Week 3: L&D Complications Flashcards
Triaging patients
• Chief Complaint
• Determine Fetal Wellbeing (EDC)
• Rapid HTT Assessment (why are they here)
• Educate Patient (POC)
• Review of Medical History (G’s&P’s, delivery type, medical conditions, meds)
• Report to MD (Orders)
What are the 4 P’s of Labor?
•Power (uterine contractions)
•passageway (bony pelvis & soft tissue)
•passenger (baby, membranes, placenta)
•Psyche (woman’s emotional structure)
What is the fetal attitude?
The position on the baby in the uterus.
•head should be ‘flexed’ (head tucked)
•head extended (causes neck injury/problems)
What is fetal Lie?
The relationship of fetal spine to mothers.
•longitudinal (wanted! Can feel head upon vaginal exam)
•oblique (this baby may rotate/may not)
•Transverse (will need c-section)
What is fetal presentation?
•Cephalic/Vertex (head down; ideal)
•Face/brow (can be delivered vaginally with manipulation)
•breech (upside down. if baby comes out butt 1st the head can get stuck and the pelvis can clamp on the neck; c-section)
•Shoulder (c-section)
Explain Pelvis station
•”Station-measurement of the progress of decent in reference to the ischial spine”
-3 to -1 = still high in pelvis
0 station = baby is at bony pelvis
+1 to +3 = baby is passed bony pelvis and ready for delivery
Define Ballotable
Ballotable- Physical exam which the hand is inserted in the vagina and can push against the baby’s head which can be “bounced” back and forth
What factors affect a patient’s Psyche?
•Past experiences (affect current situations/feeling)
•Fatigue
•Fear/Anxiety
•Environment
•Support System
•Motivation
•Knowledge /Preparation
•Sense of Control
Mechanism of Labor
•Lightening or Dropping (physical drop of baby into pelvis)
•Braxton Hicks (exercise, dehydration. Won’t dilate cervix, normally painless).
•Vaginal discharge increases
•Cervix ripens (softens/ gets thin for delivery)
•Nesting (getting everything ready for the baby)
•Weight loss (Hormonal fluid shift 24-48 hours before the onset of labor)
•Rupture of membranes (SROM)
Stage 1 of labor
Stage 1 has 3 phases:
A) latent
-the longest phase
-cervix 1-4cm
-contractions (mild) 15-30 min apart
B) Active phase
-cervix dilation 5-7cm
-contractions (moderate) 3-5min apart
C) Transition Phase
-very intense
-cervix 8-10cm
-contractions (strong) 2-3min apart
Stage 2 of Labor
•Complete dilation
•Progress is measured by fetal station
•Increase in bloody show
•Urge to push begins (can’t really stop)
•Laboring down in the patient with an epidural (tell them to use muscles like they’re bearing down)
Stage 2 of Labor cont.
Delivery!
•RN Responsibilities for mother :
•Vital signs
•Preparation for delivery (beta-dine cleaning)
•Coaching (breathing, pushing)
•MD notification (when baby is crowning)
•RN newborn responsibilities :
•Assessments
•Resuscitation (code white)
•Documentation & Infant Identification •Facilitate bonding
What is a nuchal cord?
When the umbilical cord is wrapped around baby’s neck and cutting off circulation/oxygen. Dr may cut cord early at moms perineum to save baby
Stage 3 of Labor
“From the moment baby is born to the delivery of the placenta”
•Contractions began again until the placenta is expelled
•takes 5-30 min
•After expulsion, immediately began fundal massage & start Pitocin bolus to stop bleeding.
Stage 4 of Labor
•Recovery 1-4 hours after birth
•Monitor VS ( typically q15 for 1 hour)
•Monitor lochia
•Provide warmth and food
•Support breastfeeding
Why would we induce Labor?
•Over due date
•PIH / Maternal health
•Fetal demise
•PROM (Premature)
•Suspected fetal jeopardy
•Macrosomia (big baby)
•Post date (placenta ages)
•IUGR (interuterine growth restriction; small baby)
•Fetal compromise
What do we need to know about water breaking?
