IP & IP Complications 2

1. Beginning of labor

2. Pushing to expel fetus

3. Delivery of placenta

4. Restoration

What are the four stages of labor?

1st stage of labor

Begins with onset of true labor and ends when 10CM DILATED and 100% EFFACED

• Three phases

1. Latent

2. Active

3. Transition

What are the three phases of the first stage of labor?

Latent phase

0-5cm

• Excited, talkative, early labor

Active phase

5-8cm

• Contractions intensify (pain increases)

Transition phase

8-10cm

• Very strong contractions (more painful) and fully effaced

• Bloody show

• Patient may feel anxious, fearful/serious during this phase

1. Systemic analgesics (opioids)

2. Local anesthesia

3. Regional analgesia

4. Nitrous Oxide

What is used for pain relief during labor?

Butorphanol, fentanyl, nalbuphine IV

• Lessen pain w/o loss of feeling or muscle movement

• Reduce awareness of pain and are calming

• Crosses placenta

• Baby takes longer to metabolize

What are the systemic analgesics (opioids) and what do they do?

Local anesthesia

Lidocaine injection IM

• Prevent pain in small area of the body (episiotomy)

Regional analgesia

Pudendal nerve block, epidural and combined spinal epidural

• Lessen or block pain BELOW THE WAIST

• Safe for mother and baby

• Works quickly/ wears off quickly

• Self-administered, helps with anxiety and dulls pain

• Good for early labor, while waiting for epidural

• Good for moms who do not want epidural or IV pain meds

• Easily reposition self, MUST have assistance to bathroom

Why is nitrous oxide good in labor?

• Unable to hold mask

• Impaired LOC

• Recieved IV pain meds <2 hrs

• Pre-term or unstable baby

• Recent gastric bypass

• Intraocular or inner ear surgery

What are the contradictions for nitrous oxide?

Epidural

• Local anesthetic and opioid into LUMBAR space

• Catheter remains inserted for continuing analgesia

• 60-90% women have them, PCA pump

1L lactated ringers (LR) quickly

What should you give the patient PRIOR to giving an epidural?

• LEFT LATERAL position

• FOLEY catheter inserted

• BP q15MIN

What is done AFTER a patient recieves an epidural?

• MATERNAL HYPOTENSION (can lead to fetal distress (less O2); bradycardia)

• Respiratory depression

• Allergic reaction

• Intravascular injection

• Fever/infection

• Prolonged 2ND STAGE labor

• Increases risk for use of assisted device for delivery

What are the complications of an epidural?

Prevent maternal hypotension; fluids raises BP

Why are LR given before epidural?

• Previous spinal surgery

• Spinal abnormalities

• Coagulation defects

• Anticoagulation therapy

• Infection

• Obesity (sometimes)

• LOW PLATELETS

What are the contradictions for epidural?

During c-section

When is spinal anesthesia given along with epidural?

• Somewhat independent role

  • Close attention to FHR and contraction patterns

    • q15MIN

  • ROM

  • Knowledge and performance of interventions

  • Document all communication in timely manner

What is the nursing interventions for 1st stage of labor?

• Before and after calls to provider

• Before and after interventions

• Detailed documentation of progress and changes

What does documentation of all communication look like during 1st stage of labor?

• By palpation with your hand

• Electronic monitoring

  • External and Internal

• Time, count, and assess

How are uterine contractions assessed?

Toco-transducer

What EXTERNAL device is used to monitor uterine contractions?

IUPC (intrauterine pressure catheter)

What INTERNAL device is used to monitor uterine contractions?

Leopold Maneuvers

Series of 4 hands-on ab movements used during pregnancy to figure out baby’s position

1. Normal

2. Hypertonic (TACHYSYSTOLE, hyper-stimulated)

3. Hypotonic

What are the three different types of contraction patterns?

• AUGMENTATION of LABOR with OXYTOCIN (uterotonic agent)

• Given IV on pump with protocol

What is the tx for HYPOTONIC contraction pattern?

May become HYPERTONIC; risk for fetal distress

What might happen to the contraction patterns if too much oxytocin is given?

Turn oxytocin off

What should you do if too much oxytocin is given and a HYPERTONIC contraction pattern happens?

• Fetal hypoxia

• Precipitous birth (rapid)

  • Trauma to woman/fetus

• Uterine rupture

What can happen if contractions are HYPERTONIC?

• D/C oxytocin if infusing

• Left lateral position

• Oxygen

• Increase plain IV fluids (NS)

• Closely monitor FHR

• Contact provider

• TERBUTALINE SULFATE SQ (tocolytic, stops contractions)

What are the interventions for HYPERTONIC contractions?

1. Contraction issues

2. Amnioinfusion complications

   1. Patient has ROM with thick meconium in amniotic fluid

   2. Oligohydramnios (not enough fluid)

3. Prolapsed cord

4. Placental abruption

What are the complications/emergencies in the 1st stage of labor?

Amnioinfusion

NS or LR instilled in the uterus DURING LABOR

Fetus can present with LATE decelerations or deep, PERSISTENT variable decelerations (can aspirate on it; fetal distress)

Why might ROM with THICK MECONIUM in amnioinfusion be a complication?

Fetal scalp electrode (FSE) and intrauterine pressure catheter (IUPC)

What internal monitoring device can be used to check the frequency of contractions and monitor FHR?

