Newberry College of Nursing OB checkpoint #4

Factors Affecting Labor Progress
¥ Passageway (birth canal)
¥ Passenger (fetus)
¥ Powers
¥ Position
¥ Psyche (mother)
Passageway
¥ True pelvis (space enclosed by the pelvic girdle and below the pelvic brim: between the pelvic inlet and the pelvic floor)
Ð Inlet, midpelvis, outlet

¥ Four types
Ð Gynecoid
Ð Android
Ð Anthropoid
Ð Platypelloid

¥ Cervical changes
Ð Dilation
♣ Widening of cervix during first stage; 0-10 centimeters
Ð Effacement
♣ Stretching and thinning of the cervix; 0-100%

Passenger–Fetal head
Ð Two frontal bones, two parietal bones, and occipital bone
Ð Sutures
¥ Membranous spaces b/n bones
Ð Fontanelles
¥ Intersections of the cranial sutures
¥ Anterior: diamond shape
¥ Posterior: triangle shape
Ð Molding
¥ Bones of fetal skull overlap to allow passage through birth canal
¥ Landmarks—mentum (chin), sinciput (brow), bregma (anterior fontanelle), occiput (back of head)
Fetal Attitude
Ð The relation of the fetal body parts to one another
Ð Normal attitude is flexion
Fetal Lie
Ð The relationship of spinal column of the fetus to that of the mother
Ð Longitudinal or transverse
Fetal Presentation
Ð Presenting part enters pelvic passage 1st
¥ Cephalic, Breech, Shoulder
¥ Cephalic broken down to vertex, sinciput, brow, face
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Engagement
¥ Largest diameter of presenting part reaches level of ischial spines
¥ Determined by vaginal exam

Engagement is based on how many fingers you can grasp the fetal head with.

Station
¥ Relationship of the presenting part to the ischial spines
¥ Ischial spines are zero station
¥ If presenting part above the ischial spine—negative number
¥ If presenting part below the ischial spine—positive number
Fetal Position
Ð Relationship of presenting part to maternal pelvis
Ð Right (R) or left (L) side of the maternal pelvis
Ð Landmark: occiput (O), mentum (M), sacrum (S), or acromion (scapula[Sc]) process (A)
Ð Anterior (A), posterior (P), or transverse (T)
Ð Determine by inspection/palpation of maternal abdomen or vaginal exam
********look this up for clarification******
Powers
¥ Primary forces—uterine muscular contractions
Ð Involuntary
Ð Contraction phases—increment, acme, decrement
Ð Described with frequency, duration, and intensity
Ð Braxton-Hicks: irregular and intermittent contractions; false labor
¥ Secondary forces—abdominal muscles used in pushing
Position
¥ Whatever is comfortable
¥ Allow mom to listen to her body
¥ NEVER supine!
Psyche
¥ Fears
¥ Anxieties
¥ Excitement level
¥ Feelings of joy and anticipation
¥ Level of social support
Premonitory Signs of Labor
¥ Lightening
¥ Braxton Hicks contractions
¥ Cervical changes (effacement, dilation, ripening)
¥ Bloody show
¥ Mucous plug released
¥ Rupture of membranes (ROM)
¥ Sudden burst of energy
¥ Weight loss
¥ Backache
¥ Nausea and vomiting
¥ Diarrhea
True Labor
¥ Progressive dilation and effacement
¥ Regular contractions increasing in frequency, duration, and intensity
¥ Pain usually starts in the back and radiates to the abdomen
¥ Pain is not relieved by ambulation or by resting
False Labor
¥ Lack of cervical effacement and dilatation
¥ Irregular contractions do not increase in frequency, duration, and intensity
¥ Contractions occur mainly in the lower abdomen and groin
¥ Pain may be relieved by ambulation, changes of position, resting, or a hot bath or shower
STAGES OF LABOR
FIRST STAGE
– from beginning of labor to complete dilation and effacement of cervix
¥ Latent or early phase (0-3cm)
¥ Contractions every 10-30 min, lasting 30-40 seconds, mild
¥ Active phase (4-7cm)
¥ Contractions every 2-3 min, lasting 40-60 seconds, moderate to strong
¥ Transition phase (8-10cm)
¥ Contractions every 1 ½ – 2 min, lasting 60-90 seconds, strong
Interventions for 1st stage labor
¥ Complete Admission Assessment and Review History
¥ Assessment: Maternal VS, Response to Labor and Pain, FHR and UC, Cervical Changes, Membrane Status, Fetal Position and Descent
¥ Diet and Hydration: Clear Liquids
¥ Activity and Rest: Frequent Position Changes/Ambulation/Pad Pressure Points
¥ Elimination: Frequent Emptying, Perineal Care
¥ Comfort: Meds and Non-Pharmacologic Strategies, Warm or Cool Cloths, Oral Care, Fresh Bed Linen
¥ Support: Keep Family Involved; Decrease Anxiety
¥ Education: About Labor, Procedures, Policies
¥ Safety: Safe and Friendly Environment
¥ Documentation
SECOND STAGE
– begins with complete dilation of cervix and ends with birth of baby “PUSHING”
¥ S&Sx = sudden increase in bloody show, uncontrolled bearing down efforts, bulging of the perineum
¥ Contraction frequency 1 ½ – 2 min; duration 60 – 90 sec
¥ Crowning
¥ Episiotomy
Ð Midline
Ð Mediolateral
Interventions for 2nd stage labor
¥ Support and Encourage Spontaneous Pushing Efforts
¥ Monitor for Fetal Response to Pushing
¥ Provide Comfort Measures (Cool, warm cloths, sips of fluids or ice chips, change linens)
¥ Position Changes as needed
¥ Perineal Hygiene as needed
¥ Give Praise and Encouragement
¥ Encourage Rest between Contractions
¥ Teach Breathing Technique
¥ Teach Pushing Technique
¥ Meds as ordered
¥ Assist the Support Person
¥ Advocate on Woman’s Behalf
¥ Documentation
THIRD STAGE
– begins with birth of the baby and ends with delivery of placenta
¥ Should deliver within 30 minutes
¥ Considered a “retained placenta” if greater than 30 mins.
¥ May need to remove manually
Interventions for 3rd Stage
¥ Maternal VS per protocol
¥ Encourage Breathing
¥ Encourage Rest
¥ Palpate Uterus
¥ Initial Newborn Care
¥ Encourage Bonding with Neonate
¥ Meds as ordered
¥ Documentation
FOURTH STAGE
– initial recovery time
¥ First 1-4 hours after delivery of placenta
¥ Expected amount of blood loss – 250 – 500 ml for vaginal delivery
¥ Essential for uterus to remain contracted
¥ Uterus should remain midline
¥ Uterus typically b/n symphysis pubis and umbilicus
¥ Priority problems during this stage
¥ -Risk for hemorrhage
¥ -Risk for hypotonic bladder/urinary retention
Interventions for 4th stage
¥ Maternal VS
¥ Assess Uterus Frequently: Position, Tone, Location
¥ Uterine Massage if needed
¥ Assess Lochia: Color, Amount, Clots
¥ Monitor Perineum for Swelling or Hematomas
¥ Meds as ordered
¥ Assist with Laceration/Episiotomy Repair
¥ Apply Ice to Perineum
¥ Monitor for Bladder Distention
¥ Promote Urinary Elimination
¥ Assess for motor-sensory function return if spinal or epidural used
¥ Encourage Bonding with Neonate
¥ May Eat and Drink Immediately if Vaginal Delivery
¥ Documentation
Discharge to Postpartum Care
¥ Discharge criteria
Ð Stable vital signs
Ð Stable bleeding
Ð Undistended bladder
Ð Firm fundus
Ð Sensations fully recovered from any anesthetic agent received during birth
Systemic Responses to Labor
¥ Increased cardiac output
¥ Increased blood pressure, pulse
¥ Diaphoresis
¥ Hyperventilation
¥ Changes in acid-base balance
¥ Impaired blood and lymph drainage from base of bladder
¥ Reduced gastric motility and food absorption, and prolonged emptying time
¥ Increased WBCs (25,000-30,000)
¥ Decreased maternal blood glucose
¥ Pain
Fetal Adaptations to labor
¥ Early decelerations from head compression
¥ Decreased pH, anoxic periods
¥ Aware of sensations such as light, sound, touch, pressure
Leopold’s Maneuvers: Palpation of abdomen to determine fetal position
¥ First maneuver
Ð Which part occupies the fundus?
