labor and birth complications (unit 3) Flashcards
pre-term labor (PTL)
- gestation b/t 20-37 wks
- AND uterine ctx
- AND cervical change
PTL risk factors
- hx of PTB (greatest predictor)
- low SES
- non-white
- maternal age extremes
- low pre-pref rate
- substance abuse
- inc. uterine volume
- uterine abnormalities
- infection
subjective s/sx PTL
- cramping
- low back pain/pressure
- abd. tightening
- vag. bleeding/discharge
- urinary freq.
- malaise
objective s/sx PTL
- > 6 ctx/hr
- vag. bleeding/discharge
- cervical dilation/effacement
labs for PTL
- UA/culture
- NST
- BPP
- U/S (cervical length)
- fetal fibronectin (FFN)
- swab for infection
PTL tx
- prevention/early recognition
- tocolysis drug
- steroids for fetal lungs
- bedrest/pelvic rest
- hydration
- abx for infection
tocolysis
- tx used to stop uterine activity
* goal is to but time for steroid admin
tocolytic
- med to stop uterine activity
- off label
- MgSO4
- terbutaline
- Nifedipine
- indomethacin
MgSO4
- CNS depressant to prevent seizure
- Relaxes smooth muscle (↓ vasoconstriction)
- SE is that BP is lowered
- Next to Pit, most common drug used in labor and delivery
- Given IVPB via pump
- Effect is immediate
terbutaline
- tocolytic
- SQ q20min for 3 doses
- then PO q 4-6 hr
- monitor VS, lung sounds, I/O
- DONT give if HR > 120
Nifedipine/Indomethacin
- tocolytics
- PO (not as fast as others)
- Indomethacin not used after 32 wks or longer than 48 hrs (last choice med)
steroids
- best PTL intervention
- most common is Celestone
- speeds FLM, by stimulating surfactant production
- given b/t 24-34 wks gestation
low birth weight (LBW)
- any baby born < 2500g REGARDLESS of gestation
* usually caused by IUGR
greatest preterm survival prognosis
•27+ wks have 90% chance of survival
oligohydramnios
- not enough amniotic fluid
- AFI < 5
- usually caused by renal issue, PROM, post dates, or UPI
- tx: FHR monitoring; amnio-infusion
risks r/t oligohydramnios
- cord accident
- fetal malformation
- hypoplastic lungs
polyhydramnios
- too much amniotic fluid
- AFI > 20
- caused by CNS/GI track malformations and mat. diabetes
- tx: FHR
risks r/t polyhydramnios
- unsuccessful labor
- cord prolapse
- PROM
PROM
- premature rupture of membranes
* water breaks 1+ hr before onset of labor
PPROM
•preterm premature rupture of membranes
•water breaks 1+ hr before onset of labor AND gestation < 37 wk
•hospitalized for rest of PG
*goal to get to 34 wks
PROM/PPROM risk factors
- infection
- incomp. cervix
- fetal abnormalities
- nutritional deficiencies
- polyhydramnios
- recent OB procedure
risks r/t PROM
- INFECTION
* cord prolapse (olighydramnios)
risks r/t PPROM
- INFECTION
- cord prolapse (olighydramnios)
- fetal abnormalities (musculoskeletal and lung)
how is ROM diagnosed
•Fern Test
chorioamnionitis
•infection of chorion and amnion
•higher risk if membranes ruptured long
•s/sx: fetal tachy, maternal fever, foul fld.
*notify MD
dystocia
- long, difficult, or abnormal labor r/t 5 Ps (power, passageway, passenger, position, psyche)
- can lead to infection, C/S, and PPH
dystocia risk factors
- short
- overweight
- > 40 y/o
- uterine abnormalities
- pelvic soft tissue issues
- CPD
- fetal macrosomia
precipitate labor
- < 3 hrs form labor onset to delivery
* can cause trauma, FHR disturbance, abruption, PPH
precipitate labor risk factors
- hypertonic labor
- induced labor
- hx of precipitate labor
power
- fxn of uterine ct. and maternal pushing
- hypotonic/hypertonic labor
- ineffective pushing (fear, exhaustion, epidural, etc)
hypotonic labor
•slowing or arrest of cervical change •weak ctx (corrdinated) •no fetal distress •need augmentation **occurs during ACTIVE phase
augmentation
- IV Oxy***, AROM or nipple stim
* increased risk of fetal distress and C/S
intrauterine resuscitation (IUR)
- turn pt on side (correct hypoten)
- turn off pit (rlx uterus)
- open main IV (correct hypovol.)
