the rest of week 5 Flashcards
what is amniotic fluid embolism (APE) or anaphylactoid syndrome?
Introduction of amniotic fluid into the circulation of the labouring patient during labour, during birth, or within 30 minutes after birth.
clinical manifestations of AFE
-Respiratory distress
-Restlessness
-Dyspnea
-Cyanosis
-Pulmonary edema
-Respiratory arrest
-Circulatory collapse
-Hypotension
-Tachycardia
-Shock
-Cardiac arrest
-Hemorrhage
-Coagulation failure
-Uterine atony
-mortality rate is 61% or higher
risk factors for AFE
advanced age, non-White race, placenta previa, pre-eclampsia, and forceps-assisted or Caesarean birth.
interventions for AFE
-Oxygenate.
-Administer oxygen by nonrebreather face mask (10 L/min) or resuscitation bag delivering 100% oxygen.
-Prepare for intubation and mechanical ventilation.
-Initiate or assist with cardiopulmonary resuscitation. -Tilt pregnant patient 30 degrees to side to displace uterus.
-replace fluid loss via IV
-administer blood- packed cells, fresh frozen plasma
-insert in-dwelling catheter and measure hourly urine output
-FHR/maternal status
-prepare for emergency birth once pt’s condition has stabilized
what is the bishop score?
-to see if induction is successful
-includes, dilation, effacement, station, consistency, position
Cervical ripeness is the most important predictor of successful induction.
chemical method of induction -Cervical ripening agents
Chemical agents: ripens the cervix, making it softer and causing it to begin to dilate and efface; it stimulates uterine contractions
-prostaglandins E2
-cervidil insert and prepidil gel
Cervidil insert
placed transvaginally into the posterior fornix of the vagina. removed after 12 hours or at the onset of active labour or abnormal fetal heart rate and patterns occur.
Keep the Cervidil insert frozen until just before insertion and warming is needed.
-Have the patient void before insertion.
-Prepare to pull the string to remove the insert if significant adverse effects occur. Delay initiation of oxytocin for induction of labour for 6 hours after last instillation of gel or at least 30 to 60 minutes after removal of the insert
Prepidil Gel
administered through a syringe into the vaginal canal just below the internal cervical os.
Bring the Prepidil gel to room temperature just before administration avoid force with hot water or microwave
-have the pt void before insertion
-Assist the patient in maintaining a supine position with lateral tilt for at least 30 minutes after insertion of gel or for 2 hours after placement of insert.
methods of induction: mechanical
-to to ripen the cervix by stimulating the release of endogenous prostaglandins
-balloon catheters (like a foley) is inserted through the intracervical canal
-catheter balloon is inflated above the internal cervical os with 30 to 50 mL of sterile water.
-pressure and stretching of the lower uterine segment and cervix stimulates the released of endogenous prostaglandins
-balloon will fall out when dilation is 3cm or removed after 24 hours
what are the contraindications for mechanical methods of induction?
-low-lying placenta
-antepartum haemorrhage
-rupture of membranes
-evidence of lower tract genital infection
Hydroscopic dilators
-Hydroscopic dilators-substances that absorb fluid from surrounding tissues and enlarge
-Laminaria tents (natural cervical dilators made from desiccated seaweed)
-Lamicel synthetic dilators containing magnesium sulphate
-inserted into the endocervix without rupturing the membranes
-expand as fluid is absorb, causing cervical dilation and the release of endogenous prostaglandins.
methods of Induction: Mechanical and physical methods
-sexual intercourse (prostaglandins in the semen and stimulation of contractions with orgasm)
-nipple stimulation (release of endogenous oxytocin from the pituitary gland)
-ambulation/walking (gravity applies pressure to the cervix, which stimulates the secretion of endogenous oxytocin)
Methods of Induction: Alternative and Amniotomy
Amniotomy: artificial rupture of membranes [AROM]
when do we initiate this:
-presenting part of the fetus should be engaged and well applied to the cervix
-there is no active infection of the genital tract like herpes
-HIV status is negative or viral load is low
-labour usually begins 12 hours of the rupture but we can’t predict outcome of brith or time which is why we combine it with oxytocin
assessment after giving amniotomy?
-color, odour, amount, consistency, meconium or blood
what are the complications of amniotomy?
-Chorioamnionitis resulting from prolonged rupture without labour.
-Variable FHR deceleration patterns may due occur due to cord compression resulting from umbilical cord prolapse or decreased amniotic fluid.
Oxytocin
-Stimulates uterine contractions
-Used for induction or augmentation of labour
-Administered IV in saline or lactated Ringers via a pump
-goal of oxytocin administration is to produce acceptable uterine contractions as evidenced by a consistent pattern of three to five contractions every 10 minutes
dosage of oxytocin
-The IV solution containing oxytocin should be mixed in a standard concentration. Concentrations often used are 10 units in 1 000 mL of fluid, 20 units in 1 000 mL of fluid, or 30 units in 500 mL of fluid.
