Nursing Care of Labor & Birth Complications PDF

Chapter 23 Nursing Care of a Family Experiencing a Complication of Labor or Birth  Common Types of Deviations That Can Cause Complications During Labor or Birth: The Three P’s #1 ❖Power o Ineffective uterine force o Dysfunctional labor and associated stages of labor ❖P...

Chapter 23 Nursing Care of a Family Experiencing a Complication of Labor or Birth  Common Types of Deviations That Can Cause Complications During Labor or Birth: The Three P’s #1 ❖Power o Ineffective uterine force o Dysfunctional labor and associated stages of labor ❖Passenger o Umbilical cord prolapse o Multiple gestation o Problems with fetal position, presentation, or size Copyright © 2018 Wolters Kluwer · All Rights Reserved Common Types of Deviations That Can Cause Complications During Labor or Birth: The Three P’s #2 ❖Passage o Inlet contraction o Outlet contraction o Trial labor o External cephalic version o Forceps birth o Vacuum extraction Copyright © 2018 Wolters Kluwer · All Rights Reserved 2020 National Health Goals Related to a Family Experiencing a Complication of Labor or Birth #1 ❖Reduce the number of cesarean births among low- risk women to no more than 23.9 per 100 births from a baseline of 26.5 per 100 births. ❖Reduce the number of cesarean births among women who have had a previous cesarean birth to no more than 61.7 per 100 births from a baseline of 90.8 per 100 births. Copyright © 2018 Wolters Kluwer · All Rights Reserved Assessment of a Family Experiencing a Complication of Labor or Birth #1 ❖Assessment for complications in labor and birth is based on careful uterine and fetal monitoring. o Recognition of hypertonic and hypotonic contractions o Mapping of lengths of phases and stages of normal labor o Recognition of abnormal fetal response to uterine contractions o Recognition of abnormal position of fetus or fetal heart sounds o Accurate assessment of pelvic inlet, outlet, and midpelvis Copyright © 2018 Wolters Kluwer · All Rights Reserved  COMPLICATIONS WITH THE POWER(The FORCE of Labor) Dysfunctional Labor (Inertia)- a time- honored term to denote sluggishness of contractions, or that the force of labor is less than usual. Primary- it occurs at the onset of labor Secondary- occurring later in labor Copyright © 2018 Wolters Kluwer · All Rights Reserved Assessment of a Family Experiencing a Complication of Labor or Birth #2 Copyright © 2018 Wolters Kluwer · All Rights Reserved Notes: Hypotonic contractions - no. of contractions is unusually infrequent, resting tone of the uterus remain less than 10 mm Hg, and the strength does not rise above 25 mm Hg. Hypertonic contractions - intensity of contraction is stronger and occur frequently, increase in resting tone more than 15 mm Hg. Copyright © 2018 Wolters Kluwer · All Rights Reserved Dysfunctional at the 1st stage of labor Prolonged latent phase - develops when contractions become ineffective Protracted active phase - usually asso. with fetal malposition or CPD. - if cervical dilatation does not occur at a rate of at least 1.2 cm per hr in a nullipara or 1.5 cm per hr in multipara Prolonged deceleration phase - extends beyond 3 hours in nullipara or 1 hr in multipara Secondary arrest of dilatation - if there is no Copyright © 2018 Wolters Kluwer · All Rights Reserved Dysfunctional at the second stage of labor Prolonged descent - if the rate of descent is less than 1.0 cm per hr in nullipara or 2.0 cm per hr in multipara. Arrest of descent - no descent has occurred for 2 hrs in a nullipara or 1 hr in a multipara. Copyright © 2018 Wolters Kluwer · All Rights Reserved Induction of labor - labor is started artificially Augmentation of labor - assisting labor that has started spontaneously but is not effective. Cervical ripening - change of cervical consistency from firm to soft - scoring of the cervix, greater than 8, the cervix is ready for birth and should respond to induction. Copyright © 2018 Wolters Kluwer · All Rights Reserved