Week 4 (Labour & Birth at Risk) Lecture Flashcards
Critical thinking:
Brim is G3T1P0A1L1 at 41 weeks
Presents to L&D with noticeable anxiety and indicates that her last labour was “unbearable”.
She describes her previous delivery as “traumatic” as forceps were used due to concerns with the fetal heart rate.
What effects of anxiety might impact Brim’s progress of labour?
What priorities for nursing care would be appropriate?
1) Anxiety about previous labour experience
2) Listen to experiences & acknowledge them; Ask what she wants; Post-traumatic counselling after birth
What are the causes of PPROM.
1) Weak amniotic membranes
- If multiple kids or lots of fluid -> water breaks quickly
2) Inflammation
3) Increased uterine pressure
4) Infection of the urogenital track
List the common complications of PPROM for both mom and fetus.
Maternal
- Chorioamnionitis
- Placental abruption
- Retained placenta
- PPH
- Sepsis
Fetal - Intrauterine infection - Cord compression • Fetal HR decr • Variable on fetal monitor • Deceleration
- Cord prolapse
• Baby hypoxic - Premature birth
Case study:
Kelly presents to L&D with signs of preterm labour and 275 weeks gestation. During the admission, Kelly receives betamethasone 12mg IM for two doses x 24 apart. Her contractions stop and no further cervical changes are noted, she is discharged home. Kelly was scheduled for her GTT at her appointment at 28 weeks. Results come back as 12.8mmol/L
Are these results accurate?
No b/c corticosteroids -> hyperglycemia (false-negative result)
What is chorioamnionitis? What are some signs and symptoms? What are the risks? What are the complications? What are the treatments?
It’s a bacterial infection of the amniotic cavity. Labour slows b/c contractions aren’t happening.
S&S: maternal fever, maternal and fetal tachycardia, uterine tenderness, and foul odour of amniotic fluid.
Increased risk associated with prolonged rupture, multiple vaginal examinations, internal FHR and IUCP.
Complications:
- If water breaks & labour occurs days/wks later -> infection
- Multiple vaginal exams (think about if it’ll help)
- Inserting instruments
Treated with IV broad-spectrum antibiotics
Increased likelihood to experience labour dystocia and operative birth (wound infection or pelvic abscess).
What is a prolapsed cord? What are some risks? What are the complications? What are the immediate interventions?
Cord lies below the presenting part of the fetus
Risk of fetal hypoxia (due to decr profusion) from prolonged cord compression
Immediate interventions:
- The examiner places the sterile gloved hand in the vagina and holds the presenting part off the umbilical cord
- Trendelenburg or knee-chest position
- If fully dilated, forceps or vacuum can be performed but often emergency caesarean birth.
- Have pt go on all 4s. Pressure will be put on the baby’s head to relieve pressure
- Emergency c-section (put them under general b/c no time for anything else)
• Loss of control results in strong grief (missing birth b/c under anesthesia) -> rebirth may be done after
What are the maternal and fetal risks of postdates?
Maternal risks:
- Perineal injury related to fetal macrosomia
- PPH
- Infection
Fetal risks:
- Birth injuries
- MEC aspiration
- Stillbirths
What is oxytocin?
Hormone produced from the posterior pituitary gland. It stimulates uterine contractions. This synthetic dose can induce or augment labour.
Discuss the process of oxytocin induction.
IV administration with rate controlled by pump for induction
- Dosage is increased per protocol until an adequate contraction pattern is established
What are the risks associated with oxytocin induction?
Maternal risks: Placental abruption, uterine rupture, c-section, PPH and infection
High alert: monitor for uterine tachysystole
- Over stimulated (no more than 6 contractions in 10 mins, shouldn’t last longer than 90 secs; should have adequate relaxation/break b/w contractions)
What is meconium stained amniotic fluid? What does it look like?What should you be prepared for? What is a complication?
Assess amniotic fluid for meconium after ROM.
The colour is brown/green.
Prepare for potential neonatal resuscitation
- After birth, assess respiratory efforts, HR and muscle tone
- Suctioning may be required of mouth, nose and trachea
Pneumonia is a complication.
True or false: routine suctioning of mouth and nose no longer recommended.
True
What are the risks of meconium aspiration syndrome?