- Time it broke
- Is the fetal HR okay? (The break may affect this)
- Fluid characteristics (color: straw, odor: distinct, note the amount)
Cervical ripening agents
•cervidil (looks like a flat disc with a string like tampon. Stays in for 12 hours. Softens cervix and induces light contractions)
•cytotec (misoprostol) PO or vaginally
(Much smaller dose for this reason)
Explain Bishop’s Score
“Determines if cervix is ready for contractions or not”
•position (posterior 0, midline 1, anterior 2)
•consistency (firm 0, medium 1, soft 2)
•effacement % (0-30% 0, 40-50% 1, 60-70% 2, >80% 3)
•dilation (closed 0, 1-2cm 1, 3-4cm 2, >5cm 3)
•station (-3 = 0, -2 = 1, -1-0 = 2, +1-+2 = 3)
Induction vs Augmentation
•Augmentation = Increasing strength and frequency of contractions
•Induction = starting from scratch
•Mainline IV LR
•Secondary bag with *20 units of
Pitocin 1000cc’s
•Start with 2 mu/min.
•Increase q 30 mins by 2 mu •Maximum 20 mu (Notify MD)
What are the options for pain in Labor?
•Non-Pharmacologic Interventions: (Hydrotherapy, Acupressure, Position changes, Music (R&R), Teaching.
Effleurage: early labor, rubbing stomach. Sacral massage: late labor
•IV pain medication (Nubain, Stadol, Dilaudid, Phenergan, Fentanyl, Morphine)
•Epidural: causes low BP (give IV bolus of LR 1,000-1,500)
*(if Pt has previous Hypotension or on anticoagulants they Won’t give an epidural)
*must know platelet count. (If it’s below 100 anesthesiologist won’t do the epidural)
Why is a patient in labor in pain?
•Tissue ischemia
•Cervical dilation
•Pressure & pulling of pelvic structures
•Distention of vagina and perineum
Advantages of epidural
•Pt. is alert and awake
•Comfort
•Muscle relaxation
•Little fetal depression from drugs
•May increase analgesia to anesthesia
•High pt. satisfaction
Risks of epidural
•Increased Risk of C-Section
•Prolonged 2nd Stage
•Ineffective pushing
•N &V
•Hypotension
•Delayed respiratory depression (24 hrs.) sit Pt straight up if they’re having hard time breathing
•VS q 2-5 mins x 15 mins
Epidural complication: headache
“Spotty” or ineffective
wet tap/spinal headache: (spinal fluid leaking into space. use moms own blood and inject into spinal leak to make patch).
•Cascade of invasive interventions: Give fluids and ephedrine IV push to get BP back up during epidural complication. If it doesn’t help, they go to c-section.
Episiotomy vs laceration
Episiotomy = incision made by Dr.
Laceration = 1-4th degree (skin, fatty tissue, muscle, torn all the way through)
Forceps vs vacuum delivery
Expedites delivery of the fetus due to fetal distress or maternal exhaustion.
Forceps is rarely used and leaves marks on baby
Vacuum can cause head trauma (cephalahematoma, subgleal hemorrhage)
C-Section delivery : pre-op
•Planned vs. Emergency
•Obtain informed consent
•Pt must have a IV and a foley
•Abdominal prep
•Emotional support for mother and support person
•Administer preop meds..What are they? (Vicitra, oral liquid med to help with vomiting to prevent aspiration of stomach acid)
C-Section delivery : post-op
•Monitor VS
•Fundal assessment and massage
•Manage Pain
•Encourage early ambulation, turn cough, deep breathing
•Encourage bonding and breastfeeding
Reasons for c-Section
•CPD -cephalopelvic disproportion (baby head too big to fit in pelvis)
•Medical Conditions
•Failure to progress (baby isn’t dropping/moving to pelvis to deliver)
•Repeat section or classical incision
Fetal indications for c-section
•Bad Position
•Fetal Intolerance to labor (HR drop)
•Prolapsed umbilical cord (cuts off oxygen and blood)
•Multiple gestation (all babies need to be facing down, doesn’t normally happen)
•Uterine Rupture (uterine muscle rips open, baby ends up in open abdomen)
•Placenta Previa (starts hemorrhaging because placenta wants to come out before the baby and blocks passageway)
C-Section: recovery
•EKG
•Pulse Ox
•Vital Signs
•Maintain IV
•Fundal assessments
•Anesthesia level (Aldrete score)
•Clean & Warm
Premature rupture of membrane (PROM)
“When the amniotic fluid membrane ruptures before the onset of labor, gestational age determines plan of care”
•Under 37 weeks is Premature Preterm Rupture of Membranes (PrePROM)
•goal is to get Pt to at least 34 weeks and babies do fairly well
How do we determine if membranes have truly ruptured? (PROM)
•fluid pooling (using speculum)
•nitrazine (Q-tip swab. If it reacts bright blue it’s amniotic fluid)
•Ferning (lab test- amniotic fluid becomes crystallized)
What do we do when a patient ruptured prematurely?
