Intra-Partum Complications

Pre-term labor is between…

Pre-term labor is between…

20-36.6 weeks

Number 1 risk factor for a pre-term birth?

Hx of multiple pre-term deliveries

Other risk factors for PTL?

• Multiple gestation

• Uterine/cervical abnormalities

• Infection

• IVF pregnancy

• Hypertension

• Low socioeconomic

• Age extremes

• Smoking/Drugs

Pregnant women are at a high risk for -- which could cause --

UTI; contractions

Testing for Pre-term labor?

Cervical length - vaginal ultrasound

Fetal fibronectin- positive test indicates that woman may have a baby in the next 2 weeks

What is included in management of PTL?

• fetal fibronectin

• tocolytic drugs

  • uterine relaxants

• antibiotics (ABX)

• progesterone

  • vaginal suppository; given to those who had multiple miscarriages usually

• mag sulfate

• corticosteroids

  • betamethasone

  • given two IM shots to help expand baby’s lungs

Tocolytic drugs

It’s Not My Time

• Indomethacin

• Nifedipine

• Magnesium Sulfate

• Terbutaline

Tocolytic Drugs _______ uterine contractions?

suppress

When are tocolytics given?

between 24-34 weeks gestation

Fetal Fibronectin

a protein that helps the sac “glue” to the uterus

*normally not detected in vagina until weeks 16-35

If negative, there is a <1% chance of delivery within next 4 weeks

When is fetal fibronectin test contraindicated?

pelvic exam, intercourse, or bleeding in last 24 hrs

Indomethacin use in PTL?

NSAID

• can cause ductus arteriosus to close early causing HF, dysfunction, or death

• NOT GIVEN AFTER 32 weeks

Nifedipine use in PTL?

CCB

• used for gestational HTN

• suppresses contractions by preventing calcium from entering smooth muscles

Nifedipine should not be given with

Magnesium sulfate

Nifedipine adverse effects

HA

Flushing

Dizziness

Nausea

Magnesium Sulfate use in PTL?

• CNS depressant

• helps to relax the uterus by stopping contractions

• IV with loading (4-6GM bolus) dose and maintenance dose

Magnesium Sulfate Assesment?

• VS

• EFM

• Alertness

• DTR

• Strict I&O

Signs of magnesium sulfate toxicity?

• Absent DTR

• Resp Depression

• Blurred vision

• Slurred Speech

• Severe muscle weakness

• Cardiac arrest

Terbutaline use in PTL?

Beta Adrenergic Agonist receptor

Relaxes uterus

• SQ

• short-term use in emergency

• want to stop moms contractions temporarily

• asthma drug - relaxes muscles of the airways

Terbutaline adverse effects?

Tachycardia

Arrythmias’s

SOB

Pulmonary edema

Tremors

Hyperglycemia

Terbutaline nursing care?

• Monitor HR

• I&O

• BG

• Assess for anxiety and tremors

To give terbutaline HR must be less than

120

Betamethasone?

• a glucocorticoid given to mom to enhance fetal lung maturity in preterm gestation

• given IM

• monitor for hyperglycemia

Betamethasone is given 2 doses _____ hours apart

24

Nursing interventions during intra-partum period if there are complications

• Assess for Infection, ROM, Vaginal bleeding, dehydration

• Assess FHR and UC

• Give fluids and medications

• Provide emotional support

• Discharge teaching - ROM

• Contractions to report -- 4-6 in an hour

• Vaginal discharge - may change

• Temperature

How do nurses assess for infection?

• urine sample

• take temperature

• asking if they had a fever lately

• ask if water has been broken

• ask if they had vaginal bleeding

• dehydration

How do we assess for ROM?

• Amnisure

• Fern

• Nitrazine

• Dehydration

More than 4-6 preterm contractions an hour?

Call provider

Contractions q5 minutes with a full term labor?

Call provider

PPROM?

Preterm Premature Rupture of Membrane

Risk factors for PPROM?

• Previous HX

• Bleeding during pregnancy

• Short cervical length

• Polyhydramnios (too much amniotic fluid inside uterus)

• Multiple gestation

• STIs

• Low BMI

• Cigarette smoking

• Drugs

Management of PPROM?

• Based on gestation

• Goal is to prolong gestation

• ABX

• BMZ

• Mag <32 weeks

• If mom is 34 weeks or more then she will most likely have the baby

• If mom is <34 weeks there will be aggressive management with medications to hold the baby in until 34 weeks

Nursing actions for PPROM?

• Assess FHR and UC

• Assess for infection

• Monitor for labor and fetal compromise

• Assist with testing (NST and BPP)

• Consult NICU

• Education and support

Maternal complications from PROM?

• Infections – limit number of vaginal exams done

• Hemorrhage

• Retained placenta

• Increased risk of C/S

Fetal complications from PROM?

• Infection

• Cord prolapse

• Umbilical cord compression

• Oligohydramnios (not enough amniotic fluid)

• Placental abruption

• Preterm delivery

Most common bacterial risk of PTL?

UTI

Screening of pregnant women is important to detect…

infections

What are some infections that pregnant women can develop?

• UTI

• TORCH

• STI

• HIV

What does TORCH stand for?

T - toxoplasmosis

O - other (hep. B)

R - rubella

C - CMV (cytomegalovirus)

H - HSV (herpes simplex virus)

TORCH crosses…

the placenta

If mom has HIV she needs to stay on…

antiretroviral drugs

If mom has HIV she is not allowed to…

breastfeed

STIs are passed through…

the placenta or birth canal

Multiple gestation risks for mom?

• HTN disorders

• Gestational diabetes

• Placenta previa, abruption

• Cesarean birth

Multiple gestation risks for baby?

