Complication o Labor
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Transcript of Complication o Labor
Complication o Labor
Prolapsed Cord
Umbilical cord precedes presenting part
May be visible or occult
More common withAbnormal lie
Low birth weight
> previous births
Amniotomy
Long cord
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Prolapsed Cord
Key interventionsRelieve pressure on cord
Trendelberg or knee chest position
Oxygen to increase maternal oxygen saturation
Pressure on the presenting part
Call for help, but do not leave mother
Expedite delivery
Prolapsed Cord
Maternal RiskNo direct risk
Fetal-Neonatal RiskCord compression ↓O2 possible death or neurologic compromise
TxPrevention!
If palpated, keep pressure off cord
☺When ROM occurs, listen to FHTs for full minute; if decel heard, do vag exam to r/o cord prolapse
Umbilical Cord Abnormalities
2 vessel cord: associated with abnormalities, esp kidney
Check for 3 vessels at time of birth (2 arteries 1 vein)
Amniotic Fluid-Related Complications
Embolism: bolus of amniotic fluid enters maternal circulation then lungs. OB emergency!High mortality.
Amniotic Fluid-Related Complications
Hydramnios: >2000mL of fluidCause unknown but associated with congenital abnormalities (swallowing/voiding problems); also diabetes, Rh sensitization, infections such as CMV, Rubella, syphilis, toxoplasmosis, herpesIf severe (>3000mL) may experience severe edema, hypotension (from vena cava compression) and pain
TxSupportiveCorrective: may do amniocentesis, Indocin (to ↓ fetal urine output)
Amniotic Fluid-Related Complications
Oligohydramnios<500mL fluid or largest pocket of fluid on U/S is <5cmAssociated with postmaturity, IUGR, major renal problem in fetus (malformation, blockage)If occurs early in preg, may cause fetal adhesions also fetal skin and skeletal abnormalities may occur, pulmonary hypoplasia, cord compression
Tx:MonitorAmnioinfusionFetal surgery
Complications of 3rd and 4th stage
Retained placenta
☺Lacerations: cervical or vaginal suspected when bright red bleeding in presence of well contracted uterus
1st degree: fourchette, perineal skin, vag mucousa
2nd degree: perineal skin, vag mucosa, underlying fascia, muscles of perineal body
3rd degree: extends thru perineal skin, vag mucosa and perineal body and involves anal sphincter
4th degree: same as 3rd degree, but extends thru rectal mucosa to the lumen of the rectum
Intrauterine Fetal Demise (IUFD)
May be found prior to coming to hosp or at time of admission
May be unexplained or r/t materanal disease process or fetal insult
May be induced right away or wait for spontaneous labor. C/S not automatically done
Pain med give freely
Intrauterine Fetal Demise (IUFD)
Provide privacy for familiesListenAvoid inappropriate consolationsGive accurate infoObtain mementosAllow opportunity to see and holdProvide information re: burial optionsProvide support information
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Premature Rupture of Membrane(PROM)
Spontaneous break in the amniotic sac before onset of regular contractions
Mother at risk for chorioamnionitis, especially if the time between Rupture of Membranes (ROM) and birth is longer than 24 hours
Risk of fetal infection, sepsis and perinatal mortality increase with prolonged ROM.
Vaginal examinations or other invasive procedure increase risk of infection for mother and fetus.
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PROMSigns of Infection
Maternal fever
Fetal tachycardia
Foul-smelling vaginal discharge
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PROM Detecting Amniotic Fluid
Nitrazine
Ferning: Place a smear of fluid on a slide and allow to dry. Check results. If fluid takes on a fernlike pattern, it is amniotic fluid.
