mgmt of L&D risks Flashcards
maternal risk factors for dystocia
-short stature
-overweight
-CPD
-pelvic obstructions/contracture
-40yo or greater
-uterine abnormalities
-fatigue, fear, dehydration
-hyper/hypotonic uterus
-inappropriate timing of analgesics/anesthesia
fetal risk factors for dystocia
-macrosomia
-malpresentation/malposition
->1 fetus
power problems
-protracted disorders
-arrest disorder
-precipitate labor
protracted disorders
-longer active phase dilation
-delayed fetal descent/failure to descend
-interventions: c-section
arrest disorder
-complete cessation of progress
-dilation stops
-interventions: c-section
precipitate labor
birth 3 hours or less from the start of ctx
risks to infant and mother during precipitate labor
infant
-head trauma
-nerve damage
-hypoxia
-intracranial hemorrhage
mother
-lacerations
-tissue trauma
-uterine rupture
-postpartum hemorrhage
interventions for precipitate labor
-don’t leave the client, call for help
-assist to lateral position, apply O2
-continuous monitoring, pain mgmt, provide reassurance
-dont attempt to stop delivery
-apply light pressure to perineum/fetal
-support the infant
shoulder dystocia
-fetal shoulder is stuck after the head is delivered
-call for help immediately
-place mother in McRobert’s position
-C/S if no success with position changes
-document total time from head to body delivery
risks for fetus and mother when removing baby with shoulder dystocia
fetus: hypoxia, clavicular fracture, brachial-plexus injury
mother: hemorrhage, uterine rupture
risks for baby with shoulder dystocia
-LGA
-maternal previous soldier dystocia
-post date babies
passenger/positon problems
-multiple gestation
-macrosomia
-malpresentation
multiple gestation
-infertility treatments: IVF, ovarian stimulating drugs
-risk for: PPH d/t uterine atony
macrosomia
-fetal weight >4000 g (8lb 13oz)
-risk for: PPH, shoulder dystocia, soft tissue lacerations, fetal injuries
-may require an elective c/s delivery
malpresentation
-OP, longer labor/pushing phase
-face/brow, may require c-section
-breech, c/s delivery
passageway problems
-pelvic shape: favorable?
-CPD: cephalopelvic disproportion
-maternal swelling: soft tissues, cervix
psyche problems
-dystocia caused by hormones released d/t anxiety
-increased fear, tension, pain… decreases contractility
external version
attempt to turn a malpositioned fetus
external version contraindications
-uterine anomalies
-previous c/s
-cpd
-placenta previa
-oligohydramnios
-multifetal gestation
external version risks
-prolapsed cord
-compression
-placental abruption
mgmt of external version
-assess fetal status prior and after procedures
-vitals, watch for hypotension
-assess for ROM, bleeding fetal mvmt
-IVF and tocolytics, if ordered
-rhogam if RH-
preterm labor (PTL)
early onset labor (20-37 weeks)
PTL risk factors
-anything that can cause harm to fetus
-risky behavior
PTL assessment findings
-persistent low backache
-UTI
-vaginal bleedings
-ctx
-ROM
testing for PTL
-cervical length measurement
-BPP
-NST
-early ID is key!!!!!!!!
PTL tx
-mg sulfate, stops hemorrhage and contractions
-monitor for pulmonary edema and toxicity
PTL mgmt
-continuous monitoring, initiate seizure precautions
-documentation q hr
-VS, I&O, FHM, DTRs, total IVF, neuro checks
-toxicity: stop infusion, stat lab, call dr., calcium gluconate
s/s of toxicity
-loss of DTR
-urine output <30mLs/hr
-resp. rate <12/min
-blurred vision
-chest pain
-lethargy
-slurred speech
-h/a
-n/v
-difficulty breathing
drugs used for PTL tx
-nifedipine (Procardia): inhibits calcium from smooth cells, monitor bp & hr, maternal tachycardia
-indomethacin (Indocin): NSAID blocks prostaglandin production, monitor for pulmonary edema & GI stress
-betamethasone (Celestone): promotes fetal lung development, 24-34 weeks, IMx2 24 hrs apart, monitor for pulmonary edema, hypoglycemia, and infection
intrauterine fetal demise (IUFD) assessment
-US, confirms absences of fetal movement and cardiac activity
-hx of decreased fetal movement
-requires induction of labor
IUFD mgmt
-provide support
-assist with grieving
-CLS
-prepare parents for appearance
-allow unlimited time with stillborn
-refer to support groups
-therapeutic communication
post-term pregnancy
-pregnancy longer than 42 weeks
-placenta ages and decreases perfusion
-oligohydramnios, increases risk for cord compression, fetal hypoxia
-high risk for fetal distress!!!!!!!
