Nursing Care During Labor and Birth (PDF)

NURSING CARE OF PATIENTS WITH COMPLICATIONS DURING LABOR AND BIRTH Chapter 8 Ms. Arreguin, RN  Lesson 8.1 Objectives 1. Define each key word listed. 2. Discuss each obstetric procedure discussed in this chapter. 3. Illustrate the nurse’s role in each obstetric procedu...

NURSING CARE OF PATIENTS WITH COMPLICATIONS DURING LABOR AND BIRTH Chapter 8 Ms. Arreguin, RN  Lesson 8.1 Objectives 1. Define each key word listed. 2. Discuss each obstetric procedure discussed in this chapter. 3. Illustrate the nurse’s role in each obstetric procedure. 4. Analyze the nurse’s role in a cesarean birth. Obstetric Procedures ◦Amnioinfusion ◦Version ◦Induction ◦Bishop scoring system ◦ measures how ready the cervix is ◦ higher score = successful induction ◦Augmentation Indications for Labor Induction ◦ Maternal Condition ◦ Gestational hypertension ◦ Preeclampsia ◦ Eclampsia ◦ Ruptured membranes without spontaneous onset of labor ◦ Especially GBS positive patients- why? ◦ Infection within the uterus ◦ Chorioamnionitis  Indications for Labor Induction ◦ Medical problems in the patient that worsen during pregnancy ◦ Diabetes, ESRD, other chronic conditions ◦ Fetal problems such as slowed growth, prolonged pregnancy, or incompatibility between fetal and maternal blood types ◦ Placental insufficiency ◦ Fetal death Contraindications to Induction ◦ Placenta previa ◦ Umbilical cord prolapse ◦ Abnormal fetal presentation ◦ High station of the fetus ◦ Active herpes infection in the birth canal ◦ Abnormal size or structure of the patient’s pelvis ◦ Previous classical cesarean incision Copyright © 2019, Elsevier Inc. All rights reserved.  Augmentation ◦Labor has begun spontaneously ◦ fizzled out ◦ maternal/fetal health concern ◦Natural, pharmacological and mechanical interventions available  Pharmacologic Methods to Stimulate Contractions ◦Cervical ripening ◦ Prostaglandin E2 Cervidil ◦ Prostaglandin E1 Cytotec (Dinoprostone) (Misoprostol) ◦ Intravaginal insertion ◦ Intravaginal insertion or PO ◦ sustained release -usually ◦ More effective at producing overnight vaginal delivery w/i 24 hours  Pharmacologic Methods to Stimulate Contractions ◦ Pitocin induction and the augmentation of labor ◦ IV administration of titrated Pitocin to stimulate uterine contractions ◦ Primary Risk: Uterine TACHYSYSTOLE or TETANY  Preparing the Patient for Labor Augmentation ◦Explain procedure to patient. ◦Obtain baseline VS and fetal heart rate. ◦Ensure patent IV line is placed. ◦Ensure patient remains in bed for 2 hours ◦Pitocin induction can start 6 to 12 hours after vaginal insert has been removed. ◦Assess for signs of uterine tachysystole. Dilating the Cervix ◦Stripping amniotic membranes ◦Hydroscopic dilators ◦Transcervical balloon dilators Copyright © 2019, Elsevier Inc. All rights reserved.  Obstetric ◦ Amniotomy Procedures ◦ The artificial rupture of membranes ◦ Done to stimulate or enhance contractions ◦ Commits the patient to delivery ◦ Stimulates prostaglandin secretion ◦ Complications ◦ Prolapse of the umbilical cord ◦ Infection ◦ Abruptio placentae Complications Associated with Amniotomy ◦ Prolapsed umbilical cord ◦ Infection ◦ Abruptio placentae Copyright © 2019, Elsevier Inc. All rights reserved.  Nonpharmacologic Methods to Stimulate Contractions ◦ Walking ◦ Stimulates contractions (if true labor) ◦ Eases pressure of the fetus on the patient’s back ◦ Adds gravity to the downward force of contraction ◦ Semen deposit on cervix ◦ Not safe in already ruptured membranes ◦ Nipple stimulation via suckling ◦ Causes the pituitary gland to secrete natural oxytocin  Obstetric Version ◦A method used to change fetal presentation ◦Two methods ◦External—usually performed at 37 weeks’ gestation but before onset of labor ◦Internal—emergent, during labor  Obstetric Version ◦ Risks and contraindications ◦ Disproportion between patient’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 ◦ Fetus can become entangled in umbilical cord  Episiotomy ◦Episiotomy—controlled surgical enlargement of the vaginal opening during birth ◦Indications for episiotomy ◦Better control over where and how much the vaginal opening is enlarged ◦An opening with a clean edge rather than the ragged opening of a tear ◦Note: Perineal massage and stretching exercises before labor may be an alternative to an episiotomy.  