Complications During Labor and Birth (NP03L004 ELO C PDF)

COMPLICATIONS DURING LABOR AND BIRTH NP03L004 ELO C · VERSION 2.0 INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING, 8TH ED., PP. 182-207 TERMINAL LEARNING OBJECTIVE Given a scenario of a laboring client perform nursing care on a pregnant and laboring client experiencing complications without harm t...

COMPLICATIONS DURING LABOR AND BIRTH NP03L004 ELO C · VERSION 2.0 INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING, 8TH ED., PP. 182-207 TERMINAL LEARNING OBJECTIVE Given a scenario of a laboring client perform nursing care on a pregnant and laboring client experiencing complications without harm to the mother or fetus. ENABLING LEARNING OBJECTIVE Perform nursing care on a patient during labor and birth. PERFORM NURSING CARE ON A PREGNANT PATIENT INDUCTION/AUGMENTATION OF LABOR INDUCTION OF LABOR The intentional initiation of labor before it begins naturally AUGMENTATION OF LABOR Stimulation of contractions that have begun naturally INDUCTION OR AUGMENTATION OF LABOR Fetal maturity after 39 weeks gestation Bishop score of 6 or above Assessment of the status of the cervix A high score indicates a ripened or softened cervix INDICATIONS FOR INDUCTION Labor is induced if continued pregnancy is hazardous for the mother or fetus Gestational hypertension Spontaneous rupture of the membranes Chorioamnionitis Maternal medical conditions Fetal problems Placental insufficiency Fetal death Placental Insufficiency CONTRAINDICATIONS TO INDUCTION Placenta previa Umbilical cord prolapsed Abnormal fetal presentation High station of the fetus Active herpes infection Abnormal size or structure of the mother’s pelvis Previous classic cesarean incision METHODS TO STIMULATE CONTRACTIONS Non-pharmacologic Walking Sitting Squatting Kneeling Nipple stimulation METHODS TO STIMULATE CONTRACTIONS PHARMACOLOGICAL MECHANICAL Cervical ripening Stripping of amniotic Prostaglandin E2 vaginal insert membranes dinoprostone (Cervidil) Hydroscopic dilators Prostaglandin E1 misoprostol (Cytotec) Transcervical balloon dilators ARTIFICIAL RUPTURE OF MEMBRANES Amniotomy by using disposable plastic hook AROM Amnihook AROM Finger Cot AMNIOTOMY Purpose Stimulates prostaglandin secretion Stimulation labor Prior to procedure Confirmation of vertex presentation Confirmation of station NURSING IMPLICATIONS Following amniotomy, nursing care includes: Monitor fetal heart rate Observe color, odor, amount and character of amniotic fluid Monitor woman’s temperature Promote comfort COMPLICATIONS OF AMNIOTOMY Prolapse of umbilical cord Infection Abruptio placentae Abruptio placentae AUGMENTATION OF LABOR Oxytocin (Pitocin) induction Most common method Continuous fetal monitoring Complications Hypertonic uterine activity Uterine rupture Maternal water intoxication NURSING IMPLICATIONS COMPLICATIONS OF OXYTOCIN NURSE RESPONSE Non-reassuring fetal patterns Notify healthcare provider and RN FHR change Reposition patient to left lateral Maternal vital signs side Decrease or STOP oxytocin Supplemental oxygen IV bolus of lactated Ringer’s Prepare IV terbutaline for administration Assess uterine contractions and fetal heart rate every 5 minutes AMNIOINFUSION AMNIOINFUSION Warmed saline or lactated Ringer’s infused into uterus after membranes have ruptured Indications Oligohydramnios Umbilical cord compression Reducing recurrent variable decelerations in FHR Diluting meconium-stained amniotic fluid Prevention of meconium aspiration syndrome NURSING IMPLICATIONS Continuous monitoring of uterine activity Continuous monitoring of fetal heart rate Change underpads on the bed Document color, amount, and odor of fluid expelled from vagina VERSION VERSION Method of changing fetal presentation Two methods External (more common) Internal Successful version reduces the likelihood of cesarean delivery RISKS AND CONTRAINDICATIONS Few maternal or fetal risks Contraindicated if maternal or fetal reason that vaginal birth should