Week 4 Class 1: Antepartum Complications PDF

Week 4 Class 1 **Antepartum Complications** - **High risk pregnancy**: Pregnancy that has factors that can jeopardize the life of the baby, the mom, or both. - Four main categories of high risk pregnancy: - **Biophysical** - Body is involved - Examples: Baby ma...

Week 4 Class 1 **Antepartum Complications** - **High risk pregnancy**: Pregnancy that has factors that can jeopardize the life of the baby, the mom, or both. - Four main categories of high risk pregnancy: - **Biophysical** - Body is involved - Examples: Baby may have genetic condition. Mom may have twins/triplets. Mom may have chronic HTN, diabetes, abnormal placenta attachment, abnormal history-preterm labor etc. - **Psychosocial** - Person's behavior in society - Smoking, caffeine, alcohol, drugs, domestic violence, emotional distress, obesity, inadequate support system - **Sociodemographic** - Poverty, late prenatal care or NONE, a patient that is 15 or less or someone who is of advanced maternal age (35+), being single, education, etc. - **Environmental** - Infections, radiation, pesticides, pollutants, second-hand smoking - **Missed** - No vaginal bleeding - Closed cervical os **(os = opening in the center of cervix)** - No fetal cardiac activity or empty sac - **Threatened** - Vaginal bleeding - Closed cervical os - Fetal cardiac activity - **Inevitable** - Vaginal bleeding - Dilated cervical os - Products of conception may be seen or felt at or above cervical os - **Incomplete** - Vaginal bleeding - Dilated cervical os - Some products of conception expelled and some remain - **Complete** - Vaginal bleeding - Closed cervical os - Products of conception completely expelled - Habitual abortion - Patient who has 2 or more spontanous abotions +-------------+-------------+-------------+-------------+-------------+ | ** ** | **Cramps** | **Bleeding* | **Tissue | **Cervical | | | | * | Passed** | Opening** | +=============+=============+=============+=============+=============+ | **Threatene | Possible | Spotting to | None | Close | | d** | mild cramps | moderate | | | | | | | | | |   | | | | | +-------------+-------------+-------------+-------------+-------------+ | **Inevitabl | Moderate | Mild to | None | **Dilated | | e** | | severe | | with | | | | | | membranes | | | | | | or tissue | | | | | | bulging at | | | | | | cervix** | +-------------+-------------+-------------+-------------+-------------+ | **Incomplet | Severe | Heavy, | **Partial | Dilated | | e** | | profuse | fetal | with tissue | | | | | tissue or | in cervical | | | | | placenta** | canal or | | | | | | passage of | | | | | | tissue | +-------------+-------------+-------------+-------------+-------------+ | **Complete* | Mild | Minimal | **Complete | Closed with | | * | | | expulsion | no tissue | | | | | of uterine | in cervical | | | | | contents** | canal | +-------------+-------------+-------------+-------------+-------------+ | **Missed** | None | None; | None, | Closed | | | | brownish | prolonged | | | | | discharge | retention | | | | | | of tissue | | +-------------+-------------+-------------+-------------+-------------+ | **Septic** | Varies | Varies; | Varies | Usually | | | | malodorous | | dilated | | | | discharge | | | +-------------+-------------+-------------+-------------+-------------+ | **Recurrent | Vaties | Varies | Yes | Usually | | ** | | | | dilated | +-------------+-------------+-------------+-------------+-------------+ A diagram of the stages of vaginal bleeding Description automatically generated - **[Cervical insufficiency]: [Premature dilation]** of the **[cervix in absence of contractions]** - **[Before 37 week ]** - Presentation: Painless, passive dilation, pelvic pressure, backache - H/O (History of) recurrent pregnancy loss - Prior cervical disease or trauma - Management: - **[Bedrest, pelvic rest (no intercourse), no lifting!!]