Labor Complications F24 PDF

Dr. Christi L. Camarena, DNP, RNC-OB, C-EFM CSUS School of Nursing, NURS 137  THE FOLLOWING CONTENT IS PROTECTED AND MAY NOT BE SHARED,...

Dr. Christi L. Camarena, DNP, RNC-OB, C-EFM CSUS School of Nursing, NURS 137  THE FOLLOWING CONTENT IS PROTECTED AND MAY NOT BE SHARED, UPLOADED, OR DISTRIBUTED. This PowerPoint Presentation is protected by U.S. copyright law. I am the exclusive owner of the copyright in the course materials that I create. You may not reproduce, distribute, display, post, or upload my course materials or recordings or course materials in any other way — whether or not a fee is charged — without my express written consent. The following Textbook is used throughout this presentation: Maternity and Women’s Health Care, 13th edition. Lowdermilk, Cashion, Alden, Olshansky & Perr., Elsevier Inc., 2024 This Photo by Unknown Author is licensed under CC BY  Objectives: § Explain the care of a woman with post-term pregnancy. § Explain the care of a woman with a dysfunctional labor. § Explain the challenge of caring for obese women during labor and birth. § Discuss obstetric emergencies and their appropriate management. § Discuss the physiologic complications for large for gestational-age (LGA) infants. § Discuss the characteristics of post term and post mature newborns. § Discuss risk factors associated with birth trauma and care management of a newborn experiencing soft-tissue injuries, skeletal injuries, peripheral nervous system injuries, and central nervous system injuries. § Post-term pregnancy (aka “postdates” pregnancy): § Reaches 42 0/7 weeks of gestation or more § Remember… Full-term 39 0/7 to 40 6/7 weeks and Late-term 41 0/7 to 41 6/7 weeks (0.25% of all births are actually post-term) § Maternal risks: → the longer the bigger the baby but not always n waste appearance § Dysfunctional labor (dystocia), perineal injury, hemorrhage, infection, operative birth, C/S The uterus not contract effectively since it design only for certain amount of time to stretch and contracts § Psychologic reactions: fatigue, depression, anxiety, frustration, feelings of inadequacy Stress → hyperglycemia (DM) Monitor for fetal oxygenation since § Fetal risks: More common their kidney will shut down Small gestational age if there is placenta insufficiency d/t expiration date § Risk for SGA, but more likely increased risk for macrosomia, birth injury, decrease placental reserve leading to poor fetal oxygenation, oligohydramnios, cord compression, meconium-stained amniotic fluid, meconium aspiration Risk for § Post-maturity syndrome (of the newborn): → loss the coating to moisturize the skin § Dry, cracked, peeling skin, long nails, meconium-stained skin, nails, umbilical cord, loss of SQ fat and muscle mass → far less common than macrosomia § Care Management: On the exam § Somewhat controversial → most important Note: empower pt when to come in and teach signs of labor § Antepartum testing → wont test on the time since it vary per provider and pt case § At/before 41 0/7 wks § NST, CST, AFI (SDVP), BPP § 1-2x/week until delivery Just know its multifactoral § Self-management § Induction of labor → 3-5 days if -2 and no dilation at 39 wks or longer time so warn the pt § Timing-multi-factorial decision § Favorable cervix @41weeks § Risks vs. benefits § Each intervention carries its own risks!!! § ACOG position 2019 § Care during labor: § Continuous EFM External fetal monitoring § Monitor for sources of fetal hypoxemia: § Placental insufficiency (late decels) § Umbilical cord compression (variable or prolonged decels-consider amnioinfusion*) → d/t the fluid decreasing in the amniotic sac § Dystocia=Lack of progress in labor for any reason → most common in post term labor or macrosomia baby → long but progress in labor § Dysfunctional labor: A long, difficult, or abnormal labor caused by various conditions associated with the following: § The powers: ineffective uterine contractions or maternal pushing efforts § The passage: alterations in the bony pelvic structure or soft-tissue dystocia → either the pelvic tissue or the pelvic floor not align well § The passenger: abnormal fetal presentation, position, congenital