not occur, examples include: Disproportion between mother’s pelvis and fetal size Abnormal uterine or pelvic size or shape Abnormal placental placement Previous cesarean birth with vertical uterine incision Active herpes virus infection Inadequate amniotic fluid Poor placental function Multifetal gestation Malfunctioning placenta TECHNIQUE EXTERNAL VERSION INTERNAL VERSION After 37 weeks gestation (before Emergency procedure onset of labor) Used to during vaginal delivery of Determine fetal condition twins Administer tocolytic drug Used to change fetal position of second twin Continuous fetal monitoring RhoGAM if mother is Rh-negative NURSING IMPLICATIONS Baseline maternal vital signs Fetal monitor strip Observe mother & fetus afterward for 1-2 hours Observe and report vaginal leaking of amniotic fluid Uterine contractions decrease following version Review signs of labor CHECK ON LEARNING After amniotomy, which observation should be reported immediately? a. Clear fluid draining on the underpad b. Maternal temperature of 37.9C (99.0F) c. Fetal heart rate of 95 BPM d. Moderate contractions every 3 minutes CHECK ON LEARNING Distinguish between labor induction and labor augmentation. OPERATIVE PROCEDURES EPISIOTOMY AND LACERATIONS Episiotomy Surgical enlargement of the vaginal opening during birth Better control over how vaginal opening is enlarged Clean edge Laceration An uncontrolled tear of the tissues Jagged wound edge Treatment for both are similar CLASSIFICATION Described by the amount of tissue involvement First degree: Superficial vaginal mucosa Second degree: First degree with deeper tissues of the perineum Third Degree: Second degree & involves the anal sphincter Fourth degree: Extends through the anal sphincter into rectal mucosa NURSING IMPLICATIONS Cold packs to perineum for first 12 hours Heat packs or sitz bath after 12-24 hours Mild oral analgesics FORCEPS AND VACUUM EXTRACTION FORCEPS AND VACUUM EXTRACTION Provides traction and rotation to fetal head Must be fully dilated, membranes ruptured Fetal head engaged at +2 station FORCEPS EXTRACTION Curved metal instruments Fit around fetal head Several styles for cephalic, breech or cesarean birth VACUUM EXTRACTION Vacuum extractor Used only on the occiput presentation 2001, Use of extractor increased as forceps decreased 2011, Use of cesarean section have increased, forceps & extractors have decreased INDICATIONS FOR FORCEPS OR VACUUM EXTRACTION Maternal Contraindications Exhausted or unable to push Cesarean birth is preferable if Cardiac or pulmonary disorders maternal and fetal conditions mandate a more rapid birth than can be done with forceps or Fetal vacuum Evidence of increased risk Examples of these conditions are: High fetal station Fetus is too large for the pelvis RISKS Maternal risks include lacerations and hematoma of the vagina Infant risks include ecchymosis, facial/scalp lacerations,, cephalohematoma, or intracranial hemorrhage The vacuum may create edema, called chignon, at the application area  NURSING IMPLICATIONS MATERNAL INFANT Place sterile instruments Examine the infant’s head Place cold applications Watch for facial asymmetry Observe for vaginal wall Observe scalp chignon lacerations or hematoma CESAREAN BIRTH INDICATIONS Abnormal labor Cephalopelvic disproportion Gestational Hypertension Maternal disease Active genital herpes Some previous uterine surgery Fetal compromise Placenta previa or abruptio placentae CONTRAINDICATIONS Fetal death Fetus that is too immature to survive Maternal coagulation defects Planned for convenience RISKS OF CESAREAN BIRTH MATERNAL RISKS INFANT RISKS Related to anesthesia Preterm birth Respiratory complications Respiratory Problems Hemorrhage Injury Blood clots Progress of future pregnancies Injury to Urinary tract Paralytic ileus Infection PREOPERATIVE NURSING CONSIDERATIONS Obtain consent Ordered lab work History screening Maternal and fetal vital signs Preoperative teaching Placed supine with wedge Regional anesthesia Prophylactic antibiotics Indwelling catheter POSTOPERATIVE NURSING CONSIDERATIONS NURSING CONSIDERATIONS Keep family unit together Focus on birth Postoperative assessment IV Fundus Prevent respiratory complications Changing positions Pain Management CHECK ON LEARNING Describe three nursing interventions to promote comfort in a woman who has an episiotomy or perineal laceration. CHECK ON LEARNING What are the two separate incisions done in cesarean section? Which of the two is more important and why?  