** - Follow-up visits 16-24 weeks for cervical length per transvaginal US - **[Cerclage]** - Suture to reinforce internal - Risk for infection! - Will not be done in the first trimester  - Definition: Fertilized [ovum implants outside] uterine cavity, usually in fallopian tube - Occurs 1:50 pregnancies - 3rd most common pregnancy related death condition in US - [Unilateral abdominal pain,] with spotting at 6-8 weeks gestation, shoulder pain, right pelvic pain - Risks: obstruction of the tubes; scarring, infection, pelvic inflammatory disease - Management: - Ultrasound - Pregnancy test - If **tube is not ruptured** and if it's [early in the pregnancy], we can do medical management. **[Methotrexate]** will be given; **it inhibits cell division.** Tell her to stop taking folic acid and alcohol with this medication. **Follow up with HCG levels until it decreases.** - Pregnancy will basically absorb into her body. She will not pass this - If it's later on in the pregnancy, we need to do a **salpingostomy** - Goes into the fallopian tube, and they remove it from there - Fertilized ovum is out - If ruptured, they do a **salpingectomy** - Remove the fallopian tube - Stop the hemorrhaging - [If mom rh- : after the procedure - whether it is surgical or medical, **RhoGAM !!!**] A diagram of the reproductive system Description automatically generated  - **Placenta Previa**: the placenta is implanted below the baby so that it is covering up the cervical opening (os) - Three types: - **Marginal** - Placenta is near the opening but not covering it - Blood may be coming from this because edge of placenta is close enough - **Partial** - Placenta is partially covering the os - Bleeding will occur - Not safe to deliver vaginally because placenta will tear open and hemorrhage before baby is delivered - **Complete** - Completely covering the cervix - Blood vessels will start bleeding from the placenta - Blood is bright red - Woman can quickly bleed out - First time women will bleed from a previa will be in the second trimester - **Painless** - [Has **BRIGHT RED BLOOD**] - **[DO NOT]** do a sterile vaginal exam - **Instead do an ultrasound and locate where the placenta is!!** - **Women with a previa cannot deliver vaginally** A diagram of a baby in womb Description automatically generated  - **Placenta detaches prior to birth** - **It is [separated off the wall of the uterus]** - **Has DARK RED BLOOD** - Noted when patient has: - **Painful contractions** - **Abdomen is rigid, gets hard,** doesn't relax between contractions - **[Very painful!!!]** A diagram of a baby in a womb Description automatically generated - **Hyperemesis gravidarum:** Persistent projectile vomiting, weight loss greater than **5% of prepregnancy weight,** and electrolyte imbalance!! - Patient's are very sick. It can go throughout the entire pregnancy. - Must go to hospital to get treated - Get her hydrated - **NPO initially** - Once stabilized with meds, could get **[Ondansetron (zofran), Metoclopramide (reglan)]** - **[Start on small frequent meals]** - **[Separate liquids and solids. Don't take it at the same time!]** - **[Ginger]** recommended - **Chronic HTN**: before pregnancy or first 20 weeks gestation **[(treat if \>140/90 - meds), no proteinuria]** - **Gestational HTN: after [20 weeks gestation]**, **[no proteinuria]**, [**BP \>140/90** (2 occasions / 6 hours apart)] - **Pre-eclampsia: [20 weeks gestation WITH proteinuria]** (multisystem vasopressive disorder that targets CV, hepatic, renal, and CNS) - **Mild: BP \>140/90 but less than 160/100** with **1+ or 2+ proteinuria, edema, headaches** - **Severe: BP \>160/110** with **3+ or 4+ proteinuria** with severe features, HELLP sydrome - **Chronic HTN** patient may become pre-eclamptic with superimposed preeclampsia - **[Eclampsia: seizure with preeclampsia]** - **Mild Preeclampsia** - **BP 140/90 to 160/100** - Proteinuria 1+ or 2+ ; indication of KD damage - **Dependent edema:** specific to parts of the body that that are influenced by gravity, such as your legs, feet, or arms - Also referred to as "preeclampsia without severe