Intrapartum Irat

dystocia

abnormal progression of labor - long, difficult, abnormal labor caused by various conditions - 5 p’s of dysfunctional labor

Labor dystocias can be due to issues with

powers, passenger, passageway, position, personality/psyche

hypertonic uterine dysfunction

pain of contractions is out of proportion to strength of contraction; occurs during the latent phase of the first stage of labor

hypertonic uterine dysfunction is most common in

nulliparous women

s/sx of hypertonic uterine dysfunction

increased frequency/intensity of contractions; increased resting tone - causing decreased placental blood flow; uncoordinated, ineffective contractions; lack of progress - no cervical dilation; excessively painful contractions that do not match intensity as measured by palpation of uterus

Nursing Interventions for Hypertonic Uterine Dysfunction

hydration - improves uterine perfusion and coordination of contractions (may need IV therapy); promote relaxation - warm shower or bath, quiet environment, little interruptions; assist with amniotomy to augment labor; pitocin augmentation

hypotonic uterin dysfunction

normal labor progress through the latent phase of 1st stage of labor, but UC’s decline in frequency/intensity/duration in active phase

contributing factors to hypotonic uterine dysfunction

overdistended uterus; too much pain medication given too early in labor; fetal malposition; regional anesthesia: epidural

s/sx of hypotonic uterine dysfunction

little or no cervical change in active phase; normal to low resting tone; if prolonged labor - maternal exhaustion and increased risk of PP hemorrhage

nursing interventions for hypotonic uterine dysfunction

hydration; encourage position changes and ambulation; assist with amniotomy; pitocin augmentation

ineffective contractions/pushing efforts in 2nd stage may be related to

fatigue, hypoglycemia, excessive anesthesia or analgesia, excessive stress or pain causing increased catecholamines, uterine overdistention, dehydration, maternal position

s/sx of ineffective contractions

inadequate expulsive forces or efforts; inability to push effective from effects

ineffective contractions increases the risk for

incidence of operative delivery and increased risk for need for c section

nursing interventions of ineffective contractions

identify and correct cause; turn down epidural, prevent fatigue, preserve energy, keep her hydrated, assist, teach, coach, encourage relaxation, may try pitocin augmentation, monitor fetal response

protracted disorders and arrest disorders

FTP (failure to progress)

why might there be FTP

cephalopelvic disproportion

protracted active phase

slower than normal rate of cervical dilation

protracted descent

delayed descent of the fetus in the active phase

secondary arrest of dilation

no cervical change in 2 hours

arrest of descent

fetal presenting part does not descend in pelvis for more than 1 hour in primigravidas and more than 30 minutes in multigravidas

labor augmentation

stimulation of more effective contractions after onset of labor

labor induction

stimulation of contractions before onset of labor

precipitous labor

time for labor and delivery less than 3 hours total

what can precipitous labor result in

maternal injury and fetal trauma/asphyxia; uterine rupture due to intensity of contractions; PP hemorrhage due to uterine atony/lacerations

risk factors for precipitous labor

multipara

s/sx of precipitous labor

vert strong contractions, resulting in a lot of pain and anxiety and a rapid progress

nursing interventions for precipitous labor

terbutaline; establish rapport quickly - don’t leave patient alone; anticipate PPH and fetal hypoxia

pelvic dystocia

small or abnormally shaped pelvis increases risk for CPD

CPD

cephalopelvic disproportion

CPD risks

risk for cord prolapse, fetal asphyxia, fetal injury, maternal lacerations, need for operative delivery

s/sx of pelvic dystocia

contracted pelvis + large baby; no fetal descent resultin in FHT’s found higher in abdomen; abnormal presentation with cervical exam; presenting part not engaged

soft tissue dystocai

obstructions caused by soft tissue issues - FULL BLADDER

fetal distress

fetal bradycardia/tachycardia; decelerations; meconium passage in amniotic fluid; cord prolapse, fetal emergency

nursing considerations for fetal distress

LIONS

complete breech

hips flexed, knees felxed

frank breech

hips flexed, knees extended

footling breech

foot or feet presenting first

kneeling breech

knees presenting first

breech s/sx

FHT’s heard above mom’s umbilicus; slow fetal descent; meconium; prolapsed cord; head entrapment

external cephalci version (ECV)

must not be inlabor; presenting part must not be negaged; adequate amniotic fluid; reactive NST; ultrasound guidance; tocolytic; offered at 37-39 weeks