Speculum exam
fernlike pattern
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PROM Treatment
Depends on fetal age and risk of infection
In a near-term pregnancy, induction within 12-24 hours of membrane rupture
In a preterm pregnancy (28 -34 weeks), the woman is hospitalized and observed for signs of infection. If an infection is detected, labor is induced and an antibiotic is administered
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PROMNursing Interventions
Explain all diagnostic testsAssist with examination and specimen collectionAdminister IV FluidsObserve for initiation of labor Offer emotional supportTeach the patient with a history of PROM how to recognize it and to report it immediately
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Signs of Preterm LaborRhythmic uterine contraction producing cervical changes before fetal maturity
Onset of labor 20 – 37 weeks gestation.
Increases risk of neonatal morbidity or mortality from excessive maturational deficiencies.
There is no known prevention except for treatment of conditions that might lead to preterm labor.
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Treatment of Preterm Labor
Used if tests show premature fetal lung development, cervical dilation is less than 4 cm, & there are no that contraindications to continuation of pregnancy.
Bed rest, drug therapy (if indicated) with a tocolytic
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Preterm Labor Pharmacotherapies
Terbutaline (Brethine), a beta-adrenergic blocker, is the most commonly used tocolytic
Side effects: maternal & fetal tachycardia, maternal pulmonary edema, tremors, hyperglycemia or chest pain, and hypoglycemia in the infant after birth
Ritodrine (Yutopar) is less commonly used.
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Preterm Labor Pharmacotherapies
Magnesium Sulfate Acts as a smooth muscle relaxant and leads
to decreased blood pressure Many side effects including flushing, nausea,
vomiting and respiratory depression Should not be used in women with cardiac or
renal impairment Excreted by the kidneys
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Perterm Labor Pharmacotherapies
Corticosteroids Help mature fetal lungs Betamethasone or dexamethasone Most effective if 24 hours has elapsed before
delivery
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Nursing Interventions with Preterm Labor
Nursing Intervention in Premature labor Observe for signs of fetal or maternal distress Administer medications as ordered Monitor the status of contractions, and notify
the physician if they occur more than 4 times per hour.
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Nursing Interventions with Preterm Labor
Nursing Intervention in Premature labor Encourage patient to lie on her side Bed rest encouraged but not proven effective Provide guidance about hospital stay,
potential for delivery of premature infant and possible need for neonatal intensive care
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Nursing Interventions with Preterm Labor
Discharge teaching for home care: Avoid sex in any form Take medications on time Teach to recognize the signs of preterm labor
and what to do
Birth Related Procedures
Procedures
VersionExternalInternal
Cervical RipeningCervidilCytotec
Amnioinfusion~250-500 mL warmed saline or LR is infused into uterus via IUPC over 20-30 minUsed to correct variables, dilute mec stained fluid
Labor Induction
Stimulation of U/C before spontaneous onset of labor
Prior to starting inductionVerification of gestation age
Confirmation of fetal presentation
Assessment of risk factors
Well-being assessment of mom and baby
Cervical Assessment
Labor Induction
Cervical Assessment (Bishop’s Score)
Higher the score, more successful the induction will be
Favorable cervix is most important criteria for successful induction
Bishop’s Score)
Cervical dilatation
1-2 3-4 5-6
Cervical effacement
0-40 40-80 80+
Position of cervix
posterior medial Anterior
Consistency of cervix
Firm Medium soft
Station of presenting part
-2 -1/0 +1/+2
Labor InductionMethods
Stripping membranes
Oxytocin☺Always given via IV pump (may be given IM after del)
Site closest to insertion
Continuous EFM
Risks– Hyperstimulation– Uterine rupture– Water intoxication– Fetal risks associated with maternal problems,
hyperbilirubinemia, trauma from rapid birth
Episiotomy
Decline over the years
May make it more likely will have deep tears
Lacerations heal more quickly in absence of epis
3rd or 4th degree lacerations more likely with epis
EpisiotomyMidline
from vag orifice to fibers of rectal sphincterLess blood loss, easier to repair, heals with less discomfort
MediolateralFrom midline of posterier forchette to 45° angle to right or leftProvides more room but has > blood loss, longer healing time and more discomfort
TxPain relief measuresIceInspect!