Ð Am I feeling buttocks or head?
¥ Second maneuver
Ð Where is the fetal back?
Ð Where are the small parts or extremities?
¥ Third maneuver
Ð What is in the inlet? Does it confirm what I found in the fundus?
Ð Is the presenting part engaged?
¥ Fourth maneuver
Ð Where is the cephalic prominence or brow?
Ð Some practitioners may perform the fourth maneuver first to identify the fetal part in the pelvic inlet
Nursing for Leopold’s
¥ Empty bladder
¥ Lie on back
¥ Positioning
Ð Feet on bed
Ð Knees bent
Auscultation of FHR
¥ Intermittent done with Doppler or fetoscope
Ð Okay to count 30 seconds x2
Ð Count for full minute if tachycardia, bradycardia, or irregularities
Ð Compare HR of mom and baby
Frequency in low-risk women
Ð Every 30 minutes in first stage
Ð Every 15 minutes in second stage
Frequency in high-risk women
Ð Every 15 minutes in first stage
Ð Every 5 minutes in second stage
Systemic Analgesia
¥ Goal is to provide maximum pain relief with minimal risk
¥ Alteration in maternal state affects fetus
¥ Affects the labor process
Administration of Systemic Analgesia
¥ When woman is uncomfortable
¥ Well-established labor pattern
¥ Contractions occurring regularly
¥ Significant duration of contractions
¥ Moderate to strong intensity
Maternal Assessments Administration of Systemic Analgesia
¥ The woman consents to receive medication after being advised
¥ Stable vital signs
¥ No contraindications
Fetal Assessments
Administration of Systemic Analgesia
¥ Fetal heart rate between 110 and 160 beats/min
¥ No late decelerations or nonreassuring FHR patterns
¥ Variability is present
¥ Normal fetal movement
¥ Accelerations with fetal movement
¥ Term fetus
Assessment of Labor Progress
¥ Contraction pattern
¥ Cervical status
Ð Position
Ð Consistency
Ð Effacement
Ð Dilatation
Ð Station
Nursing Considerations Prior to Medication Administration
¥ Assess for history of any medication reactions or allergies
¥ Provide information about the medication
¥ Document assessment data
Ð Maternal vital signs
Ð FHR
Ð Contraction pattern
Ð Pain level
Nursing Considerations Following Medication Administration
¥ Record the drug name, dose, route, and site on FHR strip and chart
¥ Record the woman’s blood pressure and pulse on the FHR strip and chart
¥ Safety precautions
Ð Raise side rails
Ð Assess FHR
Evaluation of Pharmacologic Effects
¥ Assess and document data
Ð Woman’s pain level
Ð Effectiveness of the medication
Ð Adverse effects, if any
Opioid Analgesics and Sedatives
¥ Opioid analgesics
Ð Used in early labor
Ð Provide analgesic effect
Ð Induce sedation
Sedatives
Ð Promote rest
Opioid Analgesics
¥ Butorphanol tartrate (Stadol)
¥ Nalbuphine hydrochloride (Nubain)
¥ Meperidine (Demerol)
¥ Sublimaze (Fentanyl)
¥ Sufenta (Sufentanil)
¥ Morphine (Astramorph)
Analgesic Potentiators (ataractics)—enhance or increase effects of analgesics
¥ Promethazine (Phenergan)
¥ Hydroxyzine (Vistaril)
¥ Metoclopramide (Reglan)
¥ Ondansetron (Zofran)
¥ Diphenhydramine (Benadryl)
¥ Main side effect: sedation
Opiate Antagonist – Naloxone (Narcan)
¥ Nurse must be proficient in basic airway management
¥ Personnel skilled in advanced resuscitative measures must be available
Regional Anesthesia
¥ Temporary and reversible loss of sensation
¥ Prevents initiation and transmission of nerve impulses
¥ Types
Ð Epidural
Ð Spinal
Ð Combined epidural-spinal
Epidural: Advantages
¥ Produces good analgesia
¥ Woman is fully awake during labor and birth
¥ Continuous technique allows different blocking for each stage of labor
¥ Dose of anesthetic agent can be adjusted
Epidural: Disadvantages
¥ Hypotension
¥ Slowed fetal descent
¥ Prolonged labor
¥ Loss of bladder sensation may cause urine retention
¥ Low back pain
Epidural: Contraindications
¥ Patient refusal
¥ Infection at needle puncture site
¥ Maternal blood coagulopathies
¥ Increased intracranial pressure
¥ Allergy to anesthetic medication
¥ Hypovolemic shock
Epidural – Patient Preparation
¥ Confirm availability of obstetrician and ancillary staff
¥ Encourage woman to void urine
¥ Foley catheter insertion
¥ Assessment data
Ð Maternal pain level, blood pressure (BP), pulse, respirations
Ð Fetal heart rate (FHR)
¥ Continuous electronic fetal monitoring
¥ Assist with patient positioning
¥ Initiate intravenous infusion (18-gauge)
Ð Bolus of 500 to 1000 mL of IV fluid
Nursing Interventions During Epidural Anesthesia
¥ Frequent assessment of maternal vital signs until block wears off
¥ Promote maternal side-lying position
¥ Frequent repositioning
¥ Assess sensorimotor ability every 30 minutes
¥ Assess for bladder distention
¥ Protect lower extremities from injury
Recovery from Epidural Anesthesia
¥ May take several hours
Ð Dependent upon anesthetic agent and dose
Potential side effects of epidural infusions:
¥ Breakthrough pain
Ð Hot Spots
¥ Sedation
¥ Nausea and vomiting
Ð –Antiemetics
¥ Pruritus—severe itching of the skin
Ð —-Benadryl
¥ Hypotension
Ð —Increase IVF rate, left uterine displacement, oxygen
Ð —If BP doesn’t return in 1-2 minutes, give ephedrine 5-10 mg IV
Epidural Opioid Analgesia
¥ Provides analgesia for approximately 24 hours after delivery
¥ Works in 30-60 minutes
¥ Injection of opioid into epidural space following delivery
¥ Side effects include
Ð Pruritus
Ð Nausea and vomiting
Ð Urinary retention
Spinal Anesthesia: Advantages
¥ Immediate onset of anesthesia
¥ Relative ease of administration
¥ Smaller drug volume
¥ Maternal compartmentalization of the drug
Spinal Anesthesia: Disadvantages
¥ High incidence of hypotension
¥ Greater potential for fetal hypoxia
¥ Uterine tone is maintained, making intrauterine manipulation difficult
Spinal Anesthesia: Contraindications
¥ Patient refusal
¥ Severe hypovolemia
¥ Central nervous system disease
¥ Infection over the puncture site
¥ Allergy to anesthetic agent
¥ Coagulation problems
Spinal Anesthesia – Patient Preparation
¥ Insert 16- to 18-gauge intravenous (IV) catheter
¥ Administer bolus of 500 to 1000 mL IV fluid
¥ Assess maternal vital signs, pain level, and FHR
¥ Position woman sitting or lateral
Nursing Interventions During Spinal Anesthesia
¥ Position woman supine with left uterine displacement
Ð Rolled towel or blanket under right hip
¥ Monitor maternal blood pressure and pulse per protocol or physician’s order
¥ If spinal block used during vaginal birth
Ð Monitor uterine contractions
Ð Instruct the woman to bear down during a contraction
Recovery From Spinal Anesthesia
¥ Cautious transfers from birthing bed (or operating room table)
¥ Bedrest for 6 to 12 hours following block
¥ Restoration of bladder control may take 8 to 12 hours
