Chapter 27: Intrapartum Complications Flashcards Preview

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Flashcards in Chapter 27: Intrapartum Complications Deck (59)
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1

what is dysfunctional labor?

  • lack of normal progress of cervical dilation, effacement, or descent
  • may result from problems with powers of labor, passenger, passage, psyche, or combination of these
  • often prolonged, but may be unusually short and intense
  • an operative birth may be needed if dysfunctional labor does not resolve or fetal or maternal compromise occurs

2

what is dystocia?

  • a general term to describe any difficult labor or birth

3

what are signs of compromise during a dysfunctional labor?

  • nonreassuring FHR
  • fetal acidosis
  • meconium passage
  • maternal exhaustion
  • maternal infection

4

problems of the powers that may result in dysfunctional labor

  • ineffective uterine contractions
  • ineffective maternal pushing

5

explain how ineffective contractions can be a problem for dysfunctional labor

  • good contractions are coordinated, strong, and frequent
  • causes of ineffective contractions:
    • fatigue
    • bedrest
    • electrolyte imbalance
    • hypoglycemia
    • excessive analgesia/anesthesia
    • overdistention of the uterus from multiple gestation or hydramnios
  • 2 patterns of ineffective uterine contractions: 
    • hypotonic dysfunction
    • hypertonic dysfunction

6

hypotonic contractions

  • coordinated by too weak and infrequent to be effective
  • usually occurs during the active phase of labor, when progress normally quickens
  • uterine overdistention is assoc with this b/c the stretched uterine muscle contracts poorly
  • comfortable but frustrating to laboring woman
  • does not cause fetal hypoxia

7

mgmt of hypotonic contractions

  • administration of IV or oral fluids corrects maternal F&E imbalances or hypoglycemia
  • change positions, esp upright positions
  • stand or sit in warm shower
  • manage pain: epidural blocks
  • therapeutic communication to identify anxieties or beliefs about labor
  • amniotomy
  • oxytocin infusion

8

for moms with hypotonic contractions:

what are the main risks assoc with amniotomy?

what are the main risks assoc with oxytocin infusion?

  • amniotomy:
    • umbilical cord prolapse
    • infection
    • placental abruption
  • oxytocin infusion: 
    • reduced placental perfusion caused by excessive contractions

9

hypertonic contractions

  • more often affect women in early labor w/ their first baby
  • contractions are uncoordinated and erratic, and they are painful but ineffective
  • uterine resting tone is high
    • dec oxygenation impacts fetus and causes constant cramping
  • woman becomes exhausted and anxious

10

mgmt of hypertonic contractions

  • warm shower: promotes relaxation and rest
  • systemic analgesics/low dose epidural
  • tocolytics: may reduce uterine resting tone and improve placental blood flow

11

what are the causes of ineffective pushing?

  • poor positioning
  • fear
  • no sensation or urge
  • exhaustion
  • analgesia or anesthesia
  • afraid to "let go" of baby

12

what are the interventions for ineffective pushing?

  • "laboring down": delayed pushing, so encourage the woman to wait until she feels the reflexive urge to push
    • also do not limit the length of the 2nd stage of labor
  • upright positions
    • squatting
    • add gravity to the pushing effors
  • "runners stance"
  • education
  • less anesthesia
  • good coaching

13

problems of passenger that may cause dysfunctional labor

  • fetal size
  • fetal presentation or position
  • multifetal pregnancy
  • fetal anomalies

14

macrosomia

  • greater than 8 lb 13 oz or 4000 g
  • head or shoulders may not be able to adapt to the pelvis if they are too large: cephalopelvic disproportion (CPD)
  • also distention of the uterus by the large uterus reduces the strength of contractions during and after birth

15

shoulder dystocia

  • EMERGENCY!
  • delayed or difficult birth of the shoulders may occur as they become impacted above the maternal symphysis pubis
    • after the head is born, it retracts against the perineum: "turtle sign"
  • more likely to occur when the fetus is large or the mother has diabete
  • problem: head is born and chest is in vagina-->prevents breathing

16

mgmt for shoulder dystocia

  • try for vaginal delivery
    • but prepare for C/S
  • McRobert's maneuver: woman flexes her thighs sharply against her abdomen, which straightens the pelvic curve somewhat
  • suprapubic pressure: push the anterior fetal shoulder downward to displace it from above the mother's symphysis pubis
  • fundal pressure should NOT be used b/c we don't want to push the shoulders even harder against the symphysis
  • once infant is born, check clavicles for crepitus, deformity, and bruising
  • timekeeper is essential

17

mnemonic for shoulder dystocia

  • H: call for Help
  • EEvaluate for Episiotomy
  • LLegs--McRobert's Maneuver
  • P: suprapubic Pressure
  • EEnter: rotational maneuvers
  • R: Remove the posterior arm
  • RRoll the patient to her hands and knees