Anomalies of placenta ❖ Placenta succenturiata - has one or more accessory lobes connected to the main placenta ❖ Placenta circumvallata - fetal side of placenta is covered to some extent with chorion ❖ Battledore placenta - cord is inserted marginally rather than centrally ❖ Velamentous insertion of the cord - instead of entering the placenta directly, separates into small vessels that reach the placenta by spreading across a fold of amnion. Copyright © 2018 Wolters Kluwer · All Rights Reserved  Interventions for Complications of Labor or Birth According to Power ❖Dysfunctional first or second stage of labor o Provide adequate hydration. o Provide pain relief. o Decrease extraneous stimulation (e.g., lights, noise). o Augmentation of labor via oxytocin infusion, cesarean birth, or amniotomy may be necessary. Copyright © 2018 Wolters Kluwer · All Rights Reserved Assessment of a Family Experiencing a Complication of Labor or Birth #3 Copyright © 2018 Wolters Kluwer · All Rights Reserved Nursing Diagnoses of a Family Experiencing a Complication of Labor or Birth ❖Fatigue related to loss of glucose stores during prolonged labor ❖Risk for ineffective tissue perfusion of woman and/or fetus ❖Risk for deficient fluid volume related to length of labor ❖Risk for maternal and/or fetal injury related to a labor complication and/or required medical treatment ❖Anxiety related to uncertainty of pregnancy outcome Copyright © 2018 Wolters Kluwer · All Rights Reserved  Examples of Expected and Revised Outcomes in a Family Experiencing a Complication of Labor or Birth #1 Expected Outcome Revised Outcome No monitoring equipment used during labor Monitoring used to assess fetal well-being and delivery and assure healthy infant No IVs, medications, or epidural used IV fluid administered to maintain blood during labor and delivery volume and maternal and fetal well-being Use of walking during labor to assist labor Bed rest needed to assure fetal process oxygenation and well-being Copyright © 2018 Wolters Kluwer · All Rights Reserved Quality & Safety Education for Nurses (QSEN) ❖Patient-Centered Care ❖Teamwork & Collaboration ❖Evidence-Based Practice ❖Quality Improvement ❖Safety ❖Informatics Copyright © 2018 Wolters Kluwer · All Rights Reserved Interventions for Complications of Labor or Birth According to the Passenger #1 Copyright © 2018 Wolters Kluwer · All Rights Reserved Interventions for Complications of Labor or Birth According to the Passenger #2 ❖Umbilical cord prolapse o Relief of pressure on the umbilical cord (positioning and manual pressure) o Prevention of cord drying o Fetal blood sampling o Surgical intervention Copyright © 2018 Wolters Kluwer · All Rights Reserved Interventions for Complications of Labor or Birth According to the Passenger #3 Copyright © 2018 Wolters Kluwer · All Rights Reserved Interventions for Complications of Labor or Birth According to the Passenger #4 ❖Multiple gestation o Measures to relieve anxiety due to multiple personnel in the birthing room o Education related to early signs of labor and to immediately report to hospital o Prepare the woman for possible cesarean birth Copyright © 2018 Wolters Kluwer · All Rights Reserved  Complications Premature separation of the placenta Lacerations in the perineum Risk for hemorrhage Pressure on the head of the baby Copyright © 2018 Wolters Kluwer · All Rights Reserved  Interventions for Complications of Labor or Birth According to the Passenger #5 ❖Problems with fetal position o Interventions related to ▪Right occipitoposterior (ROP) position ▪Left occipitoposterior (LOP) position ▪Posterior position Copyright © 2018 Wolters Kluwer · All Rights Reserved Interventions for Complications of Labor or Birth According to the Passenger #6 Copyright © 2018 Wolters Kluwer · All Rights Reserved Interventions for Complications of Labor or Birth According to the Passenger #7 Copyright © 2018 Wolters Kluwer · All Rights Reserved Interventions for Complications of