Care Mx of Premature Rupture of Membranes, Chorioamnionitis

PROM

Prelabor rupture of membranes; spontaneous rupture of amniotic sac and leakage of amniotic fluid BEFORE the onset of labor at any gestational age

PPROM

Premature prelabor rupture of membranes; occurs before 37 completed weeks of gestation

What are the causes of premature rupture of membranes?

• Infection

• Uterine overdistension d/t weakening of amniotic membranes

• Trauma

• Multiple gestation

• Cigarette smoking

What are the risks of premature rupture of membranes TO THE MOTHER??

Infection

• Chorioamnionitis

• Endometriosis

What are the risks of premature rupture of membranes TO THE NEONATAL??

• Cord prolapse

• Prematurity

• Sepsis

What is the care management of premature rupture of membranes?

• Based on assessment: maternal & fetal risks

• Prior to 34 weeks of gestation: conservative mx (no invasive procedures)

  • Continuous monitoring of FHR, biophysical profile (u/s of AFV, FBM, FM, FT)

  • Fetal movements counts (kick chart)

  • Observation for infection signs

• After 34 weeks of gestation; allowed to labor or induced

What is chorioamnionitis?

Bacterial infection of the amniotic cavity

• Occurs after membranes are ruptured

What is the presentation of chorioamnionitis?

• Maternal fever

• Maternal & fetal tachycardia

• Uterine tenderness

• Foul-smelling amniotic fluid

What is the treatment of chorioaminionitis?

• IV fluids, IV antibiotics

• Gentamicin + Ampicillin, THEN clindamycin after c-section

• Baby admitted to intermediate nursery or NICU

What is the management of chorioamnionitis?

• CBC

• Blood culture and sensitivty

• Prophylactic antibiotic therapy

Management of Postterm pregnancy/labor/birth

• Extends past 42 weeks of gestation

• Perform daily fetal movement counts

• Assess for signs of labor

• Notify provider of ROM

• Weekly appointment for fetal assessment and cervical checks

• Admit to L&D as soon as labor begins

Cephalopelvic disproportion

Disproportion between size of fetus & size of woman’s pelvis

What is the most common form of malpresentation?

Breech

What are the different types of breech presentation?

• Frank breech

• Complete breech

• Footling breech

Frank breech

• Hips flexed

• Knees extended

• Legs are straight up against the body

• Feet are near the head

• Buttocks alone present first

• Most favorable type for vaginal delivery in terms of breech (but may have rectal issues)

Complete breech

• Hips

• Knees flexed

• Baby is sitting or cannonal position

• Both buttocks and feet present together

• Cross legged

Footling breech

• One foot or both feet present before the buttocks

• LEAST favorable

• High risk for cord prolapse when membranes rupture!

Multifetal pregnancy complications

• Preterm birth or IUGR

• Placental dysfunction- twin to twin transfusion

• Fetal distress

• Birth asphyxia

• Congenital anomalies

• Malpresentation

Maternal complications for multifetal pregnancy

Increased risk for

• HTN

• Anemia

• Placental abruption

• Hemorrhage postdelivery d/t uterine atony

**Good teamwork is required for mx of patients with multiple fetuses: OB physician, neonatologist, anesthesiologist, OB nursing staff, and NICU nursing staff

What is external cephalic version oB procedure?

Turning the fetus to a vertex position by exertion of pressure on the fetus externally through the maternal abdomen

What are the indications for external cephalic version?

• Single fetus (singleton)

• Fetal breech not engaged

• Adequate amount of amniotic fluid

• Reactive NST

• Gestational age 36-37 weeks

What are the contraindications for an external cephalic version OB procedure>

• Uterine anomalies/CPD (cephalopelvic distortion)

• Suspects IUGRor fetal anomalies

• Multiple gestation

• Nuchal cord (seen on u/s)

• Abnormal FHT

• ROM or oligohydramnios

• Prior cesarean birth

Oxytocin uses

• IOL and augmentation of labor

• First-line drug for postpartum hemorrhage

• Route: IV; syarts at 1MU/min; increased q30-60 min based on maternal/fetal response and progress of labor (follow protocol)