- Often term or postdates
- Intrauterine process vs. aspiration immediately after birth
- Severe form of aspiration pneumonia
What is an amniotic fluid embolism (AFE)? What are the signs and symptoms? When can it occur? What are the maternal risk factors? List some interventions.
It’s amniotic fluid introduced into the maternal circulation.
It’s a rare but sudden, acute onset of maternal hypoxia, hypotension, cardiovascular collapse, and coagulation.
AFE occur during labour, birth or within 30 minutes after birth
Maternal risk factors: advanced age, meconium stained amniotic fluid, placenta previa, pre-eclampsia, forceps-assisted or c-section.
Interventions:
- O2 therapy
- Intubation and mechanical ventilation
- CPR
- IV fluids, blood products (PRBC, FFP)
- Prepare for emergency birth
- Emotional support
What is worse: a frank breech or a single footing breech?
Frank breech = most common & safest
Legs first = most dangerous
What is an external cephalic version (ECV)?
It’s a maneuver your doctor may use when your unborn baby is set up to come out bottom first or feet first.
- HCP can try to externally rotate baby into better positions
What is shoulder dystocia? What are some signs? What are the risk factors? What are some interventions?
Anterior shoulder cannot pass under the pubic arch.
- Pt pushes, it’s there, contraction ends & baby goes back in.
Signs:
- Retraction of the fetal head at the perineum
Risk factors:
- Fetopelvic disproportion
- Macrosomia
- Previous hx of shoulder dystocia
Interventions:
- Position changes (legs flexed apart with knees to abdomen, hands and knees position/squatting)
• Ex: McRoberts Manoeuvre
- Apply low suprapubic pressure
True or false: avoid fundal pressure as a method of relieving shoulder dystocia.
True
What are some indications for the use of forceps? (6)
1) Prolonged second stage
2) Maternal exhaustion
3) Abnormal FHR
4) Abnormal fetal presentation
5) Arrest of rotation
6) Extraction of the head in a breech
What are the prerequisites for the use of vacuum assisted birth? (5)
1) Fully dilated
2) Ruptured membranes
3) Engaged head
4) Vertex presentation
5) Greater than 34 weeks gestation
True or false: vacuum assisted birth is usually used over forceps because there are less complications.
True
What are the maternal and fetal indications for c-sections?
Maternal
- Two or more previous caesarean births
- Specific medical conditions (cardiac or respiratory disease, increased ICP)
Fetal
- Abnormal FHR pattern
- Malpresentation
- Congenital anomalies
- Maternal HIV with high viral load
Maternal-Fetal
- Placenta previa
- Placental abruption
- Dysfunctional labour (CPD, FTP)
- Actives herpes lesions
What are the 2 different incisions that can be done during c-sections? What is the difference?
Pubic line (low incision) is transabdominal
- More likely to have vaginal birth in future
- Safest
- Most common
Vertical incision
- Aggressive to get baby out
- Lots of pain after
- Risk of uterine rupture (subsequent labours)
- They wouldn’t be a candidate for VBAC
What is the success rate for Vaginal Birth after Caesarean (VBAC)? What are the risk factors? What are the benefits and risks? Who is a candidate?
Success rate of 60-80%
Strongest predictors are previous vaginal birth and spontaneous labour.
Benefits: Decrease risk of hemorrhage, infection and shorter recovery.
Risks: Uterine rupture
Candidates for VBAC
- One or two previous low-transverse caesarean
- Clinically adequate pelvis
- No uterine scars or history of uterine rupture
True or false: preterm birth and prematurity describe the length of gestation, regardless of birth weight.
True
What is low birth weight?
Low birth weight describes only birth weight < 2500 g
Differentiate b/w spontaneous and indicated preterm birth.
Spontaneous preterm birth: early initiation of the labour process (PPROM, cervical insufficiency etc.)
- Diagnostic criteria: gestational age 20-37 weeks, contractions, and progressive cervical changes.
- Fetal fibronectin (FFN) can identify placental inflammation may be diagnostic for preterm labour. The sensitivity of FFN is limited
Indicated preterm birth: a means to resolve maternal or fetal risks related to continuing the pregnancy (preeclampsia, GDM, seizures, IUGR etc.)
