Labor & Birth At Risk Flashcards
Nurse and obstetric team must use knowledge and skills in a concerted effort to provide care in event of complication
Understand normal birth process
Prevent and detect deviations from normal labor and birth
Implement nursing measures if complications arise
Get report pt and circling all risk factors and wondering how die on us - need be prepared - one can see and one cannot
Good understanding of norm - detect and intervene early to have better outcomes
Nursing responsibilities
Preterm labor: cervical changes and uterine contractions occurring between 20 and before end 37 weeks of pregnancy; 20-37 weeks; can stop preterm labor usually
Preterm birth: any birth that occurs before completion of 37 weeks of pregnancy
Spontaneous preterm birth
Indicated preterm birth
Preterm labor and birth
An early initiation of the labor process
Comprises 75% of preterm births
Spontaneous preterm birth
Induced - need baby to come out
C-section
Having absent variability - C-section so not stress baby more so not die
Severe pre-eclampsia - get baby out
A means to resolve maternal or fetal risk
Indicated preterm birth
Infection
Bleeding at the site of placental attachment
Stress
Decrease in progesterone
Causes of preterm birth
Number 1 reason
Raging GBS
Gonorrhea
Chlamydia
Bad STI
Bad bacterial vaginosis - irritate cervix and uterus
Bad UTI
Bad pyleonephritis
Ones get septic
COVID
Infection
Placenta previa
Placenta abruption
Anything disrupt placenta cause uterine to contract
Bleeding at the site of placental attachment
Find husband after commit suicide
No support
No food to eat
Nutrition - lack
Lack resources
MVC - traumatic to abdomen and her - stress and bleeding beside placenta
Stress
Progesterone - maintains pregnancy - not enough not maintain pregnancy
Hx preterm birth - no cause otherwise - lack progesterone - not monitor progesterone in labor; prophalcatically give progesterone if hx
Decrease in progesterone
Risk factors
Prevention
Preterm labor and birth
History of spontaneous preterm birth - can happen again esp if no related cause
African-American race
Genital tract infections
Multifetal gestation - lot babies in uterus
Second trimester bleeding
Low pre-pregnancy weight - underweight BMI
Risk factors
Preventive strategies to address risk factors
Health promotion and disease prevention
Preconception counseling
Interventions to prevent spontaneous preterm birth
Sometimes not know why - prepare for it
Prevention
Organization that works with preterm birth: March of Dimes - sponsoring of research into babies - infant mortality better as viability changed
Preventive strategies to address risk factors
Education - get via good prenatal care
Health promotion and disease prevention
Esp for chronic disease moms - how care for self and prepare for baby
Preconception counseling
Indomethacin, Nifidepine, Magnesium Sulfate (hospital)
Drugs identify for preterm labor - help slow down contractions or stop them
Interventions to prevent spontaneous preterm birth
Have all symptoms of true labor
Uterine Activity
Discomfort
Vaginal discharge
Symptoms and has cervical change
Signs and symptoms of preterm labor
More than 4-6 contractions in an hour or longer
10-15 mins - preterm come in; not full term
Not big contractions where start in back and come to front - dull low back pain but feel like UTI but no burning with UTI - feel like about start period or pelvic pressure - could be UTI
Water broken or change in vaginal discharge
Vaginal infection - treat that
Water broken - prepare for delivery of baby - soon after baby
Uterine Activity
Dull, intermittent low back pain
Menstrual-like cramps
Pelvic pressure/heaviness
Discomfort
Rupture of membranes
Change in discharge
Vaginal discharge
Glucocorticorticoid steroids - help mature fetal lungs - prepare baby to breathe - 24 hrs apart - improve surfactant levels so transition better
Before 32 weeks - give mag sulfate to relax everything
Sometime not stop it - may send to higher level NICU
Symptoms and has cervical change
Spontaneous (SROM)
Artificial (AROM)
Can do nitrozine papers - litmus paper - not as applicable as looking underneath stethoscope for crystalized fern - turn bright blue - semen can turn it, amniotic fluid
