OB Exam 2

What is preterm labor (PTL)?

labor before 37 weeks gestation

More common in African Americans and Caucasian/Asian Americans but incidence has decreased

Early detection of women at risk and prevention of birth is key (All pregnant women educated about S/Sx: backache, increase in vaginal discharge, ROM, UCs)

Q5min for 20 min or 8 contractions in 60 min and documented cervical change of 80%

S/Sx of PTL

preterm contractions (4/hr) *regular with cervical changes

backache

increased vaginal discharge

perianal/perineum pressure

RF of preterm labor

*50% have no known reason

*Hx of preterm birth/labor and short inter-pregnancy interval (< 18 mo)

abdominal surgery during the 2nd or 3rd trimester

abdominal trauma

african ancestry

antepartum hemorrhage

age (less than 18 or more than 35)

anemia

asymptomatic bacteriuria

*bacterial vaginosis, E. coli (ascending intrauterine infection)

cervical insufficiency; cerclage in place

cervix dilated more than 1 cm at 32 weeks

chorioamnionitis

elevated maternal serum alpha-fetoprotein level

exposure to certain environmental toxins

febrile illness

fetal abnormality

foreign body (IUD)

Hx of cervical procedures

*Hx of pyelonephritis or other maternal infection

HTN

IPV

In vitro fertilization (singleton or multiple gestation)

Inadequate prenatal care

insulin-dependent diabetes

Lack of social support

less than 6-month interval between pregnancies

low maternal weight; poor weight gain

low socioeconomic status

maternal coagulation disorders

maternal obesity

more than 2 first-trimester abortions

multiple gestation

Native American/Alaskan Native ancestry

Periodontal disease

prolonged standing or lifting

previous second-trimester abortion

*STI (trichomoniasis, chlamydia)

shortened cervical length

sickle cell disease

stress

*substance use: alcohol, drugs, tobacco

*UTIs

uterine anomaly; fibroids

uterine irritability

uteroplacental ischemia

vaginal bleeding

*multip

*smoking

dx of PTL

s/sx of labor <37 weeks

cervical exam —> cervical changes

transvaginal US

Primary prevention for Preterm Labor

*Fix prior

Treat infections (BV, trichomoniasis, chlamydia/gonorrhea, UTI, oral disease)

Progesterone administration (keeps uterus relaxed, free from contractions): Hx of preterm birth; initiated at 16-21 weeks’ gestation, vaginal 100 mg twice a day

Cervical cerclage: Hx of cervical insufficiency

Secondary Prevention for Preterm Labor

*prevent birth

Treat infections (BV, trichomoniasis, chlamydia/gonorrhea, UTI, oral disease)

Emergency cerclage: short cervix

Tocolytics: delays birth for 24-48 hours; allow for the administration of betamethasone (to develop the fetus's lungs) and transport if needed

• indomethacin: relaxes uterine muscles

• mag sulfate: prevents seizures, relaxes uterus

• nifedipine: blocks Ca++ —> decreases contractions

Complications of PTL

pre-term baby

RDS

What is PROM?

rupture of the bag of waters before labor starts

RF of PROM

previous PTB/PPROM

Infection (STI, cervical, urinary)

hydramnios/placenta

previa/abruptio placenta

multiple pregnancy

smoking/substance abuse

amniocentesis/LEEP

maternal/fetal anomalies

Risk associated with PROM

maternal: infection (chorioamnionitis)

fetal-neonatal: prematurity, infection (sepsis)

Tx for PROM

Preterm:

confirm rupture

expectant management

fetal assessment

treat infection

corticosteroid

limit vaginal exams

bed rest

Term:

Induction if labor doesn’t start in 12 hours

What is chorioamnionitis?

infection of the chorion, amnion, amniotic fluid, and by association, the fetus

RF of Chorioamnionitis

frequent vaginal exams with ruptured membranes

internal monitoring

long labors

cervical cerclage

S/Sx of Chorioamnionitis

fetal tachycardia

maternal tachycardia and fever

foul smelling fluid, uterine tenderness

Management for Chorioamnionitis

IV antibiotic therapy (commonly ampicillin, gentamicin and clindamycin)

cesarean delivery if remote from delivery or if fetal distress

induction/augmentation if vaginal delivery expected

hydration; I&O

What is abruptio placentae?