features" - Transient headache (that comes and goes) - **Severe Preeclampsia; [SEVERE]** or **"preeclampsia with severe features"**: **greater than 160/110** + - **BP \>160/110** - **with 3+/4+ proteinuria = kidney failing ;**Also referred to as "preeclampsia with severe features" - **vision changes - mother can complain of blurry vision** - **[heightened reflexes (check Deep Tendon Reflex)- hyperreflexia ]** - **HEADACHE** - CLONUS - muscle contraction - SEIZURES - vasospasms and vasoconstriction, dizziness - **EPIGASTRIC PAIN (ask for pain underneath the rib [RUQ]) = can be damage to liver/ kidney problems [(HELLP CRISIS)]** - Needs to be hospitalized - **SEVERE FEATURES IN DIAGRAM**, damage to end organs - **Priority to deliver if over 34 weeks**  - **Many theories in reference to cause - Risk factors** - **Blood vessels of placenta do not develop or function correctly, abnormality of placenta, insufficient blood flow** - **IUGR (Intrauterine Growth Restriction) occur!!!** - **Vasospasms** that cause decreased blood flow, cardiovascular, hepatic, renal, and CNS - **[Occurs in 15% of pregnancies]** - **Preeclampsia triad ("PRE"):** - **P**roteinuria - **R**ising BP - Dependent **E**dema A poster with text and images Description automatically generated  A diagram of protein sources Description automatically generated with medium confidence  - What is the Difference between chronic HTN and gestational HTN??: - First 20 weeks if you have high BP will be chronic - 20-40 weeks will be considered gestational - What is Difference between gestational HTN and preeclampsia - Both start after 20 weeks - Gestational HTN does not have protein in the urine - Preeclampsia HAS protein in the urine - Difference between mild and severe preeclampsia - \*look above\^\^\* - **[Elements of physical exam that would be included in assessment of a patient with preeclampsia:]** - 24 hour urine collection - protein, creatine - Series of blood tests - Blood pressure - must lower to 140/90 - **Instruct them to do daily kick counts, daily weight, (3 kicks in one hour, you don\'t feel kicks within 12 hour call provider)** - **Low sodium diet, 6-8 glasses of water, frequent rest periods** - Pre-eclamptic profile - everything. - **Pharmacology of [Magnesium sulfate]** [(MgSO4) - anticonvulsants ] - **Prevents seizures!** - over 160/100 - **Anticonvulsant**, smooth muscle relaxer - [IV - close to mainline bc when it discontinue, just pull out and main line flushing ] - Administer per infusion control device - pt. feel hot, sleepy. - **First 4-8 g bolus about 30 mins - 2-4 g maintain** - [Therapeutic range: **4-7 mEq/L**] - **[Hypertensive drugs: Labetalol, Hydralazine, Nifedipine(calcium channel blocker), Methyldopa (Aldmet) ]** - **[Magnesium sulfate Toxicity:] absence of patellar DTRs**, **U/O \ - Nursing care for a patient on **magnesium sulfate**: - Stabilize mother and prepare for delivery - until 37 weeks and then induce before 39 weeks - unstable preeclampsia - before 34 week - delivery - If mom has preeclampsia in early gestational week, - problem - Oxytocin to stimulate contractions- iv pump with oxytocin - [Magnesium sulfate to prevent seizures] - Vaginal birth is preferred, if patient is stable, c-section is possible bc baby come out quickly. - Monitor patient for magnesium toxicity - you know. - Hematological conditions coexist with severe preeclampsia involving hepatic dysfunction - **Hemolysis, elevated liver enzymes, low platelet count** - Laboratory specific diagnosis - Aggressive multidisciplinary management - Two types of blood incompatibility: **ABO incompatibility and Rh incompatibility** - **Who is at risk**: - Rh negative mom with Rh positive fetus will be incompatible - Type O mom will be incompatible with type A, B, or AB fetus **- Jaundice occur in baby.** - **Isoimmunization:** development of antibodies by exposure to antigens - - [**Rhogam** is given during pregnancy. It is an immunoglobulin. It will bind to antibodies that were created by mixing the blood and make it invisible to the mother\'s body. Makes antigen disappear basically] - **[When??]