Week 6 - Infection, Medical Conditions, Early Onset of Labor PDF

1 NURS 2410 Family Nursing WEEK 6 - INFECTION, MEDICAL CONDITIONS, EARLY ONSET OF LABOR, PROCEDURES, L&D COMPLICATIONS  2 Infections HIV/Aids 3  Retrovirus that attacks and causes destruction of T lymphocytes. It c...

1 NURS 2410 Family Nursing WEEK 6 - INFECTION, MEDICAL CONDITIONS, EARLY ONSET OF LABOR, PROCEDURES, L&D COMPLICATIONS  2 Infections HIV/Aids 3  Retrovirus that attacks and causes destruction of T lymphocytes. It causes immunosuppression in a client.  Clients who are severely immunosuppressed develop acquired immunodeficiency syndrome (AIDS).  HIV is transmitted from the mother to a neonate perinatally through the placenta and postnatally through the breast milk  RF: IV drugs use, multiple sexual patterns, history of STIs  Expected findings  Fatigue & influenza like symptoms  Fever, diarrhea, wt loss, lymphadenopathy, rash, anemia  Labs: enzyme immunoassay (EIA) is confirmed by Western blood or immunofluorescence assay, obtain viral load levels & CD4 cell counts HIV/Aids 4  Nursing actions  Goal: keep CD4 cells >500  Use standard precautions  Administer antiretroviral prophylaxis  triple-medication antiretroviral (ART): taken throughout pregnancy  highly active antiretroviral therapy (HAART): 3 hr prior to delivery & 6 weeks following birth to infant  Immunization against hep B, pneumococcal infection, haemophiles influenzas type b & viral influenza  Use condoms  Review plan for C/S for maternal viral load >1,000 copies or vaginal birth can be done for viral load 160/110, proteinuria +3, oliguria, >1.1 creatinine, headache, blurred vision, hyperreflexia, edema, hepatic dysfunction, epigastric & RUQ pain  Eclampsia: severe preeclampsia with seizure or coma  HELLP syndrome: H hemolysis, EL elevated liver enzymes, LP low platelets  RF: 40, first pregnancy, obesity, multifetal gestation, renal disease, HTN, family hx  Medications: low dose aspirin in late first trimester for hx of preeclampsia, antihypertensives (methyldopa, nifedipine, hydralazine or labetalol), magnesium sulfate Preeclampsia & Eclampsia Video 21  https://www.youtube.com/watch?v=RB5s85xDshA  22 Early Onset of Labor Preterm Labor 23  Uterine contractions and cervical changes that occur between 20 and 36 weeks and 6 days of gestation  RF: infections, hx, multifetal pregnancy, smoking, substance abuse, violence  Expected findings: uterine contractions, cramping, low back pain, urinary frequency, vaginal discharge, cervical dilation  Labs: fetal fibronectin, cervical cultures, CBC, urinalysis  Nursing interventions: activity restriction, hydration, treating infection, monitor FHR & contraction pattern, fetal tachycardia  Medications: nifedipine, magnesium sulfate, terbutaline, betamethasone Premature Rupture of Membranes (PROM) 24  PROM: spontaneous rupture of membranes prior to true labor  PPROM: premature rupture of membranes between 20-37 weeks  RF: infection, hx, shortened cervix, tobacco/substance abuse  Expected findings: gush or leakage of fluids from vagina  Labs: positive nitrazine paper test  Nursing interventions: monitor FHR, assess for prolapse cord, vaginal cx, limit vaginal exams, VS, CBC, antibiotics  Medications: ampicillin, betamethasone  Education: limit activity, daily kick counts, foul-smelling vaginal discharge, avoid intercourse, take temperature  Complications: infection, placental abruption, umbilical cord compression/prolapse, fetal pulmonary hypoplasia, death Common Pregnancy 25 Complications Video  https://www.youtube.com/watch?v=cIFumERBgIk  26 Therapeutic Procedures to Assist with L&D  External cephalic version 27  External cephalic version is an ultrasound-guided hands-on procedure to externally manipulate the fetus into a cephalic lie at 37-38 wks  Contraindications: uterine anomalies, previous cesarean birth, cephalopelvic disproportion, placenta previa, multifetal gestation, oligohydramnios, third- trimester bleeding, uteroplacental insufficiency, or nuchal cord.  Indications: infant in breech or transverse position  Nursing actions: informed consent, ultrasound, nonstress test, admin RhoGAM, IV fluids & tocolytic, monitor uterine activity, ROM, bleeding, monitor FHR/activity, VS, supine hypotension  Complications: placental abruption, umbilical cord compression & emergency C/S Bishop score 28  A Bishop score is used to determine maternal readiness for labor by evaluating whether the cervix is favorable by rating the following from 0-3:  Cervical dilation, effacement, consistency (firm, medium or soft), position, station of presenting part  Indications: Any condition in which augmentation or induction of labor is indicated  A score of >8 indicates at 39 wks indicates successful induction Cervical ripening 29  Cervical ripening by various methods increases cervical readiness for labor through promotion of cervical softening, dilation, and effacement.  