OB: Week 7

Hypotonic Uterine Contractions: treatment

- R/O CPD - amniotomy if presenting part is engaged - pitocin augmentation - if above fails a cesarean delivery will be needed

provide frequent attention

- be calm - be confident - be supportive

ABRUPTIO PLACENTA

- central: abruption with concealed hemorrhage - partial: abruption with external hemorrhage - total: abruption with concealed hemorrhage

maternal testing

- diabetes testing - cbc with platelet count - kleihauer-betke test - abnormal antibody testing (lupus anticoagulant, anticardiolipin antibodia) - tsh levels - infectious disease testing (rubella, syphillis, ,malaria, toxoplasmosis, cytomegalovirus) - hereditary thromophilia testing - toxicology testing

Transverse lie: Maternal implications

- dysfunctional labor - uterine rupture (s/s)

nursing care

- evaluate fetal position - educate - offer emotional support

Fetal Loss testing

- fetal blood tests - xrays - autopsy - mri - placental studies - chromosomal studies (if indicated)

Active Management of Labor

- goal: prevent dystocia - manage labor from the beginning with amniotomy, cervical exam q2 hrs, pitocin augmentation, one to one nursing care - opponents objections

velamentous insertion of the umbilical cord

- hemorrhage if one of the vessels is torn - nonreassuring fetal status, hemorrhage

treatment

- if 38 weeks external version and induction - if in active labor - cesarean delivery

Battledore placents

- increased incidence of preterm labor and bleeding - prematurity, nonreassuring fetal status

Nursing plan and implementation: continued

- keep informed on labor progress - provide frequent attention - may at times need to give firm directives - observe for s/s of alcohol or substance withdrawal and abruptio placenta

Cord Insertion Variations

- marginal cord insertion - velamentous

Placenta Previa

- marginal: low lying placenta - partial: placenta previa - complete: placenta previa

process

- misoprostol - laminaria tent - transcervical foley - pitocin induction

Cephalic Presentations

- occiput - military - brow - face

Placenta Problems

- placenta previa 1/200 births - abruption placenta 1/120 births

Retained placenta

- uterine atony allows hemorrhage to flow into uterus

Bleeding disorders

-visible bleeding - total placenta previa

The nurse in a maternity unit is providing emotional support to a client and her significant other, who are preparing to be discharged frim the hospital after the birth of a dead fetus. Which statement made by the client indicates a component of the normal grieving process?

"We want to attend a support group."

nA stillborn baby was delivered in the birthing suite a few hours ago. After the delivery, the family remained together, holding and touching the baby. Which statement, by the nurse would assist the family in their period of grief?

"What can I do for you?"

Oligohydramnios: def

<200ml of amniotic fluid at birth with AFI <5 cm

Preterm Birth

A birth that occurs after the 20th week and before the start of the 38th week of gestation.

Macrosomia - Fetus >4000 gm (9lb 14oz): Fetal/Neonatal implications

Asphyxia - Meconium Aspiration - Shoulder dystocia - Increased risk of an upper brachial plexus injury or fx clavicle - Neurologic damage &/or asphyxia from pressure exerted on head during birth

Auscultate FHT Above Level of Umbilicus: breech

At 25 wks gestation incidence is 21%, decreases after 28 weeks & is only 1.8% at 40 weeks

A nurse is providing care for a client who is 32 weeks gestation and who has a placenta Previa. The nurse notes that the client is actively bleeding. Which of the following types of medications should the nurse anticipate the provider will prescribe?

Betamethasone (Celestone)

A nurse is caring for a client in active labor. When she examined the patient 2 hours ago the cervical exam was 3/100/-2, with membranes intact. The client suddenly states "my water just broke." The monitor reveals a FHR of 80 to 85 bpm and the nurse performs a vaginal exam, noticing clear fluid and a pulsating loop of cord in the clients vagina. Which of the following actions should the nurse perform first?

Call for assistance

Oligohydramnios: s/sx

Decelerations (variable & lates), decreased variability, uterus not increasing in size according to dates, fetus is easily palpated, not ballotable.

Transverse Lie - 1/360 Births

FHT auscultated midline just below umbilicus

Oligohydramnios: treatment

NSTs, BPP, Serial ultrasounds. Amnioinfusion of 200-300ml sterile saline after ROM during labor.