* Isotonic IV solutions (e.g., 0.9% sodium chloride, lactated Ringer’s) are used to avoid electrolyte imbalance.
* Oxytocin is administered intravenously through a secondary line connected to the main line at the proximal port (connection closest to the IV insertion site). Oxytocin is always administered by pump.
* Oxytocin administration is started at a low-dose or high-dose regimen. Dosage is increased per protocol until an adequate contraction pa ern is established.
* The goal of oxytocin administration is to produce acceptable uterine contractions as evidenced by a consistent pa ern of three to five contractions every 10 minutes.
* Once labour is established, oxytocin is maintained at or decreased to a rate adequate for continued labour progress.
oxytocin indications
-Suspected fetal jeopardy (e.g., intrauterine growth restriction)
-Inadequate uterine contractions; dystocia
-Prelabour rupture of membranes
-Post-term pregnancy
-Chorioamnionitis
-Medical concerns in pregnant patient (e.g., severe Rh isoimmunization, inadequately controlled diabetes, chronic renal disease, or chronic pulmonary disease)
-Gestational hypertension (e.g., pre-eclampsia, eclampsia)
-Fetal death
Contraindications of oxytocin
-Abnormal fetal heart rate
-Cephalopelvic disproportion, prolapsed cord, transverse lie
-Placenta previa or vasa previa
-Prior classic uterine incision or other uterine surgery
-Active genital herpes infection
-Invasive cancer of the cervix – bc risk of bleeding
-Previous uterine rupture
oxytocin reportable condition (immediate)
-Uterine tachysystole (with or without FHR changes)
-Abnormal fetal heart rate and pattern (absent baseline variability and any of the following:
recurrent late decelerations,
recurrent variable decelerations
-bradycardia prolonged decelerations)
-Suspected uterine rupture
-Inadequate uterine response at 30 mU/min
nursing care during oxytocin
-Assess level of the labouring patient’s discomfort and pain and the effectiveness of pain management.
-Monitor fetal status using electronic fetal monitoring and evaluate tracing
every 15 minutes and with every change in dose during the first stage of labour
every 5 minutes during the active pushing phase of the second stage of labour.
-Monitor the contraction pattern and uterine resting tone
every 15 minutes and with every change in dose during the first stage of labour and every 5 minutes during the second stage of labour.
-Monitor blood pressure, pulse, and respirations every 30 to 60 minutes and with every change in dose.
-Assess intake and output; limit IV intake to 1 000 mL in 8 hours; urine output should be 120 mL or more every 4 hours.
-Monitor for adverse effects, including nausea, vomiting, headache, and hypotension.
Observe emotional responses of labouring patient and their partner.
Measures if any reportable conditions should occur w/ oxytocin
-Discontinue use of oxytocin per hospital protocol and notify primary care provider immediately:
-Turn patient onto lateral position.
-Give IV bolus if patient is hypovolemic or hypotensive.
-If there is evidence of hypoxia or hypovolemia in the patient, administer oxygen by nonrebreather face mask at 8 to 10 units/min or per protocol or primary health care provider’s order. Oxygen is reserved for maternal resuscitation in the presence of maternal hypoxia or hypovolemia, NOT for fetal resuscitation.
-Prepare to administer nitroglycerine (causes vasodilation), if ordered, to decrease uterine activity.
-Continue monitoring fetal heart rate and pattern and uterine activity.
-give oxygen to mum not baby
Augmentation of Labour
Stimulation of uterine contractions after labour has started spontaneously but progress is unsatisfactory.
-Implemented for management of hypotonic uterine dysfunction
Common augmentation methods
-Oxytocin infusion
-Amniotomy
-Noninvasive methods-emptying the bladder, ambulation, position changes, relaxation measures, nourishment, hydration, and hydrotherap
external cephalic version
-manual turning of a fetus from breech to transverse to cephalic/vertex
what are the contraindications of external cephalic version?
-multiple fetuses- think of dana
-non-assuring fetal stauts
-placenta previa
what are the complications associated with external cephalic version?
-prelabour rupture of membranes
-changes in the fetuses heart rate
-placenta abruption
-placenta previa
-preterm labour
-PROM
-cord prolapse bc u are moving the baby
-multiple gestations
-uteroplacental insufficiency
-fetomaternal hemorrhage
-high risk of c-section
required assessment before external cephalic version
-rule out placenta previa
-determine the fetal position
-locate the umbilical cord bc we don’t want it to prolapse
-detect multiple gestation or any fetal abnormalities
-measure fetal dimensions
induction of labour for pre-eclampsia
-Pre-eclampsia >37 weeks
-Significant maternal disease not responding to treatment
-Significant but stable antepartum hemorrhage
-Chorioamnionitis
-Suspected fetal compromise
-Term prelabour rupture of membranes (PROM) with maternal group B streptococcus (GBS) colonization
Contraindications for induction of labour
-Suspected fetal macrosomia
*Absence of fetal or maternal indication
*Caregiver or patient convenience
