Intrappartum Care Flashcards
goals of L&D
safe birth happy experience for all involved comfortable manage complications if arise support family interaction & bonding
triage for labor
time of onset of contractions, frequency, bleeding, ROM (rupture of membrane)
med/OB hx, pregnancy complications, allergies, meds. last PO intake
GBS status
VS, UA
GBS
group B streptococcus
usually found in genitourinary tract
70% rate of vertical transmission to fetus once membranes rupture
MCC of neonatal sepsis?
GBS
babies have respiratory sx’s that resemble RDS
risk factors for neonatal transmission of GBS
premature delivery
prolonged ROM
maternal fever in labor
multiple gestation
most of the time, women with GBS are ____________
asymptomatic
although some may have GBS induced UTIs
when do you want to check women for GBS?
35-37 weeks w/ vaginal & rectal swab
prophylactic Abx in labor for GBS- use what?
PCN 5 mil units IV loading dose then 2.5 mil units q 4 hrs until delivery
monitoring L&D
contraction frequency
strength by palpation
fetal heart rate by EFM or intermittent doppler
confirm status of membranes, dilatation, effacement & station
EFW (est. fetal wt)
PPROM
antenatally/preterm (preterm premature rupture of membranes)
PROM
at term but before the onset of labor
SROM
spontaneously at onset of or during labor
AROM
amniotomy or artificial rupture of membranes via practitioner
check amniotic fluid for
color
odor
presence of blood
meconium staining
term/ postterm fetus are developmentalyy able to move their bowels & may do so spontaneously causing meconium stained fluid
stressed/hypoxic baby will also pass meconium
occurs about 20%
mgnt of meconium if light
epectant mgnt
mgnt of thick/dark meconium
notify peds
most likely suction nares & mouth immediately after delivery of the head before the delivery of the body
will prepare for possible intubation immediately after deliver to visualize below the vocal cords for meconium aspiration
meconium aspiration syndrome
mechanical obstruction & chemical pneumonitis leading to serious pulmonary HTN
frequently fatal
may suffer long term neuro defects
L&D fetal monitoring should occur when?
q 15-30 min in active labor
q 5-10 min during second stage (usually by RN per protocol)
UCs are usually noted as above
pts on pit (pitosun)
VBAC (vaginal birth after c-section) need continuous EFM (electronic fetal monitoring) & toco
EFM
monitors fetal well being
tolerance of labor
occurrence of uterine contractions
what is a primary indicator of fetal well being per neurologic status & normal cardiac response?
EFM
Accels in EFM
a reassuring indicator of fetal well-being
nml response to fetal mvnt
Decels in EFM
periodic FHR changes associated w/ UCs
periodic decels
can be in response to contraction
variable decels
jagged looking
can be variable in what they mean
often caused by compression on umbilical cord d/t baby moving & getting tangled up
-over time if we keep seeing variable decels, it may become stressful to baby, b/c baby is holding its breath during these
another reason- oligohydramnios
blunted (early) decels
mirror contraction
usually in response to compression on babies head, causing a vagal response
generally represents progress & doesn’t stress baby out
late decels
most problematic
uterine placental perfusion deficiency?
-fluid boluses, lie on left side
to relieve variable decels
move mom
increase perfusion to placenta via fluid bolus to mom
give mom extra O2
things that can affect how labor progresses
mom’s health
mom’s energy
babies position, size
internal fetal monitor
attached to head of baby
tiny wire that screws into babies scalp
fetal surveillance during pregnancy
PMH FH genetic hx psychosocial hx fetal movement (FM) awareness FHR uterine growth palpable movement
measurement of term fetus
utilized in cases of preterm labor, PROM, severe maternal or fetal dz requiring delivery
GA presumed to be term at 37 wks
wt presume to be >2500g
amniotic fluid analysis
thru amniocentesis or vaginal collection if ruptured
analyzed lecithin:sphingomyelin (L:S) ratio- should be 2:1 if mature
phosphatidyglycol (PTG) presence signifies mature
fetal surveillance via sonograms
confirm GA
# of fetuses
placental location
r/o anomalies- nuchal translucency, anatomic scan
check growth & position
check amniotic fluid levels (amniotic fluid index-AFI)
doppler velocimetry
vibroacoustic stimulation (VAS)
uses artificial larynx held at belly to startle baby into activity thru sound & vibration
should ellicit accels
can also be used intrapartum if fetus has little FHR variability to determine sleeping baby vs hypoxic
NST (nonstress test)
most commonly used 3rd trimester to measure fetal well being
neurologically intact, oxygenated fetus will have >/= 2 15 bpm each lasting >/= 15 secs accelerations above baseline in 20 min of monitoring
NST findings
reactive- meets/exceeds criteria
nonreactive- nonreassuring finding
nonreactive or inconlusive usually requires f/u w/ BPP or contraction stress test (CST)
what is the most accurate predictors of uteroplacental insufficiency
contraction stress test (CST)
CST
more expensive, takes more time, high false positives
can be used from 26 wks on
used to f/u nonreactive NST
can cause labor
what do you use during a CST to create contractions?
oxytocin (pitocin) or nipple stimulation
CST grading
criteria: 3 UCs/10min, felt or not felt
negative (good): FHR stable, no late decels
positive (bad): repetitive late decels w/ each UC
equivocal: unable to obtain satisfactory tracy
hyperstimulation (UCs q <2min)
nonrepetive late decels
few false negatives, many false positives
BPP (biophysical profile)
combined w/ electronic fetal monitoring nonstress test (NST)
fully oxygenated fetus that is neurologically intact will demonstrate what during BPP (monitored w/ sonogram)
muscle tone gross mvnt respiratory activity and will have: an adequate AFI A reactive NST
looking at placenta w/ BPP
placental grade 0-3
depends upon smoothness of chorionic plate, echogenic densities, and echospared fallout areas
Rh isoimmunization
infrequently seen today w/ advent of Rh immune globulin (Rhogam) antenatally & postpartum
red cells of the fetus or newborn are destroyed by maternally-derived alloantibodies
when an Rh negative mother carries an Rh+ fetus
complications of Rh isoimmunization
alloimmune hemolytic dz of the newborn (HDN)
aka erythroblastis fetalis (when it is of the fetus)
susequent anemia & risk for neuor defects, heart failure, edema & ascites
antigens that cause IgM antibodies
cannot cross placental barrier generally innocuous: A, P(1), Le(a), M, I, IH, Sd (a) Lewis Ab & some I & IH are prevalent some Lewis have IgG component but rarely cause clinical dz
poorly expressed antigens
capable of causing significant hemolytic rxns but are poorly developed at birth & so rarely cause dz
Lu(b), Yt(a), VEL
high risk antigens
responsible for the majority of HDN cases including anti-c, anti-D, anti-E, anti-Kell
-requires intrauterine or direct fetal transfusion during pregnancy or exchange transfusion postpartum
management of Rh
blood type & Rh indirect Comb's Ab titers if indicated test FOB if mom tests + for Ab/genetic counseling repeat indirect Coomb's at 28 wks administer Rhogam @ 28 wks check neonate w/ Direct Coomb's administer postpartum rhogam if indicated
mgnt continued for Rh
serial amnicentesis to check fetal effects
possible deliver before term if fetus affected
in severe cases, fetal transfusion