Nursing care of oxytocin

• Inform patient and partner/family

• Assess maternal v/s & FHR, ctx, I&Os

• Perform vaginal exam as per protocol

• Monitor for s/e (N/V, headache, hypotension)

• Titrate oxytocin drip as needed. Notify MD

• Document all nursing activities and patient’s response

What is uterine tachysystole and its significance

Contractions too frequent for adequate uterine relaxation between them

• Inadequate resting tone

Uterine Tachysystole w/ Oxytocin Infusion; signs of tachysystole

• More than 5 ctx in 10 min

• Series of single ctx lasting >2min

• Ctx of normal duration occurring within 1min of each other

• So basically, if contractions are more frequent than every 2 minutes and alst longer than 1 minute

Management for normal fetal tracing

• Cat I

• Reposition to side-lying (either side)

• Administer IV fluid bolus 500 mL lR

• If uterine activity persists after 10mins, decrease the oxytocin dose by at least half; give another 10 min, if no change d/c infusion until 5 ctx in 10 mins

Management for indeterminate fetal tracing

• D/C oxytocin infusion STAT

• Reposition to side-lying

• Administer IV bolus

• Give O2

• Give terbutaline (tocolytic that relaxes the uterus and stops contractions)

• Notify physician

What is induction of labor?

The process of initiating labor by use of medication or surgical rupture of membranes

Maternal indications for induction of labor

• Hypertensive complications

• Fetal death

• Chorioamnionitis

Fetal indications of induction of labor

• Post-term pregnancy

• IUGR

• Isoimmunization

• PROM

What are the contraindications of induction of labor?

• fetal distress

• Shoulder presentation

• High presenting part (floating)

• Placenta previa

• Prior ceserean that prohibits trial of labor

Bishop score

• A rating system to evaluate inducibility of the cervix; a higher score INCREASES the rate of successful induction of labor

• A BISHOP SCORE OF 8 IS FAVORABLE FOR INDUCTION

• Once a patient meets all criteria, IOL should be successful

• Tests for cervical readiness

What is augmentation of labor?

• Stimulation of uterine contractions AFTER labor has already started spontaneously and progress is UNSATISFACTORY

• Used to manage hypotonic uterine dysfunction

What is a forceps-assisted birth? Indications?

Instrument w/ curved bladed used to assist in the delivery of the fetal head

• Indicated for prolonged second stage, maternal exhaustion, fetal distress

What is a vacuum-assisted birth (vacuum extraction(?

Attachment of a vacuum cap to fetal head using negative pressure to assist in delivery of the fetal head

What is the criteria for a forceps-assisted birth and vacuum-assisted birth?

The cervix must be:

• Fully dilated

• The presenting part engaged in the pelvis

• Vertex presentation

• Membranes MUST be ruptured

Cesarean birth

Delivery of the fetus through a transabdominal incision of the uterus

What are the cesarean birth indications?

• Maternal complications

• Previous cesarean section

• Certain medical conditions

• Fetal distress of anomalies

• Malpresentation

• Active maternal herpes lesions

• Bleeding disorders

• HIV viral load >1000 copies/mL

• Unplanned/emergency

What are the elective c/s indications?

• Previous cesareans

• Malpresentation

• Extremely large/small fetus

• Multiple fetuses

• Pelvic structure malformation/prior pelvic injury

• scheduled in advance

Cesarean birth surgical techniques

• Can be incised vertically or horizontally

• Two main types of uterine incisions: low transverse or vertical

• Low transverse is the most performed

• Verrtical can be low or classic incision

What are the complications and risks of a cesarean birth?

• Hemorrhage

• Bowel & bladder injury

• Amniotic fluid embolism

• Infection

• Thromboembolic disease

• Anesthesia risks: spinal, epidural, general

General care management for c/s births

• Prenatal preparation

• Preoperative care

• Intraoperative care

• Postoperative care

• Vaginal birth after cesarean (VBAC)

How should the nurse care for a patient when it comes to prenatal preparation?

Educate the patient on the labor outcomes and the possible c/s if needed

How should the nurse care for a patient when it comes to preoperative care?