Abruption Placenta

Premature separation of a normally implanted placenta from the uterine wall

A nurse is caring for a client who is in labor and experiencing incomplete uterine relaxation between hypertonic contractions. The nurse recognizes the adverse effect of this contraction pattern is

Reduced fetal oxygen supply

Macrosomia - Fetus >4000 gm (9lb 14oz): Maternal implications

Risk of CPD & dysfunctional labor - Prolonged 2nd Stage - Soft tissue lacerations & episiotomy extensions - PP hemorrhage & infections, vacuum extraction

Placenta previa

The placenta is implanted in the lower segment instead of the upper portion of the uterus

The nurse is assessing a pregnant client in the second trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abruption placentae. Which assessment finding should the nurse expect to note if this condition is present?

Uterine Tenderness

Psychological Disorders

alterations in thinking, mood, or behaviors

prevent dystocia

decreases c-sections and instrument use

may at times need to give firm directed

ensure that orders are written for any psychiatric medications that are normally taken

fetal implications

increased risk of cord prolapse and stillbirth

opponents objections:

labor should be natural without automatic interventions, early amniotomy increases infection risk and unnecessary risks of pitocin use

Previous postterm pregnancy leads to 30-40%

of future postterm pregnancies

induction of labor depends on her gestational age

scheduled when the client wants: right away or in a few days

Pelvic Dystocia: maternal implications

uterine rupture leading to hemorrhage

Pelvic Dystocia Results in CPD CEPHALOPELVIC DYSPROPORTION: s/s

• Contractions slow or fail to advance in •frequency, intensity or duration • The cervix does not dilate or efface • The fetus does not descend

Fetal Dystocia: D/T Fetal Malposition or Malpresentation

• Occiput Anterior Presentation allows for the fetus to move through the pelvis with the greatest ease. • Head is sharply flexed with the chin on the thorax and the occipital area of the skull (vertex) is presenting anterior to the mother's pelvis.

S/S of uterine rupture

• Prolonged labor & maternal exhaustion • Necrosis of maternal soft tissue • Vaginal Fistulas • Forceps or Cesarean Delivery

Neonatal

•4X higher perinatal mortality • Risk of prolapsed cord (4% vs .5% with vertex) •Risk of cervical cord injuries d/t hyperextension •Risk of trauma during vaginal or cesarean birth

Maternal Complications of Precipitous Labor

•Abruptio Placenta •Postpartum Hemorrhage •Lacerations of the cervix, vagina, & perineum

Management of Postterm Pregnancy

•Antepartum: Kick counts, NSTs, BPP, AFI, Bishop's score •Ripening of cervix &/or Induction of labor •Monitor FHR closely for s/sx of distress •Monitor UCs and cervical dilation •Assess amniotic fluid for meconium •Amnioinfusion •POISE

Substance Dependence

•Approximately 15.1 million people in the United States are dependent on alcohol (NIH, 2017). •Prevalence of smoking is 22.5% among pregnant women •The incidence of adult drug use is 20-29% •(8 million)

Non therapeutic communication

•Asking why •Being defensive or challenging •Changing the subject •Giving advice or approval or disapproval •Making stereotypical comments •Making value judgements •Placing the client's feelings on hold •Providing false assurance

Pelvic Dystocia: treatment

•Assess feto-pelvic size relationship •If borderline, may try TOL •If not borderline cesarean section

Polyhydramnios: treatment

•Be supportive •Possible amnioreduction (removal of excess fluid).

Maternal implications

•Bleeding with possible hemorrhagic shock leading to renal failure & death •Possible Cesarean Birth Risk of DIC with abruption placenta

Prolapsed Cord: fetal-neonatal implications

•Bradycardia •Hypoxia •Possible fetal death

Nursing Treatment for Multiple Gestation

•Check for risk factors of multiple gestation •Educate for s/sx of preterm labor and PIH •If bedrest is needed, maintain left lateral position •Monitor FHR simultaneously •Prepare for two babies- two warmers-two NICU teams •Assess for pp hemorrhage d/t uterine atony

Placenta Accreta

•Chorionic villa attach directly to myometrium of uterus (varying degrees of attachment- placenta increta and percreta). •May result in maternal hemorrhage and failure of placenta to separate from uterus •May result in need for hysterectomy at time of birth •Incidence of placenta accreta is 10% to 25% in presence of placenta Previa

Therapeutic Communication

•Clarifying and validating •Giving information •Listening •Maintaining silence •Restating •Sharing perceptions •Summarizing •Using broad open-ended questions •Reflecting •Providing nonverbal encouragement •Acknowledgement

Amniotic Fluid Embolism(Anaphylactoid Syndrome of Pregnancy)

