WH Delivery Complications Flashcards
Given IV and carefully titrated to achieve an effective labor pattern. Hang the Pitocin bag as a secondary line into the most proximal port to the patient of the main IV line. Then it can be discontinued readily without residual medication in the main line and alternate fluids can be run rapidly. Monitor maternal vital signs closely (per protocol) usually q30m and with every dose change. FHR and toco pattern are assessed and documented every 15 min. Maintain strict I &O. Tachysystole: contractions closer than q2min, longer than 90 seonds, lack of uterine relaxation between contractions
Oxytocin/Pitocin
“difficult birth”. Labor not progressing normally; stalled or very slow progress of dilation, ineffective contraction pattern.
Treatment: IV hydration, augmentation with IV Pitocin or amniotomy (AROM, artificial rupture of membranes). Internal monitoring with IUPC (intra uterine pressure catheter) may be used to verify strength of contractions
Labor dystocia: dysfunctional labor
Fetal heart rate lacking variability, accelerations or normal baseline. Presence of concerning variable or late decelerations. Intrauterine resuscitation: position changes, correction of maternal hypotension, oxygen supplementation, IV fluid bolus, stopping oxytocin infusion or administering tocolytics. Amnioinfusion may relieve cord compression with oligohydramnios. May indicate fetal hypoxia and if persistent, delivery is indicated. Expedite delivery with episiotomy, forceps, or vacuum if crowning, otherwise cesarean section delivery
NRFHR: non-reassuring fetal heart rate
Passage of meconium into amniotic fluid is normal in post term pregnancy. However, it can also be triggered by fetal stress or hypoxia. Presence of thick or particulate meconium fluid can cause meconium aspiration syndrome in the newborn. A neonatal care team needs to be present at the delivery to provide immediate deep suctioning if the newborn is lethargic. Vigorous newborns are not suctioned or only bulb suctioned. as they will have inspired prior to any reasonable suction attempt. Close observation is warranted for first few hours of life.
Meconium-stained fluid
Perfusion of warmed saline through IUPC to increase intrauterine fluid volume to resolve fetal cord compression with variable decelerations and oligohydramnios.
Nursing considerations: fluid is usually hung on a blood warmer prior to infusion. Monitor for fluid leakage from vagina and maintain comfort/cleanliness. Monitor for uterine overdistention (if fluid were unable to escape). Monitor uterine contractions & FHR
Amnioinfusion
Placental surface covers cervical os(opening), requires c/sec delivery before labor
Placenta previa
Vessels from placenta traveling to umbilical cord cross over the cervical os, half of all undiagnosed cases lead to stillbirth, usually a planned c/section at 34-37 weeks (should never labor!)
Vasa Previa
Labor and delivery in under 3 hours. Can be frightening for families as they may not make it to a safe delivery location. At increased risk for PPH (postpartum hemorrhage) and perineal trauma if delivery is uncontrolled. Usually not with a first birth, but common with a third.
Precipitous labor
Any position other than cephalic presentation, occiput anterior. May be able to deliver vaginally with potential longer first and second stages. Unable to deliver vaginally; shoulder, footling breech, transverse lie. If the mother is in labor or has ROM, then decision must be made regarding route of delivery. Cesarean section is the safest route of delivery with malpresentations that are not cephalic (head down).
Nursing care would include IV initiation, FHR evaluation/non-stress test before and after procedure, monitoring toco for contractions, maternal vital signs, ensuring Rhogam administration if appropriate
Malpresentation
Attempting to rotate the breech or transverse baby into a favorable presentation by applying pressure with the provider’s hands on the mother’s abdomen. Usually, 2 providers work together and use ultrasound to guide efforts. This may cause fetal distress, labor, placental abruption or PROM and should be done in a setting where there is the immediate availability of cesarean section if needed.
External cephalic version (ECV)
Back of the fetal head is toward the mother’s front
Occiput anterior
Very frequent as delivery is recommended to resolve most prenatal comps. Not advised before 39 weeks unless complications are severe due to fetal immaturity. Not advised electively- meaning there has to be a medical necessity to induce labor. Spontaneous labor is preferred: shorter, less complications, more likely to achieve a vaginal delivery. Induction process will involve cervical ripening if the cervix is not already somewhat effaced and dilated. A Bishop score is a numerical score determined by the cervical characteristics of dilation, effacement, consistency, and position. This is often used to express cervical “ripeness” or readiness for labor
Induction of labor (IOL)
May involve prostaglandins PV, misoprostol PV, buccally, or PO, or low dose oxytocin IV. Ripening can also be achieved with mechanical balloon devices placed in the cervical canal. Labor induction can be medically induced with Pitocin or AROM. Membrane sweeping or stripping is the releasing of amnion from the uterine wall by digital exam. This is thought to release prostaglandins to help induce labor. It also stimulated contractions and is uncomfortable for the woman because she will contract during the exam. Labor induction has been achieved at home with castor oil, enema, nipple stimulation and herbal preparations. All except nipple stimulation are generally not supported by the medical establishment as their effects cannot be controlled or monitored.
Cervical ripening
With ANY obstetrical intervention, primary nursing consideration should be FHR assessment, evaluate for bleeding, rupture of membranes, and maternal VS. Patient consent (verbal or written) is necessary for all interventions. On NCLEX, always place the pt in the left side-lying position. In real life, use the position that is best for mom and baby. With any medications, monitor for side effects including tachysystole (too many contractions) or tetanic contractions (too long and intense) and nausea and vomiting. Nursing interventions for NRFHR or tachysystole: increase IV fluids, left-side lying, maternal oxygen via face mask, call for help/provider, stop IV Pitocin if infusing. Pitocin can be given 4 hours after the last dose of misoprostol if the woman is not already in labor
Induction of Labor Nursing Considerations
Detachment of the placenta prior to delivery. Significant maternal and fetal morbidity and mortality. The leading cause of maternal death.
Risk factors: trauma, severe hypertension, smoking, cocaine.
S/s: maternal pain: constant, abdominal, severe and/or vaginal bleeding, NRFHR, uterine hypertonicity. If complete abruption: fetus may only have minutes to live. If partial: variable outcomes, may heal or progress to full abruption. May be able to visualize on ultrasound but often not able to confirm. Decision to deliver is made by clinical findings and consideration of gestational age. Usually move to stat cesarean section, providing uterine resuscitation until OR is ready, call for blood for potential transfusion, call for neonatal team and prepare for neonatal resusciation.
Placental abruption “abruptio placentae”