• Increase risk of morbidity and mortality

• Prematurity

• Twin to twin transfusion (monochorionic)

• Intrauterine growth restriction (IUGR)

Dystocia of labor is -- related to --

difficult or dysfunctional labor r/t the 5Ps

What are the 5Ps?

• Powers - contractions and pushing

• Passageway

• Passenger

• Position

• Psyche

What is involved in Primary and Secondary Stage of Powers?

Primary

• hypertonic uterine dysfunction

• hypotonic uterine dysfunction

Secondary

• ineffective pushing

• no urge

• exhaustion

What is hypertonic uterine dysfunction?

uncoordinated uterine contractions

frequent and painful but not causing cervical dilation

What is hypotonic uterine dysfunction?

uterine contraction pressure if insufficient to promote cervical dilation

With hypertonic contractions we turn _____ down

Pitocin

*worried about uterus rupturing

POWERS stage: what does failure to progress mean?

cervical dilation does not get past 7 cm

POWERS stage: what does cephalopelvic disproportion mean?

baby is not going to fit through moms uterus (most likely too big)

PASSENGER stage

• Asynclitic presentation

• Occiput posterior

• External version

One reason for labor dystocia is…

malposition

What is the most common malposition?

occiput posterior

External version means

breeched baby

*try to spin baby around to get to a vertex posistion

What is key to help out with labor dystocia?

MOVEMENT

mom should be in multiple positions to help out

Even with an epidural mom should be moving around at least…

once an hour

What is encompassed in the psyche component of labor?

•Fear -- Tension -- Pain cycle

•Environment

•Prior birth experiences

•History of domestic violence or sexual assault

•Anxiety

How does “epidural magic” work?

if nothing is working, an epidural may help mom to relax and when she relaxes, her cervix will immediately dilate

What is augmentation?

stimulation of contractions once a woman has started labor d/t inadequate ctx

Examples of augmentation?

• amniotomy - artificial rupture of membrane

• Oxytocin/Pitocin

What is induction?

initiating labor -- mom was not in labor until you put her in labor

Examples of induction?

• amniotomy

• cervical ripening

• oxytocin

• membrane sweeping

Membrane sweeping?

providers will go in and try to separate the membrane around the cervix-- will release prostaglandins to try to get mom into labor

Indications for an induction of labor (IOL)?

• Post term

• HTN

• Maternal complication (diabetes)

• PROM

• Chorioamnionitis

• Fetal stress or compromise (IUGR)

• Fetal demise

• Psychological

#1 indicator of successful induction?

cervix

Contraindications to an IOL?

• Any contraindication for vaginal birth

• Previous vertical uterine scar

• Placental abnormalities

• Abnormal fetal position

• Cord prolapse

• Active HSV

Risks of an IOL?

• Tachysystole

• Failed IOL

• FHR decelerations

What to do if cervix is closed?

cervical ripening

What does cervical ripening mean?

The process of softening, thinning or dilating the cervix

What are the medications used for cervical ripening?

Prostaglandins

• cytotec

• cervidil

What is a contraindication to the use of Cytotec?

if mom had a previous C/S

Oxytocin

• Education/consent

• Review prenatal records

• Continuous fetal and uterine monitoring

• Titrate accordingly

• Assess VS q30-1hr

Why timing so important with an Amniotomy?

we do not want to rupture moms membrane too early because we don’t want to cause a cord prolapse

What is the first assessment that must be done before and after performing an aminotomy?

check FHR

What else should assessed when performing an amniotomy?

• Fluid color and amount

• Time of rupture

• Temperature, infection

Complications of an amniotomy?

• cord prolapse

• variables

• infection

Contraindications to performing an amniotomy?

• Baby’s head not engaged

• HIV

• Viral Hepatitis

• HSV – only with an outbreak

Oligohydramnios is…

a low amount of amniotic fluid

Oligohydramnios is most common from a…

ROM

With not enough amniotic fluid we are worried that…

baby’s kidneys are not working as well

Polyhydramnios is…

too much amniotic fluid

What risks are associated with polyhydramnios?

• PTL

• cord prolapse

What can be causes for polyhydramnios?

• diabetes

• infection

What can we do to determine the amount of amniotic fluid in a pt?

an Ultrasound

Meconium stained fluid is due to…

fetal stress

What is the biggest concern with meconium stained fluid?

aspiration which leads to respiratory distress

-- at birth if baby is not breathing with meconium stained fluid

suction

if baby cries at birth with meconium stained fluid, do not…

suction

If mom has Chorioamnionitis then she has an…

intraamniotic infection

What are clinical signs of Chorioamnionitis?

maternal fever and tachycardia

RF for chorioamnionitis?

• Prolonged ROM (anything over 18-24hrs)

• Bacteria from vagina

Maternal complications from Chorioamnionitis?

• sepsis

• prolonged labor

• PPH

When the uterus gets infected it does not work the same and can get lazy.  So in labor moms contractions may space out or not be as intense which could cause prolonged labor.  After she delivers then the risk is that her uterus will not contract down which could lead to a post partum hemorrhage.

Fetal complications from Chorioamnionitis?

• sepsis

Management with Chorioamnionitis?

• ABX: 2-3 types

• Tylenol - fever

In order to use forceps or a vacuum extraction, baby must be at least at…

+1 station

Contraindications to the use of forceps or a vacuum extraction?

• Extreme fetal prematurity – heads are more susceptible to bleeding

• Fetal bleeding disorders

• Unengaged head

• Unknown fetal position

• Brow or face presentation

• Suspected cephalopelvic disproportion (CPD)

Risks associated with the use of forceps?

• Vaginal, cervical, or perineal lacerations

• Bladder or ureteral injuries

• Hematoma formation

• Bruising and abrasions on the neonate

• Facial nerve injury

• Eye injury