anomalies, multiple fetuses § Maternal position and psychologic response → most of the time will be in dystocia if pt not ready to have the baby since they tend to hold them in § Factors are interdependent, may exist alone or in Uterine cuppling = either the baby too big or in a weird position combination with others § Dysfunctional labor is suspected: § Alteration in UC characteristics § Lack of cervical dilation or lack of fetal descent § Care management: review H&P, past labor/birth, current physical & psychologic responses, FHR pattern, UCs, SVE, etc. Sterile vaginal exam § Latent Phase Disorders ( 95 percentile regardless of weeks of gestation § Post-term/post-mature infant: Born to a prolonged pregnancy (≥42 0/7 weeks) § Post-maturity can also be associated with placental insufficiency resulting in dysmaturity (loss of SQ fat and muscle mass), HOWEVER; most post-mature infants are “oversized” (macrosomic) § Post-mature infants: dry, cracked skin, long fingernails, absent vernix, meconium staining of skin, nails and cord, SQ wasting leads to loose skin (“old person” appearance) § Increased likelihood of intrauterine hypoxia d/t insufficient gas exchange w/postmature placenta § Meconium Aspiration Syndrome (MAS) § Approx. 8% of newborns exposed to meconium, but small percentage develop MAS § Can lead to a mechanical obstruction, chemical pneumonitis, tachypnea and deactivation of surfactant § MAS infants can also develop PPHN Short term = can be deadly § PPHN=persistent pulmonary hypertension of the newborn → complication of MAS § Pulmonary hypertension & right to left shunting of blood across the foramen ovale and ductus arteriosus § A combined cardiovascular & respiratory disorder § The lungs are healthy, but the HTN of the cardiovascular system leads to reduced blood flow to the lungs resulting in decreased ventilation and oxygenation. § Can be primary or secondary (i.e., MAS) § Tx: Based on the underlying cause of PPHN, but may include: § Pharmacologic treatment (surfactant), iNO, HFV, ECMO → all you need to know is the baby will need long term oxygen therapy § LGA infants at risk by virtue of size alone, (i.e., hypoglycemia, trauma/birth injuries) but can also have complications of being preterm, term, post-term, post-mature, infants of diabetic mothers, LGA is determined by size, not gestation § The fetus has passed its first stool! § A normal physiologic function of maturity or breech presentation (present in about 10- 15% of births) § Hypoxia-induced peristalsis and sphincter relaxation § Umbilical cord compression induced vagal MEC stimulation HAPPENS! § Meconium Aspiration Syndrome (MAS) in the NB § Most likely from a long-standing intrauterine process, rather than from aspiration with the first breath § Care management § Presence of an interprofessional team skilled in NRP at the birth Neonatal respiration provider (NRP) American academy of pediatric § AAP no longer recommends routine suctioning § Management based on the assessment of NB at birth https://doi.org/10.3390/children8030246 § ET intubation, supplemental O2, surfactant, abx, ECMO  → be able to classify where are these injuries belong to § Birth trauma/injury: Physical injury sustained by the newborn during labor and birth § Nursing role: Observe, document, report, support, and educate § Some birth injuries are avoidable (i.e., antepartum diagnosis of macrosomia, malpresentation, etc.) § Factors that predispose an infant to birth injuries: § Maternal age, primigravida, uterine dysfunction, prolonged or precipitous labor, preterm/post-term labor, CPD, macrosomia, abnormal presentation, congenital anomalies, internal monitoring, forceps or vacuum-assisted birth, and cesarean delivery § Classified according to etiology or anatomically § Soft-tissue injuries (i.e., bruising, lacerations, edema) § Skeletal injuries (i.e., fractures) § Peripheral nervous system injuries (i.e., brachial plexus injury, Erb-Duchenne palsy, facial paralysis) § Central nervous system injuries (i.e., subdural hematoma & subarachonoid hemorrhage) § Care Management: Based on type of injury § Initial & ongoing assessment § Bruising, edema, abrasions → during C/S since baby get knicked § Absence/limitation/asymmetry of movement → suspect CNS injury § Education, support, pain management → Tylenol for baby with clavicle fracture  Search up images to know theses better § Shoulder Dystocia § Prolapsed umbilical cord § Rupture of the uterus or Uterine dehiscence § Amniotic fluid embolus § Head is born, but anterior shoulder cannot pass under the pubic arch § Risk: Macrosomia (>4000g), maternal pelvic abnormalities, McRoberts maneuver maternal diabetes, hx of dystocia, prolonged 2nd stage, increasing caput, “Turtle Sign,” no external rotation § Shoulder dystocia cannot be accurately predicted. § Outcomes: Asphyxia related to the delay in completing the birth or by trauma from the maneuvers used to accomplish the birth. § Most common injuries: Fracture of the humerus or clavicle and unilateral brachial plexus injuries § Care management Pulling the leg straight back = change the pelvic diameter Push pressure on the way the baby facing § McRoberts maneuver, suprapubic pressure, Gaskin maneuver (hands & knees), NO FUNDAL PRESSURE → pretty hard to do if pt has epidural § Stay calm and immediately call for additional assistance, assist & document (time is critical), NB assessment and resuscitation as needed  Most of the time we cause this § Umbilical cord lies below the presenting part of the fetus § Occult or frank → most common when the labor isn't fast enough § Contributing factors: long cord (>100cm), malpresentation, unengaged Too much amniotic fluid presenting part, polyhydramnios, small fetus (i.e., preterm), unengaged presenting part § Care management: § Prompt recognition to prevent prolonged cord compression Vaginal exam → 2 finger lift head and leave pressure off cord § Relieve pressure on cord → vaginal exam § Cesarean birth or operative vaginal delivery if patient is fully dilated § Advocate & Prevent  → quick C/S tho Uterine Rupture or Uterine Dehiscence § Incidence approx. 1% § Care management → no vigina birth after C/S § Prevention (assess risk-type & location of scar): NO PROSTAGLANDINS! → cervical ripening (can use Pitocin) § Risks: Previous C/S or uterine surgery, prior uterine rupture, trauma, abortion, instrumentation injury or uterine perforation; grand multiparity; and uterine overdistension → can occurs spontaneously w/out any risk factors § Recognition: abnormal FHR, loss of fetal station, bright red vaginal bleeding, sudden/sharp abdominal pain, hypovolemic shock Pain break through med or epidural → start ordering blood product § Medical management depends on the severity § Nursing management: § IV fluids, transfuse blood products, oxygen Amniotic fluid embolus (anaphylactoid syndrome of pregnancy) → theses are the pt die suddenly after birth and autopsy can't detect § Sudden, acute onset of hypotension, hypoxia, and hemorrhage caused by On the exam coagulopathy. It is not preventable. It is neither an embolism nor amniotic fluid related. § True incidence is unknown (approx. 1-2 cases per 100,000 births), high maternal/neonatal morbidity & mortality § Maternal age>35 doubles the risk, other risks include rapid labor, mec stained fluid, postterm pregnancy, IOL, operative birth § Occurs during labor, birth or within 30 min. of delivery. Presentation similar to systemic inflammatory response syndrome or anaphylaxis. → will end in respiratory arrest and DIC → pt doing better with Epi given § Care management § Assist with resuscitation: → know s/s and care management for exam (prob 1 question) § Oxygenate § Maintain cardiac output § Replace fluids § Correct coagulopathies § Monitor maternal/fetal status, prepare for emergency birth, provide emotional support to patient, partner & family Birth trauma can have severe effects on nurses, including: Psychological trauma Job performance Leaving the field Increased absenteeism SUMMARY Requests for assignment changes § Post-term pregnancy § Labor Dystocia (The 5 P’s) § Latent vs. Active Phase § Care of clients with BMI>30 § Post-mature & LGA infants § Meconium & Birth Trauma → spend extra time § OB Emergencies Given s/s so be able to identify which emergencies and the priorities § Shoulder Dystocia § Prolapsed Cord § Ruptured Uterus § Amniotic Fluid Embolus