PERFORM NURSING CARE ON A PREGNANT PATIENT WITH COMPLICATION OF LABOR AND DELIVERY COMPLICATIONS OF LABOR & DELIVERY PROBLEMS WITH POWERS HYPERTONIC LABOR Characterized Occurs in latent phase Frequent, painful, uncoordinated contractions Tense uterine rest tone Medical Treatment Tocolytic drugs Nursing care Accept frustration Offer warm showers Do not equate amount of pain & point of labor Provide comfort measures HYPOTONIC LABOR Characterized Occurs during active phase Weak contractions uterine rest tone not elevated Medical Treatment Amniotomy Augmentation IV or oral fluids Nursing care Allow to express frustration Provide care related to obstetric procedures Position changes INEFFECTIVE MATERNAL PUSHING Results from Misunderstanding techniques Fears of tearing perineal tissues Blocks that depress urge to push Exhaustion Nursing care Focus on Coaching Tell her when the peak of contraction occurs Only push when feels a strong urge Explain sensations of tearing are normal Promote relaxation Changing positions Increase hydration PROBLEMS WITH THE PASSENGER NURSING CARE Apply downward pressure above symphysis pubis Change in position After birth, observe mother and infant for injuries Episiotomy or laceration care At risk for uterine atomy: Postpartum hemorrhage  ABNORMAL FETAL PRESENTATION Breech Usually delivered by cesarean section May use external version Abnormal rotation position Persistent occiput posterior Longer, intense labor More difficult for women with small pelvis May use forceps to rotate fetal head NURSING CARE Encourage positions that favor fetal rotation and decent Observe mother and Fetus for birth trauma Vaginal hematoma Excessive molding of fetal head MULTIFETAL PREGNANCY Factors in dysfunctional labor: Uterine over-distention Abnormal presentation of one or all the fetuses Difficulties lead to cesarean BONY PELVIS Small or abnormally shaped pelvis may retard labor or obstruct fetal passage MATERNAL SOFT-TISSUE OBSTRUCTIONS Full bladder (most common) Encourage laboring woman to void every 1-2 hours Catheterization may be needed Fibroids Cervical scar tissue PROBLEMS WITH PSYCHE COMMON FACTORS Excessive pain Absence of a support person Immobility Inability to practice cultural traditions EXCESSIVE & PROLONGED STRESS Releases hormones that reduce contractility of smooth muscle Uses glucose the uterus Increases tension of pelvic muscles Increases perception of pain Pain → anxiety → stress → repeat Nursing Care Promote relaxation and comfort Help client to conserve her energy PROLONGED LABOR Average rate of cervical dilation is: 1.2 cm/hr. for a woman having her first baby 1.5 cm/hr. for a woman that has had a baby previously Decent rate 1 cm/hr. in first time mother 2 cm/hr. for a woman that has had a baby previously Problem with any of the factors of labor FRIEDMAN CURVE RESULT OF PROLONGED LABOR Results in several problems Maternal or newborn infection Maternal exhaustion Postpartum hemorrhage Great anxiety and fear Causes of postpartum hemorrhage NURSING CARE Maternal Conserve energy Provide emotional support Assess for infection Fetal Watch for signs and symptoms of infection PRECIPITATE BIRTH Labor that is completed in less Nursing Care than 3 hours Support and reassurance There may be no HCP present Observe for maternal & fetal Maternal response injury Labor begins abruptly and Maternal injury: excessive pain intensifies quickly or bruising Powerful contractions can lead to uterine rupture, lacerations, Infant