Chapter 27: Intrapartum Complications Flashcards Preview

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

31

interventions for intrauterine infection

  • wash hands before and after each contact w/ all pts to reduce transmission of organisms
  • limit vaginal exams
  • maintain aseptic technique
  • keep underpads as dry as possible to reduce the moist, warm environment that favors bacterial growth
  • clean excess secretions from the vaginal area in a front to back direction to limit fecal contamination and promote the mother's comfort

32

assessment for maternal exhaustion

  • many women begin labor w/ a sleep deficit b/c of fetal movement, frequent urination, and shortness of breath
    • as labor drags on, mother's reserves are further depleted
  • signs of excessive fatigue:
    • verbal expression of tiredness, fatigue, or exhaustion
    • verbal expression of frustration w/ a prolonged, unproductive labor
    • ineffectiveness of or inability to use coping techniques (such as patterned breathing) that she previously used effectively
    • changes in her pule rate, respiration, and BP

33

interventions for conserving maternal energy

  • reduce factors that interfere w/ a woman's ability to relax:
    • lower lights
    • reduce noise
    • maintain a comfortable maternal temperature
  • position woman to maintain comfort, promote fetal descent, and enhance fetal oxygenation
    • support w/ pillows to reduce muscle strain
    • help change positions frequently, like q30 min, to reduce muscle tension
  • soothing back rub reduces muscle tension and dec fatigue
    • firm sacral pressure to reduce pain if the fetus is OP
    • use birthing ball or warmth
  • maintain IV fluids 
    • assess I&O to identify dehydration
      • dehydration may cause maternal fever
    • if not contraindicated, provide juice, lollipops, frozen juice bars to moisten her mouth

34

PROM vs pPROM

  • PROM: rupture of amniotic sac before true labor
    • normal if it occurs at term
  • pPROM: preterm premature rupture of membranes (before 37 weeks)
  • greatest newborn risks occur when birth occurs before completion of 34 weeks of gestation

35

conditions assoc with PROM:

  • chorioamniotis: fever and uterine tenderness
    • may be assoc with GBS, gonorrhea
  • vaginal or cervical infections: gonorrhea, chlamydia, trichomonas, GBS
  • weak amniotic sac
  • previous preterm births
  • fetal abnormalities or malpresentation
  • incompetent cervix
  • overdistention of the uterus
  • recent sexual intercourse
  • maternal stress 

36

complications of PROM

  • chorioamnionitis: weaken the membrane and lead to rupture
    • characterized by maternal fever and uterine tenderness
    • most likely to precede births in infants born before 34 weeks
    • frequent performance of vaginal exams inc risk of infection
  • oligohydramnios: membranes may continue to leak
    • umbilical cord compression, reduced lung volume, and deformities may result
  • RDS: if preterm birth occurs, the infant is more likely to have RDS

37

mgmt of PROM

  • depends on gestation and whether evidence of infection or maternal/fetal compromise exists
  • for a woman at or near term (36 weeks or more of gestation), PROM may herald the the imminent onset of true labor
    • often the cervix is soft, with some dilation and effacement
  • if the fetus is less than 36 weeks or the woman's cervix is not soft and favorable for labor induction, therapeutic mgmt is more complex

38

how to determine the true membrane rupture

  • urinary incontnence, inc vaginal discharge, or loss of mucous plug can make a woman think that her membranes have ruptures when they have not 
  • digital vaginal exam is avoided esp if gestation is preterm and no evidence of labor exists
    • instead, perform a sterile speculum exam to look for a pool of flui near the cervix and estimate dilation and effacement
    • pH swab or fern test  may be done to verify fluid is amniotic
  • perform tests to assess fetal lung maturity
  • if near term, cervix is favorable, and & fetal lungs are mature, induce labor
    • if cervix is not favorable and no infection, start steroids and abx
  • if preterm, risk vs benefit:
    • look at gestational age, amt of amniotic fluid remaining, fetal lung maturity
    • cerclage may be placed to prevent premature dilation
    • if no evidence of infection and fetal lungs are immature, then observe for infection and onset of labor
      • daily NSTs are performed to watch for FHR nonreactivity
    • steroids and abx given

39

nursing considerations for PROM

  • observe for signs of infection
  • at home:
    • avoid sexual intercourse or insertion of anything into vagina
    • avoid breast stimulation if preterm b/c can release oxytocin and stimulate contractions
    • take temp 4x per day: report anything over 100.4 deg F
    • maintain any activity restrictions
    • note and report uterine contractions or a foul odor to vaginal drainage