Methods:  Oxytocin IV infusion  Balloon catheter inserted into the intracervical canal to dilate the cervix  Membrane stripping & an amniotomy  Prostaglandins (misoprostol or dinoprostone) oral or vaginal suppository/gel  Considerations: urinary retention, ROM, uterine tenderness/pain, contractions, vaginal bleeding, fetal distress  Nursing interventions: informed consent, void prior to procedure, side lying position, monitor FHR, uterine activity, adverse effects (N/V, diarrhea, fever, uterine tachysystole)  Complications: Tachysystole (terbutaline), fetal distress 30 Induction of labor 31  Induction of labor is the deliberate initiation of uterine contractions to stimulate labor before spontaneous onset to bring about the birth by chemical or mechanical means.  Balloon catheter, prostaglandin, oxytocin  Indications: >42 wks, dystocia, prolonged ROM, IUGR, maternal medical complications (DM, pulmonary disease, GH), fetal demise, choroiamniotis  Nursing interventions: misoprostol admin, oxytocin admin, infusion port closest to client & connected to main IV line, monitor contractions, VS, FHR  Complications: nonreasoning FHR Amniotomy 32  An amniotomy is the artificial rupture of the amniotic membranes (AROM) by the provider using a hook, clamp, or other sharp instrument.  Labor typically begins within 12 hr after the membranes rupture and can decrease the duration of labor by up to 2 hr.  Indication: labor progression too slow, induction of labor is indicated  Nursing interventions: ensure presenting part of fetus is engaged prior to prevent cord prolapse, monitor FHR, assess characteristics of amniotic fluid, document time of rupture  Complications: cord prolapse, infection Amnioinfusion 33  An amnioinfusion of normal saline or lactated Ringer’s is instilled into the amniotic cavity through a transcervical catheter introduced into the uterus to supplement the amount of amniotic fluid.  Indications: oligohydramnios, fetal cord compression  Nursing interventions: assist with amniotomy if membranes haven’t ruptured, warm fluid via blood warmer, uterine distention, monitor uterine contractions, FHR, fluid output Artificial Rupture of Membranes 34  Vacuum assisted delivery 35  Vacuum-assisted birth involves the use of a cuplike suction device that is attached to the fetal head  Indications: vertex presentation, cervical dilation of 10 cm, cephalopelvic disproportion, ruptured membranes, fetal distress  Nursing interventions: FHR, observe for neonate bruising, abrasions & facial palsy, check client for lacerations, hematoma, report to postpartum nurse that vacuum assisted delivery was used  Complications: lacerations of cervix, vagina & perineum, injury to bladder, facial nerve palsy of the neonates, facial bruising, subdural hematoma Vacuum assisted delivery 36 Forceps 37  using an instrument with two curved spoon-like blades to assist in the delivery of the fetal head. Traction is applied during contractions.  Indications: Prolonged 2nd stage of labor, fetal distress, abnormal presentation  Interventions: lithotomy position, empty bladder, ensure fetus is engaged, assess FHR, observe for bruising & abrasions, observe for vaginal/cervical lacerations  Complications: lacerations of cervix, vagina & perineum, injury to bladder, facial nerve palsy of the neonates, facial bruising, subdural hematoma Obstetric Forceps 38  Episiotomy 39  An incision made into the perineum to enlarge the vaginal opening to facilitate birth and minimize soft tissue damage.  Indications: shorten the 2nd stage of labor, facilitate forceps or vacuum assisted delivery, prevent cerebral hemorrhage in preterm fetus, facility birth of macrosomia infant Cesarean birth 40  A cesarean birth is the delivery of the fetus through a transabdominal incision of the uterus to preserve the life or health of the client and fetus when there is evidence of complications.  Indications: breech, cephalopelvic disproportion, non-reassuring FHR, placental abnormalities, placenta previa, abruptio placentae, HIV positive, HTN disorders, DM, active genital herpes lesions, previous C/S, dystocia, multiple gestations, umbilical cord prolapse, congenital malformations  Nursing interventions:  Preprocedural: FHR, VS, ultrasound, supine position w/ wedge, insert catheter, informed consent, SCD, insert IV & admin fluids, NPO since midnight  Intraprocedural: positioning client, FHR, VS, IV fluids, UO, instrument & sponge count  Postprocedural: monitor for infection & bleeding, assess fundus, lochia, productive cough, chills, thrombophlebitis, I&O, VS, pain meds, encourage ambulation  Complications: aspiration, fluid PE, infection, wound dehiscence, thrombophlebitis, hemorrhage, UTI, injuries to bladder or bowel, fetal injuries during surgery Skin Incisions for Cesarean Birth 41 Vaginal birth after cesarean 42 (VBAC)  A vaginal birth after cesarean birth is when the client delivers vaginally after having had a previous cesarean birth.  