** A diagram of a person\'s body Description automatically generated - **Diabetes Mellitus: Understand pathophysiology and how it relates to pregnancy** - **[Pregestational Diabetes Mellitus:]** more serious than gestational 10% in diabetic patients, higher risk of congenital malformations and miscarriages - **Counseling**: a woman who has diabetes and wants to get pregnant should get a **[preconception visit]** for counseling and to check at a **[glycemic level of lower than a 6.5 (Over 6.5? May cause anomalies/ stillbirth)]** - **Maternal risks and complications:** kidney damage, cardiovascular, neuropathy, retinopathy, predisposed to **[preeclampsia, large baby = c section]** - **Fetal risks and complications:** miscarriage, stillbirth, congenital anomolies, **lungs don't mature as fast**, moms with already cardiovascular problems may have smaller baby - **Care management: amniocentesis (14-27weeks),**good glycemic control with insulin and metformin - **[Gestational Diabetes Mellitus:]** more common happens in 90% in diabetic patients, check at 24-28 weeks because placenta has insulin resistant hormones - These hormones prevent mom from utilizing all her glucose so mom can save glucose for baby, **MOM NEEDS 3X MORE INSULIN TO HELP HERSELF** - **Fetal risks:** fetal growth restriction such as **shoulder dystocia** due to cardiovascular problems of mom, **preeclampsia, c section, preterm births, lung underdevelopment** - **Screening vs. diagnosis:** 1. 1 hr GTT not fasting (if higher level than 140, will need 3 hour GTT) 2. 3 hour GTT fasting **(draw blood each hour, if 2 of tests are abnormal she has GD)** - **Care management:** 50% of woman with gestational diabetes will become type 2 diabetics, daily checks on glucose levels for 2 weeks to see if can manage with diet and exercise; if not, insulin, higher change of obesity - *Review Ricci Text Table 20.2* - 1/3rd trimester: less than 11 hemoglobin = anemia; 2nd: less than 10.5= anemia (peak of hemodilution) - **[Physiological anemia]:** normal response due to [**hemodilution**:] greater plasma, H&H low - **[Pathological Anemia:]** there is a medical reason, disease process due to **iron deficiency**, low **ferritin** (cells that store iron) levels - **[See "Teaching Guidelines", 20.3]** - Take your prenatal vitamin daily; if you miss a dose, take it as soon as you remember. - For best absorption, take iron supplements between meals and with vitamin C. - Be aware of the side effects of iron supplementation. - Avoid taking iron supplements with coffee, tea, chocolate, and high-fiber foods. - Eat foods rich in iron, such as: - Meats, green leafy vegetables, legumes, dried fruits, whole grains - Peanut butter, bean dip, whole-wheat fortified breads and cereals - For best iron absorption from foods, consume the food along with a food high in vitamin C. - Increase your exercise, fluids, and high-fiber foods to reduce constipation. - Plan frequent rest periods during the day. - **Nutritional counseling for anemia** - Both anemias, will put on **ferrous sulfate supplements** and green leafy veg/ red meat/ iron tablets with empty stomach with orange juice - NO coffee/tea/ chocolate affects absorption - Iron may cause **[constipation]** so drink lots of water - First and third trimester: - If hemoglobin is **less than 11**, diagnosed with anemia - Second semester (peak time of hemodilution) - If hemoglobin is **less than 10.5**, then diagnosed with anemia - Amniotic fluid imbalances: low or high - **1) Hydramnios:** - When it is [high] - Associated with **diabetes** and **birth defects** - Baby is more likely to be in **breech position** because of high volume of baby to float around - **High risk of cord prolapse** because of a lot of fluid and pressure. - **Greater than 2000 mL** - **2) Oligohydramnios:** - **Less than 500 mL** - Problem with perfusion - Caused by **HTN**, **elevated blood