•DEFINITION: A bolus of amniotic fluid enters the maternal circulation system as an embolism. •PATHOPHYSIOLOGY: Unknown - auto immune response like anaphylactic shock. •Can occur before or after a difficult labor. •BLOOD ENTERS CIRCULATION: • 1. Tear in amnion or chorion. • 2. May enter at site of placental separation or cervical tear. •TRAVELS TO THE MATERNAL LUNGS

Diagnosis of Fetal Loss

•Diagnosis may be made when mother notices lack of movement in fetus or at regularly scheduled physician's visit when fetal heart tone cannot be found •Confirmed with ultrasound •<20 wks or 500 grams = abortion •>20 wks or >500 grams = fetal death

Prolapsed Cord TX

•Do not remove hand- keep lifting • presenting part off the cord. • Knee chest or Trendelenburg position. • Cover protruding cord with moist sterile • dressing (if not immediate delivery) • Most likely to deliver by Cesarean Section

Oligohydramnios: maternal implications

•Dysfunctional labor and slow progress

Uterine Dystocia

•Dysfunctional or uncoordinated uterine contractions that result in a prolonged labor. • (Ineffective uterine activity) •Accounts for 40% of C-Sections for nullipara and for 5% of C-Sections for multipara.

Dystocia(Dysfunctional Labor

•Dystocia accounts for approximately 8-11% of deliveries •Due to three main factors •Results in Protracted Labor (<1cm/hr) or Arrested Labor (no change in cervical dilation for 2 hours). •Normal progress in active phase is 1.2 cm/hr for primigravida & 1.5cm/hr for a multipara

Interventions for Precipitous Labor: nursing care

•Emotional support and reassurance •Position for comfort & Pain control •Monitor UC's & dilatation, •Monitor for fetal distress (s/s hypoxia) & meconium •Have emergency pack nearby, stay with patient, when she says baby is coming

Treatment for Placenta Abruptio

•Evaluate coagulation tests for DIC •Hourly abdominal girths •Treat hypovolemia (whole blood) •Mild separation - possible induction •Moderate to severe separation - Cesarean birth •Possible Hysterectomy

Implications & Treatment for Breech Presentation: treatment and nursing care

•External version at 38-40 weeks (unless strong UC's or placenta Previa) sometimes followed by induction. • If preterm cesarean birth preferred. •Continuous monitoring of labor progression and fetus. •Provide education and emotional support. •Assess for prolapsed cord. •Auscultate FHT above level of umbilicus

Precipitous Labor

•Extremely rapid labor & birth (<3 hour) •Primigravida 5cm/hour •Multigravida 10cm/hour •Associated with cocaine abuse

Fetal/neonatal implications

•FHR changes (sudden fetal bradycardia) •Hypoxia which can result in brain damage or • Fetal Demise (20-30% with abruptio placenta) •Preterm delivery •Anemia

Prolapsed Cord - Umbilical Cord Precedes the Fetal Presenting Part - S/S

•Fetal bradycardia when auscultated after ROM. •Severe, moderate, or prolonged variable decels. •FHR baseline bradycardia. •Loop of cord may be palpated in vagina. •Loop of cord may be seen protruding out vagina.

Perinatal Loss

•Fetal factors: Fetus has or develops disorder incompatible with life •Maternal factors: Mother has disorder such as diabetes or preeclampsia that creates hostile environment for fetus •Placental or other factors: Certain conditions such as abruptio placentae or cord accident cut off blood supply to fetus, leading to death

Polyhydramnios: fetal-neonatal implications

•Fetal malformations •Malpresentation •Prolapsed Cord •Preterm delivery •Perinatal mortality is 35-40%

Multiple pregnancy: Diagnosis of twins

•Fundal height greater than expected / Wks of gestation •Auscultation of two FHR's differing by 10 bpm •Elevated Alpha Fetoprotein level •Ultrasound shows more than one fetus •Reports of increased morning sickness/hyperemesis gravidarium.

Transfer to High Risk FacilityMom or Neonate

•Help mother adjust by providing a primary nurse on each shift for the first few days. •Needs lots of reassurance • May be more difficult for support people to visit due to distance. •If possible let mother see baby prior to transfer. •Take pictures of the baby to give to mother. •Have someone from NICU come & explain what is being done for baby.

MEDICAL TREATMENT FOR MACROSOMIA

•Identify fetal size prior to labor - Leopold's Maneuver •Evaluate pelvic size •Cesarean delivery if CPD or arrest of labor - •Suprapubic pressure • McRoberts maneuver. •Never use fundal pressure! •Assess for broken clavicle

Polyhydramnios: maternal implications

•If fluid > 3000 -mother has SOB & edema • in lower extremities •Sudden removal of fluid can result in • abruptio placenta. •Dystocia r/t hypotonic contractions •Postpartum hemorrhage.

