MCN-MIDTERM-Trans-Intrapartal-Complications.pdf

INTRAPARTUM COMPLICATIONS OUTLINE I Intrapartum Complications II Problems of the Passenger III Problems with the Passageway IV Problems of Powers V Psychological Responses...

INTRAPARTUM COMPLICATIONS OUTLINE I Intrapartum Complications II Problems of the Passenger III Problems with the Passageway IV Problems of Powers V Psychological Responses During Labor VI Conditions related to Complications of Labor Process VII Operative Obstetrics INTRAPARTUM COMPLICATIONS high-risk factors related to: o passenger – fetus, other related structures o passageway – pelvic bones and other pelvic pathophysiology: compression of the cord results in structures the compromise or cessation of fetoplacental perfusion o powers – uterine contractions o cord may be protruding from the vagina o clients’ psyche – psychological state o cord may be palpated in vaginal canal or cervix PROBLEMS OF THE PASSENGER o fetal distress may occur as the cord is compressed between the presenting part and the FETAL MALPRESENTATION / FETAL MALPOSITION bony prominence UMBILICAL CORD PROLAPSED assessment findings o FHR pattern may show variable decelerations with contractions or between contractions o fetal bradycardia is present o if the cord is exposed to the cold air, there may be reflex constriction of the umbilical vessels (restricts O2 flow to fetus) nursing / medical management cord prolapse – descent of the umbilical cord into the vagina ahead of the fetal presenting part with resulting compression of the cord between the presenting part and maternal pelvis an emergency situation therefore, immediate delivery will be attempted to save the fetus occurs in 1 of 200 pregnancies o C all for help occurs frequently in prematurity o O rganize delivery o R elieve pressure on the cord rupture of membranes with the fetal presenting part o D eliver unengaged shoulder or footling breech presentations o assess a laboring client often if the fetus is may follow rupture of the amniotic membranes due to preterm or small for gestational age, if the fetal the fluid rush that may carry the cord along toward the presenting part is not engaged, and if the birth canal membranes are ruptured o periodically evaluate FHR, especially right after Two Types of Cord Prolapse rupture of membranes (spontaneous or surgical), Overt Prolapse Occult Prolapse and again in 5 to 10 minutes umbilical cord ahead umbilical cord alongside o if prolapse cord is identified, notify the physician presentation of fetal presenting part fetal presenting part and prepare for emergency cesarean birth physical seen or palpated as cord is not visible or exam soft pulsating mass palpable o if the client is fully dilated, the most emergent unexplained fetal heart delivery route may be vaginal. in this case, rate abnormalities esp encourage the client to push and assist with the heart rate * fetal bradycardia delivery as follows after sudden membrane monitoring * decelerations rupture and presence of ▪ lower the head of the bed and elevate the risk factors client’s hips on a pillow or place the client in the knee-chest position to minimize pressure from the cord ▪ assess cord pulsations constantly Trans by Sofia Danielle Tabelon – N1  INTRAPARTUM COMPLICATIONS ▪ gently wrap gauze soaked in sterile normal diagnosis saline solution around the prolapsed cord o radiologic pelvimetry x-rays or CT scans are taken of the pelvis in different angles and views FETAL DISTRESS and the pelvic diameter measured described as fetal hypoxia that may result in fetal o ultrasound estimation of the baby’s size can be damage/death if not reversed or the fetus delivered made by ultrasonogram immediately nursing interventions etiology: decreased fetal movement felt by the mother o monitor heart sounds and uterine contractions signs and symptoms continuously, if possible, during trial labor o urge the woman to void every 2 hours o increased or decreased fetal heart rate o assess FHR carefully (tachycardia and bradycardia) especially during and after a contraction, decreased variability in o establish a therapeutic relationship, conveying the fetal heart rate empathy and unconditional positive regard protects the fetus and fetal membranes from o anormal fetal heart rate (160 bpm) infection o amniotic fluid is contaminated by meconium o instruct in methods to conserve energy Fetal Distress Etiology o massage bony prominences gently and change Maternal