Labour and Delivery Complications Flashcards
What is the incidence of preterm birth in Canada?
7.7%
What are the risk factors for preterm labour?
Demographic - age, low socioeconomic status, ethnicity
Biophysical - Hx of preterm labour, genetis, uterine/cervical/placenta abnormalities
Current Pregnancy Problems - Multifetal, hydraminous, infections, hypertension in pregnancy, fetal anomalies, PPROM
DOH - tobacco/drug use, violence, excessive physical activity, inadequate weight gain/poor nutrition, stress, inadequate prenatal care
How is preterm labour managed?
Precent in those at risk, eg. progesterone injections
If in preterm labour, take fibronectin assay (24-34 weeks)
Will not stop preterm labour if complications
Meds - tocolytics (up to 32/33 weeks gestation) and corticosteroids (no if >34 weeks)
What should the nurse do with the patient in preterm labour?
Assess contractions and per vagina (PV) loss.
Monitor fetus.
Assess for side effects of meds.
Give betamethasone/dexamethasone to increase lung maturity (if <34 weeks) (MD’s order)
Prepare for a premature birth if labour continues
What is the incidence of post-term labour in Canada?
0.61% (Perinatal health, 2010)
12% (Laedwig, 2014)
What are the possible causes of post-term labour?
Error in determining ovulation and conception
Deficiency in placental estrogen (decrease in prostaglandin & decreased formation of oxytocin receptors in myometrium) & continued secretion of progesterone.
What are some potential problems for the mother in post-term labour?
Psychological stress, induction, dystocia, assisted delivery, perineal trauma (large baby), increased risk of infection and hemorrhage, increased CD, increased DVT’s
What are some potential problems for the baby in post-term labour?
Decreased placental profusion, fetal demise, oligohydramnios, macrosomia, meconiium aspiration syndrome, low apgar, SIDS, injury, CP
What are the medical interventions for post-term labour?
At 41 weeks - daily fetal movement counts. Follow-up biweekly with NST, ultrasound for fetal size and amniotic fluid index (AFI)
Elective induction or wait until 42 weeks
What are maternal conditions that are indications for induction?
Post-term Diabetes Hypertension in pregnancy PROM Chorioamnionitis Previous precipitoous labour and delivery
What are some fetal conditions that are indications for induction?
Intrauterine Growth Retardation Demise Hemolytic disease Macrosomia Mild abruptio placenta
What are some logistical reasons for induction?
Maternal request
Health care delivery reasons
What is the rate of induction in Fraser Health Authority? (percentage)
21% in Fraser Health Authority
How is induction managed in the situation of an unripe cervix?
Prostaglandins E2 - intercervical intravaginal
What is used in the induction of labour in a woman with an unripe cervix?
Cervidil - vaginal insert (10mg)
Cervical ripening balloon
What is used to induce labour in a woman with a ripe cervix?
Sweep of membranes
Amniotomy/ARM
Intravaginal PGE2 gel or IV oxytocin
What bishop’s score is considered a “ripe” cervix?
Bishop’s score of 6 or higher
What is the nurse’s role in an induction?
Baseline assessment - vital signs, leopold’s maneuver, vaginal exam, electronic fetal monitoring (EFM)
Follow MD’s orders/induction protocol
Assess pt and fetus x2 hours
If cervidil/prostaglandins (PGE2), pt may be sent home until active labour begins.
Who initiates an induction?
Induction commenced by MD/midwife
What is the rate of artificial rupture of membranes in canada?
in Canada, 17%
What are the indications for augmentation with oxytocin?
hypotonic (weak) / infrequent contractions, lack of progress (1st or 2nd stage)
What are the indications/effects of ARM?
Usually done with inductions
May shorten labour (increased effectiveness in multips)
Increased pressure on head (caput)
May increase risk of infection and CD
What is the etiology of fetal distress (decreased oxygen)?
Cord compression
Placenta insufficiency
Maternal/fetal/placenta disease or disorder
What are the warning signs of fetal distress?
Meconium stained liquoi, ominous FHR patterns
What are the nursing interventions for fetal distress?
