Maternal Child II Intrapartum Care PDF

10/13/2021 NURS 201 Maternal Child II Complicated Intrapartum Care 1 Augmentation of labor  Stimulation of ineffective u/c, after labor has begun  Pitocin admin most common  Diluted in isotonic solution, runs as IVPB  30 u oxytocin in 500 mL NS...

10/13/2021 NURS 201 Maternal Child II Complicated Intrapartum Care 1 Augmentation of labor  Stimulation of ineffective u/c, after labor has begun  Pitocin admin most common  Diluted in isotonic solution, runs as IVPB  30 u oxytocin in 500 mL NS  1 mu/min = 1 mL/hr  Slow start, titrated to u/c and fetal response  Maintained when active labor with effective u/c pattern  No signs of hyperstimulation/tachysystole –review  FHM baseline and throughout  Review non-reassuring patterns of FHM – Chap 17  Other complications to monitor:  Uterine rupture from stress/contractions  Maternal water intoxication – oxytocin is antidiuretic  Pitocin increases PPH risk 2 AROM  Amniotomy/artificial rupture of membranes  Risks  Priority post-procedure interventions  Cord prolapse – fetal heart  FHM for reassuring pattern response?  Assess fluid and document – color-  Infection odor-amount  Abruption – esp with  Monitor temp q 2 hours polyhydramnios – rapid release  Antibiotic for 18 + hr ROM  Minimize upright/walking until head engaged  Anticipate needs for abnormal fluid  Blood – color, amount  Meconium  Thick or thin/particles  Notify NB nurse, ped, team to anticipate deep suction at delivery 3 1  10/13/2021 Internal monitoring  Fetal scalp electrode  Accurate beat-to-beat variability  Sterile technique – within RN scope  Avoid sutures/fontanels  Internal pressure catheter  Accurate contraction strength  MVU can be used to titrate Pitocin  Minimize risk of uterine rupture  May be used for amnioinfusion  When much of amniotic fluid has been expelled – reduce dry/sticky/gacky cord compression 4 Version  Changing fetal presentation to cephalic for delivery to prevent a c-section  Approx 37 weeks ideal  Breech, transverse, oblique presentations  External  manipulating fetus through relaxed belly/uterus, guided by US  Internal  Common with multi fetal  Infant A born vag, cephalic; PCP can reach in and turn B 5 Version  Contraindications  Complications  Unlikely to deliver vag  Fetal distress  Uterine malformations  Cord entanglement into hypoxia  Previous c-section  Abruption  CPD = cephalo-pelvic  Rh sensitization disproportion  Uterine rupture  Placenta location/previa  Induction of labor  Oligohydramnios/ ROM  Nuchal cord  Uteroplacental insufficiency  Presenting part already engaged 6 2  10/13/2021 Version  Guided by US – AFV and cord location  Tocolytic to relax uterus  0.25 mg terbutaline SC  IV access, possibly epidural  PCP pushes breech out of pelvis in roll  RhoGAM post if mom Rh-  Monitoring x 1-2 hours  u/c and FHM, ROM  Abrupt sharp or continuous pain may indicate abruption 7 Dysfunctional labor: Dystocia  Difficult labor  Ineffective dilation, effacement, descent  FTP  Commonly a problem/issue with the P’s – review from PN  Powers  Passenger  Passage  Position  Psyche 8 Uterus: dystocia  Hypotonic  Hypertonic  Too ineffective to produce cervical  Uncoordinated and varying intensity change of u/c  Exhausting  Painful but ineffective  More common during active phase  More common in latent phase of labor  At risk for fetal hypoxia and  Augmentation abruption  Possible epidural to relax  Poor resting tone interrupts perfusion  Risk factors  Relief of pain for rest  Multi fetal – overdistended uterus  Risk factors  Hypoglycemia  Anxious primip; poor relaxation  Cervix not ready/ripe 9 3  10/13/2021 Secondary powers/position/psyche  Risk factors  Providing assist  Ineffective technique or position  Help mom gain control  Fear of injury or pain  Empower to push effectively  Absent urge to push  Labor down before pushing  Exhaustion  Upright position as allowed  Psychological  Full concentration of push effort with contractions, not between 10 Passenger/s  Macrosomic size/LGA  CPD – rough estimate head to pelvis  Shoulder dystocia risks  Risk for assisted delivery  Forcep, vacuum, extended episiotomy  Malpresentation  OP = occiput posterior  OT = occiput transverse  Face presentation  Breech  Multi fetal  Anomalies 11 Spinningbabies.com  https://youtu.be/F3iqUUJUvw  https://youtu.be/F3iqUUJUvw8 12 4  10/13/2021 Dystocia: precipitous delivery  Labor < 3 hours  Numerous risk factors  Interventions  Delivery tray/ go-bag – sterile and mobile  At bedside – coach and support  Thorough assess/history of labor start and progression  Complications  Uterine rupture  Fetal hypoxia  Postpartum hemorrhage  Lacerations – canal/peri  Amniotic fluid embolism 13 Premature rupture of membranes  PROM: spontaneous rupture before start of labor, u/c  Risk factors:  Infection  Weak membrane/sac  Incompetent cervix  Complications  Infection  Preterm delivery  Cord prolapse/compression 14 PROM  s/s  Pooling of fluid in vaginal vault, drip down leg/s  Nitrazine tape, ferning test  Amnisure swab to confirm – 15 minute  Assess fluid – color, odor, amount  VS, FHT – what FHM indicates infection?  