NURS 3334: OB Exam 4

3 questions to ask and communicate to all members of the healthcare team (NRP)

1. Term? 2. Tone? 3. Breathing or crying? Initial actions at birth 1. Warm/stimulate baby 2. Open airway 3. Clear airway (suction mouth and nose) 4. Reposition if necessary (sniffing position, nose up chin up)

Late preterm

34-36 weeks

Early term

37 weeks to 38 6/7 weeks

Small for gestational age (SGA)

<10th percentile weight for gestational age and IUGR Risk factors: fetal, maternal, or both Expected findings: -Normal skull, reduced body dimensions -Wide sutures: inadequate bone growth -Dry, loose skin, decreased subcutaneous fat, decreased muscle mass especially. buttocks and cheeks -Wide-eyed and alert due to prolonged fetal hypoxia

Preterm

A pregnancy that has reached 20 weeks of gestation but ends before completion of 37 weeks of gestation

Slow paced breathing

Approximately half normal rate (6-9 breaths per minute) Initiated when cannot talk/walk through contractions Use until no longer effective for pain relief

When should systemic pain relief be injected during labor?

At peak of contraction to lessen fetal impact (less supply to fetus)

Total physiological impact of pain during labor

DECREASED FETAL OXYGENATION AND WASTE REMOVAL AND PROLONGED LABOR

Major disadvantage of systemic pain relief

Decreased level of conscious

Post-term infants

Infants born after the 42nd week of gestation -6-12% of all pregnancies -Higher mortality rate than term infants -Placental insufficiency may lead to "post-maturity syndrome" Can appear: -Wasted -Thin loose skin -Leathery skin -Long thin body -Long hair and nails Risks: -Hypoxia -Malnourishment -LGA (and associated risks of birth injuries and c/s birth) -Decreased amniotic fluid volume -Hypoglycemia -Hypothermia -Polycythemia -Skin peeling

What are typical first signs of sepsis in a newborn?

Irritability and sepsis

Why is flexion important for a preterm newborn?

Keeps them warm, maintains temperature, provides comfort

A ______ temperature is typical in a septic newborn

Low

Narcotic antagonist

Naloxone (Narcan) -Should be available in maternal and neonatal dosages -Do not give to opioid dependent woman

Adjunctive drugs for systemic pain relief

Potentiate effect -Promethazine (Phenergan) -Diphenhydramine (Benadryl) -Hydroxyzine (Atarax, Vistaril)

Defining prematurity

Preterm: born after 20 weeks and before completion of 37 weeks Late preterm: from 34 to 36 weeks Early term: from 37 weeks to 38 6/7 weeks

Common side effect of systemic pain relief

Respiratory depression (especially in infant) -Inject at peak of contraction to lessen fetal impact (less supply to fetus -If infant born at peak of action, expect respiratory depression

Vaginal birth anesthesia

T10-S5

Cesarean section anesthesia

T4-T6 to S5

Where is turgor measured on a newborn?

The abdomen

Breathing techniques: second stage

To forestall pushing: when urge is strong and cervix not fully. dilated OR to slow birth of fetal head -Short "puff" breathing Second stage breathing: -Try to avoid closed glottis pushing (Valsalva's maneuver) -Avoid prolonged breath holding (longer than 6-8 seconds) and more than 4 pushing efforts per contraction

Kangaroo care

Treatment for preterm infants that involves skin-to-skin contact -Promotes bonding attachment -Skin-to-skin cuddling promotes growth, decreases metabolic needs -Dads and grandparents often included

Patterned-paced breathing

Used during transition phase of 1st stage of labor Side effect: hyperventilation

Why can too much oxygen given during oxygen therapy lead to ROP?

Vascularization is cut off to the retina, leading to blindness

Pain stimuli

-Cervical dilation pain enters spinal cord L1 through T10 -Pain from vaginal and perineal distention travels via pedestal nerve, enters the spinal cord at S4 to S2 region -Pathways related directly to effectiveness of pain relief measures

Oxihood

-Deliver oxygen to infant not in need of mechanical assistance -Plastic box of appropriate size surrounds infant's head -Humidified oxygen blown in via tube on top of box -Nasal cannula: rarely used in hospital setting for oxygen administration -Discharged infants who still require oxygen may go home on nasal cannula

Placement of epidural

-Epidural space entered a L3-L4, and catheter threaded -Test dose given to check placement, then therapeutic dose -Infusion can be continuous or intermittent (catheter stays in place)