injury: abnormal findings hematoma with assessment Fetal response Oxygenation compromise Birth injuries Intracranial hemorrhage Nerve damage PREMATURE RUPTURE OF MEMBRANES Spontaneous rupture at term More than 1 hour before labor contractions begin Preterm premature rupture of the membranes (PPROM): the woman’s membranes rupture earlier than 37 weeks, with or without contractions Diagnosis Nitrazine paper Fern test MEDICAL MANAGEMENT Depends on risk of early delivery vs. risks of infection Ultrasound determines gestational age & oligohydramnios If 36 weeks or greater, induction of labor Risk of umbilical cord compression with loss of amniotic fluid NURSING CARE With induction Observe for signs and symptoms of infection in mother and fetus Cultures Antibiotics & steroid therapy Without induction Report temperature above 100.4F Avoid sexual intercourse, orgasm, & nipple stimulation Activity restrictions Note contractions, fetal activity & infection Record fetal kick counts daily PRETERM LABOR PRETERM LABOR Occurs after 20 and before 37th week gestation Associated factors: Immaturity of the newborn Fetal morbidity Major medical & economic impact Prevention or identifying risk Underweight, poor nutrition, dehydration Chronic illness Smoking or substance abuse Preeclampsia Anemia Infections Chronic stress SIGNS OF IMPENDING PRETERM LABOR Shortened cervix at 20 weeks Presence of fibronectin between 22-24 weeks Contractions Feeling fetus “balling up” Menstrual cramps Constant low back pain Pelvic pressure Change in vaginal discharge Discomfort in vulva or thighs “Just feeling bad” PRETERM LABOR ASSESSMENT TOOL Toolkit to standardize care & assessment Assessment guidelines completed in 2-4 hours History Physical exam Transvaginal ultrasound Presence of fibronectin Optimal delivery of steroids TOCOLYTIC THERAPY Goal: Stop uterine contractions Magnesium Continuous IV and therapeutic levels monitored Monitor: Respirations, lungs sounds, urine output, deep tendon reflexes, bowel sounds Use only 5-7 days Calcium gluconate is antidote TOCOLYTIC THERAPY B-Adrenergic Terbutaline (Brethine) Administer SQ Increased BP & P Nasal stuffiness Hyperglycemia D/C 2 hours prior to delivery Prostaglandin inhibitor Indomethacin Causes reduction in amniotic fluid Close fetal monitoring essential TOCOLYTIC THERAPY Calcium channel blocker Nifedipine (Procardia) Most used Vasodilation; flushing & hypotension Contraindicated in use of magnesium or infection Contraindication Pre-eclampsia Placenta previa Abruptio placentae 37+ weeks gestation Chorioamnionitis Fetal death Antimicrobial therapy SPEEDING FETAL LUNG MATURATION Corticosteroids indicated if gestation is between 24-34 weeks Used together with tocolytics Betamethasone IM x 2 24 hours apart Activity restrictions Moderate restrictions NURSING CARE Recognize symptoms of preterm labor Position side lying Assess VS, I&O, pulmonary edema Teach appropriate activity & restriction Home arrangements & responsibility After delivery, monitoring FHR & prepare for admission to NICU Emotional support of the parents PROLONGED PREGNANCY Lasts between 41 weeks and 41 weeks + 6 days Risks Aging placenta, decrease delivery oxygen & nutrients Fetal weight loss, skin peeling Meconium causes respiratory problems Low blood glucose levels Poor fetal tolerance of labor Healthy placenta, leads to macrosomia MEDICAL MANAGEMENT Evaluate if truly prolonged pregnancy Ultrasound clarifies gestational age 41 weeks or more monitor NST, AFI, BPP and daily kick counts Oligohydramnios indicates induction Induction with cervix ripening and oxytocin IV NURSING CARE Observation of fetus for poor placental blood flow After birth, newborn respiratory distress & hypoglycemia CHECK ON LEARNING Describe how the following factors can contribute to abnormal labor and list some nursing measures would you implement. Ineffective pushing efforts. CHECK ON LEARNING Describe how the following factors can contribute to abnormal labor and list some nursing