Labor & Birth Complications Flashcards
what is preterm labor?
spontaneous or induced labor from 20-37 wks gestation
How many weeks is the following:
- extremely preterm
- very
- mod
- late
- extremely: < 28
- very: 28 - 31
- mod: 32 - 33
- late: 34 - 36
How many grams birth weight for the following:
- extremely low
- very low
- low
- extremely low: < 1000g (2lbs 3oz)
- very low: < 1500g (3 lbs 4oz)
- low: < 2500 g (5lbs 8oz)
what are the 4 possible causes of preterm labor
- abnormal uterine distention: multiple gestation, polyhydramnios
- decidual activation: prior PTB, shortened cervix, hemorrhage
- premature activation of maternal-fetal hypothalamic-pituitary adrenal axis (HPA): cortisol stimulates prostaglandins
- infection: UTI leading to prostaglandins
what are the 3 most common risk factors for preterm labor
- prior PTB
- multiple gestation
- uterine/cervical abnormalities, shortened cervical length
rate and length of contractions for preterm labor
contractions q4-6 times per hour that are < 10-15mins apart + cervical changes
s/s of preterm labor
- increased vaginal discharge
- pelvic or lower abdominal pressure
- constant low, dull backache
- V/D
- possible ruptured membranes
- feeling “flu-ish”
what are the criterions for diagnosing preterm labor
At least 2 contractions within 20 mins lasting 20 seconds AND:
- cervical dilation of > 4 cm
- cervical effacement of > 80%
- bloody show
- rupture of membranes
what are the key components of assessing preterm labor
Amniotic fluid analysis
- Lecithin to sphingomyelin (L/S) ratio
- phosphatidylglycerol
cervicovaginal secretion swab
- fetal fibronection (fFN) test
Maternal & Fetal monitoring
what does lecithin to sphingomyelin (L/S) ratio tell you from amniotic fluid analysis
if ratio is >= 2: low risk of resp distress syndrome in nondiabetic pregnancies
what does the presence of phosphatidylglycerol tell you from amniotic fluid analysis
if present -> fetal lung maturity & low risk for resp distress syndrome
what does fetal fibronectin (fFN) test tell you from cervicovaginal swab
protein that helps the amniotic sac attached to the fetus
- positive: preterm labor likely
- negative: unlikely
what are the managements for preterm labor
- tocolytics
- betamethasone for fetal lung maturation
- progesterone
- cerclage placement
List 4 tocolytics commonly used
- CCB: nifedipine
- NSAID: indomethacin
- Beta-adrenergic agonists: terbutaline
- MgSO4 for neuroprotection (prevent hemorrhage) as well
PROM vs. PPROM
PROM
- rupture >= 37 wks
- spontaneous prolonged rupture of fluids > 24hrs
PPROM
- rupture preterm < 37 wks
- higher risk for infection
- weakening of amniotic membranes
risk factors for PROM
- previous hx
- short cervical length
- multiple gestation
- STIs
- low BMI
- smoking/drug use
what can PROM lead to for the mother
- infection: chorioamnionitis, endometritis
- abruptio placenta, retained placenta
- c-section
what can PROM lead to in the fetus
- sepsis
- resp distress, hypoxia
- neuro: hemorrhage, impairment
- fetal deformities if < 26 wks
assessments for PROM
- no digital exams but sterile speculum okay
- FHR, UCs
- BPP, nonstress test
treatment for PROM
- based on gestational age: wait or induce?
- corticosteroids, tocolytics controversial
what is dystocia
abnormal or difficult labor
risk factors with dystocia
Power
- overstimulation with oxytocin
- maternal fatigue, dehydration, fear, electrolyte imbalances
- inappropriate use of analgesia/anesthesia
Passenger
- malpresentation, fetal position: OP, transverse lie
- cephalopelvic disproportion
Passage
- small or abnormal pelvis
- uterine issues: fibroids, tumor
what is hypertonic uterine dysfunction
uncoordinated uterine activity: contractions are frequent and painful but ineffective for cervical dilation/effacement
Management for hypertonic uterine dysfunction
- hydration: improve uterine perfusion
- pain management: allow uterine rest
- promote rest: quiet environment & naps
what is hypotonic uterine dysfunction
weak or ineffective contractions that doesn’t promote cervical dilation/effacement
risk factors for hypotonic uterine dysfunction
- multiparity
- extreme fear leads to release of catecholamines, which interfere with UCs
interventions for hypotonic uterine dysfunction
stimulate uterine activity by:
- ambulate and change positions
- hydrate
- oxytocin
empty bladder
what is fetal dystocia
difficult labor d/t fetal (passenger) issues in dystocia
causes for fetal dystocia
- macrosomnia > 4,000 - 4,500g
- malpresentation, cephalopelvic disproportion
- hydrocephalus, tumors
- multiples - twins triplets
complications from fetal dystocia
- fetal asphyxia
- fetal injuries
- maternal lacerations
what is precipitous labor
extremely rapid labor and birth lasting < 3 hrs from onset
2nd stage labor issue
management of precipitous labor
- augment with oxytocin
- assist with vacuum or forceps delivery
- c-section
induction vs. augmentation
induction
- before labor to initiate contractions
augmentation
- during labor to strengthen or regulate contractions
what are risks of using oxytocin to induce labor
- tachysystole: >5 contractinons/10 mins
- FHR decelerations
- failure to induct after 24 hrs
- water intoxication: oxytocin is also an antidiuretic
what is the goal of augmentation of labor