•Avoid vaginal exams (too much bacteria can cause infection)
•Give antibiotics
•monitor baby
Prolapsed umbilical cord
EMERGENCY 🚨 ; baby is not getting oxygen d/t compression of cord
•cord is visible or palpable
•heart rate is slow, decelerations
•nurse will have to get on Pt bed and stick hand up in the vagina and push the baby’s head up to take pressure off of the cord. Will get wheeled to OR and Dr will do emergency c-section
Supine hypotension syndrome
When supine vena cava & aorta compressed by baby and causes hypotension
*pt needs to tilt to side (left is preferred) with pillows to take pressure off of vena cava
Define preterm labor
After 20th week but before 37 weeks
Who is at risk? = multifetal pregnancy, anemia, younger than 18/older than 40
•Contractions can be painful or painless, diarrhea, low back pain, pelvic pressure, + Fetal Fibronectin Cervical Swab
•Nursing Focus: Keep the patient pregnant, Hydrate, and
•steroids:
-Betamethasone = steroid for baby for lungs/surfactant. 2 doses 24 hours apart)
-magnesium sulfate(relaxes uterine muscle to prophylactically protect brain bleed for baby)
-antibiotics
-progesterone IM or vaginally (to ward off labor)
Preterm labor Tocolytic meds
Tocolytics- slow or stop contractions
•Terbutaline (Sub-Q)
•Indocin (PO)
•Procardia (PO)
Precipitous Delivery
•Labor lasting less than 3 hours
•Stay with your patient, ensure delivery table and supplies are ready, have NICU team present
• Apply gentle upward pressure on the fetal head
•Check for cord around the neck
•Apply gentle downward pressure to move the anterior shoulder under the pubic symphysis
•Dry and place the infant on the mothers chest
•Allow the placenta to separate naturally
Shoulder dystocia
Emergency 🚨
Baby shoulder gets stuck behind pubic bone. “BE CALM”
•Breath, do not push; lower head of bed
•Elevate legs into McRoberts position (exaggerated lithotomy)
•Call for help
•Apply suprapubic pressure
•enLarge vaginal opening/ episiotomy
•Maneuvers (not tested)
Amniotic fluid embolism
Emergency 🚨
“The debris found in the amniotic fluid becomes trapped into the pulmonary arterioles” (Usually a fatal event to the mother)
•random, Abrupt onset of respiratory distress, chest pain, cyanosis, fetal bradycardia
• Began life saving measures, CPR, IV fluid, blood products, to correct coagulation failure. Deliver baby via C/S (usually perimortem: mom dies, baby lives)
• If initially survived; prepare for blood products, to correct coagulation failure=Disseminated intravascular coagulation (DIC).
Uterine rupture
Emergency 🚨
•Direct communication between the uterine cavity and peritoneal cavity
•who is At risk: Previous C/S, multifetal pregnancy, polyhydramnios, random occurrence
•Presents as: Abdominal pain, tenderness, rigid abdomen, absent FHT, signs of maternal shock, fetus palpated outside of uterus.
•Emergent C/S, treat for hypovolemic shock
Uterine inversion/prolapse
Uterus protrudes outside of the vagina -Dr. Shoves uterus back in from inside out position
•monitor for hemorrhaging and shock signs
•Pain management during the replacement of the uterus into its correct position
