Labor, Birth, & Placental Complications Flashcards
Premature Rupture of Membranes (PROM)
Rupture of amniotic sac before onset of true labor, regardless of gestational age
Preterm Premature Rupture of Membranes (PPROM)
Amniotic sac rupture before end of 37 weeks, w/ or w/o contractions
Causes of PROM/PPROM
Infection of vagina, cervix - C/G, GBS, BV Weak amniotic sac Prior preterm birth Incompetent or short cervix (<25 mm) Uterine overdistention (multi, LGA) Hormonal changes Recent intercourse (sperm PGs) High stress Low SES Nutritional deficiencies
When do contractions typically begin after PROM/PPROM?
6-8 hours
PROM/PPROM Management
Delivery - may start spontaneously, reasonable induction if 34-36 weeks
Tx of PPROM/Triple I infection - ampicillin, gentamicin (if allergic, cefazolin, clindamycin, vancomycin)
Admin IV for duration of labor & 24 hrs PP
Monitor for signs of infection - HR, temp, tenderness
Tylenol for fever
Management of PROM/PPROM <34 weeks
Maintain pregnancy, IV/oral abx prophylaxis, extended hospital stay until 34 weeks
PROM/PPROM complications
Maternal fetal risk for infection increased if >18 hrs
Umbilical cord compression
Reduced lung volume
Compression deformities
Sepsis risk for newborn
PROM/PPROM Infection
Intrauterine infection and/or inflammation = Triple I due to chorioamnionitis
Signs - maternal fever >39C w/o other sx OR fever PLUS 1+ of:
Fetal tachycardia, increased WBC count (>15k), maternal tachycardia, purulent vaginal discharge/fluid
Preterm labor (PTL)
Documented labor between 20 & end of 37 weeks
Why has PTB increased in last 15 years?
Better data, multifetal pregnancies, increased use of artificial reproductive technologies (ARTs)
What is the top cause of infant death in the US?
PTL/PTB
What is the top cause of neurologic disabilities in children?
PTL/PTB
PTL/PTB Risk Factors
Hx of PTB Multiple gestation Uterine anomaly (bicornuate uterus) Fetal conditions (IUGR, low AMI, chromosomal abnormalities) Infection Smoking, polysubstance abuse Chronic conditions - HTN, DM, CT disorders Racism Cervical surgery - LEEP Extremes of maternal age Low/high pre-pregnancy weight IVF conception Psychosocial - abuse, mental health
PTL Symptoms
Palpable contractions (painful or painless) Pelvic/vaginal pressure Low backache Pain/discomfort in vulva/thighs Cramps (abdominal, menstrual-like) Increased/changed vaginal discharge Rupture of membranes Vaginal bleeding/spotting Possible diarrhea Sense of 'feeling badly'
*Sx vary by patient
PTB Risk Assessment
Cervical length <25 mm 16-24 weeks - use US > digital exam
Contractions
Fetal fibronectin (fFn) - excellent negative predictive value
Infection - UTI, BV, STI
Dehydration status
Trauma/stress
PTL Diagnosis
Documented contractions - 4 in 20 mins or 8 in 60 mins AND either:
ROM
OR
Cervical change OR dilation of 2 cm OR effacement 80% (high false + rate, 30% of labors cease spontaneously)
PTL Management
If prior PTB - start progesterone at 16 weeks
Limited, individualized activity reductions
ID cause, relieve factor(s)
- Polyhydramnios - remove fluid w/ amniocentesis
- Poor nutrition - consult, improved intake
- Treat infections
Betamethasone for fetal lung maturity between 24-34 weeks; 2 inj 24 hours apart
Hydrate w/ IV fluids as needed
Med management by provider - tocolytics through betamethasone window
PTL Management
Tocolytics - Mg sulfate (<32 weeks), Ca antagonists (nifedipine), PG synthesis inhibitors, beta adrenergics
GBS prophylaxis
Umbilical Cord Prolapse
Medical emergency where cord prolapses out of uterus ahead of fetus, subject to compression & interruption of blood flow to fetus
Cord Prolapse Management
Position hips higher than head
Sterile glove, lift presenting part off cord and stay there until emergency C-section
Cord Prolapse Risk Factors
