Chapter 27: Intrapartum Complications Flashcards
1
Q
Macrosomia is defined as
A
A fetal weight >8lbs 13 oz (4000 g) - 9lb 15 oz (4500 g)**
2
Q
What are risks associated with macrosomia?
A
- Distention of uterus by large fetus reduces strength of contractions both during and after birth**
- Baby head/shoulder won’t fit -> shoulder dystocia.
- Most likely to get c/s
- Low blood sugar in baby (if mother has DM)
3
Q
What can be done to help baby come out when the baby’s head/shoulder won’t fit?
A
- McRobert’s Maneuver
- If the first option doesn’t work, try SUPRAPUBIC PRESSURE to try to get baby out. (Fundal pressure is avoided)
- If that option doesn’t work, doctor can break clavicle -> need to get baby out ASAP.
4
Q
McRobert’s Maneuver
A
Pull leg back to make room in pelvis to help baby come out
5
Q
What are maternal complications associated with macrosomia?
A
- Tearing
- Hemorrhage
- Trauma down to fourth degree
- Hematomas
- Long labor
6
Q
What are newborn complications associated with macrosomia?
A
- Head or shoulders may not be able to adapt to pelvis if they are too large (cephalopelvic disproportion)
- Bruising -> jaundice
- Broken clavicle**
7
Q
Assessment for a baby with a broken clavicle
A
-Check for crepitus, deformity, Nursing that suggests fracture
8
Q
What are risk factors for macrosomia?
A
- Diabetes
- Big baby or small pelvis
- Previous history of big babies
9
Q
Abnormal Fetal Positioning
A
- May interfere with cervical dilation or fetal descent
- Presence of fetus in occiput posterior or occipital transverse can contribute to dysfunctional labor.
10
Q
What is the most common fetal malposition?
A
Occiput posterior
11
Q
What are maternal risks associated with abnormal fetal positioning?
A
- Labor is longer and uncomfortable when fetus remains in OT/OP position.
- Intense back or leg pain that may be poorly relieved with analgesia (makes coping with labor difficult)
- “Back labor”
- 4th degree lacerations; instrumentation
- C/S
12
Q
Back Labor
A
- Aptly describes sensation when fetus is in the OP position. Continue to feel more pain in back or focus postpartum.
- Natural is more painful
13
Q
What can be done to help discomfort in back labor?
A
Push up against their coccyx area to help their discomfort.
14
Q
What is the nursing plan of care for abnormal fetal positioning?
A
- Maternal position changes
- Forceps or vaccum assist
- C/S may be needed if neither methods work.
15
Q
Maternal position changes to assist in movement of the fetus into a more favorable position
A
- Hands and knees: rocking the pelvis back and forth while on hands and knees promotes rotation. Knees should be slightly behind hips in this position.
- Side-lying: on the opposite side of the fetal occiput
- Lunges
- Squatting or sitting on a slightly under inflated birth ball
- Sitting, kneeling or standing while leaning forward.
- Use of a birthing ball
16
Q
Spontaneous Rupture or Membrane
A
Begins before onset of true labor.
>= 37 weeks
17
Q
Preterm PROM
A
Rupture of membranes before term <37 weeks with or without contractions
18
Q
What are causes of premature rupture of membranes?
A
- Chorioamnionitis
- Infection (asymptomatic possibly): GBS sometimes associated**
- Amniotic sac with a weak structure
- Previous preterm birth, esp. if preceded by PPROM
- Fetal abnormalities or malpresentation
- Incomplete cervix or short cervical length (<25 mm)
- Overdistention of uterus
- Maternal hormonal changes
- Recent sexual intercourse
- Maternal stress or low socioeconomic status
- Maternal nutritional deficiencies
- Periodontal disease which can affect all organs
- Multifetal pregnancy
- Frequent performances of digital examination of cervix.
19
Q
What are the types of PROM?
A
- Spontaneous Rupture of Membranes
- Preterm Premature Rupture of Membranes
20
Q
Nursing assessment for patient’s with PROM
A
- Maternal/fetal V/S changes, especially FHR
- Signs of infection: could odor, color of fluid (turning yellowish)
- BPP
- Whole CBC
- Fetal lung maturity
21
Q
Nursing interventions for care of patients with PROM
A
- Good pericare
- If ruptured, make sure she stays clean and dry
- Preterm patient can stay for awhile with premature rupture - up to a couple weeks**
- Medications
- Hydrate! (Increased fluid to fetus)
22
Q
Pharmacological management of PROM
A
- Check for more?
- Bethametasone or selestone (24 hours apart, up to 72 hours for them to work)
23
Q
What are maternal risks associated with PROM?
