Labor & Birth At Risk Flashcards by Kelsey Klipfel

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

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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

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An early initiation of the labor process
Comprises 75% of preterm births

Spontaneous preterm birth

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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

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Infection
Bleeding at the site of placental attachment
Stress
Decrease in progesterone

Causes of preterm birth

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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

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Placenta previa
Placenta abruption
Anything disrupt placenta cause uterine to contract

Bleeding at the site of placental attachment

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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

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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

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Risk factors
Prevention

Preterm labor and birth

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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

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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

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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

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Education - get via good prenatal care

Health promotion and disease prevention

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Esp for chronic disease moms - how care for self and prepare for baby

Preconception counseling

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Indomethacin, Nifidepine, Magnesium Sulfate (hospital)
Drugs identify for preterm labor - help slow down contractions or stop them

Interventions to prevent spontaneous preterm birth

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Have all symptoms of true labor
Uterine Activity
Discomfort
Vaginal discharge
Symptoms and has cervical change

Signs and symptoms of preterm labor

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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

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Dull, intermittent low back pain
Menstrual-like cramps
Pelvic pressure/heaviness

Discomfort

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Rupture of membranes
Change in discharge

Vaginal discharge

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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

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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

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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