Intrapartum Complications Flashcards
PROM
premature rupture of membranes
- before onset of labor
PPROM
preterm premature rupture of membranes
- before 37 weeks
fetal new born risks with PROM
- resp distress syndrome (need fluid for lung development)
- fetal sepsis
- malpresentation (need fluid for rotation)
- prolapse of cord
- non reassuring FHR pattern
- compression of umbilical cord (inc variables bc dec cushion)
- premature birth
betamethasone
corticosteroid that enhances fetal lung maturity
preterm labor or premature onset of labor
labor that occurs between 20-36 weeks
s/s of preterm labor
- uterine contractions at least 4 in 20 mins or 8 in 1 hr
- cervical changes (dilation)
- cramps felt in low abdomen
- constant or intermittent feelings of pelvic pressure
- ruptured membranes
- low, dull backache
- inc vaginal discharge
strongest predictors of preterm birth
- fetal fibronectin: +
- cervical length: shortening or thinning (less than 25 mm before birth)
- hx of preterm
- infection
what is fibronectin
what keeps everything like the amniotic sac in the uterus
what are tocolytics
meds that stop contractions
what meds are tocolytics
nifedipine
mag sulfate
terbutaline
progesterone therapy
nifdipine
helps relax uterine muscles
- dont give if SBP under 90
- monitor BP closely
mag sulfate
smooth muscle relaxer
- monitor alertness, RR, BP, reflexes, I&Os
s/s might be lower but should still be present
terbutaline
relaxes muscle contractions
- can cause tachycardia so do not give if over 120
progesterone therapy
helps sustain therapy
- given at night time
- delays birth
what is cervical insufficiency
painless dilation of cervix without contractions cervical defect
- less than 25 mm
- previous miscarriages without contractions
treating cervical insufficiency
- ultrasound to assess
- bed rest
- progesterone
- abx if cerclage (dont need whole pregnancy)
what is cerclage
surgical closure of cervix using sutures
- prophylactic if twins +
- monitor for bleeding
- cut before delivery
diagnosis cervical insufficiency
transvaginal ultrasound 16-24 weeks
warning signs of impending birth
- back pain
- pelvic pressure
- changes in vaginal discharge
- bleeding
placenta previa
placenta implantation in the lower uterine segment
problems with placenta previa during birth
lower uterine segment contracts and dilates
placental villi are torn from uterine wall
bright red, painless bleeding occurs
types of placenta previa
complete
partial
marginal
low lying
nursing care for placenta previa
no vaginal exams
assess for bleeding
VS, fetal status
anticipate unengaged fetal presenting parts
transverse lie is common
consent for c/s
drugs used for placenta previa
mag sulfate
nifedepine
terbutaline
abruption placentae
premature separation of a normally implanted placenta from the uterine wall
types of abruption plancentae
marginal: separates at edges
central: separates centrally
complete: total separation, BLEEDING
grades of abruption placentae
grade 1: mild, slight vaginal bleeding
grade 2: partial, moderate bleeding
grade 3: moderate to severe bleeding
main differences between placenta previa and abruption placentae
abruption: severe and steady plain, tenderness, firm and stony hard, likely enlarges and changes shape
care for abruption placentae
- external fetal monitoring
- monitor for pain
- monitor abdominal growth
- monitor for DIC (coags)
- maintain stable cardio status
- c/s is safest
multiple gestation discomforts
- shortness of breath
- backache
- heart burn
- round ligament pain
- pedal edema
comfort measures for multiple gestation
- frequent rest period
- side lying with lower legs and feet elevated
- relief of back discomfort: pelvic rocking, good posture, good body mechanics
multiple gestation nursing care
- frequent prenatal visits
- prenatal vitamins
- 1 mg folic acid
- 24 wt gain my 24 wks (40-45 lbs gain)
- serial ultrasounds
- c/s likely
normal amniotic fluid
600-1000 ml
hydramnios (poly)
more than 2000 ml
- amniocentesis
oligohydramnios
less than 500 ml
- renal and urinary malformations
- skin and skeletal abnormalities
- pulm hypoplasia (underdeveloped lungs)
- cord compression
