The Woman with an Intrapartum Complication Flashcards
Birth is one of the most natural processes that we endure
Complications can arise that make childbirth hazardous for the woman and her baby
Friedman’s labor curve
What is typically used as an expectation to how labors should progress
___ birth
Is when birth occurs without a trained attendant present
Precipitous birth
* Could have a normal labor and then a precipitous birth happen
___ labor
Is a labor longer than the expected curve
Can progress 1 cm an hour (the average) - these women will move toward a cesarean delivery
Prolonged labor
___ labor
Is faster than the curve; within 3 hours of labor onset are fully dilated
* Promote fetal oxygenation and maternal comfort
Precipitous labor
A precipitous labor and prolonged second stage could occur
___ labor is one that does not result in the normal progression of cervical effacement, dilation, and fetal descent
Dysfunctional [labor]
See it as a prolonged labor or in unusually short and intense labors
* In true labor, a progressive cervical change is occurring
___ is a general term that describes any difficult labor or birth
* Results as a problem from the 4 “P’s”
- Powers
- Passenger
- Passage
- Psyche
Dystocia
Problems of the Powers
- Ineffective Contractions
- Hypotonic Labor Dysfunction
- Hypertonic Labor Dysfunction - Ineffective Maternal Pushing
Both 1 and 2 can be caused by maternal fatigue, maternal inactivity, fluid and electrolyte imbalances, hypoglycemia, excessive analgesia or anesthesia, maternal catecholamine secretion, and uterine overdistention (in multifetal pregnancies, LGA, polyhydramnios)
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Occurs where contractions are too weak to be effective (occurs in active labor and is associated with uterine overdistention)
* Perform an amniotomy
* Administer synthetic oxytocin
Hypotonic labor dysfunction
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Are uncoordinated, erractic contractions that are painful but ineffective
* See a high uterine resting tone as in placental abruption (low intensity, high frequency contractions)
⇒ 1 way to differentiate this from a contraction is to have a warm water bath
Hypertonic labor dysfunction
Problems of the Passenger
- Fetal Size
- Abnormal Fetal Presentation (military/brow/face presentations)
- Abnormal Fetal Position (OP vs OA vs OT; a poorly flexed head creates a larger diameter)
- Multifetal Pregnancies (leads to distention of the uterus; 1 vertex, 1 breech)
- Fetal Anomalies (e.g. fetal tumors)
Fetal size
- Due to issues of CPD (cephalopelvic disproportion)
Macrosomia - large babies
Shoulder dystocia - head gets delivered but shoulders stuck at pubic bone; is an obstetric emergency
Which is the best fetal presenting position?
A
The cervix will dilate to 10 cm
Describe each presenting position of the fetus.
A = flexed, head down
B = military
C = Brow
D = Face
Problems of the Passage
Pelvis
Maternal soft tissue obstructions
* Increased risk of uterine rupture
* Consider maternal bladder
Pelvis Types
- Gynecoid
- Platypelloid
- Android
- Anthropoid
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Occurs in 25% of white women
The next “best” pelvis shape to gynecoid
Anthropoid
?
Occurs in 50% of women
Is of the “best” shape of pelvis to have
Gynecoid
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Occurs in 30% of women and leads to a poor prognosis
Android
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Occurs in 3% of women and leads to a poor prognosis
Platypelloid
Problems of the Psyche
Remember: when the body perceives stress, it does what?
- Enters a fight-or-flight mode
- See increased glucose consumption which has a decreased energy supply for the uterus
- Maternal release of catecholamines - affects uterine perfusion and uterine contractility (mother’s contractions and pushing efforts will be less effective)
- Psyche will initiate problems of the powers
- Increase pain perception = decreases pain tolerance and increases anxiety and stress
What can we do?