Indications: no uterine scars, 1 or 2 previous C/S, adequate pelvis, no current contraindications: large for gestational age, malpresentation, cephalopelvic disproportion, previous vertical uterine incision  Nursing interventions  Preprocedural: review medical record for low transverse C/S, explain procedure, informed consent  Intraprocedural: FHR, contraction patterns, assess for uterine rupture, promote breathing techniques, provide analgesia  Postprocedural: same as vaginal delivery Therapeutic Procedures Videos 43  https://www.youtube.com/watch?v=92ocoXRhDqk  https://www.youtube.com/watch?v=YUcPB5pUEXk  44 Complications Related to the Labor Process Prolapsed Umbilical Cord 45  Occurs when the umbilical cord is displaced, preceding the presenting part of the fetus, or protruding through the cervix  RF: Rupture of amniotic membranes, Abnormal fetal presentation, Transverse lie, Small-for-gestational-age fetus, Unusually long umbilical cord, Multifetal pregnancy, Unengaged presenting part, Hydramnios or polyhydramnios  Expected findings: client feels something coming through vagina, visualize or palpation of the cord, FHR monitor shows variable or prolonged decels, excessive fetal activity followed by cessation of movement (fetal hypoxia)  Nursing interventions: Call for help, do not leave client, notify provider, Using a sterile-gloved hand, insert two fingers into the vagina, and apply finger pressure on either side of the cord to the fetal presenting part to elevate it off of the cord. Stay in this position until the delivery of the baby, reposition client, apply warm sterile saline soaked towel to visible cord, 8-10 L/min O2, IV access & fluids, deliver baby Meconium-Stained Amniotic Fluid 46  Meconium passage in the amniotic fluid  RF: >38 wks gestations, umbilical cord compression, hypoxia stimulates vagal nerve  Expected findings: black to green or yellow amniotic fluid  Nursing interventions: document amniotic fluid, notify the provider, gather resuscitation equipment, suction mouth & nose, suction below the vocal cords using an endotracheal tube if HR 40, uterine abnormalities, cephalopelvic disproportion, congenital anomalies, fetal macrosomia, multifetal pregnancy  Expected findings: Lack of progress in dilatation, effacement, or fetal descent during labor, ineffective in pushing, occiput posterior  Diagnostics: ultrasound, amniotomy, oxytocin, vacuum assisted birth, C/S  Nursing interventions: assist with fetal scalp electrode, encourage client to void, position changes, ambulation, hydrotherapy, counterpressure  Medications: oxytocin Precipitous Labor 49  Labor that lasts 3 hr or less from the onset of contractions to the time of delivery.  RF: hypertonic uterine dysfunction, oxytocin stimulation, multiparous client  Expected findings: low back pain, abnormal pressure/cramping, increased or bloody vaginal discharge, Palpable uterine contractions, Progress of cervical dilation and effacement, Diarrhea, Fetal presentation, station, and position  Nursing interventions: do not leave client, encourage pant with an open mouth between contractions, side lying, do not stop delivery, apply light pressure to the perineal area & fetal head  Complications:  Maternal: lacerations, tissue trauma, uterine rupture, amniotic fluid embolism, hemorrhage  Fetal: hypoxia, intracranial hemorrhage Uterine Rupture 50  Complete rupture involves the uterine wall, peritoneal cavity, and/or broad ligament. Internal bleeding is present.  Incomplete rupture occurs with dehiscence at the site of a prior scar (cesarean birth, surgical intervention). Internal bleeding might not be present  RF: uterine abnormality, uterine trauma, overdistension of uterus, hyperstimulation of uterus, external/internal version, forceps  Expected findings: ripping or tearing or sharp pain, uterine tenderness, nonreassuring FHR (bradycardia, variable & late decels), change in uterine shape, hypovolemic shock  Nursing interventions: IV fluids, O2, administer blood products, immediate C/S Anaphylactoid Syndrome of 51 Pregnancy (Amniotic Fluid Embolism)  Occurs when there is a rupture in the amniotic sac or maternal uterine veins that causes infiltration of the amniotic fluid into the maternal circulation. The amniotic fluid then travels to and obstructs pulmonary vessels and causes respiratory distress and circulatory collapse  RF: placenta previa or abruption, preeclampsia, eclampsia, oxytocin, diabetes, C/S, forceps, uterine rupture, meconium stained fluid  Expected findings: sudden chest pain, SOB, restlessness, cyanosis, dyspnea, bleeding from incisions, petechiae, ecchymosis, ↑ HR, ↓ BP  Nursing interventions: O2, intubate/mechanical ventilation, CPR, IV fluids, side lying with pelvis tilt, blood products, catheter to monitor I&O, emergency C/S