Ð Urinary catheter may be needed if not already in place
Combined Spinal-Epidural (CSE)
¥ Can be used for labor analgesia and for cesarean birth
¥ Advantages
Ð Faster onset than medications injected into epidural space
Ð Medication can be added to increase effectiveness
Ð Motor function preserved
Ð Allows for ambulation with assistance
Pudendal Block
¥ Provides perineal anesthesia
Ð Latter part of the first stage of labor
Ð Second stage of labor
Ð Birth
Ð Episiotomy repair
Pudendal Block: Advantages
¥ Ease of administration
¥ Absence of maternal hypotension
¥ Pain reduction during use of low forceps or vacuum extraction
Pudendal Block: Disadvantages
¥ Possible complications
Ð Broad ligament hematoma
Ð Perforation of the rectum
Ð Sciatic nerve injury
¥ May diminish urge to push
General Anesthesia
¥ Potential indications
Ð Cesarean birth
Ð Surgical intervention with some complications
¥ Used in less than 1% of all modern obstetric births
Primary Dangers of General Anesthesia
¥ Fetal depression
Ð Most general anesthetic agents reach fetus in about 2 minutes
Ð Fetal depression directly proportional to anesthetic depth and duration
Ð Not advocated for high-risk fetus
Ð Maternal general anesthesia associated with higher rate of neonatal respiratory depression than is maternal epidural anesthesia
Premature Rupture of Membranes (PROM)
¥ Spontaneous rupture of membranes before onset of labor
¥ Preterm PROM (PPROM): rupture of membranes before 37 weeks’ gestation
Risk Factors Associated With PROM / PPROM
¥ Infection
¥ Previous history of PROM / PPROM
¥ Hydramnios
¥ Multiple pregnancy
¥ Urinary tract infection (UTI)
¥ Amniocentesis
¥ Placenta previa– placenta partially or wholly blocks the neck of the uterus
¥ Abruptio placentae– placental lining has separated from the uterus of the mother prior to delivery.
¥ Trauma
¥ Incompetent cervix
¥ History of laser conization or LEEP procedure
¥ Bleeding during pregnancy
¥ Maternal genital tract anomalies
Maternal Risk of PROM
¥ Related to infection
Ð Specifically chorioamnionitis (intra-amniotic infection resulting from bacterial invasion before birth) and endometritis (PP infection of the endometrium)
¥ Abruptio placentae occurs more frequently in women with PROM
¥ Rare complications include retained placenta and hemorrhage, maternal sepsis, and maternal death
Fetal/Newborn Implications
¥ Risk of respiratory distress syndrome (with PPROM)
¥ Fetal sepsis
¥ Malpresentation
¥ Umbilical cord prolapse or compression
¥ Nonreassuring fetal heart rate tracings
¥ Premature birth
¥ Increased perinatal morbidity and mortality
PROM – Nursing Care
¥ Determine duration of the rupture of membranes
¥ Assess gestational age
¥ Monitor for infection
¥ Assess fetal heart rate
¥ Evaluate the woman and partner’s childbirth preparation and coping abilities
¥ Assess uterine activity and fetal response to the labor
Ð Vaginal exams only if necessary
¥ Provide comfort measures
¥ Maintain adequate hydration
¥ Encourage left lateral positioning
¥ If PPROM
Ð Hospitalization, bed rest, monitored for infection, and assess fetal well-being
¥ Education
Signs and Symptoms of PTL (preterm labor)
¥ Uterine contractions that occur at least every 10 minutes
Ð With or without pain
¥ Mild menstrual-like cramps felt low in the abdomen
¥ Constant or intermittent feelings of pelvic pressure
¥ Rupture of membranes
¥ Low, dull backache
¥ Change in the vaginal discharge
¥ Abdominal cramping
Risk Factors of PTL
¥ Multiple gestation
¥ Hydramnios
¥ Substance abuse
¥ Trauma
¥ Hypertension
¥ Obesity
¥ History of PTL
¥ Diabetes
¥ Cervical insufficiency
Diagnosis of PTL
¥ 20 to 37 weeks’ gestation
¥ Documented uterine contractions
Ð At least 4 in 20 minutes or 8 in one hour
¥ Cervical change or dilation >1 cm; effacement ≥ 80%
Clinical Interventions for PTL
¥ Maternal lateral positioning
¥ IV fluid infusion
¥ Maternal laboratory studies
Ð CBC
Ð C-reactive protein
Ð Vaginal and urine cultures
Ð Fetal fibronectin (fFN)
¥ Ultrasounds
Tocolysis for PTL
¥ Use of medication to stop labor
Ð β-adrenergic agonists (β-mimetics)
Ð Magnesium sulfate
Ð Cyclooxygenase (prostaglandin synthetase) inhibitors
Ð Calcium channel blockers
¥ (Brethine) and magnesium sulfate are most widely used tocolytics
PTL – Community-Based Care
¥ Teach signs and symptoms of PTL
Ð Uterine contractions that occur every 10 min or less
Ð Mild menstrual-like cramps low in the abdomen
Ð Constant or intermittent feelings of pelvic pressure
Ð Rupture of membranes
Ð Constant or intermittent low, dull backache
Ð Change in vaginal discharge
Ð Abdominal cramping
¥ Teach self-assessment and self-care
Ð Evaluation of contraction activity once or twice daily for 1 hour
Ð Ensure the woman knows when to report signs and symptoms
Ð Reinforce to caregivers the need to take the woman’s call seriously and treat her positively
PTL – Hospital Care
¥ Vital Signs
¥ Intake & Output
¥ Continuous FHR monitoring
¥ Continuous contraction monitoring
¥ Position on left side
¥ Administer medications
¥ If birth is inevitable, administer corticosteroids (Betamethasone, Dexamethasone)
Ð Prevent RDS, IVH, NEC, death – especially b/n 24-34 weeks
Placenta Previa
¥ Placental implantation in the lower uterine segment
¥ As lower uterine segment contracts and dilates, placental villi are torn from uterine wall
Ð Uterine sinuses exposed at placental site
Ð Amount of bleeding may range from scanty to profuse
¥ Placenta Previa: Four Degrees
Ð Total (Internal os completely covered)
Ð Partial (os partially covered)
Ð Marginal (edge of placenta covered)
Ð Low-lying (os not covered)
Placenta Previa: Risk Factors
¥ Women of African descent
¥ Prior cesarean birth
¥ High gravidity
¥ High parity
¥ Advanced maternal age
¥ Previous miscarriage
¥ Previous induced abortion
¥ Cigarette smoking
¥ Male fetus
Placenta Previa – Fetal Prognosis
¥ Depends on extent of placenta previa
¥ Profuse bleeding yields fetal compromise and hypoxia
¥ FHR monitoring is imperative upon maternal admission, particularly if vaginal birth is anticipated, as the presenting fetal part may obstruct the placental or umbilical cord blood flow
Placenta Previa – Indications for Cesarean Birth
¥ Nonreassuring fetal status
¥ Diagnosis of complete or partial previa
Placenta Previa – Nursing Assessment
¥ Maternal assessment for painless, bright-red vaginal bleeding
Ð Most accurate diagnostic sign of placenta previa
Ð If this sign develops during the last 3 months of pregnancy, placenta previa should always be considered until ruled out by ultrasound examination
¥ Bleeding usually begins as scant and becomes more profuse
¥ Uterus remains soft