Call code OB
Nursing interventions - discontinue induction, change position to Lt./Rt. lateral, IV bolus, Vag Exam, O2 PRN, decreased maternal anxiety, EFM or internal monitor, assist with fetal scalp blood sample (>7.2), consider amnioinfusion
What are the maternal indications for forceps and vacuum extraction?
Maternal exhaustion
Lack of progress
Health conditions (Pregnancy Induced Hypertension, Heart Disease)
Decreased motor innervation with epidural
What are the fetal indications for forceps and vacuum extraction?
Fetal distress Placenta separation (2nd stage) OP position Macrosomia Breech (after coming head)
What are the maternal risks with forceps?
Tears, hematomas
What are the fetal risks with forceps?
Decreased flexion of head Echymosis Edema Caput Cephalhematoma Paralysis
What is important for the nurse to do after a forceps delivery?
Important to inspect perineum and head for complications
What is the incidence of caesarean delivery in BC? Fraser Health?
- 9% BC
32. 9% FHA
What are factors that influence caesarean delivery rate?
Delayed childbearing Obesity Decreased number of midwives Legalities Decreased skill with breech deliveries VBAC rate Personal requests Inductions
What are the indications for C-section?
Placenta previa Placenta abruptio Prolapsed cord CPD Active herpes Transverse lie Maternal health issues Failure to progress Breech Fetal distress Repeat C-section
What are the different types of incisions in caesarian delivery?
Uterine Cut - Kerr (transverse) or Sellheim (vertical lower segment)
Classic incision (rarely done) - on corpus of uterus (increased ruptures)
Skin cut - Transverse (Pfannenstiel) or vertical
What is the incidence of use of general anesthetic for caesarean delivery?
7.7
What is used for general anesthetic in a caesarean delivery?
Combination of IV and inhalation agents
What are the benefits of general anesthetic in caesarean delivery?
Quick to administer
What are the disadvantages to general anesthetic for caesarean delivery?
Depresses fetal CNS, increased blood loss, maternal vomiting and depressed GI motility
What are the effects of regional anesthesia and analgesia for caesarean and vaginal deliveries (eg. spinals/epidurals)?
Alters motor and sensory function (anesthetic agents)
Prolongs pain relief (post CD (morphine/fentanyl)
Blocks afferent and efferent nerves
What is the incidence of using spinal analgesia/anesthesia for caesarean section?
56.4%
What are the benefits of spinal analgesia/anesthesia for Caesarean delivery?
immediate
small amount of drugs used
some pain relief for apprix. 24 hours after caesarean delivery
What are the disadvantages of spinal analgesia/anesthesia for Caesarean delivery?
Headache (CSF leak)
Decreased BP -> fetal distress
What is the incidence of epidural analgesia/anesthesia in labour and delivery?
47.8%
What are the benefits of epidural analgesia/anesthesia during labour and delivery?
Pain relief for vaginal deliveries
What are the disadvantages of using epidural analgesia/anesthesia labour and delivery?
Approx. 30 minutes to work
Increased drugs required
Hypotension -> fetal distress
What are the benefits of combined spinal-epidural block (CSE)?
For labour/Caesarean delivery
Preserves motor function
Small amount of drugs used
What is the rate of attempted and successful VBAC deliveries?
- 7% attempted
68. 6% success rate
What is the risk of uterine rupture in VBAC deliveries?
2-4 in 1000 VBACs
What is the nursing care of VBAC patients?
Frequent monitoring (fetal and maternal), EFM, vital signs, assess whether there is pain over the incision site (rupture), caution with induction
What are contrainducations for a VBAC?
“classic” or “T” uterine incision
what are some factors that can increase the risk of umbilical cord prolapse?
Polyhydramnious, long cord, breech, high, irregular pp
What should the nurse do in the situation of umbilical cord prolapse?
Call cod Put patient in knee-chest, modified sims, or trendelenburg position Hand in vagina to keep pressure off cord Wrap cord Give O2 Start IV Prepare for delivery (Tx depends on stage of labour)
What is shoulder dystocia? (definition)
After delivery of head, further expulsion of the infant is prevented due to impaction of the fetal shoulders in the maternal pelvis.
What is the incidence of shoulder dystocia? (how common is it)
<1% (Obs. conference, 2010)
What are some risk factors for shoulder dystocia?