measures would you implement. Occiput posterior fetal position. CHECK ON LEARNING State 5 ways that excessive psychological stress can contribute to a difficult labor. CHECK ON LEARNING Describe the possible adverse effects of prolonged labor on either the mother or the fetus. CHECK ON LEARNING What is the difference between PROM and PPROM? CHECK ON LEARNING Describe the role of the following measures in the care of the woman with threatened or actual preterm labor. a. Transvaginal ultrasound b. Activity restrictions c. Fetal fibronectin CHECK ON LEARNING Describe nursing care of the fetus or neonate related to these problems of prolonged pregnancy. a. Placental blood supply (poor function and good function) b. Passage of meconium in utero c. Consumption of glucose reserves prior to birth EMERGENCIES DURING CHILDBIRTH Prolapsed umbilical cord Complete Palpated Occult Placenta accreta Uterine rupture Complete Incomplete Dehiscence PROLAPSED UMBILICAL CORD CLASSIFICATIONS Cord visible at vaginal opening Cord cannot be seen but can be felt as a pulsating structure when a vaginal examination is done The prolapse is hidden and cannot be seen or felt; it is suspected based on abnormal fetal heart rates. RISK FACTORS Fetus is high in the pelvis when the membranes rupture Very small fetus Abnormal fetal presentation Hydramnios MEDICAL MANAGEMENT Doctor may push the fetus upward from the vagina Oxygen and tocolytic administered The baby is usually delivered by cesarean section NURSING CARE First action is to displace fetus upward Position woman’s hips higher than her head Knee-chest position Trendelenburg Hips elevated with pillows, side lying Assist with emergency procedures Calm, quick actions to reduce anxiety in patient After the birth, explain to the patient and family what happened PLACENTA ACCRETA PLACENTA ACCRETA Abnormal attachment to uterine wall Mothers with previous c-section delivery, fibroids, increased maternal age, endometrial defects Profuse bleeding UTERINE RUPTURE RISK FACTORS Low transverse incision is the least likely to rupture. Uterine tachysystole increases risk if labor induced with oxytocin. Blunt abdominal trauma CHARACTERISTICS Shock caused by bleeding into the abdomen Pain Cessation of contractions Abnormal or absent fetal heart tones Palpation of the fetus outside the uterus AMNIOTIC FLUID EMBOLISM Occurs when amniotic fluid, with its particles such as vernix, fetal hair, and sometimes meconium, enters the woman’s circulation and typically obstructs small blood vessels in her lungs Characterized by abrupt onset of hypotension, respiratory distress, and coagulation abnormalities from thromboplastin in amniotic fluid MEDICAL MANAGEMENT Mechanical ventilation Treat shock with electrolytes and volume expanders Replace coagulation factors such as platelets and fibrinogen PRBC sometimes provided I&O monitored closely Pulse oximetry Cardiac monitoring Transfer to ICU CHECK ON LEARNING When caring for a woman following a vehicle accident at 36 weeks of pregnancy, the priority fetal assessment should be for _________. a. undetected trauma b. poor oxygenation c. intrauterine infection d. precipitous birth CHECK ON LEARNING Describe four situations in which the nurse must be especially watchful for a prolapsed umbilical cord. a. Fetus high in the pelvis when the membranes rupture b. Very small fetus c. Abnormal fetal presentation d. Polyhydramnios CHECK ON LEARNING List and describe three variations of uterine rupture. CHECK ON LEARNING A woman having her first baby has been in labor for several hours. Her nurse-midwife performs a vaginal examination and says that the cervix is 6 cm dilated and completely effaced, with the fetus in right occiput posterior position. The mother is having persistent back pain that worsens during contractions. Should the nurse take any specific action based on this examination? REVIEW OF MAIN POINTS Obstetric procedures Intrapartum complications Emergencies during childbirth QUESTIONS?