Woman with an intrapartum complication

week 3, chapter 27

What are the dysfunctional problems with the powers

the powers of labor may not be adequate to deliver the fetus because of ineffective contraction or ineffective maternal pushing efforts

Hypotonic Labor Dysfunction

Contractions are coordinated but weak, less frequent, and shorter in duration, typically occurring during the active phase of the first stage of labor (after 4 cm dilation).

• get pt up and moving

Hypertonic Labor Dysfunction

Uncoordinated, irregular contractions that are short and poor in intensity but very painful and cramp-like, with a higher-than-normal resting tone, typically occurring in latent phase (1 stage, 1 phase).

• Promote rest, side-laying position

Ineffective Maternal Pushing can result from:

Inability or failure to push effectively due to incorrect techniques, fear of injury, lack of urge to push (from epidural), exhaustion, or regional block analgesia.

what is reflex urge

the urge to push without contractions, usually happens as the fetus moves towards the pelvic floor during the second-stage of labor

Macrosomia

A large fetus weighing more than 4000 g (8 lb 13 oz), which can cause dysfunctional labor and problems with the passenger.

Baby is positioned left posterior, where is the mom going to feel pain

intense leg or back pain

Shoulder Dystocia

Delayed or difficult birth of the shoulders as they become impacted above the maternal symphysis pubis, often first identified by the turtle sign.

Turtle Sign

A sign of shoulder dystocia where the infant's head is born and then retracts tightly against the perineum like a turtle drawing into its shell.

After delivering a shoulder dystocia baby, what should be assessed

the infants clavicles should be checked for crepitus, deformity, or bruising (each suggest a fracture)

• assess muscle tone/nerve injury to brachial plexus or erbs palsy = if more poor toned on one side, possible nerve injury (typ. resolves in a few weeks)

McRoberts Maneuver

An intervention for shoulder dystocia involving flexing the mother's knees up toward her abdomen to straighten out the pelvic curve.

Suprapubic Pressure

Downward pressure applied just above the pubic bone to dislodge an impacted anterior shoulder during shoulder dystocia (never use fundal pressure).

Gynecoid Pelvis

A round, cylindric pelvic shape with a wide pubic arch (90 degrees or greater) offering the most favorable prognosis for vaginal birth (50% incidence)

Anthropoid Pelvis

A long, narrow oval pelvis where the anteroposterior diameter is longer than the transverse diameter, often resulting in occiput posterior position.

Android Pelvis

A heart- or triangular-shaped pelvic inlet with a narrow arch and narrow diameters throughout, carrying a poor prognosis for vaginal birth.

Platypelloid Pelvis

A flattened, wide, short oval pelvis with a wide transverse diameter but a short anteroposterior diameter, resulting in a poor prognosis for vaginal birth.

Precipitate Labor

A rapid birth that occurs within 3 hours of the onset of labor, risking fetal oxygenation compromise and maternal/fetal birth trauma

what could be the cause of precipitate labor

abrutio placentae, fetal pooped, maternal cocaine use, low APGAR

Intrapartum Infection Signs

can occur in normal and dysfunctional labors

• Persistent fetal tachycardia, maternal temperature >100.4 degrees F, and discolored, cloudy, or foul-smelling amniotic fluid.

Group B Streptococcus (GBS) Intrapartum Treatment

Penicillin loading dose of 5 million units IV, followed by 2.5 million units IV every 4 hours until delivery.

Premature Rupture of the Membranes (PROM)

Rupture of the amniotic sac before the onset of true labor, regardless of the length of gestation.

Preterm Premature Rupture of the Membranes (PPROM)

Rupture of the amniotic membranes earlier than the end of the 37th week of gestation, with or without contractions.

PROM Diagnostic Tests

Nitrazine paper test (turns blue in alkaline amniotic fluid) and sterile speculum exam looking for ferning patterns under a microscope or pooling of fluid.

What are possible causes of PPROM

• infections

• amniotic sac with weak structure

• previous preterm birth

• fetal abnormalities

• short cervical length

• maternal nutritional deficiences

Preterm Labor

Labor contractions accompanied by cervical change that begin after the 20th week and prior to the end of the 37th week of gestation.

S&S of preterm labor

• uterine contractions (may or may not feel)

• sensation of baby “balling up”

• cramps

• constant low backache, intermittent, or irregular

• pain or discomfort in the vulva or thighs

Preterm Birth Risk Factors + Short cervical length (<= 25 mm), previous preterm birth, positive fetal fibronectin (fFN) after 22 weeks, maternal infection, and multifetal gestation.

• Short cervical length (<= 25 mm)

• previous preterm birth,

• positive fetal fibronectin (fFN) after 22 weeks (should only be visible 16-22wks and at term)

• maternal infection, and multifetal gestation.

Magnesium Sulfate (Tocolytic) for preterm labor

A CNS depressant used to slow down uterine contractions; monitored by checking deep tendon reflexes, urinary output, and respiratory rate.

Nifedipine for preterm labor

A calcium channel blocker used as a tocolytic to suppress uterine contractions; side effects include maternal flushing, dizziness, headache, and transient hypotension.

what is Betamethasone / Dexamethasone used for in preterm labor

Antenatal corticosteroids administered intramuscularly to accelerate fetal lung maturity and reduce the incidence of respiratory distress syndrome (RDS) in preterm infants.

Prolapsed Umbilical Cord

An emergency where the umbilical cord slips down after membrane rupture and becomes compressed between the fetus and the pelvis, compromising blood flow.

• could be hidden, not seen but felt

• could be felt as a mass

• could protrude

a cord prolapse is more likely to occur in which conditions

• fetus in high station (←2)

• very small fetus

• breech presentation

• transverse lie

• hydramnios (gravity, everything flushing out)

Prolapsed Cord Emergency Interventions

Manually pushing the presenting fetal part upward off the cord with a gloved vaginal hand, placing the mother in knee-chest (doggy) or Trendelenburg position (baby head up but off pelvis), and preparing for emergency C-section.

Uterine Rupture

A tear in the wall of the uterus that cannot withstand intrauterine pressure, strongly associated with previous uterine surgery or scars.

Complete vs incomplete Uterine Rupture

• complete: A full-thickness tear extending through the uterine wall directly into the peritoneal cavity, resulting in severe hemorrhage and fetal distress.

• Incomplete: results from pressure but does not reach the cavity

Uterine Dehiscence

A partial separation or separation of a previous uterine scar or incision that does not fully reach the peritoneal cavity.

what are S&S of a uterine rupture

• chest and shoulder pain, between the scapulae (referred pain)

• pain on inspiration

• hypovolemic shock caused by hemorrhage

• signs of fetal hypoxia

• cessation of uterine contractions

what is an Amniotic Fluid Embolism (AFE)

A catastrophic pregnancy complication where fetal particulate matter enters maternal circulation, causing right ventricular failure, acute respiratory distress, and DIC.

what management is provided for AFE

baby is going into hypoxia

• CPR and airway support

• Correction of hypotension

• blood component therapy to correct coagulation defects