A
- Postpartum infection
- Chorioamnionitis: maternal fever, uterine tenderness
- Oligohydramnios if continued leaking.
- Umbilical cord compression
- Reduced lung volume
- Deformities d/t cord compression, even worse if 23 weeks.
24
Q
Fetal-newborn risks associated with PROM
A
- Infection
- Neonatal sepsis
- Repository distress syndrome
- Greatest risk for hazards of prematurity before 34 weeks of gestation, esp if no steroids.
25
When does the risk for chorioamnionitis increase after rupture?
- Increases after 24 hours of rupture.
| - More likely to precede preterm birth in infant born before 34 weeks.
26
What should the nurse teach the patient who has PROM?
- Teach mom to avoid sexual intercourse, orgasm, or insertion in vagina cause of increased risk for infection caused by ascending organisms. (Can stimulate contractions)
- Avoid breast stimulation if gestation is preterm because it may cause release of oxytocin from posterior pituitary gland and thus stimulates contractions.
27
Nursing Implications when caring for mothers with PROM
- Take temperature at least 4 times a day. Report anything higher than 100 (37.8 C)**
- Maintain any activity restrictions
- Note and report uterine contractions or any foul odor to vaginal drainage.
28
What is the first step to interventions for mothers with PROM?
Determine true membrane rupture.
- Urinary Incontinence
- Vaginal discharge
- Loss of mucous plug
29
What should the nurse avoid in a mother with PROM if no evidence of labor exists and preterm?
-Avoid digital vaginal examination
30
Nursing Interventions for PROM: Maternal
- pH swab or fern test done on fluid to verify that it is amniotic fluid.
- Transvaginal ultrasound examination performed to measure cervical length
- Induction of labor if other factors are favorable.
- ABT given during labor
- GBS drugs
31
Short cervix (<25 mm) is more likely to
Continue effacement and dilation even if gestation is far from term.
32
Labor induction in woman with PROM
- Delayed for 24 hours if not given antibiotics (GBS) and allow cervical softening
- Consider gestational age, amount of amniotic fluid remaining, fetal lung maturity and any signs of fetal compromise.
33
Cerclage**
To prevent premature cervical dilation.
*look up more info??
34
PROM: ABT given during labor
- Can delay the onset of labor and allowing fetus to mature.
| - Ampicillin, amoxicillin and erythromycin.
35
What fetal heart patterns can you expect in a baby with PROM?
Variable decelerations
36
Desired outcomes in mothers with PROM
- Absence of infection
| - Get her as close to term as possible (w/ steroids and antibiotics)
37
When does preterm labor begin?
Begins after the 20th week but before the end of 36.6th week of pregnancy.
38
Preterm labor can increase the risk for
- Increased risk for ill equipped infant if <32 weeks gestation.
- Can result in cerebral palsy, developmental delay, vision/hearing impairment
39
Preterm Labor
Not sure what these numbers represent but look it up.
| 4x in 20 min or 8 in an hour; concern if she is dilating (IT IS ABNORMAL)
40
Risk factor for Preterm Labor include
- History of previous preterm infant**
- Dehydration**
- Overdistention of uterus (i.e multifetal pregnancy, hydramnios, macrosomia)**
- Infection**
- Use of assisted reproductive technology -> c/s, prematurity, infant disability/death.
- Over half do not show known risk.
- Maternal medical conditions (UTI, reproductive organs, systemic organs; dental disorder like periodontal disease, preexisting or GDM, connective tissue disorder, chronic HTN, drug abuse.
- Conception with assisted reproductive technology
- Present/past OB conditions such as short cervical length.
- Fetal conditions such as growth retardation, inadequate amniotic fluid volume and chromosomal abnormalities.
- Social/environmental factors (maternal smoking, etc.)
- Demographics (race, age of parents, etc.)
41
Why is dehydration a risk factor for preterm labor?
Stimulates posterior pituitary gland -> releases oxytocin -> preterm contractions
42
When does a mother with preterm labor show characteristics of typical term labor?
Only when labor reaches the active phase
43
What are signs and symptoms of preterm labor?
- Uterine contractions that may or may not be painful (palpate fundus)**
- Constant low backache; irregular or intermittent low back pain**
- A sensation that baby is frequently balling up
- Cramps similar to menstrual cramps
- Sensation of pelvic pressure or a feeling baby is pushing down
- Pain, discomfort or pressure in vagina or thighs
- Change or increase in vaginal discharge (increased, watery**, spotting)
- Abdominal cramp with or without diarrhea
- A sense of “feeling bad” or coming down with something.