- make contractions stronger, more regular, and more effective to shorten the length of labor
what are reasons for augmentation of labor
- stalled labor/slow: < 3 contractions/10 mins
- no UCs when ruptured
what are contraindications for augmentation of labor
- placenta previa
- umbilical cord prolapse
- prior classical uterine incision
- active herpes
- pelvic structural anomalies
- invasive cervical cancer
what are risks with augmentation of labor
tachysystole
what is cervical ripening
- softening, thinning, and dilation of cervix
Using the Bishops score, how do you know if induction will be successful or not
- 6 +: successful induction of labor
- < 6: cervical ripening agents may be used
what is the mechanical way of cervical ripening
- balloon catheter to insert through the vagina into the cervix
what are the 2 medications used for cervical ripening
prostaglandins
- dinoprostone (Cervidil)
- misoprostol (Cytotec)
contraindications for cervical ripening
- active herpes
- fetal malpresentation
- umbilical cord prolapse
- previous classical c-section or myomectomy
- complete placenta previa
what are the procedures for operative vaginal delivery
vaccuum extraction
forceps
when should operative vaginal delivery
Shortening of the second stage of labor required d/t:
- maternal exhaustion
- inability to push effectively
- maternal cardiac dx
- arrest of descent
- rotation of fetal head
- abnormal FHR patterns
what are the risks of operative vaginal delivery for the mother and fetus
- mother: tearing
- fetus: scalp or brain bleed, head bruise or lacerations
nursing actions for operative vaginal delivery
- empty bladder
- vacuum pressure should be released between contractions
- document type of delivery
what are the conditions for elective c-section
scheduled
- previous c-section
- maternal or fetal risk via vaginal birth
- malpresentation
- on maternal request
what are the conditions for emergent c-section
- prolapse of umbilical cord
- rupture of uterus
- abnormal FHR
what are the conditions for urgent c-section
- malpresentation diagnosed after onset of labor
- placenta previa with mild bleeding
what conditions for nonurgent c-section
- failure to progress: cervix doesn’t fully dilate
- failure to descend
what are risks after c-section
- placenta accreta, increta, or percreta
what is shoulder dystocia
- head is out, but the anterior shoulder can’t pass under the pubic symphysis
what is the first sign of shoulder dystocia
turtle sign: retraction of the fetal head after delivery of the head
what fetal injuries can result from shoulder dystocia
- brachial plexus injury: shoulder, arm, and hand
- fx of clavicle and humerus
- compression of fetal neck: impaired circulation leading to increased ICP, asphyxia, neuro injury
what is the McRoberts maneuver
2 people sharply bend thighs toward belly to tilt the pelvis back for more room
what is the woods corkscrew maneuver
rotation of posterior shoulder 180 degrees to disimpact the anterior shoulder
what is the Gaskin all-fours maneuver
mother moves to hands and knees to allow gravity and positional changes to free the shoulder
what is the Zavanelli maneuver
provider pushes the baby’s head back into the uterus and an emergency c-section is done
what is the order of maneuvers to be done for shoulder dystocia
- evaluate for episiotomy
- insert straight catheter to empty bladder
- McRoberts maneuver
- Woods corkscrew maneuver
- Gaskin all-four maneuver
- Zavanelli maneuver
what is prolapse of the umbilical cord
cord slips through the cervix and into the vagina and lies below the presenting part of the fetus
what are fetal risk factors for prolapse of the umbilical cord
- malpresentation
- IUGR
- small for gestational age
- unengaged presenting part
what are maternal risk factors for prolapse of the umbilical cord
- long cord > 100 cm
- AROM
- polyhydramios
- multiple gestation
- PROM
what happens to FHR d/t prolapse of umbilical cord
- prolonged bradycardia
- recurrent variable decelerations
what is the first priority for prolapse of the umbilical cord
- relieve pressure: sterile gloved hand to push the fetal presenting part upward until delivery
what interventions should be done for prolapse of the umbilical cord
- relieve pressure with hand
- reposition to knee chest position or trendelenburg
- O2 10L
- large bore IV access for fluids and blood transfusion
- d/c oxytocin and use tocolytics
what is rupture of the uterus
separation of the uterine myometrium or tearing of previous c-section scar leading to the amniotic sac, baby, or body part to enter the abd cavity
what are the causes of rupture of the uterus
- scarred uterus from previous c-section
- uterine sx
- trauma
- tachysystole
what are the maternal s/s of rupture of uterus
- tachysystole
- sudden severe abd pain
- tearing sensating, burning or stabbing pain
- vaginal bleed
- cessation of UCs
what are the fetal s/s of rupture of uterus
- sudden bradycardia, prolonged late/variable decelerations, absent fetal heart tones
- palpable fetus outside of the uterus
- loss of fetal station
management of rupture of uterus
- hemodynamic stabilization large-bore IV access
- O2 10L
- mom in lateral position
- prep for emergency c-section
- insert foley catheter
- if defect can’t be repaired: hysterectomy