Premature separation of a normally implanted placenta

Classification: marginal, central, partial or complete; hemorrhage is concealed (bleeding occurs behind the placenta, but the margins remain intact); hemorrhage is apparent (membranes separate and vaginal bleeding occurs)

S/Sx of abruptio placentae

painful vaginal bleeding (bright red/darkened, clotted blood)

rigid abdomen

uterine irritability

DIC

maternal shock

painful uterine contraction

fetal distress

renal failure

changes in BP

weak pulses

cyanosis

cap refill > 3 sec

changes in LOC

RF of abruptio placentae

HTN

preeclampsia

hx of abruptio placenta

cocaine use

trauma

smoking

multiple gestation

domestic violence (DV)

short umbilical cord

fetal growth restriction

chorioamnionitis

ETOH

Complications of abruptio placentae

hemorrhage

DIC

couvelaire uterus (requires hysterectomy)

anemia, shock

fetal death

Tx for abruptio placentae

induction if mild and near term

IV fluids, blood transfusion

C/S

dx abuptio placentae

abnormal clotting factors: PT (> 15 sec), PTT (> 60 sec)

CBC (Hgb, Hct, Plt)

US (r/o placenta previa) *normal US does NOT r/o abruption

Kleihauer-Betke test (evaluates fetal/maternal hemorrhage in Rh negative patients

What is placenta previa?

Implantation of the placenta in the lower uterine segment; placenta that is covering the cervical opening

Classification: based on relationship to the internal os of the cervix

S/Sx of placenta previa

bright red painless bleeding

Soft, nontender uterus

slow onset

fetal distress

RF of placenta previa

previous Hx

multiparity

AMA

defects in blood vessel development

Hx of C/S or uterine surgery

cocaine use/smoking

large placenta

induced abortion or recent SAB

dx of placenta previa

transabdominal US

grade 1: low lying

grade 2: marginal

grade 3: partial

grade 4: complete

Tx of placenta previa

identify the cause of bleeding

blood transfusions

possible C/S

fluids

monitor bleeding and VS

bed rest

no vaginal exams

Hgb, Hct, Rh factor, UA

give steroids

Complications of placenta previa

hemorrhage/hypovolemic shock

fetal distress

preterm birth

maternal anemia

placental abruption

What is cervical insufficiency?

Premature dilation of cervix, usually in 4th or 5th month (painless, no contractions)

dx of cervical insufficiency

positive history of repeated, painless and bloodless second trimester abortion and/or vaginal US

Etiology of Cervical insufficiency

congenital (DES exposure, bicornuate uterus)

Acquired (inflammation, infection, trauma, cone biopsy, late 2nd trimester abortions, multiple gestations)

hormonal (Relaxin *too much)

Tx for Cervical insufficiency

cerclage reinforces weakened cervix, usually between 12-18 weeks

Nursing management for cervical insufficiency

continued monitoring for S/Sx of PTL (backache, increase in vaginal discharge, ROM, UCs)

Maternal implications of multiple gestation

spontaneous abortion

gestational diabetes, HTN

acute fatty liver

PE

anemia

hydramnios

PTL/PROM

pulmonary edema

more physical discomforts

Fetal implications of multiple gestation

perinatal mortality rate 4x greater

twin to twin transfusion

IUGR

increased fetal anomalies

prematurity

abnormal presentation

What can happen to the fetuses in multiple gestation?

Monochorionic placenta: monochorionic twins - 30% of twin gestations, susceptible to complications; almost all have anastomoses (allow flow of blood between fetuses; 15% of flow becomes unbalanced - TTS)

TTTS: 90% perinatal mortality (untreated): early laser ablation; one baby - anemic, oligohydramnios, growth issues; other baby - plethoric, edema, organomegaly

Clinical therapy for multiple gestation

serial US: assess growth

preventing PTL

restricted activities, rest on left side

close fetal monitoring during labor

majority born by C/S: presenting twin in non-vertex position

double set-up, internal version

support

assess for hemorrhage

What is polyhydramnios?

excessive amniotic fluid, also known as hydramnios or amniotic fluid disorder, a pregnancy complication in which there is an abnormal increase in the volume of amniotic fluid

S/Sx of polyhydramnios

SOB

swelling/edema in LE

feeling contractions

intense pain (if severe enough)

increase in fundal height

extremely tense/tight abdomen (in more severe cases)

Etiology/RF of polyhydramnios

gestational diabetes

Other problems that prevent the fetus from swallowing amniotic fluid

Congenital infections and other infections like syphilis, toxoplasmosis, cytomegalovirus, herpes, and rubella

Rh sensitization

multiple gestation

fetal anemia/HF

dx of polyhydramnios

US

amniotic fluid index measurement

fetal monitoring

Tx for polyhydramnios

prenatally with amnioreduction (removes a large amount) or drugs that reduce amniotic fluid volume (Indomethacin)

induction labor/delivery

fetal monitoring

hydration

bedrest

artificial rupture of membranes (AROM) or amniocentesis (removes a small amount) to remove excess fluid

needle amniotomy (in term or near-term gestations to reduce the risk of prolapsed cord and the inability to remove the fluid slowly)

What are complications of polyhydramnios?

