WEEK 7: Childbirth at Risk and Grief

Maternal complications of precipitous labor

-abruptio placenta -postpartum hemorrhage -lacerations of cervix, vagina, perineum

Treatment of prolapsed cord

-do not removed hand-keep lifting presenting part off cord -knee chest or trendelenburg -cover protruding cord with moist dressing (not immediate delivery)

Treatment for polyhydramnios

-supportive measures -possible amnioreduction

When do you start doing kick counts?

27 weeks

What is the goal delivery time for multiple gestation?

37-38 weeks

placental percreta

A condition in which the placenta extends into the myometrium

Marginal cord insertion

Abnormal cord insertion at edge of placenta

Placenta accreta

Chorionic villa attach directly to myometrium of uterus

When does hypertonic uterine activity occur?

LATENT phase

Types of previas

Marginal: low lying placenta Partial Complete

T/F: Uterine dystocia accounts for 40% of C-Sections for nullipara and for 5% of C-Sections for multipara

True

When is laceration suspected?

bright-red bleeding with contracted uterus -repaired after birth

Fetal risk of post-term pregnancy

fetal distress, shoulder dystocia, meconium aspiration, macrosomia, oligohydramnios

Macrosomia

fetus >4000gm (9lbs 14 oz)

Treatment for placenta previa

-NO VAG EXAMS -management until 37 weeks -locate placenta -treat hypovolemia (have blood cross matched) -C-section

Indications of hypertonic uterine activity

-POISE -fetal distress (decreased resting tone) -increased capit and cephalohematoma

Treatment of hypotonic uterine contractions

-R/O CPD -amniotomy if presenting part is engaged -pitocin augmentation -cesarean if all else fails (-3 station do not ROM bc of prolapse)

Maternal implications of Multiple pregnancies

-SAB -hypertension/HELLP -pee swallow -hydramnios -GDB -PTL/PROM -anemia

Fetal implications of Multiple pregnancies

-SAB or vanishing twin phenomenon (75% twin pregs in 1st trimester) -perinatal mortality rate 4x greater -IUGR / twin to twin transfusions -PREMIE -abnormal presentations -fetal distress

Treatment of pelvic dystocia

-assess feto-pelvic size -borderline: may try TOL -not borderline: C-section

S/S of oligohydramnios

-decelerations -decreased variability -uterus not increasing in size -fetus is easily palpated -not ballotable

Treatment for placental abruptio

-evaluate DIC (coagulations) -Klienhauer Betke to test blood mixing -hourly abdominal girths -treat hypovolemia (whole blood) (packed RBC is for anemia)

Treatment of breech

-external version (38-40 weeks) cannot be in labor! -continuous monitoring -FHT (up high! above umbilicus)

S/S of Prolapsed Cord

-fetal bradycardia when auscultated after ROM -severe, moderate, or prolonged variable decels -FHR baseline bradycardia

Fetal implications of polyhydramnios

-fetal malformations -malpresentation -prolapsed cord -preterm

Nursing interventions for the mother with psychological disorders during labor.

-hx of psychiatric disorders -coping mechanisms -pain lvl & response to pain -acknowledge fears & pain -frequent explanations

Treatment for macrosomia

-identify fetal size prior to labor with Leopold's -evaluate pelvic size -cesarean delivery if CPD

Maternal implications of polyhydramnios

-if fluid >3000 = mother has SOB and edema in lower extremities -sudden removal of fluid causes abruption -dystocia r/t hypotonic contractions -postpartum hemorrhage

Treatment for multiple gestation

-promote weight gain of 40-50lbs -prevent preterm -restrict activity at 20-24 wks -antenatal testing 30-34 wks -deliver at 37-38 wks is GOAL

Maternal implications of Macrosomia

-risk of CPD and dysfunctional labor -prolonged 2nd stage -soft tissue lacerations and episiotomy -PP hemorrhage & infections, vaccuum

Interventions for precipitous labor

-tocolytic agents -monitor FHR and UC

What are the 3 main factors of dystocia?

-uterine (most common) -fetal -pelvic (contraction of one or more of 3 planes of pelvis)

Fetal complications of precipitous labor

-uteroplacental insufficiency -meconium stained fluid and aspiration -low APGAR -intracranial trauma -bruising (jaundice)

How does blood enter circulation in amniotic fluid embolism?

1. Tear in amnion or chorion. 2. May enter at site of placental separation or cervical tear. *travels to maternal lung

AFP (alpha-fetoprotein)

15-16 weeks increased with multiple fetus decreased with down syndrome

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 1. A prolonged labor 2. Reduced fetal oxygen supply 3. Delayed cervical dilation 4. Increased maternal stress

2. Reduced fetal oxygen supply

What is the expected weight gain for multiple gestation?

40-50 lbs

SLIDE

46

Fetal loss gestation and weight

<20 wks/500g = abortion >20wks/>500g = fetal death

Oligohydramnios

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

Polyhydramnios

> 2000mL of amniotic fluid or AFI >25

Post-term pregnancy

>42 weeks

Pelvic dystocia results in?

CPD cephalopelvic dysproportion

Types of abruptio placenta

Central: abruption with concealed hemorrhage Partial: abruption w/ external hemorrhage Total: abruption with concealed hemorrage

DX 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 US

Uterine dystocia

Dysfunctional or uncoordinated uterine contractions that result in a prolonged labor. (Ineffective uterine activity)

Implications of pelvic dystocia for fetus

FETAL: -cord prolapse -excessive molding -skull or CNS damage if forceps used

Summarize active management of labor.