Labor or Birth According to the Passenger #8 Copyright © 2018 Wolters Kluwer · All Rights Reserved Interventions for Complications of Labor or Birth According to the Passenger #9 ❖The oversized fetus (macrosomia) o Evaluating for potential incompatibility between fetal size and woman’s pelvic capacity o Interdisciplinary interventions for shoulder dystocia Copyright © 2018 Wolters Kluwer · All Rights Reserved Interventions for Complications of Labor or Birth According to the Passage #1 ❖Cephalopelvic disproportion o Trial of labor o Forceps delivery o Vacuum extraction Copyright © 2018 Wolters Kluwer · All Rights Reserved Interventions for Complications of Labor or Birth According to the Passage #2 Copyright © 2018 Wolters Kluwer · All Rights Reserved Interventions for Complications of Labor or Birth According to the Passage #3 ❖Anomalies of the placenta o Vasa previa ▪ Preparation for cesarean delivery o Placenta accreta ▪ Preparation for methotrexate treatment or hysterectomy ❖Anomalies of the cord o Two-vessel cord ▪ Examination of infant for anomalies o Nuchal cord Copyright © 2018 Wolters Kluwer · All Rights Reserved Copyright © 2018 Wolters Kluwer · All Rights Reserved Copyright © 2018 Wolters Kluwer · All Rights Reserved Copyright © 2018 Wolters Kluwer · All Rights Reserved Complications of Two-vessel cord ❖heart problems ❖kidney problems ❖spinal defects Copyright © 2018 Wolters Kluwer · All Rights Reserved ❖A two-vessel cord is also associated with a greater risk for the genetic abnormality known as VATER. This stands for vertebral defects, anal atresia, transesophageal fistula with esophageal atresia, and radial dysplasia. ❖Babies with a two-vessel cord may also be at higher risk for not growing properly. This could include preterm delivery, slower-than-normal fetal growth, or stillbirth. Copyright © 2018 Wolters Kluwer · All Rights Reserved  Evaluating Outcomes in a Family Experiencing a Complication of Labor or Birth Expected Outcome Revised Outcome Final Evaluation No monitoring equipment Monitoring used to assess FHR was within normal used during labor and fetal well-being and assure pattern throughout labor delivery healthy infant and delivery. Infant’s Apgar scores were 8 at 1 minute and 9 at 5 minutes. No IVs, medications, or IV fluid administered to epidural used during labor maintain blood volume and and delivery maternal and fetal well- being Use of walking during labor Bed rest needed to assure to assist labor process fetal oxygenation and well- being Copyright © 2018 Wolters Kluwer · All Rights Reserved Uterine Inversion Copyright © 2018 Wolters Kluwer · All Rights Reserved  ❖Uterus turning inside out with either birth of the fetus or delivery of the placenta ❖Rare phenomenon- 1:20,000 births ❖Due to over traction of the cord and when the uterus is not contracted Copyright © 2018 Wolters Kluwer · All Rights Reserved  ❖Can lead to bleeding ❖Hypotension ❖Diaphoresis ❖Paleness ❖Dizziness ❖Never replace an inversion ❖Never remove the attached placenta Copyright © 2018 Wolters Kluwer · All Rights Reserved ❖Call for help ❖Establish an IV line ❖Give 02 by mask ❖Be ready to do CPR ❖The patient is given anesthesia, tocolytic, or nitroglycerine to relax the uterus ❖Administer oxytocin after manual replacement ❖Antibiotic therapy because endometrium was exposed ❖CS ❖Hysterectomy if manual replacement fails Copyright © 2018 Wolters Kluwer · All Rights Reserved UTERINE RUPTURE Copyright © 2018 Wolters Kluwer · All Rights Reserved ❖Rare ❖Due to: ❖CS scar ❖Prolonged labor ❖Abnormal presentation ❖Multiple gestation ❖Unwise use of oxytocin ❖Obstructed labor ❖Traumatic maneuvers of forceps or traction Copyright © 2018 Wolters Kluwer · All Rights Reserved Signs ❖Sudden, severe pain during contractions ❖“tearing” sensation ❖Contractions will stop ❖Two distinct swellings will be noticed ( retracted uterus and extrauterine fetus) o Complete rupture- until peritoneum o Incomplete rupture-peritoneum is still intact