If undiagnosed or inadequately treated, it can lead to permanent conditions like hypoxic-ischemic encephalopathy (HIE) and cerebral palsy

* Due to the serious risks involved, fetal monitoring is mandatory

placental abruption

PPH

umbilical cord prolapse

stillbirth

breech

fetal malformations and preterm birth

What is oligohydramnios and why does it occur?

low amniotic fluid levels, occurs when the volume of fluid in the amniotic sac is lower than average, usually because the placenta is not functioning properly

Patho for oligohydramnios

When the placenta is not functioning properly, the baby receives fewer nutrients and possibly less oxygen. The baby’s organ systems redirect limited resources to the brain and heart and away from the kidneys, which produce urine. Because the amniotic fluid is mostly made of the baby’s urine, this can result in oligohydramnios, which is a serious health risk.

RF of oligohydramnios

ROM

placental insufficiency

past term pregnancy/post-maturity

fetal urinary tract defects

IUGR

meds like ACEIs and NSAIDS

S/Sx of oligohydramnios

decreased fetal movement

decreased uterus measurements

leaking fluid

pain

dx of oligohydramnios

early screening (via US and amniotic fluid index measurements)

fetal monitoring

fundal height measurements

Management/Tx for oligohydramnios

hospital bed rest

fetal monitoring

hydration

delivery at the first stages of fetal distress

amnioinfusion

C/S

complications of oligohydramnios

cord compression

fetal adhesions

IUGR

birth defects

need for C/S

miscarriage/stillbirth

pulmonary hypoplasia

What is dystocia?

long, difficult, abnormal progression of labor related to the power, passenger, and/or passage (nullipara’s are more subject to dysfunction in the latent phase, Multipara’s are more subject to dysfunction in the active phase), 30-50% of all indications for C/S

Problems of the Powers in dystocia

dysfunctional labor; ineffective UCs needed to dilate the cervix or expel the baby

RF of dystocia

over-stretched uterus d/t twin, LGA, hydramnios

maternal issues - obesity, AMA, short maternal height

medications - analgesics, epidurals

complications - labor induction, chorioamnionitis/PROM, pregnancy complications

fetus - malposition/malpresentation, LGA

what is tachysystole and what does it cause?

more than 5 contractions in 10 minutes, decreased blood flow and oxygenation to fetus

RF of tachysystole

high dose oxytocin, too fast

cocaine use

uterine rupture or placental abruption

Management for tachysystole

stop oxytocin

give terbutaline

left side, O2, increase fluids

what is hypotonic labor? What defines prolonged labor? What defines arrest of progress?

cervical dilatation and effacement are not occurring, UCs are irregular and weak (prolonged labor: < 1cm/hr; arrest of progress: no change in cervical dilatation for 2 hours *must be in labor)

What is hypotonic labor in the latent phase associated with?

induction of unripe cervix, false labor, early amniotomy, and PROM

Management of hypotonic labor in the latent phase

depends on cause:

pain relief

warm showers and baths to promote relaxation

systemic analgesics

low-dose oxytocin - to coordinate uterine contractions

what is hypotonic labor in the active phase associated with?

cephalopelvic disproportion (CPD), malposition, overdistension, and fatigue

Managment of hypotonic labor in active phase

depends on cause:

adequate IV fluids

maternal position changes

pain management

therapeutic communication to identify anxieties

amniotomy

oxytocin

what is post-term pregnancy?

greater than 42 completed weeks of gestation

RF of post-term pregnancy

primiparous

previous post-term pregnancy

fetal anencephaly

male fetus

maternal obesity

genetic predisposition

Maternal risks associated with post-term pregnancy

increased discomfort in pregnancy

anxiety

insomnia

cesarean/operative birth

trauma/hemorrhage

Fetal-neonatal risks associated with post-term pregnancy

Reduced placental blood supply

Decreased oxygenation/nutritional supply

macrosomnia/CPD

trauma/meconium

shoulder dystocia

Nursing care for post-term pregnancy

determine EDB and antenatal testing

continuous electronic monitoring

assess fluid for meconium staining

assess and support labor progress

what is malpresentation/malposition?

problems with the passenger - size/position of the fetus in relation to the pelvis

Example of malpresentation/malposition and defining features

Cephalopelvic disproportion (CPD) - incompatible pelvic structure with fetal head

