Abnormal Intrapartum Care PDF

Abnormal Intrapartum Care Jordan Davis MSN, RN NUR 113  Cervical Insufficiency Describes a weak, structurally defective cervix that spontaneously dilates in the absence of UCs Occurs in second trimester or early third trimester and results in loss of pregnancy...

Abnormal Intrapartum Care Jordan Davis MSN, RN NUR 113  Cervical Insufficiency Describes a weak, structurally defective cervix that spontaneously dilates in the absence of UCs Occurs in second trimester or early third trimester and results in loss of pregnancy < 1% incidence in obstetrical population (exact cause unknown) Dilation is typically rapid, relatively painless with minimal bleeding  Management of Cervical Insufficiency Bed rest Pelvic rest No lifting heavy objects Progesterone supplementation Cervical pessary- round silicone device at the mouth of cervix Cervical cerclage procedure in second trimester  Cervical Cerclage Performed transvaginally or transabdominally Involves using heavy purse string suture to secure and reinforce internal os of cervix May place up to 28 weeks Complications: suture displacement, ROMs, and infection (chorioamnionitis)  Placenta Previa Placenta implants over cervical os Occurs during last two trimesters Odds in first pregnancy are 1/400 but increase dramatically with each cesarean section Serious consequences: hemorrhage, abruption, emergency C-section Exact cause unknown but is initiated by implantation of embryo in the lower uterus, perhaps due to scarring or damage to upper segment of uterus May incite placental growth in unscarred lower uterine segment Prenatal care and timely diagnosis on ultrasound important  Nursing Assessment of Previa Assess for risk factors: advanced maternal age (>35 years), previous C-section, multiparity, uterine insult or injury, prior previa, multiple gestations, previous surgical abortion, short interval between pregnancies Presents as painless, bright-red vaginal bleeding during second or third trimester Initial bleeding occurs on average 27-32 weeks gestation, is usually not profuse, and ceases spontaneously (only to occur again) Bleeding thought to arise due to thinning of lower uterine segment in preparation of labor  Placenta Previa: Nursing Management No vaginal exams! Assess degree of vaginal bleeding (peripad count or weighing pads) Anticipate possible blood transfusion Monitor maternal VS, pain, FHR, and UCs frequently (uterine tone usually soft/relaxed and FHR WNL) Oxygen equipment should be available for maternal or fetal distress Must have an IV site Prolonged hospitalization or home bed rest often required Educate client and family about s/s, prepare client for possibility of C-section, encourage client to notify provider if any change in condition (bleeding or back ache)  Placental Abruption Premature separation of normally implanted placenta prior to birth, which leads to hemorrhage (medical emergency) Painful, dark-red vaginal bleeding, severe abdominal pain, uterine tenderness, contractions, and decreased fetal movement Maternal risks: hemorrhage, blood transfusions, emergency hysterectomy, DIC, renal failure, death (6%) Fetal risks: low birth weight, preterm delivery, asphyxia, stillbirth, death Bleeding from blood vessel forms blood clot between placenta and uterine wall Continued bleeding causes increased pressure behind placenta, resulting in separation from uterine wall Fetal distress develops in proportion to degree of placental separation  Classifications of Abruption Classified according to extent of separation and amount blood loss from maternal circulation Mild (grade 1)- scant/minimal bleeding (< 500 mL) Moderate (grade 2)- moderate bleeding (100-1,500 mL) Severe (grade 3)- severe bleeding (> 1,500 mL) May also be classified as partial or complete, depending on degree of separation Concealed/internal vs. Revealed/external bleeding  Abruption: Nursing Management Strict bed rest in left lateral BPP, non-stress test may be position indicated Administer oxygen CBC, fibrinogen levels, PT/PTT, Maternal VS q 15 min type and cross-match Continuous fetal monitoring Foley catheter 2 large bore IV sites Assess UCs (report any increased tenseness or rigidity) Assess abdominal girth/fundal height, increase in size Watch for s/s of DIC: bleeding indicates bleeding gums, tachycardia, oozing from IV site Provide emotional support  Placental Abnormalities Cause unknown but r/t placenta previa, AMA, smoking, previous C-sections 90% will have postpartum hemorrhage, 50% will have a hysterectomy Typically diagnosed after birth when placenta fails to separate from uterine wall Profuse hemorrhage may result because uterus cannot contract to close off open blood vessels Hysterectomy often needed, depending on severity of bleeding  Polyhydramnios (Hydramnios) Too much amniotic fluid (>2000 mL) between 32-36 weeks gestation Associated with maternal disease (diabetes) and fetal anomalies but can also be idiopathic Increased incidence of preterm births, fetal malpresentation, and cord prolapse Mild to moderate- close monitoring, frequent f/u visits Severe (woman in pain or experiencing SOB)- amniocentesis or AROM Amniocentesis only temporarily effective Indomethacin may be given to decrease fetal urinary