Fetal position on bed in a regular schedule o convey confidence in clients ability to cope with cord compression current situation poor placental perfusion oligohydramnios hypovolemia entanglement PROBLEMS WITH THE POWERS hypotension prolapse DYSTOCIA / DYSFUNCTIONAL LABOR myometrial hypertonus pre-existing hypoxia or growth prolonged labor retardation excess oxytocin infection cardiac problems nursing / medical management o let the mother assume left side lying position o administer oxygen by mask o perform vaginal examination to check for prolapsed cord increase in size and firmness o administer oxygen by mask o carry out doctor’s orders for preoperative routines o monitor fetal heart tones (continuous fetal monitoring ) dysfunctional labor is a difficult, painful, prolonged o vaginal examination to check for prolapsed cord labor due to mechanical factor o rule out imminent vaginal delivery etiology o initiate preoperative routines o fetal factors (passenger) – unusually large PROBLEMS WITH THE PASSAGEWAY fetus, fetal anomaly, malpresentation, and malposition hard passage – pelvis o uterine factors (power) – hypotonic, hypertonic, soft passage – cervix, vagina precipitous, or prolonged labor o pelvic factors (passageway) – inlet contracture, CEPHALOPELVIC DISPROPORTION midpelvis contracture, outlet contracture o pysche factors – maternal anxiety and fear and lack of preparation pathophysiology: uterine contractions are ineffective secondary to muscle fatigue or overstretching assessment findings: clinical manifestations include irregular uterine contractions and ineffective uterine contractions in terms of contractile strength and duration nursing management o optimize uterine activity ▪ monitor uterine contractions for dysfunctional patterns; use palpation and an electronic implies disproportion between the head of the baby monitor (cephalous) and the mother’s pelvis o prevent unnecessary fatigue. check the client’s complications can occur if the fetal head is too large to level of fatigue and ability to cope with pain pass through the mother’s pelvis or birth canal o prevent complications of labor for the client and common cause of different complications in labor infant frequently diagnosed indication of cesarian sections Trans by Sofia Danielle Tabelon – N1  INTRAPARTUM COMPLICATIONS ▪ assess urinary bladder; catheterize as needed ▪ assess maternal vital signs, including temperature, pulse, respiratory rates, and blood pressure ▪ check maternal urine for acetone (an indication of dehydration and exhaustion) ▪ assess condition of fetus by monitoring FHR, fetal activity, and color of amniotic fluid o provide physical and emotional support ▪ promote relaxation through bathing and keeping the client and bed clean, back rubs, frequent position changes (side-lying position), walking (if indicated), and by assessment findings keeping the environment quiet o birth process may seem unnecessarily prolonged ▪ coach the client in breathing and relaxation o turtle sign – fetal head retracts against the techniques mother’s perineum as soon as the head is o provide client and family education delivered o external rotation does not occur SHOULDER DYSTOCIA nursing management in shoulder dystocia, the anterior shoulder of the baby is unable to pass under the maternal pubic arch o place the client in the McRobert’s Maneuver during vaginal delivery, when fetal shoulders become (i.e., thighs pulled up against the abdomen with lodged behind mother’s pubic bone hips abducted). the woman flexes her thighs sharply against her abdomen, which straightens the pelvic curve. A supported squat has a similar effect and adds gravity to her pushing efforts. o apply suprapubic pressure by an assistant pushes the fetal anterior shoulder downward to displace it from above the mother’s symphysis pubis. fundal pressure should not be used, because it will push the anterior shoulder more firmly against the mother’s symphysis o Rubin or Woods screw – delivering the anterior shoulder by placing in a hand by rotation o Gaskin’s maneuver – the mother moves onto her hands and knees so that gravity can help pathophysiology: the plane of the fetal shoulders release the baby's posterior arm aligns perpendicular to the pubis instead of at an angle; causes shoulder to be wedged under the pubic arch *proceed to CS delivery if all maneuvers are not working Trans by Sofia Danielle Tabelon – N1  INTRAPARTUM COMPLICATIONS UTERINE RUPTURE