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intrapartum complications Flashcards

1
Q

PROM

A

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

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2
Q

PROM: fetal risks

A

RDS (PPROM), sepsis, maplresentation, polapse of umbilical cord, nonrassuring FHR, compression of umbilical cord, premature birth

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3
Q

PROM: nc

A

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!!

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4
Q

PTL or POL

A

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

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5
Q

PTL or POL: predictors

A

fetal fibronectin = + result -> increased risk (glue holding amniotic sac to uterine lining)
cervical length = shortening/thinning, <25 is abn
hx, infection

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6
Q

PTL or POL: meds

A

tocolytic meds: stop contractions; procardia, MgSO4, terbutaline, progesterone
fetal lung dev meds (corticosteroids): release surfactant; betamethasone, dexamethasone

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7
Q

tocolytic meds: procardia (nifedipine)

A

10-20mg po q4
monitor BP (dont give <90)

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8
Q

tocolytic meds: MgSO4

A

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)

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9
Q

tocolytic meds: terbutaline (brethine)

A

0.25 mg SQ (acute use 48-72hr)
heart racing and jittery, tachy, flushed, dont give with HR >120

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10
Q

tocolytic meds: progesterone

A

to sustain preg
prometrium suppository at hospital (at night)

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11
Q

corticosteroids: betamethasone

A

12mg IM x2, 12-24hr apart
want to prolong delivery by 48 hr

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12
Q

corticosteroids: dexamethasone

A

6mg IV q12 hr x4

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13
Q

cervical insufficiency

A

incompetent cervix
painless dilation without c -> cervical defect
L<25mm before term, previous SAB (miscarriage) without C

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14
Q

cervical insufficiency: treat

A

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

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15
Q

cervical insufficiency: nc

A

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

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16
Q

placenta previa

A

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

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17
Q

placenta previa: nc

A

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)

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18
Q

abruptio placentae

A

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

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19
Q

abruptio placentae: types

A

marginal = placenta separates at edges
central = separates centrally (concealed bleed)
complete = total separation (massive vaginal bleed)

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20
Q

abruptio placentae: grade

A

1: 48%, mild separation, slight bleed
2: 27%, partial abruption, mod bleed
3: 24%, complete separation, mod-severe bleed

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21
Q

abruptio placentae: nc

A

maintain maternal CV status!!!!
EFM and toco, c/o abd pain, abd girth, DIC dev (coag tests), c/s safest

22
Q

placenta previa s/s

A

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

23
Q

apruptio placentae s/s

A

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

24
Q

multiple gestation: r

A

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

25
Q

multiple gestation: discomforts

A

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)

26
Q

multiple gestation: nc

A

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

27
Q

amniotic fluid complications

A

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

28
Q

amniotic fluid complications: amniotic fluid embolism

A

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

29
Q

amniotic fluid complications: amniotic fluid embolism - s/s

A

chest pain, dyspnea, cyanosis, frothy sputum, tachy, hypoT, hemorrhage

30
Q

amniotic fluid complications: amniotic fluid embolism - nc

A

stabilize CV and R system
displace uterus during CPR, infused whole blood, place CVP to monitor for fluid overload, maybe immediate birth

31
Q

dysfunctional labor pattern

A

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)

32
Q

post term

A

> 42 wk, post date = >EDB
assess fetus, daily movement, NDT BPP, induce (monitor fetal response)

33
Q

post term: M impacts

A

perineal damage, hemorrhage, increased risk of c/s, anx, emotional fatigue, persistance of normal discomforts

34
Q

post term: F impacts

A

decreased perfusion, oligoH, SGA (small), macrosomia, increased risk of meconium stained fluid and meconium aspiration S

35
Q

malpresentation

A

shoulder, brow, face, breech (frank, complete, footling)

36
Q

malposition

A

persistent OP position, rotate side to side, knee-chest, hands knee, physician or CNM may manually rotate fetal head during labor

37
Q

malposition/malpresentation: version

A

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 -

38
Q

nonreassuring fetal status

A

UNCOIL
variation from normal HR (brady or tachy), decreased FM, meconium stained amniotic fluid, persistent late decels, persistent severe variable decel

39
Q

umbilical cord prolapse

A

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

40
Q

CPD

A

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

41
Q

macrosomia

A

> 4000g
r: dysfunctional labor, uterine rupture, perineal lacerations, PPH, shoulder dystocia

42
Q

macrosomia nc

A

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

43
Q

shoulder dystocia

A

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

44
Q

3rd and 4th stage complications

A

retained placenta, lacerations, placental delivery issues

45
Q

retained placenta

A

> 30min
excessive bleed, manual removal, transfusion
Increased r/o subinvolution, infection, bleeding

46
Q

lacerations

A

spontaneous, bright red blood persist with well contracted uterus
observe for bleed and approximation during PP

47
Q

placenta issues

A

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

48
Q

placenta issues: types

A

accreta: chorionic villi attache directly to uterine myometrium
increta: myometrium invaded
percreta: myometrium penetrated, attach to nearby organs (bowel/bladder)

49
Q

placenta issues: nc

A

monitor for bleed close to delivery, deliver before 38, type and cross blood, abd hysterectomy to prevent hemorrhage, repair organ damage

50
Q

perinatal loss

A

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

51
Q

s of infection

A

FHR and MHR increase, fever

ob - 332 (15 decks)

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