¥ Anticipate unengaged fetal presenting part
¥ Transverse lie is common
¥ Assessment of fetal status
Ð FHR – continuous external fetal monitoring
Ð Electronic monitor tracing
¥ Anticipate need for blood transfusion
¥ Assess maternal vital signs
Ð Every 15 minutes if no hemorrhage
Ð Every 5 minutes with active hemorrhage
¥ External tocodynamometer– Electronic external monitoring of uterine contractions
¥ No vaginal exams when bleeding present
¥ Intake and output
¥ IV line
Placenta Previa – Nursing Care During Active Bleeding
¥ Assessments and management directed toward physical support
¥ Address emotional aspects simultaneously
Ð Explain assessments and treatment measures
Ð Provide time for questions
Ð Advocate for the family
Ð Stay with the family
Ð Therapeutic Touch
Placenta Previa – Newborn Care
¥ Promote neonatal physiologic adaptation
¥ Immediate laboratory assessment and monitoring
Ð Hemoglobin, cell volume, and erythrocyte count
¥ Anticipate potential need for oxygen, blood administration, and admission to special care nursery
Abruptio Placentae
¥ Premature separation of a normally implanted placenta from the uterine wall
¥ Cause is largely unknown
¥ Uterus is hard on palpation
Abruptio Placentae – Associated Risk Factors
¥ Increased maternal age (over 35)
¥ Increased parity
¥ Cigarette smoking
¥ Cocaine abuse
¥ Trauma
¥ Maternal hypertension
¥ Rapid uterine decompression associated with hydramnios and multiple gestation
¥ Preterm premature rupture of the membranes (PPROM)
¥ Previous placental abruption
¥ Uterine malformations or fibroids
¥ Placental anomalies
¥ Amniocentesis
¥ Retroplacental fibromyoma
¥ Shortened umbilical cord
¥ Subchorionic hematoma
¥ Elevated alpha fetoprotein—(Levels of the protein can be measured to detect certain congenital defects such as spina bifida and Down syndrome.) in second trimester
¥ Inherited thrombophilia– blood has an increased tendency to form clots
Three Types of Placental Separation
¥ Marginal (separates at the edges)
Ð Blood passes between the fetal membranes and the uterine wall and escapes vaginally
¥ Central (separates centrally)
Ð Blood is trapped between the placenta and uterine wall with concealed bleeding
¥ Complete
Ð Total separation and massive bleeding
Abruptio Placentae – Implications
¥ Maternal
Ð Risk of hemorrhage, shock, and DIC
¥ Fetal
Ð Neonatal outcomes depend on degree of abruption
Ð Low incidence of fetal death
♣ Typically depends upon the degree of placental separation
Ð Fetal complications include preterm labor, anemia, and hypoxia
Abruptio Placentae – Assessment and Monitoring
¥ Electronic monitoring of uterine contractions and resting tone between contractions
Ð Provides information about the labor pattern and effectiveness of oxytocin induction
¥ Hourly abdominal girth measurements
Monitor for DIC
Ð Coagulation tests (Fibrinogen and platelets decrease; PT and PTT WNL to prolonged)
Ð Levels of fibrin-degradation products (rise with DIC)

( pregnancy complications including the following: (1) acute peripartum hemorrhage (uterine atony, cervical and vaginal lacerations, and uterine rupture); (2) placental abruption; (3) preeclampsia/eclampsia/hemolysis, elevated liver enzymes, and low platelet count)

Abruptio Placentae – Clinical Therapy
¥ Immediate priorities are maintaining maternal cardiovascular status and developing a birth plan
¥ Cesarean birth is often the safest option
¥ Induction of labor may be indicated
Abruptio Placentae – Decreasing the Risk of DIC
¥ Type and crossmatch for blood transfusions (at least three units)
¥ Evaluate clotting mechanism
¥ Administer intravenous fluids
Abruptio Placentae – Moderate to Severe Separation
¥ Cesarean birth follows treatment of hypofibrinogenemia
¥ Vaginal birth impossible with a Couvelaire uterus—( is a life-threatening condition in which loosening of the placenta (abruptio placentae) causes bleeding that penetrates into the uterine myometrium forcing its way into the peritoneal cavity.)
Ð Lack of proper uterine contraction in labor
Ð Hysterectomy often needed
Abruptio Placentae – Fluid Volume Status
¥ Hypovolemia associated with severe abruptio placentae is life threatening
Ð Requires administration of whole blood
¥ If fetus is alive but experiencing stress
Ð Emergency cesarean is method of choice
¥ If fetus is stillborn
Ð Vaginal birth is preferable if bleeding has stabilized, unless maternal shock from hemorrhage is uncontrollable
¥ Administer intravenous fluids
¥ Hourly central venous pressure (CVP) monitoring
¥ Laboratory testing
Ð Includes hemoglobin, hematocrit, and coagulation status
¥ Hematocrit maintained at 30% through administration of packed red blood cells or whole blood
Third-Trimester Bleeding – Overview of Nursing Care
¥ Frequent monitoring of vital signs
¥ Assess for signs of shock
¥ Estimate blood loss
¥ Monitor FHR
¥ Electronically monitor contractions
¥ Administer blood as needed
¥ Monitor urine output
¥ Facilitate and monitor diagnostic tests and results
¥ Support and educate the woman and her family
Cervical Insufficiency
¥ Formerly called incompetent cervix
¥ Painless dilatation of the cervix without contractions due to a structural or functional defect of the cervix
¥ Woman is usually unaware of contractions and presents with advanced effacement and dilatation and, possibly, bulging membranes
Cervical Insufficiency – Risk Factors
¥ Multiple gestations
¥ Repetitive second-trimester losses
¥ Previous preterm birth
¥ Progressively earlier births with each subsequent pregnancy
¥ Short labors
¥ Previous elective abortion or cervical manipulation
¥ Diethylstilbestrol (DES) exposure— a powerful synthetic estrogen used in hormone therapy, as a postcoital contraceptive
¥ Other uterine anomaly
Cervical Insufficiency – Caring for Women at Risk
¥ Close surveillance of cervical length
Ð Transvaginal ultrasound beginning between 16 and 24 weeks’ gestation
¥ Education early in pregnancy
Ð Warning signs of impending birth
Ð Lower back pain, pelvic pressure, and changes in vaginal discharge
Cervical Insufficiency – Medical Therapies
¥ Serial cervical ultrasound assessments
¥ Bed rest
¥ Progesterone supplementation
¥ Antibiotics
¥ Anti-inflammatory drugs
Cervical Insufficiency – Surgical Therapies
¥ Cerclage-
Ð Surgical procedure in which a stitch is placed in the cervix to prevent spontaneous abortion or premature birth
¥ Elective cerclage-
Ð May be placed late in first trimester or early in second trimester
Ð 80% to 90% success rate in preventing fetal loss and premature labor and birth
¥ Emergent cerclage-
Ð Placed when dilatation and effacement have already occurred