o if the client has signs of possible uterine rupture, vaginal delivery is generally not attempted spontaneous or traumatic rupture of the uterus o if symptoms are not severe, an emergency etiology cesarean delivery may be attempted and the may be caused by injury from obstetric instruments such uterine tear repaired as uterine sound or curette used in abortion o if symptoms are severe, emergency laparotomy is may result from obstetric intervention, such as excessive performed to attempt immediate delivery of the fundal pressure, forceps delivery, violent bearing -down, fetus and hen establish homeostasis. tumultuous labor and fetal shoulder dystocia implement the following preparations for surgery spontaneous uterine rupture is most likely to occur after o monitor maternal blood pressure, pulse, and previous uterine surgery, grand multiparity combined respirations; also monitor fetal heart tones. with the use of oxytocic agents, cephalopelvic o if the client has a central venous pressure disproportion, malpresentation, or hydrocephalus. catheter in place, monitor pressure to evaluate blood loss and effects of fluid and blood assessment replacement rupture of the scar from a previous cesarean delivery or o insert a urinary catheter for precise hysterectomy determinations of fluid balance prolonged or obstructed labor (shoulder dystocia) o obtain blood to assess possible acidosis forceps delivery of fetus with abnormalities o administer oxygen, and maintain a patent airway. (hydrocephalus) prevent and manage complications. take these steps application of forceps and extraction before cervical os in order to prevent or limit hypovolemic shock has completely dilated o oxygenate by providing 8 to 10 L/min using a injudicious use of oxytocin closed mask excessive manual pressure applied to the fundus during o restore circulating volume using one or more IV delivery lines violent, bearing down o evaluate the cause, response to therapy, and TWO TYPES OF UTERINE RUPTURE fetal condition o remedy the problem by preparing the client for complete uterine rupture surgery and administering antibiotics. o clinical manifestations vary from mild to severe, provide physical and emotional support depending on the site and extent of the rupture, o provide support for the client’s partner and family degree of extrusion of the uterine contents, and members once surgery has begun intraperitoneal evidence or absence of spilled o inform the partner and family how they will amniotic fluid and blood receive information about the mother and incomplete uterine rupture newborn and where to wait. o develops over a period of hours UTERINE INVERSION Types of Uterine Rupture the uterus turns completely or partially inside out; it Complete Incomplete occurs immediately following delivery of the placenta or sudden sharp abdominal abdominal pain during in the immediate postpartum period pain during contractions contractions TWO TYPES OF UTERINE INVERSION abdominal tenderness contractions continue, but cessation of contractions cervix fail to dilate forced inversion bleeding into the abdominal vaginal bleeding may be o caused by excessive pulling of the cord or cavity and sometimes into present vigorous manual expression of the placenta or the vagina rising pulse rate and skin clots from an atonic uterus fetus easily palpated; FHT pallor spontaneous inversion cease loss of fetal heart tones o increased abdominal pressure from bearing signs of shock down, coughing, or sudden abdominal muscle - rapid, weak puls - cold, clammy skin contraction - pallor predisposing factors - flaring of nostrils due to o straining after delivery of the placenta air hunger o vigorous kneading of the fundus to expel the nursing management placenta monitor for the possibility of uterine rupture o manual separation and extraction of the placenta o in the presence of predisposing factors, monitor o rapid delivery with multiple gestation, or rapid maternal labor pattern closely for hypertonicity or release of excessive amniotic fluid signs of weakening uterine muscle pathophysiology o recognize signs of impending rupture, o the inverted uterus is unable to restore normal immediately notify the physician, and call for position or contract appropriately assistance. o the woman is placed at increased risk for assist with rapid intervention bleeding and infection Trans by Sofia Danielle Tabelon – N1  INTRAPARTUM COMPLICATIONS assessment findings