Ruptured membranes in labor
On own
Spontaneous (SROM)
Provider - Most common done by them
Risk for infection
Placenta behind it
Crochet hook - prick bag and water everywhere
Artificial (AROM)
After water breaks - assess fetus - draining bath
Polyhydramnios - GI issues - not taking in amniotic fluid
Always assess FHR immediately after membranes rupture
Risk for Prolapsed Cord - med emergency - always assess baby first
Artificially - how baby react to change in environment - assess FHR immediately
Ruptured membranes: risks
Assess FHR immediately
Note time, amount, color, odor (TACO) - qualify - HCP make determination; amount not big deal; color big deal - clear, odor - bleach - not bad - may be infection brewing in chorion
Increased risk for infection (chorioamnionitis)
Ruptured membranes: nursing care
Taken last protection for mom and baby - plug and amniotic fluid - direct conduit for infection - hands out as much
Temp qhr - rise in body temp - treat - abx - directly to baby
VS
Palpate uterus for tenderness
FHR pattern
Hygiene - pericare; water broken - keeps coming out - every time contract more fluid out
Odor
Avoid invasive procedures
Increased risk for infection (chorioamnionitis)
External Cephalic Version
Induction/Augmentation of Labor
Episiotomy
Laceration repair
Operative Deliveries
Cesarean Birth
Obstetric procedures
Baby that is breach - try get vertex - HCP on top abdomen - move baby externally - not comfy - usually in OR - may do C-section; usually not do when 40 weeks; more likely 37 weeks; risk high; ask for this - high vaginal deliveries - good canditate and everything good - cord out way
Usually to providers - epidural given - send home not give epidural; sometimes works; sometimes not - send home - and do again
Not first time mom - not know pelvis
Environment be just right to do this
Determine fetal position
Locate the umbilical cord
Rule out previa
Evaluate adequacy of pelvis
Assess for anomalies, fluid level, and gestational age
External Cephalic Version
Oxytocin/Pitocin
Not do elective inductions until 39 weeks
Increase C-section because elective inductions - increase maternal mortality and morbidity
Start labor via
Cervical ripening
Induction/Augmentation of Labor
Starting oxytocin places woman at high risk - routine often
High risk-drug
Careful monitoring of mom and fetus
contractions harder - higher epidural rate - do more interventions and more assessments - change acuity
Nurse can rupture uterus or kill baby because not put in pump correctly
Oxytocin/Pitocin
Sex - best way
Breaking water enough
Nipple stimulation - release endogenous oxytocin
Tea
Strip membranes - separate cervix from membrane
Start labor via
Warm up cervix - when 39-41 weeks
Cervidil
Misoprostol
Cervical ripening
Risks vs. benefits
Start doing cutting - extend do cutting - leave bottom alone and tends to do better
Episiotomy
4th degree - worse - down into rectal capsule - retum not sterile; have get revised and surgery over and over; suggest C-section for next delivery - mess with; sex prob; defecating is prob; heal in months
1st and 2nd degree - 6 weeks healing
Laceration repair
Forcep-Assisted
Vacuum-Assisted
Indications
Operative Deliveries
Provider skill
Pudenal block
Low or mid (more damage - nerve damage - bell’s palsy)
Forcep-Assisted
Most often used
Low
More used - soft suction
Mom pushes and they pull
Labia separated and crowning for this
Vacuum-Assisted
Do because baby low and mom exhausted
Baby has to be crowning and labia separated
Maternal - Indications
Fetal distress - pushing well and sitting on perineum - helping out - see head - not hunt
Fetal - Indications
Indications
Scheduled vs. Non-scheduled
Complications and Risks
Anesthesia
Pre-operative care
Post-operative care
Her recovery up to 1 yr; space pregnancies out; skin healed potentially - layers underneath it need to heal
Vaginal delivery - 6 weeks as long as not bad tear - heals perfectly
Cesarean Birth
Muscle in uterus - cutting with grain - heal better when go horizontal - mimics vaginal birth