Amniotic Fluid Embolism (con't 2): treatment

•Immediate delivery to obtain live fetus. •Maintain oxygenation. •Support cardiovascular system & blood • pressure. •Assess coagulopathy

Polyhydramnios> 2000 ml of amniotic fluid or an AFI > 25

•Increase in fundal ht. not consistent with gestational age •Difficulty palpating the fetus •Difficulty auscultating the FHR •Maternal abdomen may be tense and tight. •SOB •Pain •Ultrasound shows large spaces between the •fetus and uterine wall

Oligohydramnios: fetal-neonatal implications

•Kidney malformations •Pulmonary hypoplasia •Cord compression during labor •IUGR •Postmature syndrome

Lacerations

•Lacerations suspected when bright-red bleeding in presence of contracted uterus •Usually repaired immediately after birth of child •Vaginal and perineal lacerations are categorized in terms of degrees 1st- 4th •Vaginal and perineal lacerations often are extensions of midline episiotomies •Cervical lacerations can also occur

Implications & Treatment for Breech Presentation

•Maternal: Possible cesarean birth •Neonatal:

Prolapsed Cord: MATERNAL implications

•Needs emotional support •Concern for well-being •Possible cesarean.

Treatment for Placenta Previa

•No Vaginal Exams!!!!!: No exams on a bleeding pt. until you know cause •Locate placenta via ultrasound •Treat hypovolemia - have blood cross matched •Expectant management until 37 weeks •Cesarean delivery for all Previa patients

Nursing Care

•Nursing care involves supporting family through grief •Assist family through labor and birth •Provide for woman's physical needs after birth •Encourage family members to express and share their thoughts and feelings about loss •Give family an opportunity to view, hold, name infant •Teach how it is normal for husbands & wives to grieve differently

Nursing Care (cont'd)

•Nursing care involves supporting family through grief work •Prepare items for family to keep to remember infant •Provide opportunities for religious or spiritual counseling and cultural practices •Provide choice of location for post delivery care •Visit or phone family after discharge to assist in closure •Make referrals to appropriate perinatal loss counseling services if indicated

Hypertonic Uterine Activity info

•Occurs in the LATENT PHASE •Results in increased discomfort d/t uterine cell muscle anoxia, fatigue, stress on coping ability. •Increased fetal distress d/t increase resting tone •Increased caput and cephalohematoma

Placenta Previa:

•Onset - Quiet & Sneaky •Bleeding - External •Color of Blood - Bright Red •Pain - Only with UC's •Uterine Tenderness - Absent •Uterine Tone - Soft, Relaxed •Uterine Shape - Normal •FHT's - Usually Present •Engagement - Absent •Presentation - Pos. Abnormal

Pelvic Dystocia Results in CPD CEPHALOPELVIC DYSPROPORTION: confirmation of diagnosis

•Pelvic measurements by manual exam, CT, •Sonogram, X-ray pelvimetry, MRI

Types of psychological disorders

•Phobias (8.7%) •Depression (8.2%) •Post Traumatic Stress Disorder (3.5%) •Generalized Anxiety Disorders (3.1%) •Panic Disorder (2.7%) •Bipolar Disorder (2.6%) •Schizophrenia (1.1%) •Obsessive Compulsive Disorders (1.0%)

Evaluate coag tests for DIC

•Platelets and fibrinogen levels are decreased •prothrombin times are normal or prolonged

Prolapsed Cord - Umbilical Cord Precedes the Fetal Presenting Part

•Promote bed rest if ROM without engagement •Always Auscultate FHR when ROM occurs!!!!

Medical Treatment for Multiple Gestation

•Promote fetal development with maternal weight gain of 40-50 lbs. •Intervene to prevent preterm delivery •Restrict activity at 20-24 weeks •Antenatal testing at 30-34 weeks •Deliver at 37-38 weeks is the goal

Nursing Plan and Implementation

•Provide comfort measures /Offer epidural •Provide frequent explanations /Provide reassurance •Identify causes of stress and try to reduce them •Remove excessive environmental stimuli -Maintain consistent caregivers -

Grief is not proportional to the size of the person who dies

•Recognize that their infant is unique and irreplaceable. •No matter the age of the baby, it is important to realize that parental bonding begins long before birth and that a newborn is already very much a part of his/her family. •Reassure the parents that their expression of grief and the intense feelings associate with it are normal.

