ob4: care of women w complications during labor

chap 9 & 10

induction

starting the labor

• must confirm fetal maturity

Bishop Scoring System: considers factors of cervix & position of baby

augmentation

stimulating contractions

why would labor induction be done?

• gestational HTN

• ruptured membrane w/o onset of labor → infection

• uterus infection

• placental insufficiency

• incompatible blood type → rH factor

• prolonged pregnancy

• fetal death

• etc medical problems

why wouldn’t a labor induction be done?

placenta previa → c section

umbilical cord prolapse → need c section

abnormal fetal presentation → c section

high station of fetus → c section

active herpes → c section

abnormal structure of pelvis → c section

previous vertical c section → c section

non-pharm methods to stimulate contractions

walking

nipple stimulation (pituitary gland secretes oxytocin)

hot shower

acupuncture / acupressure

sexual stimulation

pharm methods to stimulate contractions

• cervical ripening w/ cervidil, prostaglandin

• oxytocin: augmentation (and helps stop bleeding after birth)

monitor fetal hr & contractions after administering oxytocin

complications w oxytocin

oxytocin can cause contractions to be too intense → fetal compromise

& water intoxication

prepping the woman

explain procedure

obtain baseline, vitals, fetal HR

IV in place

remain in bed for 2hr

oxytocin 6-12 hr after insert removed

assess for uterine tachysystole

dilating the cervix

with cervidil, prostaglandin

• stripping amniotic membranes

• hydroscopic dilators: placed lower uterine segment. mechanically swells to open

• trans-cervical balloon dilator: like foley. insert & inflate balloon

amniotomy

artificial rupture of membranes - to stimulate/ enhance contractions

• commits to delivery

• stimulates prostaglandin secretion

complications: prolapse of umbilical cord, infection, abruptio placentae

abruptio placentae

s&s: abdominal/back pain, vaginal bleeding, low bp

amnioinfusion

compression for umbilical cord

reduction of variable decels

dilution of meconium stained amniotic fluid

version

method used to change fetal presentation

before: determine: herpes previous vertical c-section. abnormal placental placement. disproportional uterine/pelvic size. twins

slow contractions with: tocolytics (ex: mg)

external: perfect at 37 weeks, but before onset of labor. ultrasound, clockwise.

internal: emergency, during labor.

episiotomy

surgical enlargement of perineum - prevent tearing/ if baby too big

numbing: pudenal block

• alternative: perineal massage & stretching exercises before

perineal lacerations

1st degree: superficial vaginal mucosa / perineal skin

2nd: vaginal mucosa, perineal skin, & deeper tissues

3rd: same as 2nd + anal sphincter

4th: extends through anal sphincter into rectal mucosa

care for episiotomy / laceration

1st: cold packs to reduce bruising & edema

after 12-24hr: heat & sitz baths

• motrin & tylenol

• monitor sister for infection

clean w: peri bottle, witch hazel

give stool softener to avoid straining

forceps extraction

traction & rotation of fetal head when mother can no longer push

done at 2nd stage - 10cm dilated

• may be used during c-section

• risk of injury to baby

vacuum extracted birth

suction applied to baby’s head to assist expulsion

baby needs to be far enough along birth canal

• only if occiput presentation (back of head facing vagina)

• baby may render cephalic hematoma / bruising (chignon)

fetal maturity

ability to survive outside uterus - assessed by amniotic fluid analysis: L/S Ratio

• surfactant needed for oxygenation

• 2:1 ratio

• 3:1 ratio: for diabetics

prep for c-section

lab to identify anemia / blood-clotting abnormalities

cbc, blood type

baseline vitals & FHR

IV & hep lock

types of incisions

c-section

nursing care in recovery room

monitor vitals q5min for 1st hour (identify hemorrhage or shock)

check fundus for firmness, midline

assess drainage → circle it to see if it gets bigger

assess lochia (discharge)

