Intrapartum Complication
N420 Childbearing Family Nursing
Week 13
April 13, 2000
PERINATAL GRIEF
“A friend asked if we had named our stillborn baby. After telling her the name, we both began referring to the baby by name, Sarah. It felt good to call her by name.”
–When Pregnancy Fails
Stages of GriefElizabeth Kübler Ross, 1969
Denial (Shock) Anger Bargaining Depression Acceptance
Tasks of GrievingParkes & Weiss, 1983
Intellectual Recognition Emotional Acceptance Assumption of New
Identity
Perinatal LossNursing Interventions
Perinatal Grief Protocol–Effort to move family into or through the first stages of grief–Set up follow up support and assessment for later stages of grief
Perinatal Provider Grief
Frequently Unacknowledged Interventions
–Case Study–Peer/ Administration Support–Resolution
Be aware of your own experiences of loss
IntrapartumComplications
Intrapartal Complications
Psychological Adaptations–Fear
» Influence of Sympathetic Nervous System Response
–Unmet expectations–Grief-like response–Family Support Needs
Labor Dystocia
“Difficult Labor”: prolonged or abnormal labor
Problem with Four P’s:Passage, Passenger, Power, Psyche
Maternal Fetal- Infection - Infection
- Exhaustion - Asphyxia
- Dehydration - Cord prolapse
- Ketosis - Insufficient
- Lacerations - Placental
- Hemorrhage perfusion - Shoulder dystocia
– Psychological trauma - Birth trauma
Risks Related to Labor Dystocia
Labor Dystocia Prolonged Latent Phase:
– > 20 hrs in nullip; > 14 hrs in multip. Protracted Active Phase:
– < 1.2 cm dilation q hr in nullip.; < 1. 5 cm. q h multip
Active Phase Arrest:– No cervical change in 2 - 4 hours
Aberrant Fetal Descent Patterns:– > 1 - 2 cm descent / hour
Prolonged 2nd Stage: > 3 hrs in nullip; > 2 hrs in multip.
Precipitous Labor:– < 3 hours
Labor Dystocia
Problem with Powers–Abnormal Uterine Contraction Pattern
–Hypertonic Contractions–Hypotonic Contractions–Precipitous Labor and Birth
Labor Dystocia
Problem with Passage–Pelvic Contracture –Non-Gynecoid Pelvis.
Problem with Passenger–Malpresentation–Macrosomia–Fetal Anomalies
Intrapartal Complications
Malposition– Occiput Posterior
Malpresentation– Breech– Transverse Lie– Brow– Face– Asynclitism
Management of Labor Dystocia
Augmentation of Labor– Amniotomy– Oxytocin Augmentation
Assisted and Operative Delivery– Vacuum - Assisted Delivery– Forceps Delivery– Cesarean Birth
Induction or Augmentationof Labor
Prostaglandin E2– for cervical ripening
Amniotomy– artificial rupture of membranes
Oxytocin (Pitocin)– induction of uterine contractions
Cytotec– Controversy
Requires Maternal or Fetal Indication
Favorable Cervix– Bishop Score 5 or greater
Necessary Equipment/Supplies– EFM (Toco & US)– Mainline IV Start– Pitocin IV Solution (10 - 20 U / L)– Infusion Pump– Terbutaline Rx
Induction or Augmentationof Labor
Bishop Score Evaluation of Readiness for Labor
0 1 2 3
Dilatation (cm) 0 1-2 3-4 5-6
Effacement (%) 0-30 40-50 60-70 80+
Station -3 -2 -1,0 +1
Cervical Firm Med. Soft
Consistency
Cervical Position Post.ML Ant
Induction or Augmentationof Labor
Augmentation of Labor
Pitocin Induction:– Informed consent– Discuss with family.– Mainline IV– Continuous maternal toco.– Continuous fetal monitoring– IV Solution: LR or D5LR with 10 - 20 Units
pitocin– Start Pitocin drip at 1 mu/ min per infusion
pump.– May increase every 20 - 60 minutes
Assisted and Operative Delivery
Vacuum - Assisted Delivery– Mechanism: Suction and Traction used to
assist delivery of presenting part.
– Indication: Most commonly related to prolonged 2nd Stage of Labor. Takes up less space and causes less injury that forceps.
– Contraindications: Cephalopelvic Disproportion (CPD); Most malpresentations and malpositions; extreme prematurity.
– Nursing Responsibility: FHR checks q 5 minutes; Hand held suction pump. Pressure release between UC’s; Assess neonatal head for caput resolution after delivery.
Assisted and Operative Delivery
Forceps Delivery– Mechanism: Traction and rotation of fetal
presenting part with curved metal tongs.
– Indication: Prolonged 2nd stage (> 3 hrs); maternal exhaustion; Outlet: > +2 station and visible at vaginal introitus; low: > +2, but not visible.
– Contraindications: Cephalopelvic Disproportion (CPD); Most malpresentations and malpositions; < +2 station.
– Disadvantages: Maternal and fetal trama.
– Nursing Responsibility: FHR checks q 5 minutes; obtain forceps; assess neonate and mother for trauma. Increased legal liability.
Cesarean Birth
25% of all births in U.S. Indication For Cesarean Birth
– Unsafe vaginal birth r/t maternal or fetal factors.
Complications – Infection– Pain– GI Dysfunction– Bladder Injury– Coagulopathy– Risks r/t Anesthesia (Epidural vs General)– Psychological Trauma– Risk to Maternal/ Infant Attachment
Cesarean Birth
Types of Cesarean Incisions–Lower Uterine Segment (Low Transverse)–Classical (Vertical Midline)
Only L. Uterine Segment Cesareans allow a trial of labor with the next pregnancy.