sugars**, **birth defects**, **kidney issues** - [**3) PROM:** premature rupture of membranes (After 37 weeks)] - [**4) PPROM:** preterm premature rupture of membranes (before 37 weeks)] - Complications: - **Infection** - **Cord prolapse** - **Preterm labor -** - **Causes:** - [Low BMI -MOM] - [Multiple gestation] - [Tobacco smoking] - [History of preterm labor] - [Placenta Previa] - [Placenta Abruption] - [UTIs] - [Vaginal infections] - [Vaginal bleeding] - [**TORCH** infections] - [**T**oxoplasmosis] - Infection from gardening, cleaning pet feces, or eating undercooked meat - Make sure they have gloves when gardening or cleaning feces, Don\'t clean cat litter. - [**O**ther] - Varicella, GBS, hepatitis, HIV, syphilis, mumps - We check prenatally through **[titers]** - Group B strep, antibiotics will be given at birth (37 to 38 week-take antibiotics) - [**R**ubella] **- baby has hearing loss, cardiac issue, dead** - Teratogen - Rubella titer, if she is not immune she gets it after delivery because it is a [live vaccine] **(TDAP and flu are okay)** -   - [**C**ytomegalovirus ] - CMV is most common - most common droplet infection - [**H**erpes simplex virus] - oral, genital area -- Immediate c-section. - HSV1, HSV2 - do not want active herpes in labor or she will need a C section, touch lesions - Active herpes? Need c section - Herpes lesions could infect baby - Transmission, incidence, and risks to fetus/newborn for each - Review screening/treatment practices for Group B Strep (CDC guidelines) - She needs antibiotics if vaginally FIRST LINE DRUG: penicillin G Q4h - if she goes into **preterm labor we will do cultures and give antibiotics prophylactically** - if + in pregancy before she will automatically get it to prevent **sepsis** of baby - Leads to gestational diabetes - **Risks:** difficulty fighting **infection**, hypertension, **postpartum hemorrhage**, increase stillbirth, **c section increase**, maternal mortality increase, postpartum hemorrhage increase, higher risk of stillbirth, larger baby due to high glucose from mom - **Dystocia** - **Preterm labor** - **Postterm (prolonged) pregnancy** - **Induction and augmentation of labor** - **Cesarean birth and VBAC** - **Obstetric emergencies** - **OB procedures** - **Dystocia:** Abnormal or difficult labor - **8-11 % of labors** - The things that put a patient at **high risk** for dystocia are problems with the 5 P's - Problems with **powers, passenger, passageway, psyche, and position** - **[Hypertonic uterine dysfunction]** - Uterus **[never fully relaxes]** between contractions - Contractions are poorly coordinated - **[Latent phase]** (0-3 cm) - **Treatment:** - **Sedative** to relax uterus - \~4-6 hours, normal uterine contractions will begin again - **[Hypotonic uterine dysfunction]** - **Active phase** of labor - Contractions become poor in quality - Lacks in sufficient intensity to dilate cervix - 0-3 centimeter dilation. - Frequency and intensity of contractions started out normal → now it decreased - **Factors:** - **overstretching uterus from large fetus, or** - **multiple fetuses,** - **Hydramnios- amniotic fluid to high** - **bowel or bladder distention** - **Treatment:** - Find out cause and correct it - Begin **oxytocin** to help stimulate effective uterine contraction - **[Precipitous labor]** - Labor that is completed in [less than 3 hours] - **Very painful for patient** - **Hypoxia to baby late deceleration** - **Contractions are high intensity** - Posterior presentation - **[LOP]** or **[ROP]** - Causes **labor dystocia** - Breech - Shoulder dystocia - Multifetal pregnancy - **Macrosomia (big baby)** - More than **4000-4500 g** - **Diabetic mom** - **Shoulder dystocia** - When the baby's shoulders are wedged behind the mother's pubic bone - **["Turtle sign"]:** when you see head come out, then it goes back in - Emergency situation!!! - **Risks:** - Vaginal operative delivery [(vacuum or forceps)] - Baby can have a lot of bruising, broken clavicle - **[Managements:]** - [**McRoberts