Perineal Lacerations ◦ Uncontrolled tearing of perineal tissue ◦ First degree—superficial vaginal mucosa or perineal skin ◦ Second degree—involves vaginal mucosa, perineal skin, and deeper tissues of the perineum ◦ Third degree—same as second degree, plus involves anal sphincter ◦ Fourth degree—extends through the anal sphincter into the rectal mucosa Perineal Lacerations  Forceps Extraction ◦ Provides traction and rotation of the fetal head when the patient’s pushing efforts are insufficient to accomplish a safe delivery ◦ Used at end of second stage of labor in vaginal delivery ◦ Forceps may also help the physician extract the fetal head through the incision during a cesarean birth  Vacuum Extraction Birth ◦Uses suction applied to the fetal head so the physician can assist the mother’s expulsive efforts ◦Used only with occiput presentation and at end of second stage of labor Copyright © 2019, Elsevier Inc. All rights reserved. Risks of Forceps or Vacuum Extraction ◦Trauma to maternal or fetal tissues ◦Patient may have a laceration or hematoma in their vagina. ◦Infant may have bruising, facial or scalp lacerations or abrasions, cephalohematoma, or intracranial hemorrhage.  Cesarean Birth: Indications ◦ Abnormal labor ◦ Inability of the fetus to pass through the maternal pelvis ◦ Maternal conditions such as GH or DM ◦ Active maternal herpes virus ◦ Previous surgery on the uterus ◦ Fetal compromise ◦ Placenta previa or abruptio placentae  Preparation for Cesarean Birth ◦ Clinical lab studies to identify anemia and blood-clotting abnormalities ◦ CBC ◦ coagulation studies ◦ blood type & cross ◦ Baseline vital signs, including fetal heart rate ◦ Position patient for comfort ◦ IV line ◦ Foley catheter inserted https://youtu.be/QGZijNGndoU?feature=shared Types of Incisions ◦ Skin ◦ Vertical allows more room for a large fetus ◦ Transverse (a.k.a. Pfannenstiel) Types of Incisions ◦ Uterine ◦ Low transverse ◦ not likely to rupture during another birth; VBAC possible with this type ◦ Low vertical ◦ minimal blood loss; more likely to rupture during another birth ◦ Classic ◦ rarely used; more blood loss; most likely to rupture during another pregnancy  Nursing Care in the Recovery Room ◦ Vital signs to identify hemorrhage or shock ◦ IV site and rate of solution flow ◦ Fundus for firmness, height, and midline position ◦ Dressing for drainage ◦ Lochia for quantity, color, and presence of clots ◦ Urine output from the indwelling catheter Copyright © 2019, Elsevier Inc. All rights reserved. https://www.merckmanuals.com/professional/multimedia/video/uterine-compression https://youtu.be/MEt2IQzia6E?si=nEEwvk2R6fiJrYVc https://youtu.be/hrozJ-EbdGI?si=tscq8lLekhEScXAP Wordy/no pictures but helpful review  Lesson 8.2 Objectives 5. Describe factors that contribute to an abnormal labor. 6. Explain each intrapartum complication discussed in this chapter.  Abnormal Labor ◦Called dysfunctional labor ◦ Does not progress ◦Dystocia ◦ Difficult labor Copyright © 2019, Elsevier Inc. All rights reserved.  Problems with the Powers of Labor ◦ Hypertonic ◦ Hypotonic Copyright © 2019, Elsevier Inc. All rights reserved.  Ineffective Maternal Pushing ◦ Woman may not understand which technique to use or fears tearing her perineal tissues. ◦ Epidural or subarachnoid blocks may depress or eliminate the natural urge to push. ◦ An exhausted woman may be unable to gather enough energy to push. Copyright © 2019, Elsevier Inc. All rights reserved.  Problems with the Fetus ◦ The passenger, or the fetus, might cause the labor’s progression to be dysfunctional. ◦ These problems include size, presentation, or positioning. ◦ Other factors might include multifetal pregnancies and birth defects. Copyright © 2019, Elsevier Inc. All rights reserved.  