40

preterm labor

  • 20th-37th week
  • ADRs of prematurity:
    • cerebral palsy
    • developmental delay
    • hearing and vision impairment
  • risk factors:
    • previous preterm delivery
    • multifetal pregnancy
    • use of assisted reproductive technology: including prematurity, C/S, infant disability

41

associated factors of preterm labor

  • maternal medical conditions: UTIs, infection of reproductive organs, dental disorders, preexisting and gestational diabetes,connective tissue disorders, chronic HTN, drug abuse
  • conceptions enhanced by assisted reproductive technology
  • present and past obstetrical conditions: short cervical length, multifetal gestation, preterm membrane rupture, preeclampsoa, bleeding disorders, or problems with placental implantation
  • fetal conditions: growth retardation, inadequate amniotic fluid
  • social and environmental factors: absent prenatal care, domestic violence, maternal smoking

42

symptoms of preterm labor

  • uterine contractions
  • sensation that the baby is frequently "balling up"
  • cramps similar to menstrual cramps
  • constant low backaches
  • sensation of pelvic pressure or feeling the baby is pushing down
  • pain, discomfort, or pressure in vagina
  • change or inc in vaginal discharge
  • abdominal cramps w/ or w/o diarrhea
  • sense of just feeling bad

43

measures to prevent preterm labor

  • reduce barriers and improve access to care
  • assess for risk factors
  • promote adequate nutrition
  • promote smoking cessation
  • teach women and their partners about subtle signs of preterm labor and ways in which they differ from normal pregnancy changes
  • empower women and their partners to take an active approach to seeking care:
    • they should know the S/S of preterm labor

44

how to predict preterm birth

  • cervical length: <25 mm-->may allow organisms easier access to the uterus and may weaken membranes and cause rupture
  • PPROM in previous birth
  • fetal fibronectin (fFn): protein present in fetal tissues
    • normally found in cervical and vaginal secretions from 16-20 wks and again at or near term
    • if it appears to early, it suggests that labor may begin early
    • maternal or fetal infection may be present if the fFn is positive during midpregnancy
  • maternal illness or infection

45

stopping preterm labor

  • first determine if any problems exist that contraindicate continuing the pregnancy including HTN, hypovolemia, cardiac dz, pyelonephritis, nonreassuring FHR
  • identify and tx infections
    • amniocentesis can be done to obtain amniotic fluid for culture if chorioamnionitis is suspected b/c this infection would contraindicate stopping labor
    • cultures: require 24-48 hr to complete, so antiinfectives started as soon as cultures obtained
  • limit activity: help them relax 
  • hydrate: dehydration can contribute to uterine irritability in some women
  • tocolytics administered
  • corticosteroids given to accelerate fetal lung maturity if birth before 34 weeks seems inevitable
    • can reduce incidence and severity of RDS and IVH in preterm infants
    • try to delay birth for 24 hr after start of corticosteroid therapy

 

46

Magnesium sulfate

  • tocolytic and used to manage pregnancy assoc HTN to prevent seizures
  • loading dose: 4-6 g over 30 min
    • maintenance tocolysis: 1-4 g/hr
  • nursing care:
    • assessment of DTRs
    • monitor that urine output is >30 mL/hr
    • monitor RR b/c can depress RR
    • EFM b/c reduce variability is common
    • monitor bowel sounds q4-8 hr b/c of smooth muscle in intestinal tract is relaxed as uterus is relaxed
    • SEs: lethargy, flushing, dizziness, visual blurring, nausea, weakness, sensation of heat
    • calcium gluconate is antidote

47

corticosteroids

  • beta/dexamethasone
    • betamethasone: 6 mg q12H times 4 doses
    • dexamethasone: IM 12 mg, 2 doses 24 hr apart
  • delay birth 24 hr
  • accelerates fetal lung maturity
    • indicated if gestation is b/w 24-34 weeks b/c of high incidence of RDS
  • increase maternal glucose
  • monitor V/S: fever and tachycardia may indicate infection assoc with steroid administration
    • assess lung sounds b/c steroids can cause fluid retention
    • assess for pain and burning on urination (UTI)

48

Nursing Actions to care for early term and late preterm infants

  • assess frequently for resp difficulty
  • observe for feeding difficulties
  • monitor frequently for temp instability
  • educate parents