Goal: prevent dystocia Protocol: manage labor with amniotomy, cervical exam q 2hrs, pitocin augmentation, 1-1 care Opponents objection: labor should be natural without automatic interventions, early amniotomy increases infection risk, and risk of pitocin use

What indicates increased risk of prolonged pregnancy?

Low fibronectin levels

Implications for Breech

Mom: cesarean possible Fetus: -4x higher perinatal mortality -risk of prolapsed cord -risk of cervical cord injuries with hyperextension -risk of trauma during vaginal or cesarean

Treatment of oligohydramnios

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

Meds for multiple gestation

PMHC

S/S of amniotic fluid embolism

SOB, Hypoxia, Chest Pain, Cyanosis, Frothy Sputum, Tachypnea, Tachycardia, Hypotension, Hemorrhage.

Hypertonic uterine activity

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

Amniotic fluid embolism

a bolus of amniotic fluid enters the maternal circulation system as an embolism

Other name for amniotic fluid embolism

anaphylactoid syndrome of pregnancy

Management of Postterm Pregnancy

antepartum: kick counts, vNSTs, BPP, AFI, Bishop's score vRipening of cervix &/or Induction of labor vMonitor FHR closely for s/sx of distress vMonitor UCs and cervical dilation vAssess amniotic fluid for meconium vAmnioinfusion vPOISE

What cephalic presentations require C-section?

brow and face

S/S of Cephalopelvic dysproportion

contractions slow/fail to advance in frequency, intensity, or duration -cervix does not dilate or efface -fetus doesn't descend

Fetal dystocia

d/t fetal malposition or malpresentation

Patho of post-term pregnancies

decreased placental estrogen leads to decreased prostaglandin precursors decreased oxytocin receptors lead to decreased UC

Placental increta

deep penetration of myometrium

Dystocia

dysfunctional labor

Maternal implications for oligohydramnios

dysfunctional labor and slow progress

Perinatal loss results from what 3 factors?

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

What is more common for mono twins (identicals)?

girls

Degrees of attachment of accreta

increta (goes in more) percreta

Hypotonic uterine contractions

irregular and low amplitude -less than 25 mmHg

Why do we never use fundal pressure? (macrosomia)

it gets the baby more stuck and presses on the shoulders

Maternal risk of post-term pregnancy

labor dystocia, lacerations, postpart hemorrhage, increased incidence of C-sections

When do you assess for broken clavicle?

macrosomia

Where do you feel HR on transverse lie?

midline below umbilicus

Fundal height greater than expected

multiple pregnancy

The nurse in a maternity unit is providing emotional support to a client and her significant other, who are preparing to be discharged from the hospital after the birth of a dead fetus. Which statement made by the client indicates a component of the normal grieving process? n1. "We want to attend a support group." n2. "We never want to try to have a baby again." n3. "We are going to try to adopt a child immediately." n4. "We are okay and we are going to try to have another baby immediately."

n1. "We want to attend a support group."

A 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? n1. "What can I do for you?" n2. "Now you have an angel in heaven." n3. "Don't worry, there is nothing you could have done to prevent this from happening." n4. "We will see to it that you have an early discharge so that you don't have to be reminded of this experience."

n1. "What can I do for you?"

nThe 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? n n1. Soft abdomen n2. Uterine Tenderness n3. Absence of abdominal pain n4. Painless, bright red vaginal bleeding

n2. Uterine Tenderness

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? n1. Place the client in the Trendelenburg position n2. Apply pressure to the presenting part with her fingers n3. Administer oxygen at 10L/min via a face mask n4. Call for assistance

n4. Call for assistance

nA 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? n nA. Betamethasone (Celestone) nB. Indomethacin (Indocin) nC. Nifedipine (Adalat) D. Methylergonovine (Methergine)

nA. Betamethasone (Celestone)

Placenta previa

placental implanted in lower segment instead of upper uterus -CESEAREAN

What is associated with cocaine abuse?

precipitous labor

Abruption placenta

premature separation of normally implanted placenta from uterine wall

What does dystocia result in?

protracted (<1cm/hr) or arrested (no change in dilation for 2 hrs) NORMAL: active phase is 1.2 cm/hr for primi and 1.5 for multi

Precipitous labor

rapid labor & birth <3hr -associated with cocaine abuse

Retained placenta

retention beyond 30 min after birth

What is turtling in delivery? (macrosomia)

shoulders are stuck head is out of vagina

Velamentous insertion

umbilical cord inserts away from the placental edge - danger of tearing vessels during delivery (usually delivered by c-section)

Patho of amniotic fluid embolism

unknown -auto-immune response like anaphylactic shock -can occur before or after a difficult labor

Where do you hear HR in breech?

up high! above umbilicus)

Implications of pelvic dystocia for Mom

uterine rupture = hemorrhage -prolonged labor/exhaustion -necrosis of maternal soft tissue -C-section -vaginal fistula

Treatment of AFE

vImmediate delivery to obtain live fetus. vMaintain oxygenation. vSupport cardiovascular system & blood v pressure. Assess coagulopath

S/S of Polyhydramnios

vIncrease in fundal ht. not consistent with gestational age vDifficulty palpating the fetus vDifficulty auscultating the FHR vMaternal abdomen may be tense and tight. vSOB vPain vUltrasound shows large spaces between the vfetus and uterine wall

Fetal implications for oligohydramnios

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

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