Maternity - Chapter 8 Nursing Care of Women with Complications During Labor and Birth

Recovery room assessments after cesarean birth

- Vital signs to identify hemorrhage or shock; a pulse oximeter is used to better identify depressed respiratory function -IV site and rate of solution flow -Fundus for firmness, height, and midline position -Dressing for drainage -Lochia for quantity, color, and presence of clots -Urine output from the indwelling catheter (the fundus is checked as gently as possible) -Return of sensation to the lower body.

Indications for episiotomy

-Better control over where and how much the vaginal opening is enlarged -Opening with a clean edge rather than the ragged opening of a tear

Maternal symptoms of preterm labor

-Contractions that may be either uncomfortable or painless -Feeling that the fetus is "balling up" frequently -Menstrual-like cramps -Constant low backache -Pelvic pressure or a feeling that the fetus is pushing down -A change in the vaginal discharge -Abdominal cramps with or without diarrhea -Pain or discomfort in the vulva or thighs -"Just feeling bad" or "coming down with something"

Indications for induction

-Gestational hypertension -Ruptured membranes without spontaneous onset of labor -Infection within the uterus -Medical problems in the woman that worsen during pregnancy, such as diabetes, kidney disease, or pulmonary disease -Fetal problems, such as slowed growth, prolonged pregnancy, or incompatibility between fetal and maternal blood types -Placental insufficiency -Fetal death

Contraindications to induction

-Placenta previa -Umbilical cord prolapse -Abnormal fetal presentation -High station of the fetus (head not engaged), which can suggest a preterm fetus or a small maternal pelvis -Active herpes infection externally or in the birth canal, which the infant can acquire during birth -Abnormal size or structure of the mother's pelvis -Previous classic (vertical) cesarean incision

Premature rupture of membranes

-Premature rupture of membranes (PROM): spontaneous rupture of amniotic sac before the onset of true labor (>38 weeks) -- Usually not concerning -- Should deliver within 18-24 hours after ROM. -Preterm premature rupture of membranes (preterm PROM): membranes rupture before the completion of 37 weeks Risk factors: urogenital tract infection.

Indications for forceps or vacuum extraction

-used to end thee 2nd stage of labor if it is in the best interest of the mother or fetus -mother may be exhausted, unable to push effectively; women with cardiac or pulmonary disorders often have one due to the risk of worsening their condition

Prolonged pregnancy

A late-term pregnancy lasts between 41 weeks and 41 weeks and 6 days. A post term pregnancy lasts 42 weeks. The term post mature most accurately describes the infant whose characteristics are consistent with prolonged gestation.

Abnormal labor

Abnormal labor, called dysfunctional labor, does not progress. Dystocia is a term used to describe a difficult labor.

Indications for cesarean birth

Abnormal labor, Inability of the fetus to pass through the mother's pelvis (cephalopelvic disproportion) (most breech presentations are delivered by cesarean section), Maternal conditions such as GH or DM, Active maternal herpes virus, which may cause serious or fatal infant infection, Previous surgery on the uterus, including the classic type of cesarean incision, Fetal compromise including prolapsed umbilical cord and abnormal presentations, Placenta previa or abruptio placentae

Risk factors for dysfunctional labor

Advanced maternal age Obesity Overdistention of uterus (Hydramnios or multifetal pregnancy) Abnormal presentation- breech Cephalopelvic disproportion (CPD) Overstimulation of the uterus Maternal fatigue, dehydration, fear Lack of analgesic assistance

Safety Alert!!!

Although assessing the uterus after cesarean birth causes discomfort, it is important to do so regularly because the woman may have a relaxed uterus that causes excessive blood loss.

Amniotic fluid embolism

Amniotic fluid embolism, also known as anaphylactoid syndrome occurs when amniotic fluid with its particles such as vernix, fetal hair, and sometimes meconium, enters the women's circulation and obstructs small blood vessels in her lungs. It is more likely to occur during a very strong labor because the fluid is "pushed" into small blood vessels that rupture as the cervix dilates. Amniotic fluid embolism is characterized by abrupt onset of hypotension, respiratory distress, and coagulation abnormalities triggered by the thromboplastin contained in the amniotic fluid.

Forceps and vacuum extraction births

An obstetrician uses obstetric forceps and vacuum extractors to provide traction and rotation to the fetal head when the mothers pushing efforts are insufficient to accomplish a safe delivery. Forceps are instruments with curved blades that fit around the fetal head with out unduly compressing it. Forceps may also help the healthcare provider extract the fetal head through the incision during cesarean birth. A vacuum extractor uses suction applied to the fetal head so that the health care provider can assist the mothers expulsive efforts.

Prolonged pregnancy medical treatment

Any pregnancy that lasts longer than 41 weeks must be monitored closely with NST, AFI and BPP twice weekly and daily kick counts. If the women's pregnancy has definitely reached 41 weeks, 6 days, labor is usually induced by oxytocin.

Prolonged pregnancy risks

As the placenta ages, it delivers oxygen and nutrients to the fetus are less efficiently. The fetus may lose weight and the skin may being to peel. These are typical characteristics of post maturity. Meconium may be expelled into the amniotic fluid which can cause severe respiratory problems at birth. Low blood glucose levels are likely complication after birth.

Nursing care during and after cesarean birth

Assessments are done every 15 minutes for the first 1 or 2 hours and then every 30 minutes for 1 hour according to hospital policy. Recovery room assessments after cesarean birth.

Preterm labor activity restrictions

Bed rest was often prescribed for women at risk for preterm birth. However, the benefits of bed rest are not clear and many adverse maternal effects can occur.