- Maintain a good relationship with the patient
- Provide a good and comfortable environment
- Provide education
- Use pharmacological and non-pharmacological techniques
Premature Rupture of Membranes (PROM)
* Rupture of the amniotic sac before the onset of true labor
* Do not confuse with preterm premature rupture of membranes (pPROM)
* Increased risk of infection for both the mother and the baby
- Can be caused by infections (GBS+, chorioamnionitis, gonorrhea), a weak amniotic sac, previous preterm births, vaginal intercourse, maternal stress, and nutritional deficiencies
Planning interventions:
Consider gestational age
Monitor for oligohydramnios (low amount of amniotic fluid)
Preterm Premature Rupture of Membranes (pPROM)
Premature rupture of membranes is when the membranes rupture earlier than the ___th week of gestation, with or without contractions
37th
Membranes have broken which can lead to different complications
* Consider the respiratory status of the infant at birth
PROM/pPROM Management
* Confirm true membranes rupture
Very common that a woman could be incontinent of urine and think her membranes have ruptured
* Based on gestational age
At or near term ⇒ likely to push towards delivery
Preterm ⇒ try to prolong delivery to give fetus more time to grow and develop
- Can give mother corticosteroids like betamethasone to accelerate fetal lung maturation
Discharge Instructions for PROM/pPROM
- Avoid sexual intercourse or insertion of anything into the vagina (due to increased risk for infection due to membrane rupture)
- Avoid breast stimulation and orgasm if preterm (this can initiate contractions)
- Take temperature at least four times per day, report if greater than 100°F (could be a sign of an intra-uterine infection)
- Maintain any activity restrictions
- Report any uterine contractions or foul-smelling vaginal drainage
Preterm Labor (PTL)
Labor onset after the ___th week of pregnancy but before the end of the __th week of pregnancy
Greatest risk is newborn may experience ___ (whenever possible delay labor to administer betamethasone)
Education is key for prevention
20th, 37th
respiratory distress
Remember,
Labor onset <20th week is a spontaneous abortion
37+ weeks is a term delivery
Symptoms of Preterm Labor
* Uterine contractions that may or may not feel painful
* Uterine cramping similar to menstrual cramps
* Sensation that the fetus is “balling up”
* Constant low backache or intermittent low back pain
* Sensation of “pelvic pressure” [fetal descent]
* Pain, discomfort, or pressure in the vulva or thighs
* Change or increase in vaginal discharge
* Abdominal cramps with or without diarrhea
* A sense of “feeling bad” or “coming down with something”
Predicting Preterm Birth
* Cervical length (done via US [noninvasive])
* History of preterm births
* Positive ___ (obtained via a speculum exam; if present = labor likely in the next 2 weeks)
* Infections (presence of which can start labor)
(fFN) fetal fibronectin
Identifying and Stopping Preterm Labor
* Notify provider of any possible signs of PTL
* Increase frequency of prenatal visits in high-risk patients
* Identify and treat infections that may cause PTL (e.g. looking at urine)
* Identify any other causes of preterm contractions (after orgasm/intercourse, infection/dehydration)
* Activity restrictions in high-risk or at-risk patients
* Hydration
* Ensure it is safe to continue pregnancy before implementing measures to stop labor
* Tocolytic administration (e.g. medications to help relax the uterus to stop contractions)
Medications Used in PTL
___ ___ (a smooth muscle relaxer)
* 1. Calcium Antagonist (e.g. ___)
* 2. Prostaglandin Synthesis Inhibitors (e.g. indomethacin)
* 3. Beta-adrenergics (e.g. ___)
! Corticosteroids (e.g. betamethasone)
- Is what will help accelerate fetal lung maturity
- Give over 2 doses
- Takes about 24 hours before ready to deliver fetus
- Monitor mother throughout and try to delay labor to reach mark
Magnesium Sulfate
nifedipine
terbutaline
Prolonged Pregnancy
* Pregnancy lasting greater than ___ weeks
* Most often results from inaccurate EDD
- Instead of a 28-day cycle has a 32-day cycle or 24-day
* Placenta does not function effectively (see more calcifications in the placenta; fetus is not being well oxygenated)
* Oligohydramnios
* Increased risk of meconium-stained fluid (MSF) [can lead to risk of respiratory distress at delivery]
42
Collaborative Care and Management of Prolonged Pregnancy
- Establish accurate gestational age measurements
- Can be off by 2 pounds on fetal weight - Assess fetal condition
- Watch fetal heart monitor
- Fetuses >42 weeks have high risk of stillbirth - Support the woman’s physiological and psychological fatigue
Intrapartum Emergencies
Placental Abnormalities
* Placenta accreta
* Placenta increta
* Placenta percreta
All of these lead to a high risk of PPH and peri-partum hemorrhage
A hysterectomy may be required in any of these conditions (especially like PP because it goes through the uterus)
Note scarring from C-section in image
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Occurs when the placenta penetrates through the uterus
Placenta percreta
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Is an adherent placenta
Stays pretty stuck to uterine wall
Hard for it to attach and come out at delivery
Placenta accreta
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Is a placenta that penetrates into the uterine muscle
Even more difficult to detach and release
Think about the wound left afterwards
Placenta increta
Prolapsed Umbilical Cord
* Slips down after membrane rupture, subjecting it to compression between the fetus and the pelvis
* Can occur immediately or at any duration after the membranes rupture
- In an AROM
- Even at a higher risk if we rupture membranes while fetus is still higher up in the pelvis (haven’t hit 0 station)
- Poor fit of fetus in pelvic inlet
- With polyhydramnios because there is more fluid pulling
* Causes ___ = impacts fetal oxygenation and can be fatal
* Interferes with fetal oxygenation and can be fatal
cord compression
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Is when the cord can be seen protruding from the vagina
Complete cord prolapse
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Occurs when the cord is compressed between the fetal presenting part and pelvis but cannot be seen or felt during vaginal examination
Occult (hidden) prolapse
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Occurs when the cord cannot be seen but can probably be felt as a pulsating mass during vaginal examination
Cord prolapsed in front of the fetal head
Moving to a C-section…
Uterine Rupture
A tear in the wall of the uterus
* Complete rupture
* Incomplete rupture
* Dehiscence
Which is the most common?