Vertical - against grain - not heal as well - preterm birth - preserve head - not squeeze head - only have C-sections - not want to contract - scar tissue not secure because against grain
Indications
Scheduled - pick date; not stressed; wet lungs for awhile after lungs sometimes
Non-scheduled - labor to C-section; babies do better with this; less amniotic fluid when stressed during labor
Scheduled vs. Non-scheduled
Hemorrhage
Infection of site - IV and indwelling of catheter
Knicking bladder or bowel - bladder knicks - catheter long time; fascia heals for longer time
Surgery - DVTs, ileus - passing gas - bowels moving
Complications and Risks
Vaginal no need
C-section do
Potential rxn
Anesthesia
Drugs
Prophylactic abx - after cord cut - for mom and baby
Settle stomach with medications
Pre-operative care
L&D - PACU as well; hook up to EKG; take VS; assess site; meet criteria - cont with fourth stage - cont VS and fundal; pressure dressing; assess fundal tone q15 then q30
Indwelling catheter - gets bloodier
Most up walking within 6 hrs - take out catheter - increased risk DVT
Post-operative care
Meconium-stained amniotic fluid
Shoulder Dystocia
Uterine rupture
Prolapsed umbilical cord
Amniotic fluid embolism (anaphylactoid syndrome of pregnancy)
Obstetric emergencies
Indicates that the fetus has passed the first stool before birth - sterile - not smell bad; baby is sterile
Concern - not know when happened - can tell how long ago because may stain baby
Issues what stain pharynx - Places infant at risk for meconium aspiration syndrome
Meconium-stained amniotic fluid
Head is born, but anterior shoulder cannot pass under pubic arch
Broad shoulders get stuck
Anterior shoulders - push out - McRoberts - push to dislodge - hyperflex hips - simulate squat - change diameter so larger
Symphysis pubis breaking apart to help it
Most time break clavicle - sometimes nere damage for awhile
Newborn is more likely to experience birth injuries
Brachial plexus
Maternal complications (hemorrhage, rectal injury, pelvic floor injury - happens) - turtle sign - comes head then head goes back
Shoulder Dystocia
FHR suddenly drop; late decels
Mom report - excruciating pain; Abdomen rigid; into shock; massive blood loss
Vaginal exam - lots blood - bright red; cervix, level of baby - no baby - tissue and no baby
Often rupture - integrity uterus so thin that ruptures - ruptures that where head goes - baby ends up in abdomen
Often after epidural - feel not right and hurts bad
Hopefully save uterus
Baby out
Abnormal FHR tracing
Loss of fetal station - moves opp direction
Titrating pitocin not right
Non gravida uterus - smaller and thicker - pitocin given after
Gravida - thinner - given during
Abdominal pain
Shock
Uterine rupture
During cervical exam - feel head and squishy thing that pulsating - not move hand until baby out
Get help in room - get mom on hands and knees; they give O2; they call for people; do not move hand; prep for C-section; position first - 2 nurses help her position - O2 on her
Need presenting part off cord - baby survivng via cord - cannot shove cord
When cord lies below presenting part of fetus
Interventions:
Prolapsed umbilical cord
DO NOT REMOVE YOUR HAND!
Call for help
100% O2
Prep for Cesarean
Position mother in trendelenberg or knee-chest
Interventions: - Prolapsed umbilical cord
Most rare comp
Amniotic fluid containing particles of debris
Causes anaphylactic rxn to particle - outcomes are bad
Acute onset of hypotension, hypoxia, cardiovascular collapse, and coagulopathy - DIC
No hives, no itching, no swelling, all sudden BP drops, not breathe
Maternal mortality to 61% or higher - affecting mom
Neonatal outcome is poor - affects baby if mom dies - get baby out quick
Amniotic fluid embolism (anaphylactoid syndrome of pregnancy)
A G3T0P1A0L1 Caucasian woman is currently pregnant with twins. She is being treated for chlamydia. What are her specific risk factors for preterm birth? Select all that apply
A) Caucasian race
B) Previous preterm delivery
C) Current vaginal infection
D) Multifetal gestation
E) Low socioeconomic status
Answer: B,C,D
Hx preterm; 2 babies, treated for vaginal infection
The risk factors - low SES - would be but not specific to her