• no change in station with increasing dilatation or pushing

• trial of labor for 4-6 hours

Describe passenger in malposition

Anything but OA

• OP - must rotate to OA with a position change or manual rotation

Describe passenger in malpresentation

brow or face

Breech - higher mortality rate

• Most turn by 33 weeks

Risks associated with breach malpresentation

asphyxia, aspiration, and cerebral hemorrhage

Maternal/fetal implications of malpresentation

C/S, severe lacerations

prolonged 1st and 2nd stage

oxytocin augmentation, vacuum/forceps

episiotomy

hemorrhage, infection

Management for malpresentation/malposition

maternal position changes (upright maternal position, squatting or kneel-chest position, side-lying)

using a birthing ball

oxytocin infusion

What is macrosomia?

fetal weight > 4000 - 4500 g

Risks of macrosomia

obesity, gestational diabetes, post-term, male, hx of macrosomia

Maternal implications of macrosomia

soft tissue laceration at birth

PPH

symphysis pubis split

fetal implications of macrosomia

brachial plexus injury

fractured clavicles, shoulder dystocia

what is shoulder dystocia?

Anterior shoulder gets stuck on the symphysis pubis; obstetric emergency

Interventions for shoulder dystocia

Lower head of bed to 45 degrees

McRoberts maneuver

Apply suprapubic pressure

Wood’s screw maneuver

Problems with the Psyche

perceived threat increases maternal stress

fear causes tension of muscles (tension < contractility and > fatigue

delays labor (educate and provide comfort: adjust temperature and lights, pain management)

Maternal implications of labor problems

fatigue

dehydration

increased incidence of infection

altered coping abilities

fetal-neonatal implications of labor problems

fetal distress

cephalohematoma

nursing assessment for labor problems

maternal VS, contractions, cervical dilatation, FHR

stress and coping

Nursing plan for labor problems

anticipate amniotomy (AROM)

anticipate augmentation

provide comfort and support

information on cause and plan of care

IV hydration

minimize vaginal exam

check for bladder distention/infection

What is an umbilical cord prolapse?

cord presents in front of the presenting part causing compression and < blood supply; medical emergency

RF of umbilical cord prolapse

breech or transverse lie, unengaged part with ROM, twins, hydramnios

Maternal-Fetal risks associated with umbilical cord prolapse

increased maternal stress, fetal bradycardia, anoxia and potential death

Nursing assessment for umbilical cord prolapse

risk status

observe perineum after ROM

assess FHR for bradycardia and decelerations

Nursing interventions for umbilical cord prolapse

prevention is key

pelvic exam with elevation of presenting part

knee-chest position

What is anaphylactoid syndrome/amniotic fluid embolism (AFE)?

obstetric emergency; occurs when a bolus of amniotic fluid, fetal cells, hair, or other debris enters the maternal circulation and then the lungs; between contractions amniotic fluid can enter veins through “micro-tears”

Sx of AFE

*sudden onset

SOB

hypoxia (severe)

cyanosis

cardiopulmonary collapse

shock

left ventricular failure —> negative inotropy

pulmonary edema

transient pulmonary vasospasm

ARDS

DIC

Management/Tx of AFE

Obtain IV access as quickly as possible

Initiate CPR immediately if respiratory and cardiac arrest occur (ensure crash cart is accessible)

Stabilize the laboring patient and prepare for emergency cesarean birth

Transfer patient to the ICU after surgery

* In the absence of the physcian/CNM, administer oxygen under positive pressure until medical help arrives.

Prepare the equipment needed for blood transfusion (cross-matched blood type) and CVP line insertion. As you replace blood volume with fresh whole blood to provide clotting factors, monitor the CVP frequently.

Epinephrine won’t work

ventilation support

dx of AFE

symptomology by the physician

autopsy

RF of AFE

trauma (ex: MVA)

microtears in placental blood vessels during labor

Complications of AFE

80% mortality

cardiac arrest

C/S (emergent)

cor pulmonale presence —> fluid overload

what is a uterine rupture?

separation of the uterine myometrium or previous uterine scar

RF of uterine rupture

Occurs frequently with vaginal birth after cesarean (VBAC) or repeat C/S

• Associated with uterine surgery, trauma, malposition, multiparity, overdistension, and Pitocin

Interval of birth between deliveries (<18 mo)

PP fever during previous C/S

Sx of uterine rupture

Fetal distress: always the first sign

Changes in station (loss)

Constant abdominal pain (except in the case of an epidural, which may present as shoulder pain)

hematuria/irritation to bladder

contraction cessation

Sx of shock (maternal tachycardia and hypotension)

variable/late decelerations followed by bradycardia

dx of uterine rupture

Leopold’s maneuver to determine postion change

fetal/maternal VS

confirmed through surgery

Tx for uterine rupture

possible blood transfusion for hemorrhage

monitor FHR

contact provider

prep for C/S

add 18 G for IV fluids

Complications of uterine rupture

hemorrhage

If hemodynamically unstable/uterus can’t be repaired —> hysterectomy

fetus: decreased oxygenation