• Physician explains to the patient and family

• Anesthesiologist assess patient

• Routine preop care- lab work (CBC, T&S), consent, IV, foley catheter insertion, emotional support ro patient and partner

• If the laboring patient has an oxytocin infusion, discontinue stat (remove line) once the physician announces “prepare for c/s”; prevents excessive uterine activity and makes it more relax during surgery

How should the nurse care for a patient when it comes to intraoperative care?

• Obtain fetal heart rate and strip once in the OR until the abdomen is ready to be cleansed

• Assist with positioning for epidural

• Continue to support the patient

• Time-out conducted

How should the nurse care for a patient when it comes to postoperative care?

• Transfer to post-anesthesia recovery area for monitoring

• VS, Fudnal assessment and incision

• Promote bonding w/ newborn

• Encourage family visits

What is a vaginal birth after cesarean (VBAC)?

A vaginal birth after having a cesarean birth in the past

• success rate: 60-80%

What is meconium-stained amniotic fluid?

• The passage of meconium or first stool before birth

• Detected on color of amniotic fluid from clear to green

• Fluid can be lightly stained, thin, heavily stained, or thick based on amount of meconium passed

What is meconium aspiration syndrome?

Respiratory distress caused when a newborn inhales meconium into the airways

• leads to obstruction and lung inflammation

• they inhale with their initial breaths following birth → leads to mechanical obstruction of airways (blocks → inflames → tachypnea → alevolar collapse)

Meconium aspiration syndrome respiratory distress signs

• Tachypnea (rapid breathing)

• Retractions

• Grunting

• Nasal flaring

• Cyanosis

• Barrel-shaped chest (air trap)

• Coarse breath sounds/rales

Meconium aspiration syndrome nursing interventions

• Ensure neonatal resuscitation team present at delivery

• Mx. is based on assessment of newborn’s condition after breath

• DO NOT routinely suction mouth/nares on perineum

• Do NOT routinely intubate for tracheal suctioning

• Continue to monitor VS, O2 sats, respiratory efforts

• O2 therapy

• mechanical ventilation if respiratory failure develops

• administer surfactant

What is shoulder dystocia?

A condition in which the head is delivered, but the anterior shoulder cannot pass under the pubic arch

What are the causes of shoulder dystocia?

LARGE FETUS! >4kg (8.8lbs)

• signs of shoulder dystocia

• Slow progress of 2nd stage of labor

• Large caput (edema over presenting part of baby’s head caused by labor pressure)

• Retraction of fetal head against the perineum (turtle sign)

What is the management for shoulder dystocia?

• McRoberts Maneuver

  • the woman’s legs are sharply flexed against her abdomen.

• Complications for maternal & fetal

Maternal complications of shoulder dystocia

• Severe perineal lacerations (3rd/4th degree tears)

• Uterine rupture

• Bladder injury

• Cervical lacerations

• Vaginal hematomas

Postpartum complications:

• Postpartum hemorrhage — from uterine atony, lacerations, or trauma

• Pelvic floor damage

• Symphysis pubis separation (if symphysiotomy performed)

Fetal complications of shoulder dystocia

• Skeletal injuries

• Nerve injuries

• Erb-Duchenne palsy (arm adducted and internally rotated)

• Death

• Cerebral palsy

• Hypoxia

What is a prolapsed umbilical cord?

Prolapse occurs when the cord lies before the presenting part

What are the contributing factors for a prolapsed umbilical cord?

• Long cord (> 100 cm)

• Malpresentation (e.g., breech)

• unengaged presenting part

What is the goal of care for a prolapsed umbilical cord?

TO RELIEVE PRESSURE OFF THE CORD!!!!!!

• Examiner puts in sterile gloved hand into the vagina and holding the presenting part off the cord.

• Assist patient to exaggerated Sims’ position (side lying) or most used position Trendelenburg (knee- chest)

What is a uterine rupture?

Rare but life-threatening obstetric injury in which there is complete non-surgical disruption of all uterine layers. Contributing factors are previous c/s or prior uterine surgery.

• Mx – close observation of patient in labor to prevent rupture