PROM, polyhydramnios, long umbilical cord, malpresentation, multiparity/gestation, high fetal station, IUGR
Cord Prolapse Nurse Role
Support fetal head, get help, set up for immediate delivery, consider O2 for mom, continuous fetal monitoring
Dystocia
Dysfunctional labor due to the 5 P ‘s of labor
Shoulder dystocia
Arrest of delivery of anterior shoulder after successful delivery of head; chin becomes retracted against vulva & neck not visible b/c shoulder(s) impacted behind pubic bone
*Common OB litigation causes
Turtle sign
Fetal head impacted against vulva w/o neck visible
Optimal time for survival and minimal brain damage to baby w/ shoulder dystocia
5-7 mins
Intrapartum factors influencing shoulder dystocia
Failure, arrest of fetal descent
Significant molding
Macrosomia
Prolonged 2nd stage of labor
Shoulder dystocia nursing interventions
Document time of each intervention
Assist w/ position changes
McRoberts maneuver - knees to ears in supine position
Suprapubic pressure (NEVER fundal pressure)
Prep resuscitation equipment
Signs of laceration
Firm fundus w/ bright red blood trickling
Signs of uterine atony
Boggy fundus w/ red blood flowing
Signs of retained placenta
Boggy fundus w/ dark blood & clots
Placental delivery methods
Shiny Schultz - fetal side appears first; shiny, membranous
Dirty Duncan - maternal side appears first; dull, muscular
Retained placenta
Placenta does not detach and deliver w/in 30 minutes after delivery
How does a retained placenta increase hemorrhage risk?
Retained placenta inhibits uterine contractions so vessels remain open and able to bleed
When can retained placenta cause bleeding?
Immediately or delayed (hrs to days)
Retained placenta removal
Manually; D&C
Types of placentas
Normal - 1 lobe w/ single layer of amnion/chorion
Succenturiate - 1+ accessory lobes
Circumvallate - fetal side exposed thru ring opening around umbilical cord due to double fold of amnion & chorion
Why can a succenturiate placenta be troublesome?
If worried about retention, one lobe may deliver providing false sense of placental removal b/c other lobe still retained
No other significant risk factors associated
Risks of circumvallate placenta
Abruptio placentae, oligohydramnios, abnormal cardiotocography, PTB, miscarriage
Where do the umbilical vessels normally insert in the placenta?
Centrally w/ firm rooting and covered in Wharton’s jelly
Velamentous cord insertion
Cord inserts into fetal membranes rather than body of placenta & travels w/in membranes (between amnion, chorion) to placenta
Complication(s) of velamentous cord insertion
Vessels are exposed/not covered by Wharton’s jelly –> vulnerable to rupture, esp if near cervix
Battledore placenta
Cord insertion at/near placental margin; usually incidental finding at birth
Vasa previa
Fetal vessels traverse fetal membranes over internal cervical os
(Similar to placenta previa but vessels cover cervix instead of body of placenta)
Vasa previa risk factors
Placental abnormalities (velamentous insertion)
Hx of IVF
Multiple gestation
Vasa Previa Signs/Sx
Classic triad - ROM, painless vaginal bleeding, fetal bradycardia (loss of blood supply)
When is vasa previa typically diagnosed?
After delivery but can be seen on US
Vasa previa treatment
Emergency C-section, often early to prevent labor & minimize risk of rupture
C-section often around 35-36 weeks
Nurse role in vasa previa
Keep hands away from vagina
Maternal and fetal monitoring
Prepare for immediate delivery
Other complications
Precipitous labor - L&D in <3 hrs
Meconium-stained amniotic fluid - postterm babies at risk for aspiration
Fetal distress - FHR <110, >160, minimal or no variability, fetal hyper- or no activity
Uterine rupture - complete (internal bleeding) vs incomplete (no internal bleeding)
Anaphylactoid syndrome of pregnancy - amniotic fluid embolism