Ð 40% to 60% success rate
¥ Abdominal cerclage-
Ð Indicated for congenitally short or amputated cervix, cervical defects, a cervix previously scarred, or unhealed lacerations or subacute cervicitis
Discovery of Unexpected Cervical Dilation
¥ Attempt may be made to “rescue” pregnancy through cerclage placement after advanced cervical dilatation
¥ May require decompression of bulging amniotic sac
Ð Preoperative evaluation for infection, ruptured membranes, and uterine activity may be prudent
¥ Perioperative and ongoing treatment
Ð Tocolytics (drugs that stop labor)
Ð Broad-spectrum antibiotics
Ð Anti-inflammatory agents
Cerclage – Hospitalization and Postoperative Plan
¥ Uncomplicated elective cerclage
Ð May be outpatient procedure
Ð May require hospitalization with discharge after 24 to 48 hours
¥ Emergency cerclage
Ð Requires hospitalization for > 5 to 7 days
¥ After 37 completed weeks’ gestation, suture may be cut and vaginal birth permitted, or the suture may be left in place and a cesarean birth performed
Physical Discomfort Associated with Multiple Gestation
¥ Shortness of breath
¥ Dyspnea on exertion
¥ Backaches and musculoskeletal disorders
¥ Pedal edema
Problems Associated with Multiple Gestation
¥ Urinary tract infections
¥ Threatened abortion
¥ Anemia
¥ Gestational hypertension and preeclampsia
¥ Preterm labor and birth
¥ Premature rupture of membranes
¥ Thromboembolism
¥ Placenta disorders (previa, abruption)
Complications During Labor for Women with Multiple Gestation
¥ Abnormal fetal presentations
¥ Uterine dysfunction
¥ Prolapsed cord
¥ Hemorrhage at birth or shortly after
Multiple Gestation – Fetal/Neonatal Implications
¥ Higher mortality rate than for single fetus
¥ Decreased intrauterine growth rate
¥ Increased incidence of fetal anomalies
¥ Increased risk of prematurity
¥ Abnormal presentations
¥ Increase in cord accidents
¥ Increase in cerebral palsy
Multiple Gestation – Clinical Therapy
¥ Prenatal visits more frequent than for mothers with single gestation
¥ Maternal education
Ð Nutritional implications
Ð Assessment of fetal activity
Ð Signs of preterm labor
Ð Danger signs of pregnancy
¥ Serial ultrasounds
Ð No risk factors present: every 3-4 weeks to assess growth
Ð Identified risk factors present: every 2-3 weeks
Multiple Gestation – Third-Trimester Testing
¥ Usually begins at 32 to 34 weeks’ gestation
¥ May include nonstress test (NST) or biophysical profile (BPP)
Multiple Gestation – Intrapartum Management
¥ Insertion of large-bore IV in mother
¥ Anesthesia and crossmatched blood readily available
¥ Continuous dual electronic fetal monitoring of twins
¥ Method of birth might not be chosen until labor begins
¥ Cesarean birth may be indicated if complications
Multiple Gestation – Maternal Dietary Counseling
¥ Prenatal vitamins
¥ Daily intake of 1 mg of folic acid
¥ Recommended total weight gain of 40 to 45 lb, with a 24-lb gain by 24 weeks
Multiple Gestation – Maternal Activity Counseling
¥ Frequent rest periods
Ð Side-lying position with her lower legs and feet elevated to reduce edema
¥ Relief of back discomfort
Ð Pelvic rocking
Ð Good posture
Ð Pregnancy belt
Ð Good body mechanics
Multiple Gestation – Labor Care
¥ Continuous FHR monitoring
¥ Most multiple gestations are now delivered via cesarean birth
Multiple Gestation – Postdelivery Care
¥ Duplicate all necessary supplies
¥ Additional staff members should be available
¥ Special precautions to ensure correct identification of newborns
Amniotic Fluid Complications
¥ Hydramnios (polyhydramnios) >2000 mL
¥ Oligohydramnios <500 mL
Hydramnios
Hydramnios—Risk Factors
¥ Multiple gestation
¥ Diabetes
¥ Rh sensitization
¥ Infections (syphilis, toxoplasmosis, CMV, herpes, rubella)
¥ Fetal malformations—swallowing or neurologic disorders
Hydramnios – Diagnosis
¥ Fundal height increases out of proportion to gestational age
¥ Difficult to palpate fetus and auscultate FHR
¥ Severe cases: abdomen tense and tight, ultrasound shows large spaces between fetus and uterine wall
Hydramnios – Nursing Care
¥ Supportive care unless distress or symptoms of pain and dyspnea
¥ May need to remove fluid either vaginally or through amniocentesis
Ð Maintenance of sterile technique during amniocentesis
¥ Psychologic support for the family
Hydramnios – Maternal Implications
¥ Rapid fluid removal could lead to abruptio placentae
¥ Risk of postpartum hemorrhage
Fetal/Neonatal Implications with Hydramnios
¥ Malformations
¥ Preterm labor/preterm birth
¥ Prolapsed cord
¥ Malpresentation
¥ Cesarean section
Oligohydramnios
Oligohydramnios – Risk Factors
¥ Intrauterine growth restriction (IUGR)
¥ Fetal conditions—renal malformations
¥ Post-maturity
¥ Maternal HTN
Oligohydramnios – Diagnosis
¥ Largest vertical pocket of fluid measure 5 cm (2 inches) or less on ultrasound
¥ Uterus does not increase in size with dates
¥ Easily palpated fetus
¥ Not ballottable—meaning floating or unengaged
Oligohydramnios – Maternal Implications
¥ Dysfunctional labor, slow progress
Oligohydramnios − Fetal Risks
¥ Fetal skin and skeletal abnormalities
¥ Pulmonary hypoplasia— incomplete development of the lungs
¥ Cord compression
¥ Fetal head compression
Oligohydramnios − Clinical Therapy
¥ Fetal assessment
Ð Biophysical profiles (BPPs)– measures your baby’s heart rate, muscle tone, movement, breathing, and the amount of amniotic fluid around your baby.—(may include NSTs, ultrasound, and EFM)
Ð Nonstress tests (NSTs) goal of the test is to measure the heart rate of the fetus in response to its own movements
Ð Serial ultrasounds
Ð Continuous EFM to detect cord compression
¥ Induction of labor when fetus at term
¥ Possible amnioinfusion
Tachysystolic Labor
more than 5 contractions in 10 minutes, over a 30 min period
Oligohydramnios − Nursing Care During Labor and Birth
¥ Evaluate continuous EFM for nonreassuring signs
¥ Maternal repositioning if variable decelerations noted
Ð Notify physician/CNM
Ð Nonreassuring tracing may warrant cesarean
¥ Assess newborn for signs of congenital anomalies, pulmonary hypoplasia, and postmaturity
Tachysystolic (hypertonic) Labor Patterns
need at least a 30 sec. break and this does not allow that to happen
¥ Ineffective uterine contractions in latent phase (the first of stage 1) of labor
¥ Increased myometrial resting tone—not getting break, so tone stays hard
¥ May develop prolonged latent phase
Ð –Fetal hypoxia can result
Risks of Tachysystolic Labor Patterns
¥ Increased discomfort and fatigue
¥ Frustration and stress
¥ Dehydration
¥ Increased risk of infection
¥ Nonreassuring fetal status-because blood flow is diminished.