• Malpresentation (baby position)

• Growth restriction

• Premature

• ROM at high station

• Hydramnios

• Grandmultiparity

• Multifetal gestation

What are the risk factors for prolapsed cord?

1. Occult (hidden)

2. In front of fetal head

3. Complete (protruding from vagina)

What are the types of prolapsed cord?

• AROM

• Decrease risk prior to AROM being done

  • If not hidden (occult):

    • PUSH fetus upward and off cord with gloved hand

    • REPOSITION mom; KNEE-CHEST position, TRENDELENBURG (head down)

• Prepare for emergency C-section if necessary

What is the tx for a prolapsed cord?

• Verify station of fetal head

• Closely monitor women with HYDRAMNIOS for SROM

How do you decrease the risk of prolapsed cord prior to AROM being done?

1. Partial (w/ concealed)

2. Partial with hemorrhage

3. Complete (w/ concealed)

What are the types of placental abruption?

Get to OR

• deliver immediately

What is the tx for placental abruption?

2nd stage of labor

Laboring down

• Starts when mom is FULLY dilated and effaced until the delivery of the fetus. “Complete”

• Allow rest prior to onset of pushing

• D/C urinary catheter PRIOR to pushing

• Allow woman to push when feel urge

• Limit breath holding, encourage grunting or exhaling

• Change positions

• Nurse get provider to bedside and set up equipment for delivery

What are the nursing interventions for 2nd stage of labor?

Pudental nerve block

What is given before an episiotomy?

Episiotomy

Surgical cut through tissue to get baby head out or prevent tearing

1. Shoulder dystocia

   1. Brachial plexus injury

2. C-section

What are the complications in 2nd stage of labor?

Shoulder dystocia

Emergency with the anterior shoulder of baby stuck under the pubic symphysis (baby stays in)

• MCROBERT’S MANEUVER; position the mother on back, legs to KNEE TO CHEST, helps open pelvis

• Apply SUPRAPUBIC pressure to help release the shoulder from under then PELVIC bone to deliver fetus

What are the interventions for shoulder dystocia?

Brachial plexus injury

Complication of shoulder dystocia where there is damage to the nerves near the clavicle of the baby

• Arm is limp

• Forceps

• Vacuum extractor

  • ex.) Kiwi device

What are the assisted delivery devices that can be used during labor?

C-section

Surgery used to to a deliver the baby through the abdomen or uterus

• Most common: low transverse (anesthesia higher up)

• VBAC (vaginal birth after c-sec)

• Classical: for transverse or emergencies, no VBAC in future

• Oxytocin 20 units, IM

• Oxytocin 20 units in 500mL NS/LR

What medication is given to a mom post delivery?

Give a 30 min bolus between delivery of ANTERIOR SHOULDER of baby and the PLACENTA, then

• oxy 20U IM

• 20U in 500mL NS/LR

When is oxytocin given to the mom post delivery?

Increases uterine contractions to help reduce blood loss and decrease the risk of POST-PARTUM HEMORRHAGE

• Contractions cause uterine wall blood vessels to contract and decrease bleed

Why give oxytocin post delivery?

Increases afterbirth pains

What is the downside to giving oxytocin post delivery?

3rd stage of labor

Delivery of the placenta

5-30 mins

How long may the placenta take to deliver after the baby is born?

• Gush of dark red blood

• Umbilical cord lengthening (placenta is coming off wall)

• Firm fundus

What are the signs the placenta is coming out?

In a placental bowl from provider, ensures a second look to be sure there are NO MISSING FRAGMENTS

• Cord blood testing

How should the nurse exam the placenta after delivery?

Can cause late post partum hemorrhage, uterus cannot contract and blood vessels stay open if tissue remains

tx: scrape uterus

Why is it important to get all the placental fragments?

• Rh- and O+ moms

• Blood gases

• Infection (blood cultures)

• Fetal hypoxia (acidosis)

• Drug screening

Why is the cord blood tested?

4th stage of labor

Restoration (1-4 hours after delivery)

• Unhurried, uninterrupted bonding of mother and baby

• Initial attachment to the newborn

• Patient is excited and awake

• Provide comfort

  • Warm blankets, hot/cold beverages

  • Ice pack to perineum (prevents hematoma)

• Assess bleeding and bladder distention

  • Can impact firmness of fundus

  • Contractions necessary to stop/minimize bleeding

• ASSESS PERINEUM AND FUNDUS

• APGAR

What are the nursing interventions for the 4th stage of labor?

Should be FIRM (check for laceration)

What should the mom’s fundus look like after delivery?

If fundus is FIRM and there is BRIGHT RED trickling blood

What indicates a LACERATION after delivery?

Bad sign

• UTERINE ATONY (not contracting); bright red flowing blood, hemorrhage

• RETAINED PLACENTA; dark blood with clots

What does it mean if the fundus is NOT FIRM or “BOGGY”?

Massage the fundus using a BI-MANUAL APPROACH

• One hand on the pelvic bone and one at the top of the fundus while massaging it

What is the nursing intervention for a boggy fundus?

Quick assessment of the baby after birth

• Appearance

• Pulse

• Grimace

• Activity

• Respirations

What is APGAR?

At 1MIN and 5MIN after birth

When should a nurse do an APGAR?