Abnormal Fetal Presentation or Position ◦ Prevents the smallest diameter of the fetal head to pass through the smallest diameter of the pelvis  Nursing Care for Abnormal Fetal Presentation or Positions ◦ Encourage patient to assume positions that favor fetal rotation and descent and reduce back pain. ◦ Sitting, kneeling, or standing while leaning forward ◦ Rocking the pelvis back and forth while on hands and knees (encourages rotation) ◦ Side-lying ◦ Squatting (in second stage of labor) ◦ Lunging by placing one foot in a chair with the foot and knee pointed to that side Copyright © 2019, Elsevier Inc. All rights reserved.  Multifetal Pregnancy ◦ May cause dysfunctional labor ◦ Uterine overdistension contributes to poor contraction quality. ◦ Abnormal presentation or position of one or more fetuses interferes with labor mechanisms. ◦ Often one fetus is delivered as cephalic and the second as breech unless a version is done. Problems with the Pelvis and Soft Tissues ◦ Bony pelvis ◦ Gynecoid pelvis most favorable for vaginal birth ◦ Soft tissue obstructions ◦ Most common is a full bladder  The Psyche ◦ Most common factors that can prolong labor ◦ Lack of analgesic control of excessive pain ◦ Absence of a support person or coach ◦ Immobility and restriction to bed ◦ Lack of ability to carry out cultural traditions  Effects of Hormones Released ◦ The uterus uses more glucose for energy. ◦ Diverts blood from the uterus ◦ Increases tension of pelvic muscles; can impede fetal descent ◦ Increases perception of pain  Abnormal Duration of Labor ◦ Friedman curve ◦ Often used to graph the progress of cervical dilation and fetal descent ◦ Used as a guide to assess and manage the normal progress of labor ◦ Prolonged labor can cause ◦ Maternal or newborn infection ◦ Maternal exhaustion ◦ Postpartum hemorrhage ◦ Greater anxiety and fear Precipitate Birth ◦ A birth that is completed in less than 3 hours from labor onset ◦ Labor begins abruptly and intensifies quickly ◦ Contractions may be frequent and intense ◦ May have uterine rupture, cervical lacerations, or hematoma ◦ Fetal oxygenation may be compromised ◦ Birth injury may occur from rapid passage through the birth canal ◦ Injuries can include ◦ Intracranial hemorrhage ◦ Nerve damage Premature Rupture of Membranes (PROM) ◦ Spontaneous rupture of membranes at term, more than 1 hour before labor contractions begin ◦ Vaginal or cervical infection may cause PROM ◦ Diagnosis confirmed by ◦ Nitrazine paper test ◦ Looking for a “ferning” pattern from vaginal fluid placed on a slide and viewed under the microscope  Patient Teaching for a Woman with Infection or in Preterm Labor ◦ Report a temperature that is above 38°C (100.4°F). ◦ Avoid sexual intercourse or insertion of anything into vagina. ◦ Avoid orgasms. ◦ Avoid breast stimulation. ◦ Maintain any activity restrictions prescribed. ◦ Note any uterine contractions, reduced fetal activity, and other signs of infection. ◦ Record fetal kick counts daily and report fewer than 10 kicks in a 12-hour period. Preterm Labor: Some Risk Factors ◦ Exposure to DES ◦ Underweight ◦ Chronic illness ◦ Dehydration ◦ Preeclampsia ◦ Previous preterm labor or birth ◦ Previous pregnancy losses ◦ Substance abuse ◦ Chronic stress Preterm Labor: Some Risk Factors ◦ Infection ◦ Anemia ◦ Preterm PROM ◦ Inadequate prenatal care ◦ Poor nutrition ◦ Low education level ◦ Poverty ◦ Smoking ◦ Multifetal presentation  Signs of Impending Preterm Labor ◦ A shortened cervix on ultrasound at 20 weeks may be predictive of preterm labor. ◦ Diagnosis of preterm labor is based on cervical effacement and dilation of more than 2 cm. ◦ A fibronectin test ◦ Fibronectin is a protein produced by the fetal membranes and leaks into vaginal secretions if uterine activity, infection, or cervical effacement occurs. ◦ The presence of fibronectin in vaginal secretions between 22 and 24 weeks’ gestation is predictive of preterm labor. Copyright © 2019, Elsevier Inc. All rights reserved.  