¥ Prolonged pressure on fetal head—could cause injury
Clinical Therapy for Tachysystolic Labor
¥ Bed rest and sedation
¥ If tachysystolic pattern continues and prolonged latent phase develops
Ð Oxytocin (Pitocin)-(make contractions more effective) infusion or amniotomy (artificially rupture the membranes) may be considered to start a more natural progression
¥ If vaginal birth impossible—if baby is too big, or in a malposition
Ð -No stimulation of labor
Ð —Cesarean section
Care of Patient with Tachysystolic Contractions
¥ Assess contractions, vitals, and FHR
¥ Provide comfort and support measures
¥ Change positions, provide back rubs, quiet environment
¥ Warm showers, tub baths
¥ Sedation, pain medication
¥ Client education
Hypotonic Labor Patterns
¥ Usually develop in active phase of labor
¥ Characterized by fewer than two to three contractions in a 10-minute period
¥ Contractions may be of low intensity and are minimally uncomfortable
Hypotonic Labor Patterns – Associated Factors
¥ Overstretched uterus (twin gestation)
¥ Large fetus
¥ Hydramnios
¥ Grand multiparity
¥ Bladder or bowel distention
¥ CPD—cephalopelvic disproportion—baby too big for pelvis
Risks of Hypotonic Contractions
¥ Maternal exhaustion
¥ Stress
¥ Postpartum hemorrhage—if uterus does not contract, can bleed after delivery
¥ Intrauterine infection
¥ Nonreassuring fetal status
¥ Fetal sepsis
Hypotonic Contractions – Goals of Therapy
¥ Improve uterine contraction quality
¥ Ensure safe maternal and fetal outcome
¥ Uterine contractions may be stimulated
Ð Pitocin, amniotomy (artificially stimulate labor), or stimulation of the nipples (releases oxytocin)
Hypotonic Contractions – Active Management of Labor (AMOL)
¥ Labor managed from beginning with amniotomy, timed cervical exams, augmentation of labor with IV Pitocin
¥ May be instituted for treatment
¥ Goals of AMOL include cervical exam changes and more active labor pattern
¥ If improvement not significant, cesarean birth may be indicated
Care of Patient with Hypertonic Contractions
¥ Assess contractions, vitals, and FHR
¥ Verify adequacy of the pelvic measurements
¥ Rule out malpresentation
¥ Maintain adequate hydration
¥ Monitor for signs of infection
¥ Stimulation of uterine contractions
Postterm Pregnancy – after 42 weeks
Postterm Pregnancy – Maternal Risks
¥ Labor induction
¥ Dystocia—abnormal labor
¥ Large-for-gestational-age (LGA) infant
¥ Forceps-assisted or vacuum-assisted birth
¥ Increased psychologic stress
¥ Infection—especially if membranes ruptured
¥ Severe perineal trauma related to macrosomia
¥ Double the risk of cesarean birth
¥ Hemorrhage—uterus has been distended for so long and can lead to bleeding
Postterm Pregnancy – Fetal Risks
¥ Decreased placental perfusion—kinda starts to breakdown
¥ Oligohydramnios—soon there may be not enough fluid
¥ Meconium aspiration—during birth baby ends up swallowing its own poop.
¥ Low Apgar score—because they were compromised in utero
¥ Orthopedic or neurologic injury—some type of trauma during birth leads to this
Growth Beyond 42 Weeks – Fetal Risks
¥ Macrosomia
Ð Shoulder dystocia—may break clavicle if not careful
¥ Intrauterine growth restriction (IUGR) / Small for gestational age (SGA)—without fluid, this may result
Ð Postmaturity or dysmaturity syndrome—loss of muscle mass and subcutaneous fat
¥ Small-for-gestational-age (SGA)
Postterm Pregnancy – Clinical Therapy After 40 Weeks’ Gestation
¥ Biweekly assessments of fetal well-being
Ð Nonstress test (NST), biophysical profile (BPP), modified BPP, or contraction stress test (CST) as assessment tools
Ð Nonreassuring results may suggest need for delivery
Community-Based Nursing Care
¥ Teach the woman to perform daily assessment of fetal movement
¥ Education about post-term pregnancy
¥ Provide opportunities for the woman and her partner to ask questions and seek clarification
Hospital-Based Nursing Care
¥ Careful assessment and evaluation
Ð Fetal response to labor
Ð FHR tracing
Ð Labor progress
¥ Emotional support
¥ Encouragement and support
¥ Acknowledgement of the woman’s anxiety
Fetal Macrosomia
¥ Weight of more than 4500 g at birth
Ð Some sources cite weights up to 4000 g
¥ Increased maternal risks
Cephalopelvic disproportion (CPD), dysfunctional labor, prolonged
Macrosomia – Risk Factors
¥ Obesity
¥ Excessive weight gain
¥ Diabetes
¥ History of macrosomia
¥ Male fetus
¥ Grand multiparity
¥ Prolonged gestation
¥ Hispanic descent
Macrosomia – Fetal Complications
¥ Shoulder dystocia
¥ Upper brachial plexus injury
¥ Fractured clavicle
¥ Meconium aspiration
¥ Asphyxia
¥ Hypoglycemia
¥ Polycythemia
¥ Hyperbilirubinemia
¥ Obesity in childhood and adolescence
¥ Diabetes in later life
Identification of Macrosomia Before Labor Onset
¥ May reduce the occurrence of associated maternal and fetal problems
¥ Evaluation of maternal pelvis if large fetus suspected
¥ Estimation of fetal size
¥ Ultrasonography may be indicated
Macrosomia – Method of Birth
¥ Cesarean if weight estimated > 4500 g
¥ Vaginal delivery
Ð Unexpected shoulder dystocia is critical problem
Ð Nurse may be asked to assist woman into McRoberts maneuver or to apply suprapubic pressure in an attempt to aid in the birth of the fetal shoulders
Ð Application of fundal pressure contraindicated b/c can further wedge shoulder under symphysis pubis
Dystocia
: abnormal or difficult labor—ends up being a prolonged labor
¥ Most common cause is dysfunctional or uncoordinated contractions; irregular in strength, timing, or both
Nursing Care of the Laboring Woman with Fetal Risk for Macrosomia
¥ Help identify women who are at risk for carrying a large fetus or those who exhibit signs of macrosomia
¥ Frequent assessment of FHR for indications of nonreassuring fetal status
¥ Evaluation of rates of cervical dilatation and fetal descent
Nursing Care of the Fetus with Macrosomia During Labor
¥ Continuous fetal monitoring
Ð Early decels could be disproportion at the bony inlet
¥ Report any sign of labor dysfunction or nonreassuring fetal status to physician/ CNM
Ð Lack of fetal descent should raise suspicion that infant may be too large for vaginal birth
¥ Support and inform laboring woman and her partner
Neonatal Assessment of the Infant with Macrosomia
¥ Nurse inspects newborn for cephalohematoma (bruising on head), Erb’s palsy (paralysis of the arm caused by injury to the upper group of the arm’s main nerves), and fractured clavicles
¥ Inform nursery staff of any problems
¥ Ensure close monitoring for cerebral, neurologic, and motor problems
Postpartum Care of the Woman who Delivers Infant with Macrosomia
¥ Anticipate excessive uterine stretching leading to contracting issues during labor and postpartum
¥ Expect uterine atony and boggy (soft) uterus
¥ Monitor for and treat uterine hemorrhage
Ð Fundal massage
Ð IV or IM Pitocin may be needed
¥ Closely monitor maternal vital signs for development of shock
¥ Electronic fetal monitoring – can tell if pressure relieved
Umbilical Cord Prolapse – Cord precedes the presenting part causing compression
Umbilical Cord Prolapse
¥ Relieve compression with gloved fingers–
¥ Position for gravity to help relieve compression (knee chest; Trendelenburg)
¥ Oxygen via mask
¥ Cesarean birth if cervix not complete and pelvic measurements are not adequate
Umbilical Cord Prolapse – Prevention
¥ Keep horizontal after ROM until head well engaged
¥ If SROM or amniotomy – FHR auscultated for 1 minute at beginning and end of contraction for several contractions
¥ If fetal bradycardia – perform vaginal exam to rule out prolapse
