Maternity week 4-2 Flashcards
should dilate
1 cm an hour, or at least be progressing.
latent - how many cm? (latent is zero)
0-5 cm
active - how many cm?
6-10 cm
Induction of nulliparous patients who were induced after 37 weeks for nonmedical purposes,
doubled their chances of having a cesarean birth.
Hypertonic Uterus - what phase is prolonged? (are you hyper, or latent?)
- uterus never fully relaxes
- contractions ineffective
3. prolonged latent phase (2-3cm)
4. reduced placental profusion
Hypertonic Uterus - nursing management (not much but fluids)
Bedrest
Monitor fetal wellbeing
Assess for maternal infection
Promote adequate hydration
Pain management
Educate
Hypotonic uterus - at risk for what?
Hypotonic uterine dysfunction
1. poor quality and intensity
2. arrest of dilation & effacement
3. see this more in the active face of 1st stage (5-6cm)
4. at risk for PP hemorrhage***
hypotonic uterus - nursing management
Administer oxytocin
Assist with amniotomy
Continuous EFM
Assess for maternal/fetal infection
Educate
problems of power - Precipitate labor
Precipitate labor
1. birth <problems of power 3 hours from start of contractions
2. maternal injury
3. fetal traumatic & asphyxia insults
problems of power - Nursing Management
Closely monitor contractions & FHR
May administer tocolytics
Stay with patient
Inform Health Care Provider
Anticipate RN delivery
problems w/ passenger/position - Occiput Posterior Position (takes longer from the back)
Occiput posterior – face up
1. Labor usually longer
2. Maternal exhaustion
3. Extensive caput (fluid bulge on head)
problems w/ passenger/position - nursing management
Pain management
Intense back labor 1st stage
Encourage/Assist patient for position changes
Anticipate operative vaginal delivery (this is forceps or vacuum)
Educate
problems w/ passenger/position - Breech Presentation (frank is extended)
Breech – fetal buttocks, foot, or shoulder as presentation
1. Frank breech – buttocks present with legs fully extended
2. Complete breech – buttocks present with fetus in full flexion
3. Footling/incomplete breech – 1or 2 feet presenting with hips fully extended
problems w/ passenger/position - Breech Presentation - nursing management
Arrange ultrasound to confirm position
Assist with external cephalic version
Trial labor 4-6 hours for progress with unsuccessful version
Prepare for cesarean
Check with provider for Rhogam administration
Educate
Problems with PASSENGER/POSITION - Shoulder Dystocia
Shoulder dystocia – axis of shoulders prevent fetal descent after delivery of the fetal head.
1. fetal injury
2. maternal injury
3. risk for PP hemorrhage
Problems with PASSENGER/POSITION - Shoulder Dystocia - nursing management
Recognize and intervene immediately
McRobert maneuver along with suprapubic pressure (legs behind ears)
Call for help, OR notified
Patient position changes
Educate
Problems with PASSENGER/POSITION - face or brow
Face/Brow present at cervix
1. Poor force against cervix
2. Very rare
3.Associated with fetal anomalies (anencephaly - no brain)
Problems with PASSENGER/POSITION - face or brow - nursing management - prepare for what?
Brow presentation prepare for cesarean birth
EFM for fetal wellbeing
Emotional help patient fetal demise
Educate
breech risk factor - major
cord prolapse
consequences of breech
5,000 new cases of permanent “brachial plexus palsy” a year.
Problems with PASSENGER - Multiple Gestation
More than one fetus
1. higher perinatal mortality rate
2. uterine overdistention
3. Fetal hypoxia
4. Presenting fetus must be in vertex position
Problems with PASSENGER - Multiple Gestation - Nursing Management
EFM for contraction pattern, assess for hypotonia
Confirm gestational age
Notify OR of possible cesarean
Notify NICU of multiple gestation birth (esp if baby is less than 37 weeks)
Educate
percentage of twins
4%
Problems with PASSENGER - Macrosomia
Macrosomia – neonate weight > 4,000 mg
1. fetopelvic disproportion
2, overdistended uterus
3. fetal injury
4. maternal injury
5. maternal fatigue
Problems with PASSENGER - Macrosomia - Nursing Management
Fetal wellbeing
Pain management
Inadequate contraction pattern/strength
Anticipate vaginal operative delivery
Educate
Problems with PASSAGEWAY - Pelvic or Canal Disproportion
Contraction of any 3 of the pelvic planes or swelling of soft tissues or placenta issues.
