Childbirth at Risk: Part II

Oligohydramnios

<500 mL amniotic fluid, 5-8% of all pregnancies, associated with prevention of urine production or collection in amniotic sac Post term GA, IUGR/placental insufficiency, fetal renal malformations Fetal adhesions/impaired movement Cord vulnerability Pulmonary hypoplasia

(Poly)Hydramnios

>2000ml amniotic fluid, 2% of all pregnancies, associated with fetal anomalies Preterm birth/dysfunctional labor possible Risk of prolapsed cord

oligohydramnios nursing mgmt

Amnioinfusion possible in labor Intrauterine resuscitation PRN Possible indication for IOL

Post-term Pregnancy

Pregnancy that extends beyond 42 completed weeks Maternal risks: IOL, FAVD/VAVD, perineal damage, hemorrhage, C/S Fetal-neonatal risks: decreased uteroplacental circulation, oligohydramnios, macrosomia, meconium-stained fluid Clinical therapy NST/BPP IOL in 41st week

Prolapsed Umbilical Cord: Clinical Therapy

Prevention Presenting part well engaged—minimal risk After AROM, FHR monitored, bedrest possible EFM: variable to prolonged decelerations After occurrence—Emergency! Remain calm, explain situation to patient Use SVE to maintain upward pressure on presenting part, off of cord Emergency Cesarean Section Notify anesthesia and NICU Woman on side, knees to chest

mcroberts maneuver

The woman flexes her thighs up onto her abdomen.

suprapubic pressure

pressure with fist above pubic bone to push shoulders out

A client has just had a C/S for a prolapsed cord. In reviewing the client's history, which of the following factors places a client at risk for cord prolapse? Select all that apply.

-2 station at time of rupture Prior elective abortion Assisted rupture of membranes Breech presentation Low lying placenta 1,3,4

dystocia

Abnormal or difficult labor Problems with the Powers Protracted (Slower than normal rate of dilation or descent) vs. Arrest (No progress in dilation or descent) Hypertonic uterine dysfunction Hypotonic uterine dysfunction Precipitate labor Problems with the Passenger OP malposition Face/brow and breech presentation Shoulder dystocia Multifetal pregnancy Cephalopelvic disproportion Problems with the passageway CPD

A client who is in labor is at risk for shoulder dystocia because she has a history of this event with her first delivery. Which of the following is an important nursing intervention?

Assess for complaints of intense back pain in the first stage of labor. Anticipate possible use of forceps to rotate to anterior position at birth. Assist with positioning the woman in squatting position. Assess for prolonged second stage of labor with arrest of descent. 3

polyhydramnios nursing assessment

Disproportionate fundal height increases Difficulty palpating fetus/auscultating FHR Assist with AFI

Precipitate Labor and Birth

Entire labor and birth within 3 hours Causes: low resistance of soft tissue, abnormally strong uterine contractions 5 cm+/hour primigravida 10 cm/hr multigravida Maternal risks Very few if adequate passageway Anxiety and fear; perineal laceration risk, uterine rupture possible Fetal-neonatal risks Non-reassuring FHR d/t intense UCs, head trauma

Cephalopelvic Disproportion nursing mgmt

Fetopelvic relationships Pelvimetry Estimated weight of fetus Borderline diameters Trial of labor vs. Decision for C/S? EFM for signs of fetal distress Repositioning during labor to change pelvic angles

Shoulder Dystocia

Following birth of head, shoulders do not emerge Complications Brachial plexus injury Fractured clavicle

oligohydramnios nursing assessment

Fundal height < than expected for GA NST/BPP/Continuous EFM, observe for signs of cord compressions Assist with AFI

Which of the following clients is most at risk for cephalopelvic disproportion?

G3 P2002 Fetus presenting in ROP Poorly controlled Type 2 DM Severe pre-eclamptic 3

Which patient is most at risk for uterine rupture?

G3P2 with history of 2 prior LTCS G2P1 with history of 1 prior classical C/S G3 P1102 G3 P0030 with history of 3 elective abortions

shoulder dystocia clinical therapy

Identify macrosomia before labor onset 3 maneuvers: McRoberts maneuver Suprapubic pressure, NOT fundal pressure Rubin's/Wood's Screw maneuver Hands/Knees Episiotomy Elective clavicular fracture Zavanelli maneuver

polyhydramnios nursing mgmt

Maternal dyspnea and pain No AROM with amnihook, Consider alternative methods...

Cephalopelvic Disproportion

Narrowing in any part of passageway (bony pelvis or soft tissue) Inlet and Outlet contractures Excessive fetal size for pelvis Implications Prolonged labor Uterine rupture

You are caring for a GDM A2 G2 P1001 who complains of severe dyspnea. At her 39 week prenatal visit, her AFI was determined to be 30. An induction of labor is scheduled for this patient. Which of the following is an appropriate plan of care?

Needle amniotomy with FSE Amniocentesis Administration of Indocin (Indomethacin) Amnioinfusion 1,2,3

Uterine Rupture: Clinical Therapy

Non-reassuring FHR noted *Loss of fetal station Only diagnosed via surgical incision Vaginal bleeding Pad count/weigh loss Preparations for emergency birth Pediatrics team for neonatal resuscitation

Care of the Woman with a Uterine Rupture

Nonsurgical disruption of uterine cavity Complete Endometrium, myometrium, and serosa separated Incomplete Risk Factors Previous uterine incision Operative vaginal delivery/uterine manipulation Abdominal trauma Complications Maternal Hemorrhage Pain, uterine tenderness Fetal-Neonatal Anemia, Hypoxia Fetal demise

Shoulder Dystocia Nursing Care

Observe for dysfunctional labor pattern or pushing issues "Turtling" (head out and back in) Prepare for extra staff/neonatal team to be at delivery NB assessment for clavicle fracture or signs of brachial plexus injury Fundal checks and assessment for signs of PPH

Precipitate Birth: Clinical Therapy

Obtain history prenatally; possible IOL Stay calm Stay with patient, call out for help. Don't leave her! Support the perineum Dry off baby, stimulate

The nurse is caring for a multigravid client who speaks little English. As the nurse enters the client's room, the nurse observes the client squatting on the bed and the fetal head crowning. After calling for assistance and helping the client lie down, which of the following actions should the nurse do next?

Tell the client to push between contractions. Provide gentle support to the fetal head. Apply gentle upward traction on the neonate's anterior shoulder. Massage the perineum to stretch the perineal tissues. 2

Prolapsed Umbilical Cord

Umbilical cord precedes fetal presenting part Presenting part not firmly against cervix Cord trapped between presenting part, maternal pelvis Compression of umbilical cord persistent variable decelerations progressing to prolonged/terminal deceleration Higher risk when presenting part does not fill pelvic outlet