Vag exam dependent on gestational age  Speculum exam by PCP can ID fluid in vault, cervix status  Management based on gestational age  Pelvic rest, no nipple stim, activity restriction  Allow labor if near term (34-36 weeks) , fetal lungs are ready  PPROM = preterm, premature ROM  Antibiotics – Ampicillin, Amoxicillin, Azithromycin  IV x 48 hours, oral x 5 days 15 5  10/13/2021 Preterm labor  Weeks 20-37; INFECTION primary risk – good health promotion  Very – moderately – late preterm  s/s  u/c > 10 minutes, 30 sec + duration  Cervical change: 1 cm, effacement  Painful or painless  Abdominal cramp with or without diarrhea  Low back pain, suprapubic pain  Pelvic pressure  Discharge –bloody show, red, brown, clear, mucous plug  ROM 16 Preterm labor  Interventions  Speculum exams to ID rupture, cervix status  US to help ID cause  Fetal fibronectin – swab at cervix can ID proteins that indicate labor with 2 weeks  Bedrest, activity restrictions  Tocolytics  Terbutaline- SC q 4 hours  HOLD for tachycardia > 120 bpm  Indomethacin, Sulindac – inhibit prostaglandin  Nifedipine – CCB  MgS04 – relaxes smooth muscle/uterine 17 18 6  10/13/2021 19 Fetal lung development for preterm  Admin at least 24 hours before delivery  Betamethasone 12 mg: two IM doses, 24 hours apart  Dexamethasone 6 mg: four IM doses, 12 hours apart  SE  Glucose intolerance  Temporary increase in leukocytes  Insomnia  Irritable – ‘roid rage’  Increase risk infection /mom 20 Prolonged pregnancy  Postdate = >42 weeks  Complications  Aging placenta = uteroplacental insufficiency  Fetal distress  Oligohydramnios with aging = cord compression risk  Meconium in utero = aspiration risk and resp distress, pneumonia  If placenta healthy, fetus continues growth = dysfunctional labor  L/D trauma  Postpartum hemorrhage (PPH) risk  Maternal fatigue and exhaustion 21 7  10/13/2021 Prolapsed cord  Umbilical cord displaced between presenting part and the anmion or is protruding through the cervix  Results in cord compression and hypoxia  s/s  Cord observed at peri – potentially  Mom reports ‘something coming out’  FHT bradycardic with variable decels  Fetus very active, then minimal variability  Risk factors  Hydramnios (poly)  Small fetus  Fetus station high (-2 to -3) – review from PN 22 Variable decelerations 23 24 8  10/13/2021 Cord prolapse actions  Relieve cord pressure  Position  Knee-chest, Sims, Trendelenberg  Sterile glove  Support head /presenting part off of cord  FHM continuous  02 face mask  Prepare for assisted delivery/c-section 25 Uterine rupture  Separation of the uterine tissue due to a tear in the wall, caused by contractions  Complete = direct communication into peritoneal cavity  Incomplete = rupture into peritoneum covering the uterus but not into peritoneal cavity  Risk factors  Previous uterine surgery, c-section  Hydramnios (poly)  Multi fetal – overdistention  Abdominal trauma  Multi –para/gravid  Hyperstimulation of uterus during labor 26 Uterine rupture  s/s  Actions  Abdominal tenderness or severe pain  CV STABILIZATION  Chest pain, pain between scapula,  C-section may save fetus if rapid inspirational pain enough  Hypovolemic shock  High potential for hysterectomy  Hidden hemorrhage into peritoneum  Small rupture may be repaired  Fetal distress – what FHM would you expect?  Sudden absent FHT and u/c  Sudden pain relief  Palpation of fetus through abdominal wall  Incomplete = slower bleed 27 9  10/13/2021 VBAC  Vaginal birth after cesarean  Risk for uterine rupture  Not all PCP, facilities allow due to risks  PCP and OR team within facility  Internal pressure monitor to evaluate stress on uterus  TOLAC  Trial of labor after cesarean 28 Anphylactoid syndrome  Amniotic fluid embolism  50% maternal death rate  Site of interweaved placental villa/attachment  Amniotic fluid is drawn into maternal circulation  Fetal particles obstruct pulmonary vessels  Right ventricle fail, followed by left  s/s  Abrupt resp distress  Depressed cardiac function  DIC – d/t interrupted clotting mechanisms 29 Amniotic fluid embolism  Risk factors  Management  Hyperstimulation of uterus  EARLY ID OF S/S  Trophoblastic/Molar pregnancy  CV STABILIZATION  LGA / stressed fetus  CPR  Meconium stool in fluid increases  02 risk  Fluid replacement  Blood products  Fibrinogen  PRBC  Plt  FFP 30 10