CONDITIONS RELATED TO COMPLICATIONS OF o excruciating pelvic pain with a sensation of extreme fullness extending into the vagina LABOR PROCESS o extrusion of the inner uterine lining into the vagina PRECIPITOUS LABOR or extending past the vaginal introitus o vaginal bleeding and signs of hypovolemia nursing management o promptly identify and assist with the resolution of uterine inversion o recognize signs of impending inversion, and immediately notify the physician and call for assistance o immediate manual replacement of the uterus at the time of inversion will prevent cervical entrapment of the uterus, if reinversion is not performed immediately, rapid and extreme blood loss may occur, resulting in hypovolemic shock o if manual reinversion is not successful, prepare rapid labor and birth of less than 3- hour duration the client and family for possible general caused by lack of resistance of uterus/ cervix to passage anesthesia and surgery of fetus or intense uterine contractions o take steps in order to prevent or limit hypovolemic hazards to mother shock o perineal laceration and postpartum hemorrhage, o insert a large gauge intravenous catheter for fluid and infection replacement hazards to infants o measure and record maternal vital signs every 5 o anoxia and intracranial hemorrhage to 15 minutes to establish a baseline and document change assessment findings o open an established intravenous line for optimal o rapid cervical dilation fluid replacement o accelerated fetal descent o a fibrinogen level should be drawn to determine o history of rapid labor the risk for formation of a blood clot o rapid uterine contractions with decreased periods o prepare for anesthesia as needed of relaxation between contractions o prepare to administer CPR, if required. Precipitate Labor nursing nursing interventions management (outside hospital setting) PSYCHOLOGICAL RESPONSES DURING LABOR prepare sterile environment note bulging of membranes instruct client to pant when crowning head crowns urge to bear down support infant’s head; apply monitor vital signs slight pressure for control promote fetal oxygenation deliver fetal head in between stop Pitocin induction contractions give oxygen rotate infant externally as IV Fluids head emerges tocolytic drugs as ordered deliver shoulders, then trunk prepare for delivery clear airway and drain mucus remain with mother and dry baby and place on mother monitor closely abdomen keep mother and partner hold placenta as delivered informed throughout wrap baby in blanket and put process of labor and birth to breast support and guide fetal check for bleeding and fundal head through birth canal tone when birth occurs arrange for transport to hospital Trans by Sofia Danielle Tabelon – N1  INTRAPARTUM COMPLICATIONS PRETERM LABOR nursing management preterm labor is labor that begins after 20 weeks’ focus and method: focus of medical treatment is a gestation and before 37 weeks’ gestation prevention of a preterm infant considered to be established if regular contractions can o method depends on the cervical dilation and be documented at least 4 in 20 minutes or 8 in 60 contraction pattern minutes with progressive change in the cervical score in o note: if contractions are detected early and the form of effacement of 80% or more and cervical treatment begun early, there is a higher rate of dilatation >1cm labor stoppage parturition – physiology of labor conservative treatment CAUSES OF PRETERM LABOR o bed rest in left lateral position o hydration with IV therapy and continuous fetal PROM and uterine contraction monitoring preeclampsia o tocolytic therapy not needed if contractions stops hydramnios o discharge planning includes placenta previa ▪ complete bed rest or limited activity abruptio placentae ▪ stress management incompetent cervix ▪ promotion of nutrition Trauma ▪ increased intake to 10 cups/day uterine structural abnormalities ▪ no sexual activity or breast manipulation intrauterine infection (chorioamnionitis) tocolytic therapy congenital adrenal hyperplasia o started if conservative treatment if unsuccessful fetal death o beta-mimetic agents maternal factors such as stress (physical and ▪ ritodrine HCl (Yutopar) emotional), urinary tract infections, and dehydration ▪ terbutaline sulfate (Brethine) ▪ magnesium sulfate (given in smaller doses than in PIH) o steroid therapy ▪ NSAIDs and indomethacin (Indocin) ▪ betamethasone pathophysiology: the uterus begins the