Umbilical Cord Prolapse – Symptoms
¥ EFM will show severe, moderate, or prolonged variable decels with baseline bradycardia
Amniotic Fluid Embolism
¥ Currently known as anaphylactoid syndrome of pregnancy
¥ Small tear in amnion or chorion high in the uterus; small amount of amniotic fluid may leak into chorionic plate and enter maternal system; can enter at areas of placental separation or cervical tears; the uterus contracts, pushes fluid embolism into maternal circulation and into maternal lungs
¥ Occurs during or after the birth when the woman has had a difficult, rapid labor
Amniotic Fluid Embolism – Risk Factors
¥ Tumultuous labor
¥ Placental abruption
¥ Trauma
¥ Induction of labor
¥ Eclampsia
¥ Operative vaginal birth
¥ Cesarean section
¥ Multiple gestation
Amniotic Fluid Embolism – Maternal Implications
¥ Sudden onset of respiratory distress, circulatory collapse, acute hemorrhage, and cor pulmonale (failure of the right ventricle)
¥ Immediate birth may be required to obtain a live newborn
¥ Signs and symptoms include dyspnea and cyanosis progressing to hemorrhage, shock, and death
Amniotic Fluid Embolism – Clinical Therapy
¥ Monitor woman for signs and symptoms
Ð Chest pain, dyspnea, cyanosis, frothy sputum, tachycardia, hypotension, and massive hemorrhage
¥ Implementation of immediate life-saving efforts by healthcare team
¥ Medical interventions are supportive
Cesarean birth if necessary
Cephalopelvic Disproportion (CPD)
¥ Fetus is larger than passageway
¥ Causes of passageway contractures (narrowed diameter)
Ð Narrowed pelvis or soft-tissue dystocia (fibroids, Bandl’s ring, stool, full bladder)
Ð Reproductive tract anomalies can also impact birthing ability
CPD – Maternal Implications
¥ Prolonged labor
¥ Rupture of membranes
¥ Increased risk of uterine rupture
¥ Maternal soft tissue necrosis
¥ Difficult, forceps-assisted birth
CPD – Fetal/Neonatal Implications
¥ Danger of cord prolapse
¥ Excessive cranial molding
¥ Bruising
¥ Nerve trauma
¥ Eye socket damage
CPD – Clinical Therapy
¥ Assessment of fetopelvic relationships
Ð Compare pelvic measurements obtained by manual exam before labor
¥ Estimate weight of the fetus with ultrasound
Ð Can be obtained by ultrasound measurements
¥ Trial of Labor (TOL) if pelvic diameters borderline
Ð Frequently assess dilation and fetal descent
Nursing Care of the Woman with Suspected CPD
¥ Assess adequacy of maternal pelvis for vaginal birth both during and before labor
¥ Intrapartum assessment of fetal size, presentation, position, and lie
¥ Suspect CPD when labor is prolonged, cervical dilatation and effacement are slow, and engagement of the presenting part is delayed
¥ Support couple in coping
¥ Nursing actions during TOL
Ð Similar to care during any labor except that cervical dilatation and fetal descent are assessed more frequently
¥ Continuous monitoring of contractions and fetus
¥ Report signs of nonreassuring fetal status
¥ Assist mother with positioning to increase diameters – sitting, squatting, changing from side to side, hands and knees
Third- and Fourth-Stage Complications
¥ Retained placenta—beyond 30 mins after birth
¥ Lacerations
¥ Placental adherence
Retained Placenta
Ð Retention of the placenta beyond 30 minutes after birth
Ð Bleeding can be excessive
Ð May require manual removal of placenta
Ð If no epidural, potential IV sedation
Ð If manual removal fails, surgical removal with curettage (scraping it out)
Cervical or Vaginal Lacerations
Ð Suspected when bright red vaginal bleeding persists despite well-contracted uterus
Ð Factors associated with increased incidence:
♣ Nullipara, epidural anesthesia, forceps-assisted or vacuum-assisted birth, episiotomy, birth weight greater than 3634 grams, macrosomia
Degrees of Laceration—at least one test question here!!!
¥ First-Degree
Ð Laceration limited to the perineal skin, and vaginal mucous membrane
¥ Second-Degree
Ð Perineal skin, vaginal mucous membrane, underlying fascia, and muscles of the perineal body; may extend upward on one or both sides of the vagina
¥ Third-Degree
Ð Extends through the perineal skin, vaginal mucous membranes, and perineal body and involves the anal sphincter; it may extend up the anterior wall of the rectum
¥ Fourth-Degree
Ð Same as third but extends through the rectal mucosa to the lumen of the rectum
¥ Placenta accreta
Ð Chorionic villi attach directly to the uterine myometrium (the smooth muscle tissue of the uterus.)

Ð Associated with maternal hemorrhage and failed placental separation after birth
Ð High incidence of abdominal hysterectomy

¥ Placenta increta
Ð Myometrium is invaded
Placenta percreta
¥ Ð Myometrium is penetrated
Perinatal Loss
– death of a fetus or infant from time of conception through the end of the newborn period 28 days after birth; Also referred to as intrauterine fetal death, stillbirth, fetal demise
Perinatal Loss – Potential Causes
Fetal
¥ Chromosomal disorders
¥ Birth defects
¥ Exposure to teratogens
¥ Infections
¥ Complications of multiple gestation
¥ Fetal growth restriction
Perinatal Loss – Potential Causes
Maternal
¥ Chronic HTN
¥ Preeclampsia & Eclampsia
¥ Diabetes
¥ Advanced maternal age
¥ Rh incompatibility
¥ Uterine rupture
¥ Ascending maternal infection
¥ Placenta previa
¥ Abruptio placentae
¥ Cord problem
Perinatal Loss – Confirmation
¥ Absence of heart action on ultrasound
Perinatal Loss – Removal
¥ Prolonged retention of dead fetus increases risk of DIC and infection
¥ Most women have spontaneous labor 2 weeks after death
¥ Want a vaginal expulsion if possible
¥ Will use prostaglandin agents to ripen and dilate the cervix
¥ Former c/s may require removal by c/s due to risk of uterine rupture
Grief
Ð An individual’s total response to a loss, including physical symptoms, thoughts, feelings, functional limitations, and spiritual reactions
Ð Manifestations may include certain behaviors and rituals of mourning, such as weeping or visiting a gravesite, which help the person experience, accept, and adjust to the loss
Bereavement
Ð Period of adjustment to loss
Stages of Grief
¥ Denial
¥ Anger
¥ Bargaining
¥ Depression
¥ Acceptance
External Version
¥ Physician applies external manipulation to maternal abdomen
¥ May be done after 36 weeks’ gestation to change breech or shoulder presentation to cephalic presentation
¥ Fetal presenting part must not be engaged
¥ Reactive NST performed to establish fetal well-being—done first
¥ Before procedure, ultrasound to check position, placenta
¥ Tocolytic (terbutaline) given during procedure to relax the uterus
¥ Nursing assessment
Ð Mom: IV line, BP, HR, Pain
Ð Baby: EFM before, during, after at least 30 min
Internal Version
¥ Physician reaches into uterus and grabs feet of fetus and pulls them down through cervix
¥ Tocolytic given during procedure to relax uterus
Podalic version
¥ Used to turn second twin during vaginal birth
¥ Used only if second fetus does not descend readily and heartbeat is not assuring
Amniotomy – artificial rupture of membranes (AROM)
¥ Use of amnihook or gloved finger
¥ Need at least 2cm of dilation
¥ Fetal head should be engaged (dropped down into true pelvis) to avoid cord prolapse
Purpose of Amniotomy
¥ Stimulate or induce labor
¥ Apply internal fetal or contraction monitors
¥ Obtain fetal scalp blood sample for pH monitoring
¥ Assess amniotic fluid (consistency, color, amount, odor, meconium or blood present)
Nursing Care for amniotomy
¥ Check FHR before procedure and immediately after
¥ Assess for cord prolapse
