intrapartum complications Flashcards
PROM
water breaks before onset of labor
prolonged >18hr (want to deliver w/n 18 hours of ROM)
PPROM <37wk
causes: infection, hx, hydraminos, multiple preg, UTI, amniocentesis, placenta previa, abrupto placentae, trauma, incompetent cervix, hx of laser conization or LEEP, bleeding during preg, genital tract anomalies
PROM: fetal risks
RDS (PPROM), sepsis, maplresentation, polapse of umbilical cord, nonrassuring FHR, compression of umbilical cord, premature birth
PROM: nc
duration, gestational age, s/s infection, hydration status, fetal status (NST, BPP), childbirth prep and coping (hospital till birth), rest on L side, comfort, educate, steroids for lungs (betamethazone 12mg IM x2 q12-24 hr)
limit SVE’s!!
PTL or POL
20-36 wk
s/s: c 4/20 min or 8/1hr, dilation or cervical change, mild cramp low abd, constant/intermittent pelvic P, ROM, low-dull backache (c or I), increased discharge
PTL or POL: predictors
fetal fibronectin = + result -> increased risk (glue holding amniotic sac to uterine lining)
cervical length = shortening/thinning, <25 is abn
hx, infection
PTL or POL: meds
tocolytic meds: stop contractions; procardia, MgSO4, terbutaline, progesterone
fetal lung dev meds (corticosteroids): release surfactant; betamethasone, dexamethasone
tocolytic meds: procardia (nifedipine)
10-20mg po q4
monitor BP (dont give <90)
tocolytic meds: MgSO4
hemorrhage and neuroprotective feature, necrotizing enterocolitis
4-6g bolus (20-30 min), 2-4g/hr, monitor alertness, RR, BP reflex, I+O
primary line
Also neuroprotective (for premies)
tocolytic meds: terbutaline (brethine)
0.25 mg SQ (acute use 48-72hr)
heart racing and jittery, tachy, flushed, dont give with HR >120
tocolytic meds: progesterone
to sustain preg
prometrium suppository at hospital (at night)
corticosteroids: betamethasone
12mg IM x2, 12-24hr apart
want to prolong delivery by 48 hr
corticosteroids: dexamethasone
6mg IV q12 hr x4
cervical insufficiency
incompetent cervix
painless dilation without c -> cervical defect
L<25mm before term, previous SAB (miscarriage) without C
cervical insufficiency: treat
meds: serial cervical US, bed rest, progesterone, abx
sx: cerclage (closure of cervix with suture stitching), prophylactic in triplets and quads, monitor for bleed, cut for vaginal or deliver c/s and leave in place
cervical insufficiency: nc
monitor L closely, TVUS 16 and 24 wk
educate: warning s of impending birth, lower back pain, pelvic P, change in discharge, heavy bleeding, light bleed and cramp after cerclage
placenta previa
implants in lower uterine segment, when in c and dilates, placental villi are torn from uterine wall -> bright red painless bleed
causes: higher gravidity, older, prior c/s, recent spont or induced abortion, cigs, male fetus
complete= cover cervix; partial = partial; marginal = near cervix; low lying = close
need c/s for complete and partial
vaginal possible for marginal (high risk) and low lying
placenta previa: nc
no vaginal exams!, assess bleed (transfusion), VS, EFM, toco, anticipate unengaged fetal presenting part, transverse lie common, consent for c/s, admin tocolytics prn (MgSO4, procardia, terbutaline)
abruptio placentae
premature separation of normally implanted placenta from uterine wall
cause largely unknown: htn, violence, abd trauma, fibroids, overdistension (uterine), growth retardation/restriction, male fetus, increased alpha fetoprotein, OH, cigs, cocaine, short umbilical cord, higher parity, higher age
ABD PAIN
FHR = brady and late decels
abruptio placentae: types
marginal = placenta separates at edges
central = separates centrally (concealed bleed)
complete = total separation (massive vaginal bleed)
abruptio placentae: grade
1: 48%, mild separation, slight bleed
2: 27%, partial abruption, mod bleed
3: 24%, complete separation, mod-severe bleed
abruptio placentae: nc
maintain maternal CV status!!!!