- O2 mask
- vag. exam (r/o prolapse)
hypertonic labor
•ctx uncorrdinated •inc. resting tone •painful, but ineffective •false labor b/c NO cervical change **occurs during LATENT phase
risks r/t hypertonic labor
- fetal distress (UPI)
- fetal head trauma
- maternal exhaustion
RN care hypertonic labor
- MONITOR FHT
- IUR if necessary
- may give ambien or narcotics
- if FHTs reactive, false labor and can DC
problems r/t passageway
- maternal pelvic structure abnormalities
* soft tissue obstruction
pelvic abnormalities
•small or abnormal shape
•genetics, rickets, young age, trauma
*gynecoid preferred shape (oval)
causes of soft tissue obstruction
•full bladder (#1)
•cervical edema
•HPV
*empty bladder and don’t push until complete dilation
problems r/t passenger
- macrosomia
- malposition
- multifetal PG
- fetal anomalies
macrosomia
- > 4,000 g
* r/t GDM, obesity, multiparity
macrosomia risks to neonate
- head trauma
- shoulder dystocia
- brachial plexus injury
- fractured clavicle
- asphyxia
- underdevelopment
- hypoglycemia
turtle sign
•head retracts agains perineum and external rotation doesn’t occur
•r/t shoulder dystocia
*can lead to nerve injury or asphyxia
shoulder dystocia interventions
•call MD •McRobert's maneuver •suprapubic pressure •Gaskin maneuver •Zavanelli maneuver (last resort) ***NEVER apply fundal pressure
McRobert’s maneuver
•hyperflex mom’s legs tightly to abd.
Gaskin maneuver
•all fours
Zavanelli maneuver
•push fetal head back in and do C/S
problems r/t postions
•interfere w/ dilation/descent •long dysfunctional labor •poor pain control (back) •inability to push *freq. position changes crucial
breech
- feet or butt first
- requires C/S
- associated w/ fibroid, hydrocephalus, fetal tumor, ONTD
complications of breech delivery
•prolapsed cord
•cord compression
•head entrapment
*only do vag. if no time for C/S
multiples
- only vag. delivery if both vert
* r/o dysfunctional labor and PPH
problems r/t psyche
- previous experience/knowledge
- culture
- lack of support
- loss of control
- fear/stress
complication of post date PG
- > 42 wks
- placental failure
- UPI
- oligo
- r/o fetal distress, IUGR, IUFD
intrapartum emergencies
- prolapsed cord
- uterine rupture
- amniotic fld. embolism
risks for cord prolapse
- polyhydramnios
- malpresentation
- multiples
- high station
- small fetus
signs of cord prolapse
•sudden severe variable FHR
•sudden fetal bradycard
•see/feel cord
*ALWAYS vag. exam if suspected
uterine rupture
- complete rupture of uterine scar
- rare
- r/t C/S, myomectomy, over-distended uterus, trauma
s/sx uterine rupture
- sudden loss of ct.
- loss of fetal station
- sudden fetal distress
- shock
- back/shoulder pain
- vag. bleeding
uterine rupture intervention
- call MD
- start IUR
- prepare for C/S
- anticipate infant resuscitation
- have lots of blood products
uterine dehiscence
- incomplete rupture of uterine scar
- usually little pain
- does NOT involve fetal distress
- labor slows/stops
- if no tx, will complete rupture
amniotic fluid embolism (AFE)
- embolism of amniotic fld. enters maternal circulation
- r/t hypertonic ctx, precipitous birth, uterine rupture, placenta abruption
- rare, but high mortality rate
s/sx AFE
- Abrupt onset of respiratory distress, chest pain, cyanosis
- Hypotension and shock
- Frothy sputum
- HF/arrest
- Coma
- Fetal Bradycardia
- DIC
- Massive hemorrhage
AFE intervention
- CPR
- large bore IV
- foley
- MD chooses if delivery or save mom
placenta accreta
- slight abnormal growth of placenta into uterine muscle tissue (myometrium)
- high risk of AFE, hemorrhage, hysterectomy, and death
placenta increta
•deep placental growth into myometrium
placenta percreta
•placenta grows completely thru myometrium and may adhere to structures of surrounding uterus
uterine inversion
- involution of uterus during delivery of placenta
- results in massive hemorrhage
- tx: replace blood and hysterectomy
retained placenta
- failure of entire or parts of placenta to deliver after 30 min
- may require surgical removal
- fragments can go unnoticed and lead to PPH