General nursing care/promoting growth and development of premature baby

-Excess light, sound, touching stressful -Increases metabolic/oxygenation needs, cause behavioral changes Nursing considerations: -Group care activities, promote rest -Reduce light, noise -Turn and position q2h, flexed, use rolls either prone, supine, side to side -ADAPT to individual infant's tolerance level by attention to s/s of overstimulation Signs of overstimulation in preterm infants: Oxygen changes: -Increase or decrease in pulse or respiratory rate -Cyanosis, pallor, or mottling -Flaring nares -Decreased oxygen saturation levels Behavior changes: -Stiff, extended arms and legs -Fisting of the hands or splaying of the fingers -Alert, worried expression -Turning away from eye contact -Hiccuping -Regurgitation -Fatigue -Coughing -Yawning

Nutrition: oral feeding

-Goal: graduate premature infants to bottle or breast -Nurses assess infant readiness to "graduate" to nipple feeding -Feedings typically slow at first requiring many breaks -Special "premie" nipples and special technique (assisting jaw movement) Signs of readiness for nipple feedings: -Rooting -Sucking on gavage tube, finger, or pacifier -Able to tolerate holding -Respiratory rate <60 breaths per minute -Presence of gag reflex Sings of nonreadingess for nipple feedings: -Respiratory rate > 60 breaths per minute -No rooting or sucking -Absence of gag reflex -Excessive gastric residuals Adverse signs during nipple feeding: -Tachycardia -Bradycardia -Increased respiratory rate -Markedly decreased oxygen saturation level -Apnea -Coughing -Gagging -Falling asleep early in feeding -Feeding time beyond 25-30 minutes

General nursing considerations for pain during labor

-History of significant allergies: needs to be MARKED -Last food, drink consumed should be known -Current alterations in respiratory status should be known -Initial assessment: include mother's knowledge of pain options -Listen to woman's subjective description -Impact of pain management on self-esteem should be considered -Assess pain continuously -On-going assessment must include s/s of allergic reactions -Keep epinephrine/ antihistamines available for severe reactions

Continuous Positive Airway Pressure (CPAP)

-Infuses oxygen or room air under pressure (via nasal prongs or ETT) -Increases FRC by keeping alveoli partially expanded at end of each respiration -Requires OGT to decompress stomach if delivered by nasal prongs

Periventricular/intraventricular hemorrhage

-Leading cause of death in first few days of life -Neonatal brain injury with severe impact on short term and long term outcomes -Rupture of blood vessels around ventricles of brain r/t pressure fluctuations especially related to hypoxia S/S: -Bulging fontanels -Seizure activity -Decreased tone/ respiratory status

Spinal

-Local anesthetic injected into subarachnoid space in single dose (dura mater punctured) -Complete sensory and motor function lost below level of block -Only used immediately prior to delivery, not during labor -Quicker than epidural for emergency C/S when no epidural -Contraindications and nursing care similar -Potential side effect: positional headache from leakage of spinal fluid requiring a "blood patch"

Most commonly used opioids for systemic pain relief during labor

-Meperidine (Demerol) -Fentanyl (Sublimaze) -Nalbuphine (Nubaine) -Butorphanol (Stadol): do not give Stadol or Nubaine to opioid dependent women

General anesthesia

-Only used as last resort r/t infant respiratory depression -Contraindication exists to spinal or epidural -Emergency C/S -Extreme anxiety -Short-acting barbiturate renders woman unconscious -Muscle relaxant makes intubation easier -Anesthesia given, usually by face mask -Added recovery concerns: maintenance of airway, cardiopulmonary function -A nurse may assist during intubation by applying pressure to cricoid cartilage

Pudental block

-Pudental nerves near ischial spines injected with local anesthetic (delay follows onset of numbness) -Anesthetizes lower vagina/perineum for episiotomy and vaginal birth -Does NOT impact pain from contractions

Epidural

-Regional pain relief -Local anesthetic combined with an opioid injected into the epidural space -Provides pain relief and moderate loss of sensation (cannot ambulate unless only small doses of opioid used) -Common epidural agents: lidocaine with epinephrine, bupivacaine -Contraindications: coagulation defects (platelets lower than 100,000), uncorrected hypovolemia, allergy Potential adverse effects: -Maternal hypotension (20% decease from baseline) -Prolonged second stage labor (decreased urge to push) -Catheter migration -Slight fever (unrelated infection) -Back soreness Potential side effects of opioid analgesics: -Nausea and vomiting (phenergan) -Pruritis (Benadryl) -Respiratory depression (observe for 24 hours) Nursing care: -Bolus with 1000 mL fluid prior to procedure (prevent hypotension) -Continuous IV fluids -Frequent bladder assessment r/t decreased sensation -Frequent V/S (especially blood pressure) -Safety precautions r/t decreased sensation -Observe for S/S of adverse reactions (medicate PRN) and side effects of opioid analgesia -Treatment of hypotension (systolic below 100): position of left lying, increase IV fluids, 10-20 degree Trendelenburg position, if not resolved within 1-2 minutes will need ephedrine