risks for post term pregnancy
-macrosomia, shoulder dystocia, CPD
-meconium aspiration-> fetal distress
-PPH d/t uterine atony
mgmt of post term pregnancy
-fetal monitoring
-update nursery staff, prep for resuscitation
-support anxiety
labor induction
medically initiation of labor
labor augmentation
mother’s labor has stalled or needs to be sped up via oxytocin or AROM methods
labor induction & augmentation contraindications
-placenta previa
-transverse fetal lie
-umbilical cord prolapse
-previous classical C/S incision
-active HSV
-previous myomectomy
-poor bishop score
bishop score
-used to determine maternal readiness for labor at 39 weeks or greater
-evaluates through scoring: dilation, effacement, station, cervical consistency, position of the cervix
cervical ripening
-increases cervical readiness for labor
-softens, effaces, and dilates the cervix
-performed in conjunction to labor induction or can be performed alone
-mechanical and chemical ripening
mechanical ripening
-balloon dilation
-membrane stripping
-amniotomy
-hygroscopic dilators (seaweed)
chemical ripening
-misoprostol (Cytotec)
-dinoprostone (Cervidil)
-oxytocin (Pitocin)
-can cause hyperstimulation which can lead to fetal distress
oxytocin (pitocin)
-used for induction and augmentation of labor, stimulates ctx
-iv titration
-hospital policy and MD order
mgmt of oxytocin (pitocin)
-obtain NST and SVE prior to starting infusion
-continuous FHM, VS q 15min
-document
-call MD for any fetal distress, d/c if fetal distress occurs or uterine hyperstimulation (<2min apart), and tetanic ctx (<90 seconds)
-educate on s/s to report
amniotomy
-AROM
-deliberate puncture of the amniotic sac to release fluid
-MD only
risks of amniotomy
-umbilical cord prolapse
-infection (maternal or fetal)
-fetal distress
mgmt of amniotomy
-perform SVE prior, if ballotable can have cord relapse
-continuous FHM
-assess amniotic fluid, ongoing until delivery
-obtain temp q 2hr, risk of infection
meconium staining
-amniotic fluid is black, brown, green, or yellow, can be thick or thin
-loss of sphincter control d//t umbilical cord compression, fetal hypoxia, or fetal distress
meconium staining mgmt
-document findings
-notify: MD, RT, neonatal team
-suction mouth/nose when head is delivered
-assess RR, HR, tone
fetal distress
-FHR <110 or >160
-decreased or absent variability
-recurrent decelerations
-fetal activity: hyperactive or inactive
fetal distress interventions
-continuous monitoring, notify MD, call for help
-maternal position change, left or side lying
-IVF bolus LR
-d/c oxytocin
-O2 via facemask at 10L/min
-give terbutaline if ordered (hold if maternal hr >120, or for bleeding)
-prepare for c/s
operative delivery
-assisted delivery of fetus head
-vacuum assisted
-ineffective pushing, fetal distress
mgmt of operative delivery
-lithotomy position
-empty bladder
-FHM
-document pop offs, release of vacuum extraction
infant monitoring with operative delivery
-lacerations
-cephalohematoma
-caput
-bruising
-facial nerve palsy
-subdural hematomas
maternal monitoring with operative delivery
-vag/cervical lacerations
-hematoma
-urinary retention
-hemorrhage
cesarean delivery risks
-infection
-hemorrhage
-UTI
-DVT
-paralytic ileus
-atelectasis
indications of c/s
-high risk pregnancy
-malpresentation
-abnormalities (maternal or fetal)
-multiple gestation
-previous c/s
-OB emergencies
preop care for c/s
-ensure consent
-document time of decision by provider if not planned
-IVF bolus to prevent hypotension
-IV abx if non emergent
-foley, scd, shave, baseline labs
TOLAC
-trial of labor after cesarean
-attempt to deliver or be induced
VBAC
-vaginal birth after cesarean
ACOG guidelines for TOLAC and VBAC
-adequate pelvis
-1 previous c/s delivery with low transverse incision
-no other uterine scars or previous uterine rupture
-OBGYN and anesthesia must be immediately available through active labor
contraindications to TOLAC/VBAC
-cervical ripening agents
-previous classical incision, myomectomy
-obesity, 40yo or greater, inadequate pelvis, inadequate staff/facility
mgmt of TOLAC & VBAC
-consent
-educate on risks and benefits
-document all interventions
-continuous monitoring
-ensure anesthesia, neonatal, and medical staff are aware of current status and prepared for emergency c/s if needed
-advocate for pt
uterine rupture
-uterus tears at previous scar into the abdominal cavity, obstetrical emergency
uterine rupture risk factors
-uterine scars
-prior molar pregnancy
-placenta accreta/increta
-cocaine/crack use
-excessive uterine stimulation
uterine rupture s/s
-abrupt fetal distress or complete loss of FHTs
-acute/continuous abdominal pain
-vaginal bleeding, hematuria
-irregular abdominal wall contour
-loss of station/presenting part!!!
-hypovolemic shock
umbilical cord prolapse
-umbilical cord protrudes through the cervix before presenting part
-cord compression, compromised fetus
umbilical cord prolapse risk factors
-ballotable fetus during ROM
-polyhydramnios
-fetal malpresentation
-prematurity
mgmt of umbilical cord prolapse
-immediately relive pressure off the cord- SVE, maternal position
-call for help
-prep for immediate c/s delivery
placental abruption
premature separation of the placenta, emergency
placental abruption risk factors
-pre-eclampsia
-HTN
-AMA
-uterine rupture
-trauma
-smoking/drug use
-external cephalic version
placental abruption assessment findings
-sudden vaginal bleeding (sometimes none)
-rigid abdomen on palpation, extremely painful!!!
-fetal distress
-no relaxation between ctxs!!!!!
mgmt of placental abruption
-fetal monitoring
-maintain iv access, IVF bolus
-monitor maternal CV status, bleeding, pain, FHT
-immediate c/s delivery
amniotic fluid embolism
-amniotic fluid particles of debris enters maternal circulation, obstructing pulmonary vessels
-causes rapids resp. distress and cardiovascular collapse
-obstetric emergency, rare but often fatal for mother and fetus
amniotic fluid embolism s/s
sudden hypotension, hypoxia, dyspnea, restlessness, cyanosis, pulmonary edema, tachycardia, DIC bleeding, petechiae/ecchymosis, uterine atony, sense of impending doom
mgmt of amniotic fluid embolism
-O2, IVF bolus LR
-Immediate C/S delivery!
-Maternal position change – side tilt
-Continuous monitoring of CV status (VS)
-CPR
-Mainly supportive to maintain resp/cardio function
-**Immediate recognition is key!