44
Nursing interventions for preterm labor
- HYDRATION!
- If hydration doesn’t work, tocolytic mag sulfate is preferred.
- Steroids given at 36 weeks.
45
Patient teaching for preterm labor
- Preterm labor has subtle signs compared to near term, making her aware to seek care promptly rather than waiting for more definitive signs of labor. (Half of preterm births occur in women with no identified risk factors**)
- Drink adequate amounts of water
- Empty bladder frequently
- Side-lying position
46
How long should you palpate contractions in a woman with preterm labor?
Palpate for 1 hour
47
Predicting Preterm Birth
- Evaluate cervical length
- PPROM in a previous birth
- Fetal fibronectin
- Infection
48
How does evaluating cervical length predict preterm birth?
Short cervix <25 mm, with transvaginal ultrasound, allows vaginal organisms easier access to uterus, weakening the membranes and causes premature rupture.
(Women may have no symptoms of infection or pressure against the cervix)
49
How can a PPROM in a previous birth predict preterm birth?
Some may have predisposition to weak amniotic membrane structure that predates actual leak of fluid and repeats in subsequent pregnancies.
50
How does fetal fibronectin help predict preterm birth?
- fFN is protein found in fetal tissue.
| - If appears too early -> suggests labor may begin early.
51
When is fetal fibronectin found in cervical and vaginal secretions?
Normally found until 16-20 weeks of gestation and again at or near term.
52
If fFN is + during mid pregnancy,
Maternal/fetal infections may be present
53
When is a specimen taken for identification of fetal fibronectin?**
Specimen is collected BEFORE significantly vaginal examination from exam.
False + if cervical exam, recent sex and vaginal bleeding.
54
How can infection predict preterm birth?
Pneumonia can cause increase risk to give birth preterm.
| Asthma or crowded conditions can lead to pneumonia.
55
How can preterm labor be identified?
- Frequent prenatal visits
| - Transvaginal ultrasound: can identify shortened thinned cervix that precedes onset of labor in an ASYMPTOMATIC woman.
56
When should preterm labor be stopped?
If fetus is showing nonreassuring FHR
57
What is the point of no return for stopping preterm labor?
3 cm dilation
58
Nursing assessments when giving a mother with preterm labor magnesium
-Breath sounds (risk for pulmonary edema, HR (risk for tachycardia!)
59
What is important for the nurse to know when a preterm labor patient is on magnesium?
- Mother is not allowed to get out of bed! Will need a foley**
- Need to keep track of urine output since magnesium is excreted through kidneys!**
*Need to look up and clarify information about treatment for preterm labor and magnesium/terbutaline
60
If a mother with preterm labor has a HR >120 and doctor orders terbutaline
Tell him the V/S because terbutaline is contraindicated in this situation
*Look up more info
61
When is tocolysis ordered?
Ordered if preterm labor occurs before the 34th week of gestation because infant’s risk for respiratory and other complications of prematurity are high if infant is born at this time.
62
What is the purpose of tocolysis?**
- Provides time to give maternal corticosteroids to reduce respiratory distress in newborn**
- Gives time for transfer of mother to a facility with a NICU that is appropriate**
63
When is tocolysis more likely to be effective?
If cervix is less than 3 cm dilated. **
64
Assessments for Tocolysis (Not sure what these are but check book)
- If cervix is 2-3 cm dilated, recheck cervix for further dilation/effacement in 1-2 hours.
- EFM done for contractions
- fFN test
- Ultrasound imaging to determine fetal age
- Adequacy of placental supply
- Status of cervix
- Test for infection
65
What are the tocolytic drugs? (Not sure if that’s what these are, check book)
1. Magnesium sulfate
2. Calcium antagonists
3. Prostaglandin Synthesis inhibitors
4. Beta adrenergics
66
Tocolysis: What to give (Not sure what this means, look up in book and fix flashcards accordingly)
- Aminoglycosides (gentamicin and pen/ampicillin given broad.
- Clindamycin or metronidazole for anaerobic organisms causing infection. For woman, requires c/s.
- Progesterone supplementation -> Delutin (but in the form of makena can reduce preterm birth to woman who have had a previous preterm birth)
- Promote adequate nutrition
67
Steroid Therapy for Preterm Labor
-Steroid therapy considered as late as 37 weeks if fetal lung studies on maturity demonstrate immature lungs later than 34 weeks. Like betamethasone/dexamethasone
-Indicated between 24 – 34 weeks
Report chest pain or heaviness SOB inciate edema or pneumonia.
68
What are adverse effects of steroid therapy used for preterm labor? (I.e betamethasone)
- Can cause sodium retention w/ fluid retention and pulmonary edema so assess lungs.