Signs of nonreadiness for nipple feedings

-Respiratory rate > 60 breaths per minute (risk for aspiration) -No rooting or sucking -Absence of gag reflex -Excessive gastric residuals

Signs of readiness for nipple feedings

-Rooting -Sucking on gavage tube, finger, or pacifier -Able to tolerate holding -Respiratory rate <60 breaths per minute -Presence of gag reflex

Pain during second stage of labor

-Somatic pain prominent from stretching, distention of perineal tissues, pelvic floor, traction, and pressure from presenting part -Quality: more intense, sharp, burning, well-localized

Adverse signs during nipple feedings

-Tachycardia -Bradycardia -Increased respiratory rate -Markedly decreased oxygen saturation level -Apnea -Coughing -Gagging -Falling asleep early in feeding -Feeding time beyond 25-30 minutes

Goals of respiratory support

1. Use minimal amount of O2 2. Least invasive type of support possible 3. Wean ASAP to prevent complications associated with O2 therapy

Bolus with ______________ prior to epidural insertion

1000 mL fluid

During labor, the client at 4 cm suddenly becomes short of breath, cyanotic, and hypoxic. The nurse must prepare or arrange immediately for which of the following? Select all that apply. A. Intravenous access B. Cesarean delivery C. Immediate vaginal delivery D. McRobert's Maneuver E. A crash cart

A, C, E Rationale: The mother is experiencing an amniotic fluid embolism, which occludes the vessels and leads to total respiratory collapse

Large for gestational age (LGA)

Above 90th percentile or more than 4,000 grams (8 lbs, 13 oz) -Also called macrosomic -Can be preterm, post mature, or full term -Risk for birth injuries, polycythemia -Common maternal condition: uncontrolled hyperglycemia, maternal diabetes during pregnancy -Labs: glucose testing, ABG's, CBC (polycythemia: HCT higher than 65%) due to utero hypoxia, hyperbilirubinemia, hypocalcemia due to long birth process Expected findings: -Large head, plump. and full face -Increase subcutaneous fat -Tremors from hypocalcemia -Hypoglycemia -Respiratory distress Newborn does not have the inner maturity to keep up with the physical size of the baby

When do symptoms typically improve with RDS if the newborn survives?

After 72 hours when infant's own surfactant production increases

Amniotic fluid embolism

Anaphylactoid syndrome of pregnancy -Intrapartum emergency -Amniotic fluid enters maternal circulation/obstructs maternal pulmonary vessels -Pushed by increased intrauterine pressure, enters through an opening in amniotic sac or maternal uterine veins -Results in ACUTE maternal respiratory distress and circulatory failure (DIC almost always occurs simultaneously) -10% of maternal deaths in US, fetal mortality rate 50% Nursing role assist with management: -CPR/_2 mechanical ventilation -Assist intuition and mechanical: side position 30 degree angle to displace uterus -Replacing lost blood volume with fluid, blood products for correction of coagulation disorder -EMERGENCY c/s delivery once mother stabilized

Nutrition: types/forms

Breastmilk: -Preferred nutrition r/t greater digestibility, immunoglobulins -Moms PUMP and freeze until infant breastfeeds or begin diluted feeds via ogt/ngt -Breastmilk frequently fortified to increase to 24 KCAL/OZ -Feeding from breast often requires special intensive assistance -This is also good for mom emotionally and physically Formulas: -Only used if breastmilk unavailable or specific malabsorption problem Gavage feeding: -Breast milk or formula give via nasogastric or orogastric tube Total Parenteral Nutrition (TPN): -INDIVIDUAL order to meet infant's electrolyte, caloric, protein, fat needs if unable to tolerate sufficient quantities of enteral feedings

A nurse is caring for a client following the administration of an epidural block and is preparing to administer an IV fluid bolus. The client's partner asks about the purpose of the IV fluids. Which of the following is an appropriate response for the nurse to make? A. "It is needed to promote increased urine output" B. "It is needed to counteract respiratory depression" C. "It is needed to correct hypotension" D. "It is needed to prevent oligohydramnios

C. "It is needed to correct hypotension" Rationale: Hypotension is the primary adverse effect of epidural administration

If the physician indicates a shoulder dystocia during the delivery of a mcorosomic fetus, how would the nurse assist? A. Call a second physician to assist B. Prepare for immediate cesarean delivery C. Assist the woman into McRoberts maneuver D. Utilize fundal pressure to push the baby out

C. Assist the woman into McRoberts maneuver Rationale: Do not want to use fundal pressure because this can lead to a ruptured uterus, should use suprapubic pressure. Remember acronym BE CALM.