process of contraction prior to term gestational age assessment findings: signs of true labor that occur when the gestational age of the fetus is greater than 20 and less than 37 weeks o low back pain o suprapubic pressure / vaginal pressure o rhythmic uterine contractions o cervical dilation and effacement o possible rupture of membranes o expulsion of the cervical mucus plug o bloody show Trans by Sofia Danielle Tabelon – N1  INTRAPARTUM COMPLICATIONS POSTTERM / POSTDATE / PROLONGED LABOR pregnancy that extends beyond 42 weeks’ gestation or 2 weeks’ beyond EDC. Postterm Labor Risks Maternal Fetal decreased amniotic fluid may lead to INDUCTION OF LABOR cord compression during labor the deliberate initiation of labor before spontaneous decreased placental function (aging contractions begin may either be: lowers O2 and nutritional transport), o mechanical (amniotomy) present if infant is fetus may become compromised during excessively large labor (hypoglycemia and asphyxia) o physiologic (ambulation and nipple stimulation) increased size (mainly length) and o chemical (prostaglandins and oxytocin) hardening of skull may contribute to AMNIOTOMY cephalopelvic disproportion artificial rupture of the membranes presenting part of the fetus puts greater pressure on the cervix stronger contractions initiated when the cervix assessment findings is soft, partially effaced, o weight loss and decreased uterine size (when the and slightly dilated when the fetal part is engaged infant is suffering from placental dysfunction) o excessively large uterus STRIPPING THE MEMBRANES o meconium-stained fluid o nonreassuring FHR patterns laboratory and diagnostic study o ultrasound examination to assist in determination of fetal size nursing management o carefully assess the fetus to identify risk o closely monitor fetal status o assist with induction of labor o prepare for a difficult delivery o notify the pediatric staff for birth-injured baby o provide emotional and physical support separating the membranes from the lower uterine segment without rupturing the membranes usually done during vaginal examination membranes and amniotic fluid now act as a wedge to dilate cervix OXYTOCIC (ADMINISTRATION OF OXYTOCIN) used to initiate and sustain uterine contractions given IV piggy back (Pitocin, Syntocinon) maternal and fetal signs and length, intensity, and frequency contractions are monitored carefully and augment labor Trans by Sofia Danielle Tabelon – N1  INTRAPARTUM COMPLICATIONS mechanism of action keep suppository cold and bring it to room temperature in labor before insertion. after insertion, have the client remain in o used for induction of labor dorsal recumbent for 15-30 minutes o stimulates uterine smooth muscle to contract the gel is inserted into the cervical os by catheter 2x for o increases intracellular calcium 6 hours apart after delivery nursing management o acts to stimulate contraction and prevent prepare mother for induction. explain all procedures. hemorrhage as a result of atony obtain consent side effects obtain and record baseline information such as V/S, in labor FHR, contractions for later comparison. continue o maternal: overstimulation of uterus resulting in monitoring all vital indices every 15-30 mins depending rapid labor, delivery; tetany and uterine rupture; onstage of labor and risk status. assess for impending abruptio placenta, water intoxication delivery o fetal: hypoxia, distress, trauma with precipitous monitor oxytocin administration delivery monitor effect of prostaglandin. if hypertonic contractions after delivery occur, discontinue. if it persist, prepare for tocolytic o water intoxication, uterine atony (if overused) therapy nursing management assist with AROM gradually increase drip rate until contractions occur o maintain asepsis every 2-3 minutes o immediately monitor FHR after rupture slow rate if hypotension or tachycardia occurs; keep o note color, amount of amniotic fluid client hydrated o record time of rupture, prolonged rupture may predispose to infection and sepsis record I&O. monitor for water intoxication maintain hydration mix 10 IU oxytocin in 1000mL Ringer’s Lactate and hang “piggy-back” solution provide for blood typing, Rh compatibility, and cross- matching limit IV fluids to 150mL/hour have O2, suction, and resuscitation equipment readily discontinue infusion if contractions exceed 70-90 available seconds, fetal acceleration/decelerations persist, UO