49

post term

  • lasts longer than 42 weeks
  • cause of prolonged labor: miscalculation of estimated delivery date b/c woman has irregular periods or miscalculated her LMP
  • complications:
    • placenta aging-->placental insufficiency (dec supply of O2 and nutrients to baby)
      • calcification and abruption can occur
      • may start to notice late decels or dec variability
    • oligohydramnios
      • cord compression can result from reduced fluid
    • passage of meconium-->RDS if aspirated
    • late growth retardation
    • loss of weight
    • large babies are a birthing risk: dysfunctional labor, PPH, shoulder dystocia

50

placental abnormalities

  • women w/ placental abnormalities may experience hemorrhage 
    • placenta previa (abnormal implantation in lower uterine segment) is sometimes assoc with an abnormally adherent placenta (placenta accreta)
  • strongest risk for placenta accreta is previous uterine surgery
    • may cause intrapartum hemorrhage or hemorrhage immediately after birth b/c the placenta does not separate cleanly, often leaving fragments behind that prevent full contraction
  • placenta increta: placenta penetrates uterine muscle itself
  • placenta percreta: placenta penetrates through entire uterine wall
  • hysterectomy may be required if large portion of placenta is abnormally adherent

51

causes of prolapsed cord

  • high station with ROM
  • small fetus
  • breech presentation: esp footling breech
  • transverse lie
  • hydramnios

52

nursing care w/ a prolapsed cord

  • priority:
    • to relieve pressure on the cord
    • to  inc fetal oxygenation
    • prompt delivery of the fetus
  • get help
  • steps:
    • position woman's hips heigher than head: knee chest, trendelenberg, hips elevated w/ pillows in side lying position
    • maintain vaginal elevation while woman is transferred to OR: minimize cord compression from the hand that is elevating the presenting part
      • use a gloved hand to push the fetus up and off the cord
    • avoid or minimize manual palpation or handing of cord
      • do not try to replace cord or manipulate cord
    • U/S exam to confirm presence of FHR before C/S
    • while prepping for C/S, give woman 8-10 L/min of O2 by face mask
      • may use a tocolytic to inhibit contractions to inc placental blood flow and reduce pressure on fetus
      • warm, saline moistened towels slow cooling and drying of the cord

53

3 variations of uterine rupture

  • complete: direct communication exists b/w uterine and peritoneal cavities
  • incomplete: rupture into peritoneum covering the uterus or into the broad ligament but not the peritoneal cavity
  • dehiscence: partial separation of an old uterine scar
    • little or no bleeding may occur
    • rupture or "window" may be found incidentally in a subsequent C/S or surgery

54

clinical manifestations of uterine rupture

  • abdominal pain and tenderness: can be excruciating or it may not be severe if at the peak of contraction
    • feels as if something "ripped"
  • labor progress may stop b/c the open area prevents efficient expulsion of the fetus
  • chest pain, pain b/w scapulae, pain on inspiration
  • hypovolemic shock caused by hemorrhage: tachycardia, tachypnea, hypoTN, pallor, cool/clammy skin
  • rigid abdomen
  • signs of impaired fetal oxygenation: late decels, reduced variability, tachy/bradycardia
  • absent FHR
  • fetus palpated outside the uterus-->fetus likely dead 

55

risk factors for uterine rupture

  • high parity
  • blunt abdominal trauma
  • intense contractions
  • cephalopelvic disproportion
  • previous uterine surgery or C/S

56

nursing care for uterine rupture

  • monitor maternal and fetal V/S
  • administer uterine stimulant drugs cautiously to reduce risk of excessive contractions
  • prepare client for C/S
  • provide emotional support for client and partner
  • treat shock: replace fluids/blood

57

anaphylactoid syndrome

  • AKA amniotic fluid embolism
  • occurs when amniotic fluid is drawn into the maternal circulation and carried to the woman's lungs 
    • fetal particulate matter (skin cells, vernix, hair, meconium) obstructs pulmonary vessels
    • abrupt respiratory distress, depressed cardiac function, circulatory collapse, DIC, and usually death result
      • can also cause sepsis, preeclampsia, and cardiac dz
  • more likely if labor is very strong and high intrauterine pressure forces amniotic fluid into open uterine/cervical veins
  • presents like a PE

58

therapeutic mgmt of anaphylactoid syndrome

  • CPR and support
  • O2 with mechanical ventilation
  • correction of hypoTN
  • blood component therapy (ie fibrinogen, packed RBCs, platelets, FFP) to correct coagulation defects

59

maternal cardiac arrest

  • CPR in pregnancy:
    • left tilt or manual uterine displacement
    • compression placement elevated
    • AED use is the same, but remove fetal monitors
  • perimortem C/S: 4 min after arrest