Neonatal Resuscitation Program (NRP)

Certification renewed every 2 years -Required of all personnel working with newborns -At least a 2 person effort -Overview and Principles of Resuscitation -One member has the skill to perform: airway management, line placement, ventilation

Apneic spells

Cessation of breathing - >20 seconds -Accompanied by color change (frequently cyanosis) -Often associated with bradycardia

Retinopathy of prematurity (ROP)

Common complication of prematurity Multi-cause disorder r/t oxygen therapy -Retinal vascularization may be incomplete Highest risk: -Males -Less than 32 weeks -Under 1500 g -Oxygen therapy Regular vision screening begins in NICU at 6 weeks

Prolapsed cord

Cord lies below fetal presenting part -Most obvious directly after rupture of membranes Risk factors: -Small fetus -High station -Breech presentation -Transverse lie -Polydramnios (extra fluid) *Fetal hypoxia may result in cord compression > 5 minutes* In some cases: -A patient in TRENDELENBURG or side lying -Warm sterile saline soaked towel to visible cord (settings where stat c-section is not available) Main objective: to take pressure off the umbilical cord either by repositioning mother or with a sterile gloved hand apply pressure to the fetal presenting part and elevate off umbilical cord Nursing interventions: -Fetal heart rate before and directly after water breaks -Vaginal exam -Push hand up and onto fetal presenting part to relieve compression of cord -Have mother in Trendelenburg position (all 4's) -Use warm sterile saline soaked towel to visible cord -"Ride the bed" to operating room

Non-pharmacological pain relief

Cutaneous stimulation: -Counter-pressure -Effleurage -Walking -Position changes -Application of heat or cold -Water therapy (hydrotherapy) -Rocking -Accupressure Sensory stimulation: -Aromatherapy -Breathing techniques -Imagery -Use of focal points -Music Cognitive strategies -Promote relaxation/ confidence/ feeling in control -Childbirth education -Hypnosis Hydrotherapy: cautions required (hyper/hypothermia, dehydration) -Benefits: relaxation, nipple stimulation increases oxytocin production -Risks: hyperthermia or hypothermia (decrease O2 to fetus), dehydration r/t diuresis prompted by emersion, infection from tub if not disinfected properly, safety Breathing techniques: -Usefulness: provide distraction and reduce perception of pain, promote relaxation of abdominal muscles -3 basic techniques: slow paced breathing, modified-paced breathing, patterned-paced breathing

IUGR vs SGA

Definition: -IUGR: growth of a fetus is restricted/retarded while in the uterus -SGA: size of the fetus is small for gestational age Appearance: -IUGR: babies always appear malnourished -SGA: babies appear small and do not always appear malnourished Diagnosis: -IUGR: ultrasound and doppler of blood flow, measurements of the fundus to the pubic bone -SGA: ultrasound and measurements of the fundus to the pubic bone Measurement: -IUGR: based on the change in growth over time -SGA: based on a one-time measurement that falls below a statistical line Growth rate in utero: -IUGR: always slower than normal -SGA: can be normal or slower than normal Birth weight: -IUGR: sometimes lower than normal but not always -SGA: always lower than normal Pathological condition: -IUGR: always due to some sort of problem or disorder -SGA: not always due to a disorder or a problem, can be a small-sized mother

Intrauterine growth restriction (IUGR)

Definition: underground newborn because of circumstances of advanced gestation and decreased growth potential of the fetus 2 typical patterns: -Symmetric (proportional) -Asymmetric (disproportional) Contributing factors: Maternal: -Multiparity -Multiple gestation -Lack of prenatal care -Age extremes -Low socioeconomic status Maternal disease: -Heart disease -Drug use -Sickle cell. disease -PKU -Lupus -Complications associated with preeclampsia, chronic hypertensive vascular disease, advanced diabetes Environmental: -Toxins -Exposure to x-ray -High altitude -Nicotine -Cocaine -Heroin Placental: -Small placenta -Abnormal cord insertion -Single umbilical artery -Placenta previa -Inherited coagulopathy disease Fetal: -Congenital infections such as TORCH (toxoplasmosis, other, rubella, cytomegalovirus, herpes simplex) -Syphilis -Chromosomal deltions