output, however this medication may cause premature closure of fetal ductus arteriosus  Nursing Assessment and Management of Polyhydramnios Measure fundal height- often a discrepancy between fundal height and gestational age UCs result from overstretching of uterus Dyspnea- SOB from pressure on diaphragm Edema in lower extremities from increased pressure on vena cava Fetal parts and FHR often difficult to obtain because of excess fluid Diagnosis: ultrasound done to measure pockets of amniotic fluid for a total volume Educate client concerning preterm labor and preterm ROMs  Oligohydramnios Decreased amount of amniotic fluid ( 42 weeks, amniotic fluid levels naturally decline Reduces ability of fetus to move freely without risk of cord compression, increasing the risk for fetal death and intrapartal hypoxia Typically identified on ultrasound  Management of Oligohydramnios Serial ultrasounds, non-stress tests, and biophysical profiles (BPPs) If fetal well-being compromised, birth is planned along with amnioinfusion Amnioinfusion improves abnormal FHR patterns, decrease C-sections Risk factors: uteroplacental insufficiency, PROM prior to labor, HTN, maternal diabetes, IUGR, post-term pregnancy, fetal renal abnormalities Continuously monitor FHR Variable decelerations indicating cord compression commonly seen Carefully monitor amnioinfusion to prevent overdistention of uterus  Management of Multiple Gestation Once confirmed, serial ultrasounds to assess fetal growth and development BPPs, non-stress tests, possible hospitalization in late pregnancy to prevent preterm labor and closer monitoring C-section often needed due to fetal malpresentation Be alert for any c/o fatigue, severe N/V, and larger than expected uterus Educate client on s/s of preterm labor and to report immediately During labor, monitor FHRs continuously Postpartum, monitor woman closely for hemorrhage secondary to uterine atony  Premature Rupture of Membranes PROM: the rupture of the bag of waters before onset of true labor Refers to a woman who is > 37 weeks gestation, presents with SROM, and is not in labor Complications: infection, prolapsed cord, abruption Woman presents with leakage of fluid, vaginal discharge, vaginal bleeding, and pelvic pressure but is not having contractions Diagnosed via speculum vaginal exam (pooling of fluid, ferning, nitrazine)  Preterm Premature Rupture of Membranes PPROM: Rupture of membranes prior to onset of labor in woman < 37 weeks Perinatal risks stem from immaturity: respiratory distress syndrome, intraventricular hemorrhage, patent ductus arteriosus, necrotizing enterocolitis Unknown etiology but may be associated with vaginal bleeding, abruption, infection, defective placentation Increased risk if previous hx of PPROM and short interval between pregnancies Treatment of PROM and PPROM Depends on gestational age If fetal lungs mature: induction of labor If fetal lungs immature: hydration, activity restrictions, pelvic rest, close observation for infection, betamethasone Antibiotics (infection increases with duration of PPROM) Nursing assessment focuses on obtaining complete health hx and performing physical exam to determine maternal and fetal status Maternal risk factors, s/s of labor, continuous FHR monitoring, observation of amniotic fluid (foul-smelling)  Nursing Management of PROM & PPROM Determine date, time, and duration of SROM Rule out recent UTI or vaginal infection Administer antibiotics Monitor VS Serial WBC measurements Determine gestational age of fetus Assess continually for signs of labor Report fetal tachycardia (maternal infection) or variable decels (cord compression) Typically admitted until delivery  Shoulder Dystocia The obstruction of fetal descent and birth by axis of fetal shoulders after the fetal head is delivered (shoulders remain wedged behind mother’s pubic bone) - Emergency! Increasing incidence due to increasing birth weights No predictor for shoulder dystocia Maternal risks: PP hemorrhage, vaginal lacerations, anal tears, uterine rupture Fetal risks: transient brachial plexus palsy, clavicle or humerus fractures, cord compression McRoberts maneuver or suprapubic pressure can reduce severity of maternal and fetal injuries  Management of Shoulder Dystocia McRoberts maneuver Suprapubic pressure Light pressure applied just above pubic bone, pushing the fetal anterior shoulder downward to displace it from above the mother’s symphysis pubis Newborn's head depressed towards mother’s anus while pressure applied  Macrosomia Newborn weighs > 4,500 g (9.9 lb.) at birth Risks: maternal diabetes, obesity, suspicion of macrosomia via ultrasound Complications: increased risk PPH, shoulder dystocia, low Apgar scores, dysfunctional labor, fetopelvic disproportion (fetus unable to fit through maternal pelvis), vaginal lacerations, fetal injuries or fractures, perinatal asphyxia Scheduled C-section often done with primigravida Vacuum and forceps-assisted births common  Preterm Labor Occurrence of regular UCs, cervical dilation and effacement before 37 weeks UCs must be persistent, effacement > 80%, dilation > 1 cm Etiology unknown, prevention is the goal Management of preterm labor: Tocolytic drugs- promote uterine relaxation by interfering with