maneuver**:] mother's legs are flexed and abducted as much as possible - straight out the pelvic curve! - **Suprapubic pressure**: light pressure is applied above the pubic bone and pushing the fetal anterior shoulder downward - **Empty bladder - why? haha**  - **Suprapubic pressure**: A diagram of a baby in an uterus Description automatically generated - Maternal age 35 and older - No heavy lifting - Rest throughout the day - **Low back ache** - **Pelvic pressure** - **Cramping** - **Contracting** - **Pelvic pressure** - **Vaginal discharge** - **Leaking fluids** - Smoking cessation - Stress management - **fFN** (Fetal Fibronectin) : glycoprotein - Fetal fibronectin (fFN) is used to test pregnant women who are between 22 weeks and 35 weeks of pregnancy and are having symptoms of premature labor. The test helps predict the likelihood of premature delivery within the next 7-14 days. - **Cervical length measurements** - 3 centimeter or more: indicated delivery within 14 days - Tara has received **tocolytic therapy** with **MGSO4** during admission to hospital. She is discharged to home care. - **PTL is a huge cause of infant mortality and morbidity** - Definition: **Regular uterine contraction with cervical dilation and effacement between 20-37 week gestation** - **[Subtle signs:]** - **Low back ache** - **Pelvic pressure** - **Cramping** - Labs and diagnostic testing: (p.764) - **Fetal fibronectin test** (fFN) to predict the likelihood of premature delivery within the next 2 weeks. glycoprotein - Fetal fibronectin (fFN) is used to test pregnant women who are between 22 weeks and 35 weeks of pregnancy and are having symptoms of premature labor. The test helps predict the likelihood of premature delivery within the next 7-14 days. The test is a useful marker for impending membrane rupture within 7 to 14 days if the level increases to more than 0.05 mcg/mL. - **Cervical length measurements** - **CBC** - **Urinalysis - make sure the pt. UTI present** - **Amniotic fluid analysis** - determine fetal lung maturity - **Risk factor (Box 21.2)** - **Treatment: [tocolytic therapy (see drug guide 12.1) ]** - [**Magnesium sulfate**: ] - Relaxes uterine muscles to stop irritability and contracting - **[Terbutaline]** - b2 receptor agonist - Delays preterm labor - Black box warning!! - [**Nifedipine (Calcium channel blocker)**:] - Ca Channel blocker - Inhibits uterine activity - **[Indomethacin (Indocin)] - NSAIDs** - [inhibit prostaglandin cascade] - Causes the arrest of preterm labor - Cannot be used after 32 weeks!! - **[Beta/Dexamethasone] - Know role of corticosteroids** - Helps develop fetal lungs - **inject to mother.** - Two doses, take it 24 hours apart - IM - Given to mother but will benefit the baby - **Stimulates surfactant production - Lung** - **Patient education is key!!!** - [Risks] for PTL (Box 21.2) - African american - Age younger than 16, older than 40 - **[Low socioeconomic status]** - Alcohol and drugs - Cigarette smoking - Signs and symptoms: - Uterine contractions - Cramping - Low back pain - Pelvic pressure - Feeling of fullness - N/V - Leaking of fluids - Teaching to prevent PTL (Box 21.1 Teaching Guidelines): - Avoid heavy physical work - Do not travel long distances where you are sitting for long periods of time - train, airplane - Tests to be ordered: - FFN- fetal-fibronectin - Cervical length measurements - Transvaginal ultrasounds - Promotion of fetal lung maturity is vital!! **- that is number one goal!!!!!** - **Antenatal glucocorticoids: (the best 48 hours administration??)