Failure to descend with adequate contractions
Obstruction of the birth canal
Problems with PASSAGEWAY - Pelvic or Canal Disproportion - Nursing Management
Assess for contraction pattern, cervical dilation
Evaluate for bladder distention
Evaluate for fecal interference
Plan for cesarean birth
Educate
Problems with PSYCHE - Psyche Dystocia
Sympathetic nervous system releases hormones.
1. catecholamines can create myometrium dysfunction
2. norepinephrine and epinephrine can lead to uncoordinated or increased uterine activity
3. increased fear & tension can reduce pain tolerance
Problems with PSYCHE - Psyche Dystocia - Nursing Management
Environment control
Encourage partner participation
Keep patient informed
Encourage relaxation & comfort techniques
Educate
All patients
Monitor vital signs
EFM (external fetal monitoring) (10-15 min an hour to start, then 10-15 every 30 min, then continuous and need to document every 5 min)
Assess fluid balance
Provide physical & emotional comfort
Empower your patient
Preterm Labor
Regular contractions causing cervical change at < 37 weeks gestation (and greater than 20 weeks).
Sequelaeofcomplications
Lifelong disabilities for many
low back ache, discharge. how to tell if it’s preterm labor: can do fetalfirbronectin test to check if it’s really preterm labor, pH paper, ferning test,
preterm labor - Nursing Management
Prediction and prevention
Administering Tocolytics – oral or IV
Administering Antibiotics for presumed or confirmed infections
Corticosteroids
Lab work
Educate
Post-Term Pregnancy - what is the main issue?
Pregnancy lasting > 42 weeks gestation
Unknown etiology
Incorrect dating
Maternal injury- baby can recede also
Fetal injury
Hypoxia
oligohydramnios
main issue is placental deficiency***
Post-Term Pregnancy - nursing management
EFM Fetal wellbeing
BPP
Assessing maternal coping
Anticipate induction
Educate
post maturity syndrome - loss of sub q fat and muscle and meconium stain due to prolonged time in utero***
Labor Induction (before 37 weeks)
Stimulation of uterine contractions by medical or surgical means before onset of labor.
Maternal injury
Fetal injury
Medical reasons only
Labor Induction (before 37 weeks) - Nursing management
U/S fetal/placental positioning
Non-stress test (EFM)
Lab work
Cervical exam (Bishop scoring)
Non-pharmacological
Cervidil or misoprostol
Oxytocin IV
Pain management
Confirm gestational age
Educate
Informed consent
Oxytocin Administration - does it cross placenta?
Side effects – water intoxication, hypotension, & uterine hypertonicity
Short half-life (1-5) minutes, works well for titration
Use facility protocol
Does not cross the placental barrier.
Continuous EFM – document every 15” during active phase and every 5” during2nd stage
Fluid balance assessment
VBAC - what is the main concern? (Volcano rupture)
Vaginal birth after cesarean birth
Contraindicated if they had a classic incision (up and down-rupture more often)
Why did they need a cesarean?
Contraindications
Uterine rupture***this is the main concern
VBAC- Nursing Management
Continuous EFM
Pain management
Consent form signed
Advise OR, Anesthesia of VBAC
Educate
emergency c-section - how fast?
30 min from call to the cut (this is reportable)
Intrauterine Fetal Demise
Fetal death occurring > 20weeks but before birth
Maternal injury
Shock
Induction wanted by most women
Intrauterine Fetal Demise - Nursing Management
EFM for contractions only
Recovery care
Environment
Allow grieving
Allow unlimited time with stillborn
Provide baby mementos
Follow facility guidelines
Educate – support groups
Umbilical Cord Prolapse - when does this occur most often? *
Umbilical cord is either visualized or is palpated with cervical exam.