UCs Antibiotics- for GBS+ women Steroids- to improve fetal lung maturity (24-34 weeks)  Tocolytic Therapy Most likely ordered if preterm labor occurs before 34th week Does not prevent birth, but can delay it A serious side effect is maternal pulmonary edema Contraindicated for abruptions, fetal distress or death, fetus before viability, severe preeclampsia, PPROM, active vaginal bleeding, dilation > 6 cm, chorioamnionitis, maternal hemodynamic instability  Tocolytic Drugs Magnesium sulfate Indomethacin (Indocin) Nifedipine (Procardia) Terbutaline sulfate (Brethine)  Corticosteroids Betamethasone (Celestone) Given to mother in preterm labor to help prevent or reduce severity of respiratory distress syndrome in premature infants between 24-34 weeks Promotes fetal lung maturity by stimulating surfactant production Administer two doses IM, 24 hours apart Beneficial effects have been reported within 48 hours of initial dose Use of repeat doses supported if still at risk for preterm birth 7 days or more after initial course  Labs and Diagnostic Testing Preterm Labor Fetal fibronectin- useful marker for impending SROM within 7-14 days Negative test is a strong predictor that preterm labor in next two weeks is unlikely Accuracy of test decreased in presence of lubricants, blood, recent intercourse, or cervical manipulation in last 24 hours Cervical length measurement- > 3 cm indicates delivery within 14 days is unlikely Cervical length of < 2.5 cm during mid-trimester have greater risk of preterm birth prior to 35 weeks gestation Negative results can be reassuring and prevent unnecessary interventions  Preterm Birth Education Risk factors: multiple gestation, prior preterm birth, low socioeconomic status, maternal medical disorders, and maternal infections African American race (double the risk), maternal age extremes (younger than 16 and older than 40 years) Avoid lifting heavy objects, wait at 18 months between pregnancies, avoid use of substances, no sexual activity, s/s of preterm labor, call provider Any s/s of preterm labor: drink water, lie down on side and rest x 1-hour, palpate abdomen for strength of UCs, call HCP  Post-term Pregnancy Any pregnancy > 42 weeks gestation Maternal risks: C-section, shoulder dystocia, birth trauma, PPH, infection Fetal risks: macrosomia, shoulder dystocia, brachial plexus injuries, low Apgar scores, CPD Uteroplacental insufficiency, meconium aspiration, intrauterine infection contribute to perinatal death As placenta ages, perfusion decreases Amniotic fluid begins to decline after 38 weeks Fetal hypoxia and increased risk of cord compression predispose fetus to meconium aspiration, which is released by fetus in response to hypoxic insult  Nursing Management of Post-term Pregnancy Accurate gestational age via ultrasound Induction can be deferred until 42 weeks if reassuring FHR pattern Daily fetal movement counts Non-stress tests with amniotic fluid assessments Priority: monitoring fetal well-being  Umbilical Cord Prolapse Rare OB emergency involving protrusion of umbilical cord alongside or ahead of the presenting part of a fetus Usually leads to total or partial occlusion of the cord Perfusion deteriorates rapidly and fetus will die if cord compression not relieved Risk factors: malpresentation, FGR, prematurity, ROM with fetus at high station, polyhydramnios, grandmultiparity, and multiple gestation  Nursing Management of Cord Prolapse First sign of cord prolapse: sudden fetal bradycardia or recurrent variable decels that become progressively more severe Call for help immediately but do not leave client Assist with measures to relieve compression Place a sterile gloved hand into vagina and hold the presenting part off the umbilical cord until delivery Change position to left lateral, Trendelenburg, or knee-chest Monitor FHR, maintain bed rest, and administer oxygen Emergency C-section  Amniotic Fluid Embolism (AFE) Amniotic fluid containing particles of debris (hair, skin, vernix, or meconium) enters maternal circulation and obstructs pulmonary vessels, causing sudden respiratory distress and circulatory collapse Pathophysiology involves an abnormal maternal response to fetal tissue exposure associated with breaches of the maternal-fetal physiologic barrier Normally amniotic fluid does not enter maternal circulation because it’s contained within the uterus, sealed off by the amniotic sac Embolus occurs when the barrier between the maternal circulation and amniotic fluid is broken and amniotic fluid enters maternal venous system via the endocervical veins, placenta site, or site of perineal trauma 50% die within first hour of onset of symptoms, 85% of survivors have permanent neurological damage  Nursing Care: AFE Immediate recognition and diagnosis is key: acute onset of dyspnea, chest pain, frothy sputum, hypotension, tachycardia, and massive hemorrhage Supportive care: maintain oxygenation, hemodynamic function, and correct coagulopathy Resuscitation, intubation, mechanical ventilation Vasopressors (drugs that cause constriction of blood vessels) used to maintain hemodynamic status Management of DIC involves replacement with packed red blood cells and fresh-frozen plasma Oxytocin infusions to address uterine atony Transfer to ICU