¥ Assess amniotic fluid
¥ Limit vaginal exams -limit exposure and prevent infections
¥ Check temperature every 2 hours—assessing for infection
¥ Clean perineum as needed
¥ Change perineal pads as needed
Amnioinfusion
¥ Used to increase volume of fluid with oligohydramnios–<500mL ¥ Potentially used in preterm labor with premature rupture of membranes ¥ Transcervical instillation through IUPC of 250 mL sterile NS or LR at a continuous rate of 100-200 mL/hr ¥ Administered at room temperature
Nursing Care
for amnioinfusion
¥ Help administer fluid
¥ Maternal VS
¥ Monitor contractions
¥ Continuous EFM
¥ Maintain bedrest
¥ Pericare/Change pads
¥ Intake and output (count pads)
Labor Induction
– stimulation of uterine contractions before the spontaneous onset of labor, with or without ruptured membranes for the purpose of accomplishing birth
¥ Indications: Diabetes, preeclampsia, eclampsia, PROM, chorioamnionitis, postterm, intrauterine fetal death, IUGR, alloimmunization, nonreassuring antepartum testing
¥ Any contraindication to spontaneous labor or vaginal birth are contraindications of labor induction
¥ Labor readiness:
o Assess gestational age, amniotic fluid studies to determine lung maturity, Bishop score
Cervical Ripening
¥ Consists of effacement and softening of the cervix
¥ May be used at or near term to enhance success of and reduce time needed for labor induction when continuing pregnancy is undesirable
¥ May hasten beginning of labor or shorten course of labor
¥ Bishop score done to determine favorability of cervix for labor
Ð <8 not favorable and will receive ripening agent Ð 8 is favorable and cervix will respond to Pitocin induction Ð >9 spontaneous labor likely—no need to induce
¥ May cause hyperstimulation of uterus—at risk for rupture
¥ Pharmacologic agents include Cytotec and prostaglandin agents (Prepidil, Cervidil) given intracervically or intravaginally
Ð Can cause uterine stimulation after insertion
Nursing Care for cervical ripening
¥ Maternal VS
¥ EFM
¥ Lie supine with right hip wedge or left side for at least 1 hour
¥ Monitor for uterine hyperstimulation, nonreassuring FHR for at least 2 hours
Ð If seen, insert should be removed
Stripping of the Membranes
¥ Mechanical method
Ð Gloved finger inserted into internal os and rotated 360 degrees twice
♣ Separating amniotic membranes lying against lower uterine segment
Ð Releases prostaglandins to stimulate contractions
Ð Does not require monitoring or other assessments
♣ Often done as outpatient service
Ð May not induce labor
♣ If labor is initiated, it typically begins within 48 hours
Ð May cause bleeding
Mechanical Dilatation with Intracervical Catheter
¥ Foley balloon inserted into cervix and inflated to stretch cervix without fetal side effects
¥ Disadvantages: difficulty with placement; failure to maintain placement; limited ambulation
Pitocin Infusion
¥ Usually effective at producing contractions or enhancing ineffective contractions
Ð May cause hyperstimulation of the uterus, uterine rupture, water intoxication, fetal hypoxia, fetal death
¥ Goal: stable contractions every 2-3 minutes, lasting 40-60 seconds, strong intensity
¥ Progress is determined by checking effacement, dilation, and fetal station
¥ Requires small, precise dosage; MUST use infusion pump
Ð Run as a secondary infusion (piggybacked into the primary line of 1000 mL of LR)
Ð Start with 10 units Pitocin = 1 milliunit/min = 6 mL/hour
¥ Maximum rate and dosing interval based on facility protocol, clinician order, individual situation, and maternal-fetal response
¥ Palpating uterus essential, unless IUPC in place—MVU’s to assess intensity of contractions
¥ May initially decrease blood pressure
Episiotomy
¥ Surgical incision of perineal body to enlarge outlet during 2nd stage of labor
Ð Commonly used to avoid spontaneous laceration
¥ usually performed with regional or local anesthesia
Complications: increased risk of 4th degree laceration, blood loss, infection, pain
Episiotomy–two types
Ð Midline
♣ Incision begins at bottom center of perineal body and extends straight down midline to fibers of rectal sphincter
Ð Mediolateral
♣ Incision begins in midline of posterior fourchette and extends at 45 degree angle downward to the right or left
Nursing Care for episiotomy
¥ During procedure, provide mother with support and comfort
¥ Use distraction if needed
Ð If procedure is uncomfortable, act as advocate for mother
¥ Document type of episiotomy in records and report to subsequent caregivers
¥ After procedure, provide comfort and apply ice pack (on for 20-30 min; off for 20 min)
¥ Assess perineal area frequently
Ð Inspect every 15 minutes during first hour after birth for redness, edema, tenderness, ecchymosis, and hematomas
¥ Instruct mother in perineal hygiene and comfort measures
Forceps-Assisted Birth
Indications
¥ Any condition that threatens the mother or fetus relieved by birth
¥ Can assist in pushing efforts of the woman
Forceps-Assisted Birth risks for baby
¥ Newborn may experience
Ð Bruising
Ð Edema
Ð Facial lacerations
Ð Cephalohematoma/Caput Succedaneum
Ð Brachial plexus injury
Ð Transient facial paralysis
Ð Cerebral hemorrhage, brain damage
Forceps-Assisted Birth risks
¥ Woman may experience
Ð Vaginal or perineal lacerations
Ð Infection secondary to lacerations
Ð Increased bleeding
Ð Bruising
Ð Perineal edema
Ð Anal incontinence
Vacuum Extractor
¥ Assists birth by applying suction to fetal head
¥ Should be progressive descent with first two pulls, procedure should be limited to prevent cephalohematoma
Ð Risk increases if birth not within six minutes
C/S indications
¥ Most common indications for cesarean birth–
Ð Fetal distress
Ð Active genital herpes
Ð Multiple gestation (three or more fetuses)
Ð Umbilical cord prolapse
Ð Lack of labor progression (“failure to progress”)
Ð Pelvic size disproportion
Ð Placenta previa—( placenta partially or wholly blocks the neck of the uterus, thus interfering with normal delivery of a baby.)
Ð Placental abruption—( separation of the placenta from the wall of the uterus)
Ð Previous cesarean section
¥ Preparation for cesarean birth requires
Ð Establishing IV lines
Ð Placing indwelling catheter
Ð Performing abdominal/perineal prep
Ð NPO except antacids 30 min prior—due to spinal anesthesia, to prevent aspiration of stomach contents
Ð Maternal VS
Ð EFM
C/S incisions
¥ Skin – Vertical (b/n navel and symphysis pubis); Transverse (below pubic hairline)
¥ Uterus – Transverse (upper or lower uterine segment); Classical (vertical in upper uterine segment)—typically used in emergency situation. If this type of C/S is done, will always have a C/S with future pregnancies.
Nursing Care for C/S
¥ Vital Signs
Ð Every 5 min til stable
Ð Every 15 min for 2 hours
Ð Every 4 hours until transferred to postpartum
¥ Check dressing and perineal pads every 15 min for 1 hour
¥ Numbness/sensation checked every 15 min until full feeling returns
¥ Intake and output
¥ Monitor IV Pitocin if given
¥ Assess fundus
Vaginal Birth After Cesarean (VBAC) OR Trial of Labor (TOL)
¥ Can occur after trial of labor in cases of nonrecurring indications for cesarean birth
¥ Most common risks are:
Ð Uterine rupture
Ð Hemorrhage
Ð Surgical injuries
Ð Infant death or neurological complications
Nursing Care for VBAC
¥ Continuous EFM
¥ Internal Monitoring
¥ IV fluids
¥ Avoid Pitocin if at all possible
¥ Classic or T uterine incision is contraindication to VBAC
¥ Important for nurse to support couple, explore their feelings, and provide information throughout labor