Maternal Symptoms of Preterm Labor ◦ Contractions that may be either uncomfortable or painless ◦ Feeling that the fetus is “balling up” frequently ◦ Menstrual-like cramps ◦ Constant low backache ◦ Pelvic pressure or feeling that the fetus is pushing down ◦ A change in vaginal discharge ◦ Abdominal cramps with or without diarrhea ◦ Pain or discomfort in the vulva or thighs ◦ “Just feeling bad” or “coming down with something” Tocolytic Therapy (1 of 2) ◦ Goal is to stop uterine contractions ◦ Keep fetus in utero until lungs are mature enough to adapt to extrauterine life ◦ Magnesium sulfate (IV), beta-adrenergic (PO), calcium channel blockers (PO) ◦ Prostaglandin synthesis inhibitors  Tocolytic Therapy (2 of 2) ◦Contraindications ◦ Preeclampsia ◦ Placenta previa ◦ Abruptio placentae ◦ Gestational age over 37 weeks ◦ Chorioamnionitis ◦ Fetal demise Copyright © 2019, Elsevier Inc. All rights reserved. Stopping Preterm Labor ◦ Initial measures to stop preterm labor ◦ Identifying and treating infection ◦ Activity restriction ◦ Hydration ◦ If successful, patient may be sent home with strict return instructions and activity restrictions.  Stopping Preterm Labor ◦ Secondary measures to stop preterm labor ◦ Drug therapy - Oral or IV Stopping Preterm Labor ◦If it appears preterm birth is inevitable ◦ Amniocentesis to assess fetal maturity ◦ Steroids increase fetal lung maturity ◦ Betamethasone ◦ Thyroid-releasing hormone also enhances lung maturity in fetuses younger than 28 weeks.  Prolonged Pregnancy ◦ Lasts longer than 41 weeks ◦ Placenta ages ◦ Delivers oxygen and nutrients to the fetus less efficiently ◦ Fetus may lose weight. ◦ Fetal skin may peel. ◦ Fetus continues to grow. ◦ Meconium may be expelled. ◦ Low blood glucose levels in the fetus  Tests Used to Confirm the Diagnosis of Prolonged Pregnancy ◦Any pregnancy that lasts longer than 40 weeks may require ◦Nonstress tests (NST) ◦Amniotic fluid index (AFI) ◦Biophysical profile (BPP) ◦Kick counts  Lesson 8.3 Objectives 7. Discuss the nurse’s role in caring for women having each intrapartum complication. 8. Review the nurse’s role in obstetric emergencies. Emergencies During Birth ◦ Prolapsed umbilical cord ◦ Complete ◦ Palpated ◦ Occult ◦ Placenta accreta  Emergencies During Childbirth ◦ Uterine rupture ◦ Complete ◦ Incomplete ◦ Dehiscence ◦ Primary risk: VBAC ◦ Painful ◦ sharp pain in abdomen & chest ◦ change in belly shape ◦ loss of contractions  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 Copyright © 2019, Elsevier Inc. All rights reserved. artificial rupture The intentional puncture of the amniotic sac and release of amniotic fluid for of membranes the purpose of inducing or augmenting labor (AROM) augmentation of The enhancement of labor after it has begun; the stimulation of contractions labor after they have begun naturally. Bishop score A scoring system that uses cervical dilation, effacement, fetal station, cervical consistency, and position to determine if labor can be safely induced. cephalopelvic A condition in which the fetus cannot pass through the maternal pelvis; also disproportion called fetopelvic disproportion. chignon Newborn scalp edema created by a vacuum extractor. chorioamnionitis an ascending infection, originating in the lower genitourinary tract and migrating to the amniotic cavity. Intrauterine infection during pregnancy. dysfunctional ineffective labor pattern that will not effectively deliver the infant labor an obstetric emergency where the anterior fetal shoulder becomes stuck on shoulder dystocia the maternal pubic symphysis, delaying the birth of the baby's body hydramnios polyhydramnios; a condition in which there is too much amniotic fluid around the fetus induction of labor to cause labor to begin macrosomia An abnormally large infant, or neonatal birth weight above the 90th percentile. oligohydramnios a condition in which there is not enough amniotic fluid around the fetus oxytocics Drugs that intensify uterine contractions to hasten birth or control postpartum hemorrhage. tocolytics Drugs that reduce uterine contractions, used to delay labor onset and prevent pre-term delivery. spontaneous SROM; rupture of fetal membranes occurring on its own rupture of membranes Version Turning of the position of the fetus in the uterus before birth; can be spontaneous or manually induced. tachysystole Uterine contraction frequency of more than once every 2 minutes, or five or more contractions within 10 minutes with duration longer than 90 seconds, or resting interval between contractions less than 60 seconds.