Transient tachypnea of the newborn (TTN)

Delayed removal of fetal lung fluid Common etiologies: -C/S delivery -Low APGAR scores (asphyxia) -Precipitous delivery S/S: -Respiratory distress (mild retractions, grunting, flaring, retracting) -TACHYPNEA -Cyanosis on room air -Coarse breath sounds Management/ nursing considerations: -Typically resolves within 24-72 hours -Oxygen to maintain sats, usually oxihood, sometimes CPAP -IV and/or savage feeding until RR below 60

Parenting and premature infants

Disruption in boding, attachment, adaptation NICU environment -Overwhelming -Anxiety provoking -Requires introduction Parents may experience anticipatory grief, depression, distance from infant Nurses need to: -Listen -Communicate -Be honest, supportive, promote parenting Kangaroo care: -Promotes bonding, attachment -Skin-to-skin cuddling promotes growth, decreases metabolic needs -Dads and grandparents often included

What is a cord prolapse?

Emergency umbilical cord complication Normally, the baby exit the mother before the umbilical cord. In a cord prolapse, the umbilical cord comes before the baby. This can happen when the mother's water breaks before the baby has moved into the birth canal. Cord prolapse is an obstetrical emergency because the cord is at high risk for compression, blocking oxygen and blood flow to the baby. In these cases, an emergency C-section is often necessary, with recommendations stating that they should occur less than 12 minutes from the onset of fetal distress

What is given for hypotension due to an epidural?

Ephedrine

Regional pain relief

Epidural or spinal -Directed at relieving pain below level of spinal cord where inserted by increasing nerve impulses -May be analgesia or anethesia Major benefits: -Pain relief without alteration in consciousness, mother may actively participate in birth -Less impact on fetus (any effects secondary to maternal effects not directly from drugs)

The epidural goes into the ____________ space and does not go past the _____________________

Epidural; dura mater

Respiratory distress syndrome (RDS)

Etiology: prematurity -Lack of surfactant -Weak respiratory muscles -Compliant chest wall Physiological consequences: -Progressive atelectasis -Loss of functional residual capacity -Acidosis Potential for: -Increased pulmonary vascular resistance -Right to left shunting -Re-opening of ductus arteriosus and/or foramen ovale (revert back to fetal circulation) Management: -Prevention is KEY -Decreased severity/ incidence if antenatal corticosteroids administered (given to mother before birth) Treatment supportive: -Support respiratory efforts (CPAP or mechanical vent) -Lung surfactant: beractant, calfactant, luicinactant down ETT -Frequent monitoring of ABG's, etc. IF SURVIVE: symptoms usually begin to improve after 72 hours (when infant's own surfactant production increases) Greatest concerns: -Survival over first 72 hours -LONG TERM CONSEQUENCES

Types of pain in childbirth

First stage of labor: -Visceral pain prominent in lower abdomen r/t cervical changes, distention of lower uterus, tissue ischemia -Pain usually only with contractions -Back pain may be continuous -Pain may be "referred" radiating from uterus Second stage of labor: -Somatic pain prominent from stretching, distention of perineal tissues, pelvic floor, traction, and pressure from presenting part -Quality: more intense, sharp, burning, well-localized Third stage of labor: -Similar to pain of first stage

Pharmacological methods of pain relief

General considerations: -May directly or indirectly affect fetus -May slow labor -Potential for complications increased r/t physiological adaptations of pregnancy Major categories: -Systemic -Regional: epidural, pedestal, spinal (subarachnoid) -General -Local

Fluid and electrolyte balance of preterm newborn

Inability to: -Adequately excrete metabolites and drugs -Concentrate urine -Maintain acid-base, fluid, and electrolyte balance Nursing implications: -Maintain temp WNL -Strict I/O -Weigh infant as ordered Observe for physical signs of OVER HYDRATION: -Bulging fontanelles -Wet breath sounds -Edema -Unusual increase in weight or output SERIOUS COMPLICATIONS of over-hydration: -PDA -CHF -Respiratory distress

Overview of common problems associated with prematurity

Increased risk of ALL common neonatal problems including: -RESPIRATORY DISTRESS SYNDROME (RDS)** -Hypoglycemia -Hyperbilirubinemia -Cold stress -Feeding difficulties -Infection -Polycythemia -Aspiration -Apnea of prematurity -Intraventricular hemorrhage -Retinopathy of prematurity (ROP) -Patent ductus arteriosus -Necrotizing enterocolitis (NEC)