Hypoxia for fetuscan lead to asphyxia and death.
50% mortality rate
Cesarean birth
most commonly occurs when fluid breaks***
Umbilical Cord Prolapse - nursing management
Assessing EFM
Keep fingers in between cervix and head
Call for help
Trendelenburg or hands/knee position
Immediate cesarean
Educate
Placenta Previa
Complete or partial covering of the internal os by the placenta
Placental separation with cervical dilation
Hemorrhage/hysterectomy
Fetal hypoxia and/or death
Vaginal bleeding > 24 weeks gestation
Vaginal U/S increase the accuracy of diagnosis,all placentas covering part of the cervix are placenta previa, those close to cervix are termed low-lying
Placenta Previa - nursing management
Partial – bedrest, EFM
Measure blood loss
Possible blood transfusion
Check for sepsis
Plan for cesarean delivery
U/S for confirmation
Administer Rhogam if indicated
Administer steroids if indicated
Educate
Uterine Rupture - main symptom* (ruptured my shoulder)
Catastrophic tearing of the uterus at a previous scar.
Sudden fetal bradycardia
Constantabdominal pain, vaginal bleeding, loss of fetal station,maternalhypovolemic shock
Fetalmorbidity or mortality
shoulder pain is one main symptom***
Uterine Rupture - nursing management
Assess maternal history
EFM
Alert OR, anesthesia VBAC is being attempted
Immediate cesarean/hysterectomy
IV fluids for volume replacement
Educate
Uterine Inversion
Uterine inversion occurs when the uterine fundus collapses into the endometrial cavity, turning the uterus partially or completely inside out. It is a rare complication of vaginal or cesarean delivery
●1stdegree (also called incomplete) – The fundus is within the endometrial cavity
●2nddegree (also called complete) – The fundus protrudes through the cervical os
●3rddegree (also called prolapsed) – The fundus protrudes to or beyond the introitus
●4thdegree (also called total) – Both the uterus and vagina are inverted.
Uterine Inversion - cont
Discontinue uterotonic drugs
Call for immediate assistance
Establish adequate intravenous access and aggressive fluid/blood product resuscitation
Do not remove the placenta
Immediately attempt to manually replace the inverted uterus
Give uterine relaxants (tocolytics)
Prepare for surgical repair if the above interventions do not work.
Oxygen
Blood transfusions
Anaphylactoid Syndrome of Pregnancy
Amniotic fluid containing fetal particles enters maternal blood stream blocks pulmonary vessels.
a.k.a. “amniotic fluid emboli”.
Rare and often fatal
1 in 40,000 births with 20% mortality rate (50% in the 1st hour)
Fetal & Maternal hypoxicneurologicdamage
Anaphylactoid Syndrome of Pregnancy - Nursing Management
Recognize symptoms – sudden onset of hypotension, cardiac collapse, and respiratory distress.
Resuscitation,100% oxygen
IV fluids to maintain cardiac output/B/P
Hemorrhage control
Steroids for inflammatory process
Seizureprecautions
Transfer to ICU
Educate
Forceps
Metal instruments look like large tongs
Lock so as not to crush fetal skull
Outlet forceps & Low forceps
Fetal injury
Maternal Injury
Forceps - Nursing Management
EFM
Mark application time, and amount of time for each pull. (work with contractions).
Assess maternal tissues for damage & hemorrhage
Assess fetalface and skull for soft tissue damage
Educate
Vacuum Extractor
Soft cup placed on the occiput with negative pressure
Fetal Injury
Maternal Injury
2 types
Vacuum Extractor - Nursing Management
EFM
Mark application time, and amountof time for each pull. (work withcontractions).
Mark pop-offs
Assess forneonate injury
Assess for maternal injury
Educate
Cesarean Birth
Neonate born through an incision of the abdomen and uterine walls.
Most common surgery in theU.S.
Maternal complications
Fetal injury
Cesarean Birth - nursing management
Preoperative blood work and education
EFM
Type & Cross Blood
U/S for fetal & placental lie
Informed consent
Educate partner
Post-operative care – policy protocol
Educate