Retained Placenta

•Retention of placenta beyond 30 minutes after birth •Occurs in 2% to 3% of all vaginal births •If not expelled, placenta must be manually removed from uterus - if woman does not have an epidural anesthesia in place, conscious sedation may be required •Maternal antibiotics are usually given for manual extraction •May need a D&C to remove placental fragments

Pelvic Dystocia: fetal implications

•Risk of cord prolapse •Excessive molding •Skull or CNS damage if forceps used

Postterm Pregnancy >42wks

•Risks to Fetus: • fetal distress, shoulder dystocia, meconium aspiration, asphyxia, macrosomia, oligohydramnios •Risks to Mother: •labor dystocia, lacerations, postpartum hemorrhage, increased incidence of C-sections •Patho • placental estrogen prostaglandin precursors • oxytocin receptors uterine contractions

Fetal/Neonatal Implications of Multiple Gestations

•SAB or Vanishing Twin Phenomenon result in the loss of up to 75% of twin pregnancies in the first trimester. •Perinatal Mortality Rate 4 X's greater than single fetuses •IUGR & twin to twin transfusions •Prematurity (5.9% higher in twins & 10.7% higher with triplets. •Abnormal Presentations •Fetal Distress

Treatment for Hypertonic Contractions

•Sedation to promote relaxation &/or tocolytics •R/O CPD & fetal malpresentation •Pitocin to improve quality of UC's •IV Fluids to maintain hydration •Position changes (left lateral side, high fowler's, rocking on birthing ball, walking), shower, backrub, relaxation and breathing techniques •Emotional support & explanation of dystocia

Differences in Grief Among Others

•Siblings under age 6 have limited understanding of death •Older siblings may blame themselves •Grandparents can feel a double loss •Mothers bond with baby in early pregnancy •Fathers may not bond until they see the baby

Amniotic Fluid Embolism (con't)

•Signs and Symptoms •SOB, Hypoxia, Chest Pain, Cyanosis, Frothy Sputum, Tachypnea, Tachycardia, Hypotension, •Hemorrhage. •MATERNAL IMPLICATIONS: •Dyspnea, Cardiovascular Collapse, Shock, Coma, •DIC with massive hemorrhage •FETAL-NEONATAL IMPLICATIONS: •Hypoxia, Fetal demise • • •

Maternal Implications of Multiple Pregnancies

•Spontaneous Abortion •Hypertension (PIH 2-3X higher)/ HELLP •Cervical Incompetence •Gestational Diabetes •Hydramnios •Anemia •Increased Hyperemesis Gravidarum •PTL/ PROM •Uterine dysfunction, malpresentations, instrument • or cesarean delivery, postpartum hemorrhage

Abruptio Placenta

•Sudden & Stormy •External or Internal •Dark Venous •Severe & Constant •Present •Firm to Stony Hard •Enlarged & Abnormal •Present or Absent •May be Present •No Relationship

MULTIPLE PREGNANCY

•TWINS OCCUR IN 3% OF PREGNANCIES IN U.S. •DIZYGOTIC TWINS MAKE UP 67% •MONOZYGOTIC TWINS MAKE UP 33% •TRIPLETS OR MORE MAKE UP 1.8%

Be real...Share feelings of distress and sadness with the parents

•These are not unprofessional behaviors. Parents greatly appreciate caring nurses who express their feelings. •Don't rationalize the loss with comments such as "You can have other babies" or "You have other children at home." •Do say "I'm sorry", "This must be so hard" or "How can I help?"

Interventions for Precipitous Labor: Medical management

•Tocolytic agents (Terbutaline) •Monitor FHR tracing and UC pattern

Hypertonic Uterine Activity

•Uncoordinated, painful strong, and frequent uterine contractions that are ineffective in promoting cervical effacement and dilation.

Hypotonic Uterine Contractions

•Uterine Contractions are irregular and of low amplitude •less than 25 mmHg

3 Main factors

•Uterine dystocia (most common) •Fetal dystocia (2nd most common) •Pelvic dystocia (contraction of one or more of the • three planes of the pelvis)

Fetal Complications of Precipitate Labor

•Uteroplacental Insufficiency •Meconium Stained Fluid •Meconium Aspiration •Low Apgar's •Intracranial Trauma •Bruising

Nursing Assessment includes:

•past & present psychiatric disorders •alcohol or substance use •coping mechanisms that have helped in the past •pain level & response to pain relief interventions •Acknowledgement of fears & pain