Uterine rupture

Intrapartum emergency -A uterine "tear" -"Complete": through uterine wall to peritoneal cavity or broad ligaments -"Incomplete": does not extend to peritoneal cavity or broad ligaments Background risk factors: -Intense uterine contractions -Labor stimulation (oxytocin, prostaglandin) -Over-distended uterus -Malpresentations -Difficult forceps-assisted birth S/S vary: may be silent or dramatic -Signs of hemorrhage and FHR impact may be noted first -If complete, pain shape and contraction will cease (fetal mortality high) Management: -Prevention: avoid VBAC after classic c/s, monitor medically argument labor (discontinue if tachysystole) -Fluid and blood loss replaced and birth precipitated -Laparoscopic repair if partial, hysterectomy if complete

Shoulder dystocia

Intrapartum emergency -Head born, anterior shoulder cannot pass under pubic arch (>60 seconds from delivery of head to delivery of shoulders) -Often UNEXPECTED, high potential for litigation -Factors that increase risk: fetus >4000g, previous dystocia Signs: -Slowing of progress of labor -Caput succedaneum that increases in size -CARDINAL SIGN: "turtle" sign, no external rotation Management: -Breathe, do not push, lower head of bed -Elevate legs into McRoberts position (sharp hip flexion while in supine position) -Call for help: nurses, anesthesiologists, pediatricians, another physician -Apply suprapubic pressure: downward and lateral to release anterior shoulder -Enlarge vaginal opening with Episiotomy to facilitate extra maneuvers -Maneuvers: delivery of posterior arm, pressure against baby's posterior shoulder either anteriorly or posteriorly and anterior rotation (Woods corkscrew or Rubin maneuver), mother on hands and knees (all fours, Gaskin maneuver), replacement of baby's head to vagina followed by cesarean delivery (Zavanelli maneuver) Increases fetal/neonatal and maternal morbidity and mortality: Fetal: -Asphyxia (CNS injury) -Brachial plexus damage -Fracture of humerus or clavicle Maternal: -Hemorrhage from uterine atony or rupture -Trauma to perineum -Bladder, liver injury -Endometritis

Precipitous labor

Labor that lasts less than 3 hours from onset of contractions to birth -Frightening for patients Increases risk of maternal and fetal complications: -Uterine rupture -Lacerations of birth canal/ perineal trauma -Amniotic fluid embolism -PP hemorrhage -Fetal hypoxia -Fetal intracranial hemorrhage Management: -Do not attempt to stop labor -Do not leave patient unattended -Side-lying to increase placental perfusion -Control rapid delivery with light pressure -Delivery fetus between contractions and check for nuchal cord

Dystocia

Long, difficult, or abnormal labor -Primary indication for cesarean section -Abnormal contractions prevent cervical dilation, effacement, or descent Associated with "5 P's" affecting labor -Primary power (poor quality of contractions) -Secondary power (inability to push adequately) -Passage (bony pelvis insufficiency/ soft tissue obstruction) -Passenger (size, presentation, position, number) -Position (mechanical advantage) -Psyche (stress, anxiety) Risk factors: -Body Bild (30 lbs or more overweight, short stature) -Uterine abnormalities -Fetal malpresentation and/or position -Cephalopelvic disproportion (CPD) -Tachysystole with oxytocin -Fatigue, dehydration, electrolyte imbalance

BE CALM

Management of shoulder dystocia -Breathe, do not push, lower head of bed -Elevate legs into McRoberts position (sharp hip flexion while in supine position) -Call for help: nurses, anesthesiologists, pediatricians, another physician -Apply suprapubic pressure: downward and lateral to release anterior shoulder -Enlarge vaginal opening with Episiotomy to facilitate extra maneuvers -Maneuvers: delivery of posterior arm, pressure against baby's posterior shoulder either anteriorly or posteriorly and anterior rotation (Woods corkscrew or Rubin maneuver), mother on hands and knees (all fours, Gaskin maneuver), replacement of baby's head to vagina followed by cesarean delivery (Zavanelli maneuver)

Assessments before administering systemic analgesics

Maternal: -Informed consent -Vital signs stable -Contraindications: drug allergies, respiratory compromise, current drug dependence) -Knowledge of other medications being administered Fetal: -FHR between 110 and 160 -Reactive non-reactive stress test -Variability present -Periodic late or nonperiodic late decelerations are absent Labor: -Contraction pattern -Cervical dilation -Cervical effacement -Fetal presenting part -Station of presenting part -Should not be in transition phase of labor, do not want to cause respiratory depression

