Partner Violence and Obs Emergencies Flashcards
Abuse in pregnancy?
May begin, escalate, or diminish in pregnancy (less common). Most begins during pregnancy but the rates are likely underreported.
Impact of IPV on pregnancy and fetus?
P- delayed/less PN care, increased stress/depression, may have no access to money, inadequate weight gain, increase substance use, increased physical/sexual health complaints
F- physical trauma causing injury/miscarriage, negative effects of behaviours, preterm labour/birth, LBW or SGA
Impact of DV postnatal? on mom and child
Decreased BF, maternal mental health issues associated with difficulties in parenting/mother-child bonding, increased risk of child abuse=risk taking behaviours in teens, and increase risk of aggression/emoitonal disorder/hyperactivity in child
How to assess/screen for IPV?
Providers include questions about violence in assessing patients as part of prenatal care but the nature of clinician-patient relationship/how questions are asked are more important than the screening tool
How can HCP build trust?
Know resources, be supportive, provide info, recognize diversity/avoid stereotypes, find private moment to talk alone, have resources available in offices/bathroom, believe in them/help them, be aware of ACEs, and be trauma informed
What is dystocia? what can it be caused by
Abnormal or difficult labour.
- Problems with powers- hypo or hypertonic uterine contractions, arrested labour (no progress), precipitous labour (contractions start and within 3 hrs baby is out)
- Problems with passenger- breech, cord prolapse, shoulder dystocia, POP (persistent occipital posterior- aims toward back of hip), CPD (pelvic too small for head or baby too big for normal pelvis)
What can dystocia result in ?
Operative delivery- use of forceps, vacuum, C-section
3 types of breech?
- Frank- most common, legs up by ears
- Footling- one or both feet hanging down or coming out of cervix
- Complete- baby sites cross legged on the cervix
How do we dx breech?
Maternal perception of movement (is baby kicking lower), leopoldo’s maneuver (hard moveable part in fundus aka the head), FH auscultated above umbilicus (usually in lower quadrants, preterm/small fetus may still be below umbilicus), vag exam (don’t feel head but bum, maybe get mec on fingers), U/S (only real way to confirm), and passage of meconium if ROM (could mean maybe breech)
Fetal risk for breech?
Cord prolapse common with ROM, injury to aftercoming head could cause ICH or anoxia, preterm breech could cause footling/body delivery before full dilation so head is trapped
Recommendations for breech deliveries? set of criteria?
Try external cephalic version and if unsuccessful: vag birth if OBGYN is skilled in vag breech birth, uncomplicated/term/frank or complete breech/single baby >2800 and <4000 g with flexed head
Plan C section if above criteria not met or if client chooses
What is external cephalic version? and risks
If baby is breech then trained HCP with use hands to move baby/flip it. Need a normal NST and presenting parts can’t be engaged. Give tocolytic to relax uterus before. Risk of nuchal cord (cord around neck because you’re spinning the baby around)
C-section indications?
Active genital herpes, abnormal FHR findings, multiple gestation (3+), cord prolapse, pelvic size (CPD), lack of progression/failed induction, maternal infection, previous C-section (sometimes), fetal anomalies or extremes in size, and placenta problems
Different incisions for C-section?
- Transverse lower uterine segment (most common, horizontal incision)
- Vertical lower segment (seen in very preterm babies)
- Classical incision (in body of uterus, vertical incision, do in severe cases)
Skin incision are different than uterus incisions
What does C-section increase risk for intra and post-op?
I- aspiration, difficult airways management (general anesthesia), PPH >1000 mLs
PO- hemorrhage, infection, poor bladder emptying, paralytic ileus (rare), thrombophlebitis
What does a C-section require and teaching?
Require- establish IV lines, insert in dwelling cath, abdominal prep, ranitidine/sodium citrate (to reduce risk of reflex), NICU present
Teaching- what to expect before/during/after, why its being done, expected sensations, role of significant others
Post op/PP for C section?