EFM and toco, c/o abd pain, abd girth, DIC dev (coag tests), c/s safest
placenta previa s/s
quiet and sneaky onset, external bleed, bright red, anemia and shock = to blood loss, labor pain, no uterine tenderness - soft and relaxed with normal contour, FHT usually present, not engaged, may have abn presentation, no toxemia
apruptio placentae s/s
sudden and stormy onset, external or concealed bleed, dark venous blood, anemia and shock greater than apparent blood loss, may have toxemia, pain is severe and steady, uterine tenderness present - firm to stony hard and contour may enlarge or change chage, FHT present or absent, engagement may be present, no relationship to presentation
multiple gestation: r
preT, uterine dysfunction, abn fetal presentations, instrumental or c/s, PPH, increased mortality, decreased IUG rate, increased fetal anomalies, more cord accidents, increased cerebral palsy
multiple gestation: discomforts
SOB, doe, backache (pelvic rock, good posture and body mechanics), round ligaments pain, heart burn, pelvic or suprapubic P, pedal edema
freq rest (side lying, legs and feet up)
multiple gestation: nc
more freq visits
educate: nutrition (vits, 1mg folic acid/day, 40-45 lb with 24 + by 24 wk), fetal activity, s of preterm labor
serial US
anesthesia and cross matched blood available, continuous dual electronic fetal monitoring, delivery method may change (fetal position), c/s maybe
amniotic fluid complications
600-1000mL (AFI 5-25 cm is normal)
hydraminos: preT, amniocentesis to remove
oligohydraminos: renal and urinary malformations, skin and skeletal abn, pulomary hypoplasia, cord compression
amniotic fluid complications: amniotic fluid embolism
anaphylactoid S
leaks into M circulation via tear in amnion or chorion of uterus during placental separation or cervical tears under P from c, blocks vessel of lungs
rare, high mortality
amniotic fluid complications: amniotic fluid embolism - s/s
chest pain, dyspnea, cyanosis, frothy sputum, tachy, hypoT, hemorrhage
amniotic fluid complications: amniotic fluid embolism - nc
stabilize CV and R system
displace uterus during CPR, infused whole blood, place CVP to monitor for fluid overload, maybe immediate birth
dysfunctional labor pattern
dystocia - abd fetal presentation
hypertonic c: tachysystole, >5c in 10 min (q2 min); assess FHR, c, VS, comfort and support, change position, backrubs, no oxytocin, tocolytic, sedation, pain med
hypotonic c: <2-3 c in 10 min, low intensity; assess FHR, C, VS, consider CPD, rule out malpresentation, maintain adequate hydration, s/s infection, stim uterine C (oxytocin)
post term
> 42 wk, post date = >EDB
assess fetus, daily movement, NDT BPP, induce (monitor fetal response)
post term: M impacts
perineal damage, hemorrhage, increased risk of c/s, anx, emotional fatigue, persistance of normal discomforts
post term: F impacts
decreased perfusion, oligoH, SGA (small), macrosomia, increased risk of meconium stained fluid and meconium aspiration S
malpresentation
shoulder, brow, face, breech (frank, complete, footling)
malposition
persistent OP position, rotate side to side, knee-chest, hands knee, physician or CNM may manually rotate fetal head during labor
malposition/malpresentation: version
turn fetus in utero
ECV = external manipulation of abd to change cephalic
podalic (internal) = deliver 2nd twin, less common; care: c/s consent, US, IV access, terbutaline, if c, fast 8hr before, fetal monitor before, during ,after, reactive NST, prophylactic rhogam if -
nonreassuring fetal status
UNCOIL
variation from normal HR (brady or tachy), decreased FM, meconium stained amniotic fluid, persistent late decels, persistent severe variable decel
umbilical cord prolapse
precedes presenting part and is compressed against maternal pelvis
prevent! bed rest of presenting part high in pelvis and ROM
if cord noted in exam, keep fingers in to relived P
knee chest or trendelenberg -> gravity relives P
o2 10L /tight face mask
prep for c/s
CPD
true = deliver via c/s
maternal R: prolonged labor, increased risk of uterine rupture, forceps assisted or vacuum, c/s
fetal R: increased risk of cord prolapse, excessive molding of fetal head, bruising, nerve trauma
macrosomia
> 4000g
r: dysfunctional labor, uterine rupture, perineal lacerations, PPH, shoulder dystocia
macrosomia nc
identify before labor, eval pelvis, estimate size with US
c/s possible
vaginal: lack of fetal descent (increased suspicion - too large), shoulder dystocia = critical problem, McRoberts or apply suprapubic P to help with back of shoulders, no fundal P
shoulder dystocia
entrapped behind suprapubic bone
danger = brain damage - hypoxia, brachia plexus damage, umbilical cord occulssion
lower HOB, McRoberts (legs up and out), suprapubic P, doc interventions and L of dystocia
3rd and 4th stage complications
retained placenta, lacerations, placental delivery issues
retained placenta
> 30min
excessive bleed, manual removal, transfusion
Increased r/o subinvolution, infection, bleeding
lacerations
spontaneous, bright red blood persist with well contracted uterus
observe for bleed and approximation during PP
placenta issues
abn adherence to uterine wall
hemorrhage and failed placenta separation, increased incidence of abd hysterectomy
rf: placenta previa, previous uterine sx, endometrial defects, age and parity, increased c/s
placenta issues: types
accreta: chorionic villi attache directly to uterine myometrium
increta: myometrium invaded
percreta: myometrium penetrated, attach to nearby organs (bowel/bladder)
placenta issues: nc
monitor for bleed close to delivery, deliver before 38, type and cross blood, abd hysterectomy to prevent hemorrhage, repair organ damage
perinatal loss
denial, anger, bargaining, depression, acceptance
nc: prep for birth and death (counselor, chaplain), support decision, view/hold infant (actualize loss, picture, membox, mementos, baptism, burial), PP care, d/c care, referrals, KODA
I am sorry for your loss, how can I help, listen, acknowledge the baby was special and loved
dont say: you can get preg, have another, for a reason, grateful for what you have, i know how you feel
s of infection
FHR and MHR increase, fever