Pharmacological and mechanical methods to stimulate contractions

Cervical ripening; cervical ripening is the physical softening of the cervix that leads to effacement and dilation. Induction of labor is more effective if the woman's cervix is "ripe". Oxytocin used to induce labor without a "ripe cervix" can result in the need for a cesarean section. Laminaria; and lamicel are mechanical dilators placed in the lower uterine segment that stimulate the release of prostaglandins from the fetal membranes and maternal decidua.

Nursing care for episiotomy or laceration

Cold packs should be applied to the perineum for at least the first 12 hours to reduce pain, bruising and edema. After 12 to 24 hours of cold applications, warmth in the form of heat packs or sitz baths increases blood circulation, enhancing conform and healing.

Risk factors for preterm labor

Exposure to DES, Underweight, Chronic illness, Dehydration, Preeclampsia, Previous preterm labor or birth, Previous pregnancy losses, Substance abuse, Chronic stress, Infection, Anemia, Preterm PROM, Inadequate prenatal care, Poor nutrition, Low education level, Poverty, Smoking, Multifetal presentation

Perineal lacerations/ Episiotomies Fourth Degree

Extends through the anal sphincter into the rectal mucosa.

Before labor is induced, it is important that __________

Fetal maturity be confirmed, as induction is avoided before 39 weeks gestation.

Most favorable pelvis

Gynecoid pelvis

Speeding fetal lung maturation

If it appears that preterm birth is inevitable, the physician may given the woman steroid drugs (glucocorticoids) to increase fetal lung maturity if the gestation is between 24 and 34 weeks. Betamethasone may be given for this purpose in two intramuscular injections 24 hours apart

Perineal lacerations/ Episiotomies First Degree

Involved the superficial vaginal mucosa or perineal skin.

Perineal lacerations/ Episiotomies Second Degree

Involved the vaginal mucosa, perineal skin, and deeper tissues of the perineum.

Cesarean birth

Is a surgical procedure in which a fetus is delivered through an incision in the mother's abdomen and uterus.

Laceration

Is an uncontrolled tear of the tissues that results in a jagged wound.

Precipitate birth

Is completed in less than 3 hours and there may be no health care provider present. Labor often begins abruptly and intensifies quickly, rather than having a more subtle inset and gradual progression.

Induction of labor

Is the intentional initiation of labor before it begins naturally

Augmentation of labor

Is the stimulation of contractions after they have begun naturally

Episiotomy

Is the surgical enlargement of the vaginal opening during birth.

Bishop score

Is used to assess the status of the cervix in determining its response to induction. A score of 6 or more indicates a favorable prognosis for induction

PROM diagnostic test

It is confirmed by testing the fluid with nitrazine paper, which turns blue in the presence of amniotic fluid. A sample of the vagina fluid placed on the slide and sent to the laboratory will show ferning pattern under the microscope, confirming that it is amniotic fluid.

Prolonged labor can result in several problems

Maternal or newborn infection, maternal exhaustion, postpartum hemorrhage and greater anxiety and fear in an ensuing pregnancy. In addition mothers who have difficult and long labors are more likely to be anxious and fearful about their next labor.

Episiotomy technique

Performed with blunt tipped scissors just before birth. Midline (median): extending directly from the lower vaginal border toward the anus. Mediolateral: extending from the lower vaginal border toward the mother's right or left.

Preterm labor

Preterm labor occurs after 20 weeks and before 37 weeks of gestation. The main risks are the problems of immaturity in the newborn. Preterm delivery is a major cause of perinatal morbidity and mortality has a major medical and economic impact and is a factor in the rising costs of health care.

Teaching combines information about infection and preterm labor and include

Report a temperature that is above 38 degrees C (100.4 degrees Fahrenheit), avoid sexual intercourse or insertion of anything in the vagina which can increase the risk for infection, avoid orgasm which can stimulate contractions, avoid breast stimulation which can stimulate contractions because of natural oxytocin release, maintain any activity restrictions prescribed, note any uterine contractions, reduced fetal activity or other signs of infection and record fetal kick counts daily, and report fewer than 10 kicks in a 12 hour period.

Perineal lacerations/ Episiotomies Third Degree

Same as second degree, plus involves the anal sphincter.

How to check the fundus

The fundus is checked as gently as possible. The woman flexes her knees slightly and takes slow, deep breaths to minimize the discomfort of the fundal assessments. While supporting the lower uterus with one hand, the fingers of the other hand are gently "walked" from the side of the uterus toward the midline. Massage is not needed if the fundus is already firm. The woman is told to take deep breaths at each assessment and to cough to move secretions from her airways. A small pillow or folded blanket supports her incision when she coughs or moves, which reduces pain. Changing her position every 1 or 2 hours helps expand her lungs and also makes her more comfortable.

Nursing care for premature rupture of membranes

The nurse should observe, document and report maternal temperature above 38 degrees C (100.4 degrees Fahrenheit), fetal tachycardia and tenderness over the uterine area.

Prolapsed umbilical cord

The umbilical cord prolapses if it slips downward in the pelvis after the membranes rupture. In this position, it can be compressed between the fetal head and the woman's pelvis interrupting blood supply to and from the placenta.

Risks associated with forceps or vacuum extraction

Trauma to maternal or fetal tissues is the main risk when forceps or vacuum extraction is uses. The infant may have bruising, facial or scalp lacerations or abrasions, cephalhematoma or intracranial hemorrhage.

Tocolytic therapy

goal is to stop uterine contractions and keep the fetus in utero until the lungs are mature enough to adapt to extrauterine life. Magnesium sulfate is the drug of choice. Not very effective but it is used to protect the fetus from developing cerebral palsy. A continuous IV infusion is administered and therapeutic levels are monitored. Overdose can affect the cardiorespiratory system and vital signs are recorded evert hour. Calcium gluconate should be on hand to treat adverse effects in the newborn.