Copyright © 2018 Wolters Kluwer · All Rights Reserved  Complications ❖Hemorrhage ❖Signs of shock ❖FHT fades and is absent o What to do? ▪ Administer IV ▪ Anticipate the use of IV oxytocin ▪ Prepare patient for possible laparotomy ▪ Patient is advised not to conceive again ▪ CS hysterectomy ▪ Be prepared to tell the client the extent of surgery Copyright © 2018 Wolters Kluwer · All Rights Reserved Question #1 A pregnant woman who is carrying triplets is concerned when her obstetrician suggested that she give birth by cesarean delivery. What is the most accurate statement that the nurse can make to the woman regarding this? A. Traditional labor room suites cannot accommodate the personnel needed during the birth of three infants like the operating room can. B. It is safer to know exactly when the delivery will occur so that the healthcare team will be available. C. A cesarean delivery helps to prevent complications due to cord prolapse or premature placental separation. D. Labor contractions are so powerful in a multiple gestation that a cesarean delivery is safer for the infants and mother. Copyright © 2018 Wolters Kluwer · All Rights Reserved Answer #1 C. A cesarean delivery helps to prevent complications due to cord prolapse or premature placental separation. Rationale: Multiple gestations are more likely to have labor complications such as prolapsed cords and premature placental separation. Cesarean delivery should not be suggested as a matter of convenience or availability of healthcare providers. Because the uterus is “overstretched” during a multiple pregnancy, it is more likely that hypotonic contractions might occur, which would prolong labor. Copyright © 2018 Wolters Kluwer · All Rights Reserved Question #2 You assess that the fetus of a woman is in an occiput posterior position. You know that her labor most likely will be different from a woman whose fetus is in an anterior position in that the woman A. Will have a shorter second stage of labor B. May experience more pronounced back pain C. May need to have an external cephalic version performed D. Probably will need to have the delivery assisted by forceps or vacuum extraction Copyright © 2018 Wolters Kluwer · All Rights Reserved Answer #2 B. May experience more pronounced back pain Rationale: An occiput posterior presentation means that labor will be longer because the occiput needs to rotate to an anterior position. Women often complain of intense back pain during labor. External cephalic versions are not used to correct posterior cephalic positions. Most woman are able to deliver without instrument assistance. Copyright © 2018 Wolters Kluwer · All Rights Reserved Question #3 You are preparing for an induction of labor. Which of these would the nurse expect to do in preparation? A. Prepare oxytocin as prescribed using a piggyback intravenous setup. B. Teach the pregnant woman to lie on her back as much as possible during labor. C. Make sure that a fetoscope is available in the room for monitoring. D. Assure the pregnant woman that the induction process will assure a shorter than usual labor. Copyright © 2018 Wolters Kluwer · All Rights Reserved Answer #3 A. Prepare oxytocin as prescribed using a piggyback intravenous setup. Rationale: As a safety measure, oxytocin should always be administered through a secondary line. A side-lying position (especially the left side) is preferable because it is the optimum position for fetal oxygenation and avoids vena cava syndrome. It is anticipated that continuous uterine and fetal monitoring will be performed rather than episodic monitoring with a fetoscope because this does not monitor uterine contractions. Induction of labor does not assure that the period of labor will be any shorter. Copyright © 2018 Wolters Kluwer · All Rights Reserved Read on: ❖Breech Presentation ❖Face presentation ❖Brow Presentation ❖Transverse Lie ❖Forceps Birth ❖ANOMALIES of the placenta Copyright © 2018 Wolters Kluwer · All Rights Reserved