monitor I&O → uterine will not contract/be firm if bladder is full

abnormal / dysfunctional labor

dystocia: difficult labor

risk: advanced maternal age, over-distended uterus. abnormal presentation

problems with powers of labor

hypertonic

problems with powers of labor

hypotonic

nursing care for abnormal fetal presentation

LOP or ROP positioning: most common cause

multi-fetal pregnancy dyfunctional labor

effects of hormones release

uterus uses more glucose for energy

diverts blood from uterus

can increase tension of pelvic muscles, interfering w/ descent

can increase pain perception

can promote relaxation

abnormal duration of labor

can cause post-partum hemorrhage

precipitated birth

completed in less than 3 hours

• frequent, intense contractions → may lead to fetal compromise

• may have uterine rupture, cervical lacerations, hematoma

• fast labor → may cause baby injury ex intracranial hemorrhage

premature rupture of membranes

more than 1 hour before labor contractions begin

signs of impeding preterm labor

shortened cervix on ultrasound at 20 weeks

dx: cervical effacement & dilation 2cm+

• presense of fibronectin at 22-24 weeks

how to stop preterm impending labor

tocolytic therapy

goal: stop contractions - keep fetus in utero until lungs are mature

tx: mg IV, beta blockers po, calcium channel blockers po, postaglandin inhibitor

stopping preterm labor

contradictions of tocolytic therapy

education for woman w/ infection or preterm labor

• report temp above 100.4

• avoid sex & orgasms

• avoid breast stimulation

• note any contractions, reduced fetal activity (report <10 kicks in 12hr)

DES: estrogen used to treat vaginal cancer

prolonged pregnancy

longer than 41 weeks

• placenta may become insufficient & baby becomes bigger

• meconium may be expelled → respiratory distress

• hypoglycemia → jittery, irritable, poor feeding, difficulty thermoregulation

tests to diagnosis prolonged pregnancy

prolapsed umbilical cord

complete, palpated, occult

occult: cannot be seen/ felt → detected because of decels

tx: c section

placenta accreta

abnormal placenta attachment (covering the cervix)

s: profuse bleeding

tx: blood transfusion & fluids → c section

uterine rupture

uterine wall tears → baby slips into abdomen

• causes severe bleeding in the mother, sufficating baby

amniotic fluid embolism

amniotic fluids (w vernix, meconium, fetal hair) enters circulation & obstructs vessels in lungs

s: abrupt hypotension, respiratory distress, coagulation abnormalities, chest pain, crackles/wheezing

tx: intubation, ventilation, monitor I&O

post-partum changes

uterus

involution: uterus returning to regular size 5-6 weeks post - 1cm descent per day

• will experience post uterine-contractions. common w breastfeeding

placental site heals 6-7 weeks post

lochia / discharge

rubia: lasts 3 days

serosa: 3rd - 10th day

alba: clear, mucus like. 3rd - 10th day

• less lochia w c-section

• absence is abnormal!

perineum: watch for - REEDA (redness, edema, ecchymosis, discharge, approximation)

what should you do if uterus is flaccid/ boggy post?

massage & see if woman needs to use bathroom

med used to stop heavy bleeding post?

methylergonovine - IM or PO

tips w breast feeding

continue breast feeding & switch breasts

prevent mastitis

nursing care post birth

how long after birth can you begin ovulating post birth?

3 weeks

around 6 weeks if breast feeding

cardiovascular changes post birth

diuresis: increased urinary output - 3000 cc/day

diaphoresis

bradycardia (50-60 bpm first 48hr)

edema in feet & hands (due to iv fluids)

coagulation & blood value changes post birth

chills & orthostatic hypotension post birth

immune system changes post birth

Rh- mother needs: Rhogam within 72hr

Rubella vaccine: avoid pregnancy 3 months post-vacc

etc changes post birth

Edinburgh Postnatal Depression Scale

max scale 30

possible depression: 10 or greater

post birth is aka

perinatal

neonatal transition to life

phase 1: reactivity. 0-30 min post

phase 2: decreased responsiveness. 30min - 2hr post

phase 3: 2nd reactivity. 2hr - 8hr post

prevent heat loss in newborns

identifying maturity in newborn

skin

if vernix stays on → pre-term

lanugo all over → pre-term (black babies usually have more)

genitalia undeveloped / labia majora & minora equal size

how do you take temperature in newborn?

axillary

normal vitals for newborn

110 - 160 beats pm

30 - 60 breaths pm

bp: 65 - 95 / 30 - 60

risk for neonatal hypoglycemia

pre-term & post-term at risk. less than 5lb & more than 9lb. moms that have gestational diabetes

< 45 indicated hypoglycemia

hypoglycemic signs: jitterness, lethargic, low temp, respiratory difficulty, sweating, high-pitch cry, seizure

screening tests

if circles merge, test is invalid

skin care + bonding & attachment

do not wait until baby cries to feed → watch for cues

• calling infant by name

• holding infant face-to-face, skin-to-skin

• talking genty

benefits of breastfeed

• maintains temp bc skin to skin

• uterus returns to normal size faster

• will loose weight faster

• antibodies for baby

evaluating intake of infant

recognizing hunger in newborns

storing & freezing breast milk

how often should one breastfeed if using formula: q3 - 4hr

room temp milk should not be left un-refrigerated for more than 3hrs

can be left in fridge for 24hr & freezer up to 3 months

newborn discharge care