Fetal macrosomia Maternal diabetes Maternal obesity Multiparity Post term
What should the nurse/physician do in the case of shoulder dystocia?
Activate ALARMER Ask for help Lift/hyperflex patient's hips (McRobert's Maneuver) Anterior shoulder disimpaction Rotation of the posterior shoulder Manual removal of the posterior shoulder Episiotomy Roll woman over to "all fours"
What are the potential maternal complications with shoulder dystocia?
Postpartum hemorrhage
Trauma
Infection
What are the potential neonatal complications with shoulder dystocia?
Brachial plexus injury Fractures Asphyxia Neurological damage Fetal demise
What is the definition of a precipitous labour and delivery?
Under 3 hours for labour and delivery
What are factors that can contribute to a precipitous delivery? (risk factors)
Multiparity
Large pelvis
Previous precipitous deliveries
Small fetus
What are some associated problems for a mother during a precipitous delivery?
Lacerations
Decreased coping
Postpartum hemorrhage
What are some associated problems for the baby in a precipitous labour and delivery?
Fetal distress (hypoxia) Cerebral/nerve (brachial) trauma
How much blood loss after a vaginal delivery is considered a hemorrhage?
Loss of >500 mls
How much blood loss after a Caesarean section is considered a hemorrhage?
> 1000 mls
When are postpartum hemorrhages considered late pph? Early pph?
Early PPH - during 3rd or 4th stage, or first 24 hours after delivery
Late PPH - 24 hours to 6 weeks after delivery (usually 1-2 weeks after delivery)
What are the causes of hemorrhage? (Etiology)
The 4 T’s
Tone (i.e. uterine atony)
Trauma (i.e. lacerations of genital tract)
Tissue (i.e. retained placenta or membranes)
Thrombin - (i.e. coagulation problems)
What are some factors that can impact the tone of the uterus (as a risk for postpartum hemorrhage)?
Over-distention of uterus Grand multiparity Anesthetics Prolonged or rapid labour Induction/augmentation Distortions of the uterus Distended bladder History of PPH
What are some factors that can impact the development of a postpartum hemorrhage related to trauma?
Uterine surgery, lacerations of the genital tract
What are some factors associated with the development of a postpartum hemorrage, other than the 4T’s? (Tone, Trauma, Tissue, Thrombin)
Pregnancy induced hypertension
Anemia
Infection
Asian/Hispanic heritage
What are some nursing interventions for hemorrhage, in order to prevent it before it happens?
Avoid traumatic procedures Predict those who may hemorrhage (i.e. start Iv, cross-match) Active 3rd stage best practice! Assess patient frequently Have pt. void every 2 hours
What are nursing interventions for postpartum hemorrhage?
RN to massage uterus
Express clots
Apply pressure PRN
Give oxytoxic drugs IM/IV prn
What are the medical interventions for uterine atony?
Get help, call code
MD to explore uterine cavity and lower genital tract, formulate diagnosis
May perform uterine compression/massage
Depending on cause MD may repair lacerations, remove tissue, pack, perform arterial ligation, B-lynch suture.
Hysterectomy is last resort
What is a first degree perineal tear? (What tissues does it involve)
Perineal skin, vaginal mucosa
What is a second degree perineal tear? (What tissues does it involve?)
Perineal skin, vaginal mucosa, fascia, muscles of perineal body
What is a third degree perineal tear?(What tissues does it involve)?
Perineal skin, vaginal mucosa, fascia, muscles of perineal body, anal sphincter
What is a fourth degree perineal tear? (What tissues does it involve?)
Perineal skin, vaginal mucosa, fascia, muscles of perineal body, anal sphincter, rectal mucosa to lumen of rectum
What is done in the case of retained products of conception causing early postpartum hemorrhage?
Methylergonovine
Cytotec
Exploration and manual removal of products
What is the treatment for late postpartum hemorrhage due to infection?
Antibiotics
What is the treatment for late postpartum hemorrhage due to retained products of conception?
Methylergonovine
What is the etiology of a late postpartum hemorrage?
Abnormal involution related to retained products of conception, or infection
What are some potential sites for a postpartum infectioin?