** - NIH recommends for all women at risk for preterm - **Betamethasone** - **Dexamethasone** - Bigger gauge needle, **Give IM** into a large muscle - **ventral gluteal or vastus lateralis**; not into the deltoid! The liquid is thick  What is the Vastus Lateralis Muscle? - Orchard Health Clinic - Osteopathy, Physiotherapy and Chiropractic - **Prolonged pregnancy:** When the pregnancy continues **[past 42 weeks gestation]** - We do not know the exact reason why patient does not go into labor - We think that there\'s a deficiency of **estrogen and a continued secretion of progesterone and inhibits uterus from contracting** - **[Risks for mom:]** - [C/S: c-section] - **[Postpartum hemorrhage]** - **[Infection]** - [Vaginal operative delivery (because of a larger baby - **Macrosomia**) - increase possibility use vacuum or forceps ] - **[Risk for baby:]** - Macrosomia (over 4000-4500 g (9-10 lbs) ) - Shoulder dystocia - Brachial plexus injury - **[Meconium aspiration ]** - **[Placenta:]** - **Perfusion decreases** - Amniotic fluid also decreases after 38 weeks - Not holding up as it should - the placenta shuts down - no more O2 to baby - **Jennifer is a 21 y/o G1P0 at 41 2/7 weeks gestation. She is coming to the hospital for evaluation. What nursing assessments are important in this case?** - **We want to know EDB, Daily fetal movement count, nonstress test 2times a week, weekly cervical exam.** - Assessments: - NST - EDC - Daily fetal movement counts - Cervical exams - **Why is it important to monitor this pregnancy more frequently until delivery?** - **Perfusion decreases** - Amniotic fluid also decreases after 38 weeks  - Very important to monitor prolonged pregnancy more until delivery because of the placenta not functioning as it should and also because amniotic fluid decreases - **[Induction of Labor (IOL)]** - Stimulation of uterine contractions by medical and surgical needs before the onset of spontaneous labor - Assess woman first to see if she is eligible for IOL - Use **Bishop's score** (done by **SVE**) - **Should have a score of 8 or greater - ripen of cervix** - Start with **oxytocin** - **Cervical ripening: different methods of ripening (P.768-769)** - Medications: soften and dilate cervix - **[dinoprostone (cervidil)]** - **Surgical method**: inserts a **cervical hook** through cervical os to rupture membranes - **Mechanical method:** application of **local pressure that stimulates release of prostaglandins to ripen cervix**; involves a balloon thingy - **[Cook cervical ripening balloon - very uncomfortable to pt., risk of increasing maternal infection.]**  - **[Augmentation of Labor]** - **When already in labor** - We want to stimulate uterus to enhance contractions when labor has already begun - **Under 6, ripen cervix first and then induce** A table with numbers and text Description automatically generated - Administration of **[oxytocin]** - Close monitoring - **Make sure she is getting a rest in between contractions** - **Contractions better not last more than 90 seconds** - Proper titration of meds - start lowest dose and increase dose. - Frequency of BP and pulse monitoring - Whenever oxytocin is increased - When dosage has been stabilized - Side effects: - Contractions can last too long - **[Watch fetal HR on monitor - very important to monitor deceleration.]** - **[Resuscitation nursing actions:]** - Turn off the **oxytocin** - Position on the side - Supplemental oxygen 10 L via mask - Bolus with LR (final exam- steps) - Medication to relax the uterus: **tocolytics** If needed - **[Closely monitor baby]** - **How and when is AROM performed?** - AROM occurs when we use the **amnio hook** - **Indications for AROM** - It is performed when the baby's presenting part is below the **ischial spines** (in the +'s) - **[Nursing considerations]** - We do it because labor is close - **We also need to put an internal fetal monitor** - **[Concern → cord prolapse]**  - **[Considerations:]** - **Check FHR - No. 1 main thing you need to check** - **Check odor and color** - **Anesthesia** - **Indications** - **Scheduled cesarean birth** - **Unplanned cesarean birth** - **Prenatal preparation** - **Intraoperative care** - **Immediate postoperative period** - **Postoperative and postpartum care** - **What is it? - C/S:** Surgical birth - **Why do we do it?