Systemic pain relief

Most frequently opioid analgesics -Small, frequent IV doses or PCA Major advantage: -Fast acting -Predictable duration Major disadvantage: -Decreased level of consciousness Most commonly used opioids: -Meperidine (Demerol) -Fentanyl (Sublimaze) -Nalbuphine (Nubaine) -Butorphanol (Stadol): do not give Stadol or Nubaine to opioid dependent women Adjunctive drugs (potentiate effect): -Promethazine (Phenergan) -Diphenhydramine (Benadryl) -Hydroxyzine (Atarax, Vistaril) Narcotic antagonist: Naloxone (Narcan) -Should be available in maternal and neonatal dosages -Do not give to opioid dependent woman Common side effect: Respiratory depression (especially in infant) -Inject at peak of contraction to lessen fetal impact (less supply to fetus -If infant born at peak of action, expect respiratory depression

Neonatal pain: nursing interventions

Non-pharmacological pain relief/comfort: -Physical containment (rolls, swaddling, holding snug, etc.) -Non-nutritive sucking -Soft talking -Holding/rocking Pharmacological pain relief: -Topicals (to decrease discomfort with line insertion) -Sucrose solution -Regional nerve blocks (for specific procedures like circs) -Opioid drugs of choice: morphine, fentanyl

Necrotizing enterocolitis (NEC)

Often fatal acute inflammatory disease of the GI mucosa Common complication of prematurity From perinatal asphyxia causing blood flow away from GI tract to vital organs S/S: -Increased abdominal girth -Increased gastric residual

Signs of overstimulation in preterm infants

Oxygen changes: -Increase or decrease in pulse or respiratory rate -Cyanosis, pallor, or mottling -Flaring nares -Decreased oxygen saturation levels Behavior changes: -Stiff, extended arms and legs -Fisting of the hands or splaying of the fingers -Alert, worried expression -Turning away from eye contact -Hiccuping -Regurgitation -Fatigue -Coughing -Yawning

Physiologic impact of pain during labor

Pain = increased fear/anxiety -> Increased secretion of catecholamines fr/ SNS -> increase simulation of alpha receptors and increase stimulation of beta receptors Increase stimulation of alpha receptors -> vasoconstriction, increase in uterine muscle tone, increase maternal BP Increase stimulation of beta receptors -> vasodilation, decrease uterine muscle tone, maternal blood pooling Result: reduced effectiveness of uterine contractions, reduced blood flow to placenta Final result: DECREASED FETAL OXYGENATION AND WASTE REMOVAL AND PROLONGED LABOR

Common respiratory patterns in premature infants

Periodic breathing "pauses" in respiratory movements that last for up to 20 seconds alternating with breathing Apneic spells (cessation of breathing) - >20 seconds -Accompanied by color change (frequently cyanosis) -Often associated with bradycardia S/S of increased respiratory effort -Early signs: expiratory grunting, nasal flaring -Later signs: substernal (diploid area) or intercostal retractions

Key nursing care related to support of the premature infant

Physical assessment: -Apical HR -Auscultate for murmurs -Patent Ductus Arteriosus (PDA) -BP monitoring -Respiratory rate/ rhythm/ depth -? respiratory distress -Color Positioning (usually laid up higher): -Maintain airway -Prevent reflux -Promote decreased oxygen and metabolic needs Interventions: -Chest PT/ suctioning/ postural drainage -Oxygen monitoring/ labs/ lines (frequently UA or PICC in NICU) -Maintain respiratory support/ oxygenation/ titrate oxygen as ordered (use least amount of oxygen needed) -Meds for respiratory support: artificial or natural surfactant (betamethysone steroid), deficient prior to 34 weeks gestation, RDS a result of lack of surfactant -Keep newborn warm

Infection and premature infants

Premature infants are at increased risk for infection: -Shortage of tired maternal IgG, most transferred 3rd trimester -Impaired ability to manufacture antibodies -Compromised integumentary system (thin skin) -Subject to multiple invasive procedures (in NICU) Nursing considerations: Prevention -SCRUB/ STRICT HANDWASHING -Avoid alterations in skin integrity -Reposition frequently -Paper tape when possible -Minimize sticks -Umbilical or PICC lines rather than peripheral IV's Early identification of signs and symptoms of infection is key: -Temp instability (hypo/hyper) -CNS changes (lethargy, irritability) -Color changes (cyanosis, pallor (pale), jaundice) -Cardiovascular instability (poor perfusion, hypotension, bradycardia) -Respiratory distress -GI problems (feeding intolerance)