Operative Assisted Deliveries
ForcepsMaternal complications
TraumaIncreased pain in pp periodWeakening of the pelvic floor
Fetal-neonatal complicationsCaputCaphalohematomaTransient facial paralysistrauma
Operative Assisted DeliveriesVacuum Extractor
Longer duration of suction, more likely scalp injuryMaternal complications
Perineal traumaEdemaGenital tract and anal sphincter probs (< than with forceps)
Neonatal complicationsScalp lacerationsBruising/subdural hematomaCephalohematomaJaundiceFx clavicleRetinal hemorrhagedeath
Cesarean Birth1970 - ~5%1988 – 24.7%2001 – 21%2005 - ? But higherIndications
Failure to progress/descendPrevia/abruption/prolapse cordNon-reassuring fetal statusMalpresentationPrevious C/S
Maternal morbidity and mortality is > than vag delivery
Cesarean Birth
TechniqueNOTE: Skin incision NOT indicative of uterine incision
Transverse (Pfannenstiel)-lower uterine segment
Adv: below pubic hair line, less bleeding, better healing
Disadv: difficult to extend if needed, requires more time, if adipose fold difficult to keep clean and dry
Vertical-between naval and symphysisAdv: quicker, more room
Disadv: scar obvious, longer
Cesarean Birth
Cesarean Birth
Cesarean Birth
TechniqueUterine incision (type depends on need for C/S)
Transverse-lower uterine segmentAdv: thinnest less blood loss, only mod dissection of bladder, easier to repair, site less likely to rupture during subsequent pregnancies, less chance of adherence of bowel or omentum to incision line
Disadv: takes longer, limited in size due to major blood vessels, greater tendency to extend into uterine vessels
Cesarean Birth
TechniqueLower Uterine Segment Vertical Incision
Preferred for multiple gestation, abnormal presentation, previa, preterm, macrosomia
Adv: more room
Disadv: may extend into cx, more extensive dissection of the bladder is necessary, if extends upward hemostasis and closure more difficult, higher risk of rupture in subsequent pregnancies
Cesarean Birth
TechniqueClassic incision
Upper uterine segment
Adv: more room, quicker to do
Disadv: more blood loss, difficult to repair, higher risk of rupture in subsequent pregnancies
Cesarean Birth
Prep for C/S (time dependent)Permits NPO
IV Oral/IV antacids, H2 inhibitors
Foley Teaching
Shave
Immediate PP careFreq vs (q 5-10 min) Lungs
Check dressing I&O
Lochia and uterus Anesthetic level
VBAC (vaginal birth after cesarean)
That was then, this is now
Specific criteria
Must sign consent
ContraindicationsClassic incision or previous fundal uterine surgery
Most common risk is hemorrhage and uterine rupture
Placental accreta
occurs when the placenta attaches too deep in the uterine wall but it does not penetrate the uterine muscle. Placenta accreta is the most common accounting for approximately 75% of all cases. Approximately 1 in 2,500 pregnancies experience placenta accreta, increta or percreta. There are two further variants of the condition that are known by specific names and are defined by the depth of their attachment to uterine wall.
Placental increta
occurs when the placenta attaches even deeper into the uterine wall and does penetrate into the uterine muscle. Placenta increta accounts for approximately 15% of all cases.
Placental percreta
occurs when the placenta penetrates through the entire uterine wall and attaches to another organ such as the bladder. Placenta percreta is the least common of the three conditions accounting for approximately 5% of all cases.
Deep attachment to uterine wall
management
Treatment: Managing placenta accreta requires controlling hemorrhaging; removing the placenta that has adhered to the uterine wall is very difficult and can result in blood loss. If the diagnosis is made before labor begins, a cesarean section should be performed whenever possible and blood products should be readily available In the majority of cases, a hysterectomy remains the treatment of choice.