** - **Indications:** - Large baby - Shoulder dystocia - **Fetal pelvic disproportion** - Baby is breech - **Fetal distress** - **[Two incisions (p.782)]** - [**Classic** (vertical through skin)] - This would be for emergencies - [**Low transverse incision** ("bikini cut")] - Most widely done - Classic or low transverse incision (see Figure 21.8, p. 782) - Major surgical procedure with accompanying risks A close-up of a person\'s buttocks Description automatically generated  - **[Antibiotics]** - One dose in the OR prophylactically - **[Considerations:]** - Make sure she is not bleeding - Check fundus - Check dressing - Let her cough and deep breathe - Manage pain - **SCDs (A Sequential Compression Device) - Prevention of DVT - at picu - ambulation asap.** Close-up of a surgical operation Description automatically generated - Also called **TOLAC: Trial of labor after cesarean** - VBAC can be done under certain conditions - **[Risks:]** - **[Uterine rupture]** - [**Contraindicated** if you have the classic uterine incision **(vertical incision)**] - "Once a cesarean, always a cesarean" is no longer the rule - Who can attempt a VBAC? - Support of health care provider, partner is essential. - Reduction in cesarean rate is a goal at many institutions - VBAC classes are offered at many hospitals - Challenge: See if you can find out the c-section rate at your clinical site! - What are some nursing diagnoses for preoperative, intraoperative and postoperative for a woman undergoing a c-section? - Write at least one nursing intervention for each nursing diagnosis - Hint: Think about what you have seen the nurses do during a c-section. 1. **Cord prolapse (p.787)** - **Cord enters vagina before birth of infant** - **More common with AROM** - **Common with breech presentation** - **Prepare for emergency cesarean delivery** - **Really important because could prevent the baby from getting oxygen: Apply upward digital pressure on the presenting part** 1. **Placenta previa** - **This is a condition that puts a pregnant woman at risk for complications** - **Diagnosis - ultrasound** - **What is the best way to manage this risk?** 1. Painless, **bright red bleeding** 2. Puts a pregnant woman at risk for complications 3. Diagnosed per ultrasound 1. **Managed by bedrest** 1. Monitor per doctor's order 2. 2nd or 3rd trimester 1. **Placenta abruption** 1. Painful, **dark red blood** 2. Abdomen area is boardlike, rigid, extreme pain and decelerating 1. **Manage by immediate C/S** 2. **Due to trauma** 1. **Uterine rupture** 1. **S/S: pain** 1. Managed by **C/S - C/S needs before the rupture.** 2. **Uterine needs repair first.** 1. **[Amniotic fluid embolism]** - **[Occurs in 1/40,000 - 1/60,000]** - **[Sudden cardiac respiratory collapse- (FULL CODE) ]** - **Causes: Uterine rupture or placenta abruption? Unknown** - **High mortality rate!!! - most of people get neurological damage** - **Management: C/S if baby is still in her, ventilating mom** - **Cord enters vagina before birth of the infant** - More common with **[AROM]** - Common with [breech] presentation - **[Prepare for emergency C/S]** - [Call for help] - [Do not leave the patient] - [Have sterile glove and hold presenting part until delivery] - **[Amnioinfusion (p.790)]** - Warmed sterile NS or LR is introduced into the uterus transcervically to increase volume of fluid when **oligohydramnios is present** - [Indications:] - **[Meconium]** - **[Oligohydramnios]** - [Resolving **variable decelerations (cord compression)**] - [Management: ] - Informed consent - Vitals - Vaginal exam before doing it - **[Contraindicated when there is vaginal bleeding or cord prolapse or infection in uterus ]** - **Forceps and Vacuum Delivery (P.791)** - [Indications: ] - **[Prolonged second stage of labor]** - **[Distressed full fetal heart rate pattern]** - **Risks:** - Neonatal injury - **[Cephalohematoma ]** - Intracranial bleeding - Vacuum -- only 3 tries - [Forceps ] - **[Outlet forceps]** - baby crowned already - Can cause bleeding  - **[Low Forceps]** - baby crowning yet A diagram of a baby in a womb Description automatically generated