Neonatal pain S/S

Preterm infants cry in response to pain LESS THAN 50% of the time, therefore it is NOT A RELIABLE INDICATOR** Common signs of pain in infants: -High-pitched, intense, harsh cry -Cry face -Eyes squeezed shut -Mouth open -Grimacing -Rigidity or flailing of extremities -Color changes: red, dusky, pale -Increased or decreased heart rate -Increased respirations -Increased blood pressure -Decreased oxygen saturation -Increased intracranial pressure -Fussiness* -Irritability*

Meconium aspiration syndrome

Release of meconium IN UTERO into amniotic fluid -4-9% mortality rate (often term/post-term) -Hypoxia stimulates anal sphincter relaxation and colonic peristalsis Prevention: -Recognize compromised fetuses early -Use of amnioinfusion to dilute meconium in labor -Suction infant head at perineum before body born (NOT SUCTIONING ANYMORE) -Intubation and tracheal suction for depressed infants and those with symptoms

Modified paced breathing

Shallow breathing twice normal rate Used when contractions become more intense Requires more concentration so blocks more pain

Pain during third stage of labor

Similar to pain of first stage

Is the placenta of an IUGR baby smaller or bigger than normal?

Smaller

Later signs of increased respiratory effort in newborns

Substernal (xiphoid area) or intercostal retractions

Non-pharmacological pain relief and gate control theory

Theoretical basis: Gate Control Theory -Gates in dorsal spinal cord control pain impulses to brain -If "large-diameter" fibers in skin are stimulated, "small-diameter" sensory fibers are blocked (the "gate" is closed along pathway to brain) -Impulses from brain originating from auditory and/or visual stimuli are also believed to impede transmission

Mechanical ventilation

Use if other methods are not effect -Infant intubated and ventilation support and/or oxygen supplied -CPAP or pre-set # of ventilations with continuous oxygen PRN High frequency ventilation: enhances oxygenation more effectively than conventional ventilation with less barotrauma Examples of use: -RDS -Meconium aspiration -Severe asphyxia -Congenital defects

3 categories of pain interventions during labor

What works: -Epidural -Inhaled analgesia What may work: -Water immersion -Relaxation techniques -Acupuncture -Massage and nonopioid drugs may reduce pain Insufficient evidence of effectiveness: -Hypnosis -Biofeedback -Aromatherpy

A nurse is reviewing a client's maternal prenatal record and notes that the mother used narcotic drugs during her pregnancy. What nursing intervention should the nurse implement when caring for a drug-exposed neonate? a. Assess vital signs including blood pressure every hour b. Minimize environmental stimuli c. Place the infant in a well-lighted area d. Increase eye contact with caregiver

b. Minimize environmental stimuli Rationale: vital signs are usually stable, BP not typically done on newborns, eye contact important

After birth, a direct Coombs test is performed on the umbilical cord blood of a neonate with Rh-positive blood born to a mother with Rh-negative blood. The nurse explains to the client that this test is done to detect which information? a. Appropriate dose of Rho(D) immune globulin b. Degree of anemia in the neonate c. Initial bilirubin level d. Presence of maternal antibodies

d. Presence of maternal antibodies Rationale: A direct Coombs test is is done on the umbilical cord blood to detect maternal antibodies coating the neonate's red blood cells. Rho(D) immune globulin does are determined by amount of Rh-positive neonatal blood found in the mother after birth. Hemotcrit is used to detect anemia. A direct Coombs test does not measure bilirubin but may help explain the underlying cause of increased bilirubin levels.

S/S of increased respiratory effort in newborns

-Early signs: expiratory grunting, nasal flaring -Later signs: substernal (diploid area) or intercostal retractions

Early signs of increased respiratory effort in newborns

-Expiratory grunting -Nasal flaring

Major advantage of systemic pain relief

-Fast acting -Predictable duration

Common complications of prematurity

-Necrotizing enterocolitis (NEC) -Retinopathy of prematurity (ROP) -Periventricular/ intraventricular hemorrhage -Respiratory distress syndrome (RDS) -Transient tachypnea of the newborn (TTN) -Meconium aspiration syndrome

Types of respiratory support

-Oxihood -Continuous Positive Airway Pressure (CPAP) -Mechanical ventilation

Local infiltration anesthesia

-Used for episiotomy, laceration repair -Injected locally, onset of numbness awaited, then repair -Side effects are rare

Pain during first stage of labor

-Visceral pain prominent in lower abdomen r/t cervical changes, distention of lower uterus, tissue ischemia -Pain usually only with contractions -Back pain may be continuous -Pain may be "referred" radiating from uterus