Perineal infection C-section delivery incision innfection UTI's Group B Strep (risk for baby) Uterine infection Infectious mastitis/breast abscess STD/STI's
What is the incidence rate of Group B streptocccus?
10-30% of women
What are the problems caused by group B streptococcus during pregnancy?
Increased risk of premature labour and perinatal transmission
Increased risk of chorioamnioitis and sepsis
Increased risk of PROM
What parts of the body are colonized by group B streptococcus?
Genital and GI tracts, urethra
How can group B strep be acquired by newborns?
Can be acquired by aspiration or passage (or infected others)
What is considered “Early onset Group B strep”?
1st week of life
What is late onset group B strep? (How does it manifest)
Meningitis
What are the symptoms of early onset group B strep in the neonate?
Pneumoni
Apnea
Sepsis
Shock
What is the incidence of group B strep being contracted by newborns? What is the mortality rate?
1-2%
Mortality rate 5-9% in Canada
How is group B strep managed/prevented from being passed on to baby?
Prevention - identify those who are group b strep positive (vaginal and recta swal at 35-37 weeks)
When should a mother be treated with IV antibiotics in labour?
Mom is group B strep positive (also if group B strep in urine) Temperature > 38 degrees Celcius PROM >18 hours Previous infected baby & PROM Preterm labour
What are common sites for deep vein thrombosis during the postpartum period?
Saphenous or pelvic veins
What is the etiology of DVT during the postpartum period?
Hypercoagulability
Venous stasis
Injury to the epithelium (blood vessel)
What are some associated risk factors for deep vein thrombosis postpartum?
Hydramnious Preeclampsia Operative births History of clots Varicose veins Obesity
What is the treatment for inversion of the uterus?
Put back in, call MD - if not, the patient will hemorrhage
What proportion of women experience mental health disorders in the perinatal period? (pregnancy to 1 year postpartum)
1 in 5
What are four common disorders experienced by women during the perinatal period? (pregnancy to 1 year postpartum)
Depression
Generalized Anxiety Disorder
Bipolar disorder
Psychotic disorders and postpartum psychosis
What is the incidence of major depression in pregnancy?
5-16%
What is the incidence of major depression postpartum? (birth03 months)
4.2-9.6%
What is the incidence of major depression during the first year postpartum?
9.6-31% (similar to the non-perinatal populations)
What are the risk factors for major depressive disorder during the perinatal period?
Greater risk of personal or family history, previous pregnancies
What is the treatment for major depressive disorder during the perinatal period?
Treatment with non-pharmacological and pharmacological methods
What are the common types of anxiety disorders experienced during the perinatal period?
Generalized anxiety disorder
Obsessive-compulsive disorder
PAnic disorders
What are the risk factors for anxiety disorders during the perinatal period?
Previous personal/family or pregnancy history of anxiety disorders
Perinatal period may act as a trigger
What is the treatment for anxiety disorders during the perinatal period?
Treatment non-pharmacological and pharmacological methods
What is the incidence of anxiety disorders during the perinatal period comparted to the general population’?
Rates of GAD may be slightly higher during perinatal period than non-perinatal population
What are the risks associated with a history of bipolar disorder during the perinatal period?
No increase in incidence of bipolar, but increased risk or relapse
Increases risk of postpartum psychosis
What is the treatment of bipolar disorder during the perinatal period?
Supportive
Pharmacological
What is the incidence of postpartum psychosis?
1-2 cases per 1000 live births
When is the typical onset of postpartum psychosis?
72 hours to 4 weeks postpartum
What is the typical duration of postpartum psychosis?
1 day to 1 month and beyond
What are the treatments for postpartum psychosis?
Hospitalization
Pharmacological
Supportive
This is a psychiatric emergency
What is the incidence of postpartum PTSD?
Rates vary 7-16% at one month (full/partial PTSD)
What are the signs and symptoms of postpartum PTSD??
Feeling numb, dazed, flashbacks, intrusive thoughts, difficulty thinking, sleeping
What are the consequences of postpartum PTSD?
Severe dysfunction
Impaired bonding
Avoidance of childbearing
What is the treatment of postpartum PTSD?
Discuss the event and compare it to reality.
Supportive
Pharmacological
Psychotherapy