Dehiscence
Dehiscence (most common)
* At the site of a previous scar on the uterus; a prior C-section
* Increased risk if woman had a classical incision (a cut upwards)
* Also increased risk if there’s been multiple incisions (e.g. multiple C-sections)
* Can happen in an unscarred uterus (from a thin uterine wall, blunt trauma to uterus or abdomen) or if there are overly intense uterine contractions
Symptoms of Uterine Rupture
* Abdominal pain and tenderness
* Chest pain, pain in the shoulder area, between the scapulae, or pain on inspiration (because fluid filling into abdomen irritates diaphragm)
* Hypovolemic shock caused by hemorrhage
* Signs of impaired fetal oxygenation
* Absent fetal heart sounds
* Palpation of the fetus outside the fundus
Nursing Considerations with Uterine Rupture
* Be aware of women who are at risk for uterine rupture
* Be cautious with administration of Oxytocin [can cause tachysystole]
* Hypertonic (frequent, strong, painful but ineffective) contractions occur in stimulated and unstimulated labor (oxytocin-administered)
* Excessive postpartum bleeding with a firm fundus can be a sign of birth canal trauma, including low uterine rupture
* Bleeding may be concealed - women will develop signs and symptoms of hypovolemic shock quickly
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The uterus completely or partially turned inside out, often during the 3rd stage of labor (after baby is born and awaiting expulsion of placenta)
Uncommon, but potentially fatal
Leads to hemorrhage, shock, and severe pain (very rapid onset of all 3)
Uterine inversion
Uterine inversion can be caused by;
* Pulling umbilical cord before placental detachment
* If fundal pressure is applied during birth
* Give fundal pressure on an incompletely contracted uterus = fundal massage
* From increased abdominal pressure or uterine wall weakness
* From fundal-placental implantation
Quick action by nursing and medical personnel is essential to prevent maternal morbidity and mortality.
- At high risk for losing high amounts of blood volume quickly
- Give tocolytics then oxytocin
- Keep indwelling catheter in
- If this happened once, woman at risk of it happening again in future pregnancies
- OB will start to try to replace uterus through vagina (takes a fist and places it into vagina to hold it up and into spot)
- Next, head to OR for laparotomy and replace
- In severe cases, a hysterectomy may be needed
- Have several units of blood on hand (initiate mass transfusion protocol)
Anaphylactic Syndrome
- Formally termed ___
- Occurs when amniotic fluid is drawn into maternal circulation and carried to the woman’s lungs
- Fetal particulate matter (skin cells, vernix, hair, meconium) blocks pulmonary vessels
- Signs and symptoms include: abrupt respiratory depression, depressed cardiac function, and circulatory collapse
- High risk of disseminated intravascular coagulation (DIC)
- Often fatal
Amniotic Fluid Embolism (AFE)
Anaphylactoid Syndrome Management
* Cardiopulmonary resuscitation and support
* Oxygen and mechanical ventilation
* Correction of hypotension
* Blood component therapy (fibrinogen, packed RBCs, platelets, FFP) [especially if DIC develops]
* If still pregnant and cardiac arrest occurs, immediate cesarean delivery (could be at bedside)
Intrapartum Trauma
- Common causes are motor vehicle accidents, assault, or suicide
- Types of trauma: blunt, penetrating (e.g. glass breaks through), burns, electrical injury
- May cause neurological deficits of the fetus
- The most common cause of fetal death is death of the mother (suicide/homicide)
- Monitor for S/S of abruptio placentae and preterm labor