AMBULATION!, comfort measure, assess for hemorrhage/infection, what’s their pain, bonding/feeding, and pay attention to fatigue
What is trial of labour after C-section (TOLAC)? common risks
Planning on doing a vag birth after having a previous C/S but depend on indication/type of 1st section (like if you have CPD then cant have another vag delivery). Common risks- hemorrhage, uterine rupture, infant death/neuro complications
What uterine incision qualifies for TOLAC?
Transverse lower uterine segment
TOLAC care?
On continuous EFM, montior contractions, avoid oxytocin (it increase risk of uterine rupture), avoid cervical ripening methods (increase risk for rupturex4), support, be prepped for urgent C-section, and complete pre op work
What does an operative delivery involve and indications for it?
Use of vacuum or forceps when fully dilated/ROM. Indications- fetal indications, maternal (exhaustion, inability to push, lack of rotation- head gets stuck, maternal disease- like having heart condition where HR can’t go above certain rate)
How to prevent operative delivery?
Support throughout labour, mobility, position changes, rest, keep bladder emptying, well hydrated/nourished
considerations for forceps/vacuum use?
Need to be fully dilated/ROM, empty bladder before, know fetal position/pelvis adequacy, give pain meds if able, and be prepared for plan B if it doesn’t work (C/S)
How is vaccum used?
Suction applied to fetal head and doctor pulls with contractions
Complications of vacuum and forceps? newborn vs mom
Newborn- brushing, laceration, edema (common), uncommon are retinal hemorrhage, nerve injury, cephalohematoma, cerebral hemorrhage, skull fracture (with forceps), ICB, hyperbilirubinemia
Mom- genital tract trauma, increased bleeding (PPH), bursting/edema
Nursing care during/after operative delivery
During- attention to bladder, assess fetal wellbeing, document ease of application, time on/# of pulls, any pop offs
After- any lacerations, hematoma for mom, any trauma/injury/jaundice for baby
What is shoulder dystocia? and risk factors for it
Anterior shoulder impacts/gets stuck against mom symphysis pubis which causes fetal shoulder to not deliver spontaneously/failure to deliver. Risk factors- maternal obesity and macrosomic infant (large)
What is the turtle sign?
Head delivers and tightly recoils back so babies head/face gets blue and their face is squished down. Caused by shoulder dystocia
Interventions for shoulder dystocia? ALARMER
ALARMER
A- ask for help
L- lift/hyperflex legs (nurse)
A- anterior shoulder disimpaction by applying suprapubic pressure by standing on footstool or on bed (nurse)
R- rotate posterior shoulder
M- manual removal of posterior arm
E- episiotomy
R- roll over onto all course
Shoulder dystocia complications for client vs fetus?
C- episiotomy, lacerations, hematoma, uterine atony, hemorrhage, bladder or rectal injury
F- asphyxia, practical plexus injury/spinal nerve damage, # of clavichord or humerus, erb’s palsy, death
What is cord prolapse?
Cord proceeds fetal presenting part and is compressed (partial or total). This is an emergency b/c it causes decelerations or absent FHR (you may see the cord or not=occult).
Risk factors for cord prolapse?
Polyhydramnios, long cord, malpresentation (breech, transverse), premature ROM, amniotomy before engaged vertex
How to intervene for cord prolapse?
Get help, prep for C-section, hold presenting part off the cord, assume knee chest position, keep gloved hand in vagina, decrease contractions if able, have warm wet sterile cloth if cord is outside vagina, and complete vag delivery if fully dilated
What is amniotic fluid embolism? risk factors, S+S
Amniotic fluid enters client circulation/obstructs pulmonary system. Risk factors are placental absorption, uterine over distension, trauma, fetal demise, oxytocin use in labour, multiparity, advanced age, and ROM. S+S are difficulty breathing, hypotension, tachycardia, cyanosis, hypoxemia, uterine atony, seizures, DIC, and cardiac arrest
What is uterine rupture? S+S
Complete separation of myometrium with/without extrusion of fetal parts into peritoneal cavity. Requires prompt detection/intervention. S+S are abnormal FHR*, vaginal bleeding/hematura, maternal tachycardia/hypotension/shock, easier abdominal palpation of fetal parts, acute onset of scar pain, chest/shoulder pain, sudden SOB, change in uterine activity