18

rotation abnormalities that may lead to dysfunctional labor

  • persistence of the fetus in occiput posterior (OP) or occiput transverse (OT)
    • these positions can prevent the cardinal movements of normal labor from occurring
  • most fetuses that begin in occiput posterior rotate spontaneously to the occiput anterior (OA)-->promotes normal extension and expulsion of the head
  • labor is longer or more uncomfortable if the fetus is in OP-->back pain b/c contractions is intense
  • mgmt: 
    • counterpressure of the sacrum
    • hands and knees
    • side lying
      • 2 above both tend to rotate toward the anterior uterus
    • lunge positioning: widens the pelvis

19

deflexion abnormalities that may lead to dysfunctional labor

  • poorly flexed fetal head presents a larger diameter to the pelvis that if flexed with the chin on the chest
    • vertex presentation: head diameter is smallest
    • military and brow presentations: head diameter is largest
    • face presentations: head diameter is similar to the vertex presentation but the maternal pelvis can be transversed only if the fetal chin is anterior

20

breech presentation and how it may contribute to dysfunctional labor

  • dilation and effacement are slower in breech b/c the buttocks and feet do not form a smooth, round dilating wedge like the head
  • greatest risk: fetal head (largest part) is last to be born
    • by the time the lower body is born, the umbilical cord is well into the pelvis and may be compressed
      • shoulders, arms, and head must be delivered quickly so the infant can breathe
  • normally an external cephalic version is performed to try to position the infant in cephalic position or a C/S is performed if the baby can't be turned

21

how does a multifetal pregnancy contribute to dysfunctional labor?

  • multifetal pregnancy may lead cause dysfunctional labor b/c of uterine overdistention (-->hypotonic contractions) and abnormal presentation of the fetuses
  • potential for fetal hypoxia is greater and risk of PPH is greater
  • almost always C/S: esp if 3 or more fetuses
  • monitor both babies FHR during labor and continue to monitor 2nd baby's FHR once first baby is born (usually w/in 30 min of first)
  • equipment necessary for each baby: radiant warmers, resuscitation equipment, meds, blankets, hats, ID materials

22

fetal anomalies which can lead to dysfunctional labor

  • hydrocephalus
  • large fetal tumors
    • usually discovered by U/S
    • vaginal birth if possible but C/S is common

23

what are problems with the passage that may lead to dysfunctional labor?

  • small or abnormally shaped pelvis
  • maternal soft tissue obstructions: like full bladder

24

how can a woman's psyche contribute to dysfunctional labor?

  • if a woman's perception of stress is high:
    • inc glucose consumption
    • inhibition of contractions
    • poor pushing as abdomen and pelvic muscles tighten
    • inc pain perception
  • nursing measures:
    • develop trusting relationship
    • make environment comfortable by adjusting temp/light
    • promoting physical comfort like cleanliness
    • provide accurate info
    • implement pain mgmt

25

prolonged labor

  • guideline once in active labor:
    • 1.2 cm/hr dilation for nullipara
      • descend 1 cm/hr
    • 1.5 cm/hr dilation for parous woman
      • descend 2 cm/hr
  • risks of prolonged labor:
    • maternal or neonatal infection
    • maternal exhaustion-->ineffective pushing
    • high levels of anxiety/fear during subsequent labor

26

nursing measures for prolonged labor

  • promote comfort, conservation of energy
  • emotional support
  • position changes that favor normal progress
  • assess for infection
  • observe fetus for signs of intrauterine infection or compromised fetal oxygenation

27

precipitate labor

  • one in which birth occurs w/in 3 hrs of its onset
    • instense contractions have abrupt onset
  • risks:
    • placental abruption
    • fetal meconium
    • maternal cocaine use
    • PPH
    • low apgar scores for infant
    • fetal intracranial hemorrhage or nerve dmaage
    • fetal hypoxia
    • late decels and bradycardia

28

nursing measures for precipitate labor

  • promote fetal oxygenation and maternal comfort
    • side lying position: enhance blood flow and reduce aortocaval compression
    • administer O2 to mom 
    • IV fluids for blood volume
    • stop oxytocin if being given and begin tocolytic
    • epidural analgesia may not be possible
    • opioid analgesia given close to birth-->resp depression
    • breathing techniques for comfort

29

precipitate birth

  • labor of any length that occurs when a trained attendant is not there to assist
  • unexpected, sudden birth
  • nurse should wear gloves and support infant's body as it emerges
    • teach to pant b/w contractions
  • prepare for ROM
  • do not try to keep fetus from being delivered
  • apply gentle pressure to fetal head upward
  • infant: airway and warmth

30

assessment for intrauterine infection

  • fetal tachycardia may be first sign
  • maternal temp: assess q2-4 h in normal labor and q2 h after membranes rupture
    • assess hourly if elevated over 100.4 deg F
  • maternal pulse rate, respirations, and BP
    • assess at least hourly to identify tachycardia or tachypnea
  • assess amniotic fluid for normal clear color and mild odor
    • yellow or cloudy color and foul odor-->infection