- Report chest pain or heaviness, SOB which indicates edema or pneumonia.
69
Magnesium sulfate uses
- Manages pregnancy associated HTN to prevent seizures
| - Quieting uterine activity, inhibits/suppresses preterm labor
70
Adverse effects of magnesium used in preterm labor
- Lethargy
| - Sedation
71
A patient receiving magnesium must have
- UO of at least 30 mL/hour
- Presence of DTRs
- At least 12 respirations per minute
72
Maternal assessments for patients taking magnesium
- Heart and lung sounds with hourly VS (d/t fluid overload and electrolyte imbalances which can lead to pulmonary edema or cardiac dysrhythmias**)
- Bowel sounds (d/t risk for paralytic ileus)
73
What are normal magnesium levels?
1.5-2.5 normal
74
What magnesium levels are considered toxic?
8+
75
What indicates hyperreflexia?
3+ is slight hyperreflexia
| 4+ hyperreflexia
76
What is the loading dose of magnesium sulfate?
4-6 grams must be given first
77
Fetal assessments for baby’s with mothers taking magnesium
-Monitor for reduced variability of fetus (This is common and normal to observe in preterm)**
78
What is used to reverse magnesium toxicity?
Calcium glucophage (10%)
79
Magnesium Toxicity Symptoms
.....
80
When is magnesium toxicity less likely?
When given for preterm because renal function is normal.
81
Calcium Antagonists include
Nifedipine (adamant, procardia)
| CCB given for HTN
82
Calcium Antagonists: MOA
- Ca is essential for muscle contraction in SMOOTH muscles such as the uterus.
- Vasodilator
83
What are adverse effects of calcium antagonists?
- Flushing of skin
- Headache**
- Transient increase in maternal/fetal HR
- Postural hypotension (d/t vasodilator effect)
- Possible dizziness, faintness
84
Prostaglandin Synthesis Inhibitors include
Indomethacin (Indocin) which is an NSAID (has anti-inflammatory effects)
85
Prostaglandin Synthesis Inhibitors
To inhibit synthesis of uterine contractions by prostaglandins; short therapy
86
Maternal side effects of prostaglandin synthesis inhibitors**
- GI side effects
- N/V
- Heartburn
- Reducing amniotic fluid
- Can mask maternal fever.
87
Fetal side effects of prostaglandin synthesis inhbitors
- Constriction of ductus arteriosus**
- Pulmonary HTN
- Oligohydramnios
88
What can decrease the likelihood of fetal adverse effects caused by prostaglandin synthesis inhibitors?
-Less likely if therapy is shorter than 48-72 hours and gestation <32 weeks.
89
How can prostaglandin synthesis inhibitors help with hydramnios?
-Drug effect can reduce amniotic fluid
90
If prostaglandin synthesis inhibitors were given and baby was delivered less than 24 hours, the nurse needs to monitor for
Pulmonary HTN
| Intracranial hemorrhage
91
Nursing monitoring in patients taking prostaglandin synthesis inhibitors
- Monitor prolonged bleeding
| - Keep monitoring fundus location and FHR acceleration and movements.
92
Beta-Adrenergic Drugs include
-Ritodrine (Yutopari), Propanolol and Terbutaline (Brethine)
93
Ritodrine (Yutopari)
-Has significant side effects and increases the length of pregnancy
94
Terbutaline (Brethine)
- BRONCHODILATOR
| - Longer duration of action and ability to administer via SQ = quicker administration
95
What should you monitor in a patient taking terbutaline?
Cardiorespiratory system: Maternal and fetal tachycardia is common.
96
Terbutaline is contraindicated in
Tachycardia and hemorrhage
97
Propanolol (Inderal)
Blocks beta-adrenergic drugs**
| Should be able to reverse it (not sure what “it” is so look up)
98
What should you assess in a patient taking Propanolol?
-Assess apical HR and lung sounds before administration.
99
What can indicate beta-adrenergic drug toxicity?
- Maternal HR >120
- Wet lung sounds
- Rapid respiratory rate
- SOB
100
Add table from end of notes!!
+ Listen to lecture and find out what table she said to know!!!
101
Prolapsed umbilical cord
....
102
What are causes of a prolapse umbilical cord?
1. PROM
2. Malpresentation (i.e breach)
3. A minus station (head needs to be at zero station)
*Check for more
103
What are signs of umbilical cord prolapse?
1. Bradycardia, deep variable
| * Check for more
104
Maternal therapeutic Management of prolapsed umbilical cord
.....
105
Fetal therapeutic management of prolapsed umbilical cord
...
