetic Oxytocin IV
Indications for Vacuum extraction
Maternal fatigue, ineffective pushing, vacuum
C-Section STAT Indications (5)
Fetal distress (prolonged deceleration without recovery) Umbilical cord prolapse Placenta Abruptio Uterine rupture Hemorrhage
C-Section Scheduled (6)
Scheduled Repeat Multiples Infection: HIV, active herpes lesions Previous 4th degree perineal laceration
Scheduled during last weeks
Placenta previa
Presentation: breech, transverse
C-Section Not emergent (5)
Not emergent
Failure to progress – prolonged labor
Failed labor induction
Macrosomia / CPD
Complications:
Preeclampsia and HELLP
Preterm labor (if progressing and 22-28 wks)
Surgical Procedure
Major Risks
Respiratory Depression
Anesthetic gases or medications (epi/spinal)
Maternal or Newborn respiratory depression
Infection -> Pre-operative prevention
Surgical Care Improvement Project Measure
General Anesthesia for C/S
Though an increased risk for post-op complications
Respiratory
Preferred if
Platelet count is less than 100,000
Epidural/spinal is not effective
“STAT” emergency section for fetal or maternal distress
Perinatal Fetal Loss
Communication and care techniques Actualize the loss Provide time to grieve Interpret normal feelings Allow for individual differences Cultural and spiritual needs of parents Physical comfort
High Risk Newborns
Birth weight
Birth Weight
Low birth weight (LBW) 2500
Very low 1500
Extremely low 1000
High Risk newborns
IUGR
SGA
Intrauterine Growth Restriction
Lack of intrauterine fetal growth may also be SGA
Small for Gestational Age
Infants born at any gestational age, birth weight is below the 10th percentile on the growth charts
High Risk Newborns
Risk Factors
Physiology
Risk Factors
Intrauterine development
Intrapartum processes
Extrauterine adaptation
Physiology
Lung immaturity
Circulatory immaturity
Neurological immaturity
Lung Immaturity
Lower airway characteristics
(3)
At 24-28 wks gestation, surfactant begins to line the alveoli
Inhibits alveolar collapse at end of expiration
Increases area available for gas exchange
Premature newborn
Severe vs. Moderate
Severe prematurity
22 to 26 weeks
Moderate prematurity
26 to 30 weeks
Apnea of Prematurity
Treatment
Apnea – not breathing >15 to 20 secs accompanied by pallor, hypotonia, cyanosis, and bradycardia
Apnea
Periodic breathing
Central apnea
Reflux
Caffiene
Apnea Monitor
CPR training for parents and caregivers before D/C
Respiratory Distress Syndrome
Premature newborn –>
Underdeveloped alveoli, lack of surfactant
Atelectasis, congestion, edema in lung spaces
GFR = grunting, flaring, retractions
Preterm Newborn Challenges
Hypoglycemia
Hypothermia
Hyperbilirubinemia
Transient tacypnea of the newborn
Fetal lung fluid not fully absorbed
Meconium aspiration syndrome
Meconium-stained amniotic fluid
Light
Moderate
Pea Soup
-> Suctioning before first breath to prevent aspiration pneumonia
Post term newborn
Newborns remain in utero after the optimal growth
Skin is parchment-like
Fingers are long and peeling
Muscle wasting is present
Infections of Newborn Bacterial --4 Fungal -- 1 TORCH -- 3 \_\_\_\_\_\_\_
Bacterial infections Group B strep Escherichia coli Tuberculosis Chlamydia
Fungal infections
Candida
TORCH
Cytomegalovirus
Toxoplasmosis
Herpes
HIV
Symptoms of Sepsis
Temperature Instability Feeding Poor suck Feeding intolerance Hypoglycemia Respiratory - “GFR” Hypotonia
GFR