amniotic fluid embolism
- anaphylactoid syndrome
amniotic fluid leaks into maternal circulation through a small tear in amniotic sac
- happens during placental separation or contracting
- embolism blocks vessels in the lungs
- rare but 80-90% mortality
amniotic fluid embolism sx
chest pain
dyspnea
cyanosis
frothy sputum
tachycardia
hypotension
massive hemorrhage
amniotic fluid embolism care
stabilize cardio and resp system
CPR –> displace uterus if 20 wk + bc will prevent good blood flow
blood infusion
CVC
maybe immediate birth
dysfunctional labor patterns
hypotonic and hypertonic contractions
hypertonic contractions
more than 5 contractions in 10 mins
hypotonic contractions
2-3 contractions in 10 mins
- low intensity
hypertonic contraction care
- change positions
- turn off oxy
- terbutaline
- sedation, pain meds
hypotonic contraction care
- consider CPD
- rule out malpresentation
- adequate hydration
- s/s of infection
- give oxy
post term pregnancy
beyond estimated date of birth
post term: beyond 42 wks
maternal risk of post term pregnancy
perineal damage
hemorrhage
inc risk of c/s
anxiety
emotional fatigue
persistance of normal discomforts
fetal risks of post term pregnancy
dec perfusion
oligohydramnios
small for gest age
macrosomia
inc risk for meconium stained fluid which inc risk for aspiration
malposition
persistent occiput posterior position
- mother rotates from side to side
- knee to chest position
- hands and knees position
- HCP may manually rotate fetal head
malpresentation
- shoulder presentation
- brow presentation
- face presentation
- breech (frank, complete, footling)
version
turning of the fetus in utero
- external cephalic version: external manipulation of maternal abdomen to change fetus from breech to cephalic
- podalic version: internal, used in delivery of 2nd twin, less common
care during ECV
- consent
- ultrasound
- IV access
- terbutaline
- fasting 8 hrs
- fetal monitoring
- rhogam if in -
non reassuring fetal status
- brady or tachy
- dec fetal movement
- meconium stained amniotic fluid
- persistent late variables
umbilical cord prolapse
umbilical cord precedes presenting fetal part and gets compressed against pelvis
- prevention is key
umbilical cord prolapse nursing care
- keep gloved fingers in vagina to relive pressure
- position for gravity to help relieve pressure
- position in knee to chest or trendelenburg
- oxygen
- prepare for c/s
cephalopelvic disproportion
head is too big to pass through pelvis
- c/s
macrosomia
large fetus (4000+ g)
- risks: dysfunctional labor, uterine rupture, perineal laceration, postpartum hemorrhage, shoulder dystocia
if vaginal delivery for macrosomia baby
- lack of fetal descent should be indicator
- unexpected shoulder dystocia
- McRoberts maneuver or apply suprapubic pressure
- application of fundal pressure contraindicated
shoulder dystocia
shoulder entrapped behind suprapubic bone
dangers of shoulder dystocia
brain damage from hypoxia
brachia plexus damage
umbilical cord compression
interventions for shoulder dystocia
- lower HOB
- McRobert’s maneuver
- suprapubic pressure
- document intervention and length of time
third and fourth stage of labor complication
retained placenta
lacerations
placental adherence (accreta, increta, percreta)
retained placenta
retention of placenta beyond 30 mins after birth
- bleeding can be excessive
- may require manual removal
- possible blood transfusion
lacerations
spontaneous tearing of the perineal area
- bright red vaginal bleeding that persists despite well contracted uterus
- observe bleeding and approximation during postpartum
accreta
chorionic villi attach directly to the uterine myometrium
increta
chorionic villi invade myometrium
percreta
chorionic villi penetrate myometrium, sometimes attaching to nearby organs
placenta adherence
abnormal adherence of placenta to uterine wall
- associated with hemorrhage and failed separation at birth
- high incidence of abdominal hysterectomy
care for placenta adherence
monitor for bleeding
deliver before 38 wks
type and cross
hysterectomy to prevent maternal hemorrhage
general surgeon may be need to repair