Classical is used for emergency Cesareans or for some mal presentations.
Pre-0p Activities and Prep Ethical/ Legal Issues
Anesthesia for Cesarean Birth
Epidural Anesthesia Spinal Anesthesia General Anesthesia
Epidural Anesthesia for Cesarean Mechanism: Variety of Caine drugs administered
in the epidural space at L-2 to L-4 with a T-8 to S-5 block
Nursing Responsibilities:– Informed Consent– Pre-hydration by IV bolus– Assisting Anesthesiology with placement– Comfort the patient.– Monitor maternal / /fetal physiologic response
including level of anesthesia.
Contraindications: Clotting disorders, agent allergies, hx of spinal injuries
Adverse Effect:– Maternal Hypotension; Inadvertent Spinal or systemic
administration; Incomplete pain relief.
Spinal Anesthesia for Cesarean
Mechanism: Variety of Caine drugs administered in the subarachnoid space at L-3 to L-4 a block up to T-6.
Nursing Responsibilities:– Informed Consent– Pre-hydration by IV bolus– Assist anesthesiology with positioning patient– Comfort to patient.– Monitor maternal / /fetal physiologic response including level
of anesthesia. Protect from injury.
Contraindications: Clotting disorders, agent allergies, hx of spinal injuries; meningitis.
Adverse Effect:– Maternal Hypotension; Inadvertent Spinal or systemic
administration; Incomplete pain relief.
General Anesthesia for Cesarean Mechanism: Inhalation anesthesia such as nitrous
oxide in combination with an IV short-acting barbiturate, such as thiopental sodium, rendering patient unconscious.
Nursing Responsibilities:– Informed Consent– Pre-hydration by IV bolus– Assisting anesthesiology with cricoid pressure for
intubation– Circulation Nurse for the Cesarean.
Contraindications: Allergies, fetal compromise
Adverse Effect:– Neonatal respiratory depression– Maternal response to general anesthesia
Case Study:Augmentation of Labor
S/ O: 24 y.o. G1 P0 with ruptured membranes x 17 hours. Normal Pregnancy. EFW: 8 1/2 lbs..
Cervix on admission: 2cm, 50% effaced, -1 station, ROM in elevator. Reports UC’s x 2 hours
After 11 hours of labor: UC’s q. 4 minutes x 40 seconds, moderate to
palpation Cervix: dilated 3-4 cm, 60-70% effaced, -1
station, soft, anterior (Bishop Score 10) : Prolonged Latent Phase (?).
Case Study:Augmentation of Labor
After 17 hours of labor: S/ O: UC’s q 4 - 5 minutes x 45
seconds, strength: moderate to palpation. UC’s painful.
Cervix dilated 5 cm, 90% effaced, -1 station, soft anterior
FHR tracing reassuring A: Labor Dystocia (See Partogram):
P: Obtain Informed Consent for Oxytocin Augmentation
Case Study:Augmentation of Labor
S / OS / O:: Oxytocin (Pitocin) begun at 1 mu/min per infusion pump and increased 1-2 mu every 20 minutes until strong labor pattern established.
After 20 Hours of Labor (3 hrs of augmentation):
UC”s q 3 min. x 50 secs, strong to palpation.
Sonya c/o UC pain/ wants an epidural. Cervix: 8 cm dilated, 100% effaced, -1
station. FHR: 150-160’s, average variability, early
decelerations. A / P: ________________________
Case Study:Labor Dystocia
After 24 Hours of Labor: S/O: VS: T 100.2, P100, RR20, BP98/52
(Baseline BP 115/68). Epidural Effective as evidenced by
_________ UC’s q 3 min x 50-80 secs. IUPC in place. Cervix: Complete Dil. & Effaced, O station FHR: Decelerations resolved, Baseline
increased at 160’s with minimal variability maybe. r/t __________
A/P: ____________________
Case Study:Labor Dystocia
At 27 Hours of Labor S / O: Sonya has been pushing for 3
hours UC’s q 2 - 3 mins. x 60-80 secs,
adequate forces. Station: +4 IV antibiotics given. Temp. 99.8. FHR reassuring Head Delivers w/o restitution: “Turtle
Sign” A/ P: _________________
Intrapartum Complications
Intrauterine Fetal Death–Diagnosis–Medical Management–Psychological Impact
Obstetrical Emergencies
Fetal Distress Cord Prolapse Shoulder Dystocia Uterine Rupture Amniotic Fluid Embolism
Obstetrical Emergency:Shoulder Dystocia
Failure of anterior shoulder to deliver spontaneously after delivery of fetal head.
Incidence: Less than 1 % (1.6% if than 4 Kg)
Risk Factors:– Hx large Infants, maternal obesity, maternal diabetes
Maternal Morbidity:– Perineal trauma, PP hemorrhage, endometritis
Perinatal Morbidity/Mortality:– High mortality rate r/t asphyxia– Developmental delay, brachial plexus Injury, clavicle/ humerus
fx
Shoulder Dystocia
Obstetrical Maneuvers–Suprapubic Pressure–McRobert’s Maneuver–Rotation and Delivery of Posterior Shoulder
–Maternal Position Change– Issue of Fundal Pressure
Case Study:Obstetrical Emergency
S / O: Silvia is a 28 y.o. G2P1 in active labor.
Cervix: 4 cm dilated, 90% efface, -3 station.
Resting in bed. SROM with immediate FHR bradycardia to the 70’s.
A / P: ________________
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