shoulder presentation

transverse or oblique lie

risk factors for shoulder presentation

relaxed maternal abdominal muscles

s/sx of shoulder presentation

asynclitism common

cephalic but not vertex position

caused by anything that delays engagement (CPD or nuchal cord)

examples of cephalic malpresentations

brow or face

most common fetal malposition

occiput posterior

s/sx of occiput posterior

severe back pain, prolonged second stage, increased risk of larger lacterations including fourth degree

nursing interventions for occiput posterior

to help baby rotate; rocking pelvis; lunge to side; side-lying; McRobert’s maneuver

shoulder dystocia

OB emergency; difficult delivery of fetal shoulders

turtle sign

shoulder’s don’t deliver

risk for fetal injury with shoulder dystocia

clavicle fracture; humerus fracture; brachial plexus injuries from stretching or tearing of nerves; fetal hypoxic injury or death; risk for maternal injury

shoulder dystocia interventions

mcrobert’s; suprapubic pressure; no fundal pressure; bladder empty

risks with multifetal pregnancies

preterm labor; hypotonic contractions; malpresentation; fetal hypoxia; increased risk for PPH

fetal anomalies

hydrocephaly, ascites, open neural tube defects

anxiety and pain

increase in catecholamine release, which leads to increased production of beta endorphines, adrenocorticotropic hormones, cortisol, and epinephrine

uteroplacental insufficiency

impaired circulation/bloodflow

aging placenta

infarcts, calcification

invasive placentas

accreta, increta, percereta

accreta

attached to myometrium

increta

invades myometrium

percreta

penetrates through myometrium

placenta previa

placenta covers or partially covers cervix

abruptio placenta

premature separation of placenta from utuerus

battledore placenta

umbilical cord inserted at or near placental margin

circumvallate placenta

membranes double back around edge of placenta, causing a fibrous ring

succenturiate lobe

>= 1 accessory lobes of fetal villi have developed

risk factors for placental problems

multiparity, placenta previa, endometrial defects, scarring of uterus, age >35

prolapsed cord

occurs inrelationship to rupture of membranes if presenting part not engaged in pelvis

normal umbilical cord

whaton’s jelly surrounds the blood vessels; length 55cm; central insertion in placenta; 2 arteries and 1 vein

nuchal cord

cord around neck, common

true knots

may see variable or prolonged decelerations due to cord compression; baby dies if true knot is tight and stops blood flow

false knots

abnormal, but doesn’t cause decels or fetal demise

marginal insertion of umbilical cord

longer

velamentous insertion of cord

shorter - more potential for impaired descent

preterm labor

onset of true labor between 20 and 36 weeks gestation

risk factors for preterm labor

non-hispanic black infants; <17 and >35; income, education level, marital status, inadequate prenatal care, smoking, alcohol, drug use, inadequate nutrition, working long hours, domestic violence, lack of social support, prior preterm birth, multiple gestation, uterine/cervical anomalies

medications for pre term labor

tocolytics, magnesium sulfate, nifedipine, indomethacin, steroids, progresterone

terbutaline

not routinely used to stop preterm labor any longer; risk of pulmonary edema

nifedipine

calcium channel blockers - procardia

indomethacin

prostaglandin inhbitor/nsaid - used short-term before 32 weeks gestation due to infreased risk of premature closure of ductus arteriosus

glucocorticoids

stimulates srufactant production

progesterone supplement

patients at high risk for preterm birth should be offered this

incompetent cervic

painless dilation of the cervix

uterus tears

usually dehiscience of old uterines car tissue - acute medical emergency

causes of uterus tears

rupture of preexisting uterine scar

s/sx of uterine tears

sharp, shooting severe abdominal pain; something tore; contractions may stop; severe fetal distress; FHT’s may be lost

four cardinal signs of AFE

respiratory failure, altered mental status, hypotension, DIC

management of amniotic fluid embolus

oxygenation, circulation, control of hemorrhage and coagulopathy, seizure preautions, steroids

uterine inversion

uterus completely or partially turns inside out, usually during the third stage of labor

nursing interventions for uterine tears

prevent hypovolemic shock

induction

stimulating contractions before onset of sponatneous labor

augmentation

stimulating contractions after onset of sponatenous labor

contraindications for induction

placenta previa, abnormal fetal position, cord prolapse, previous C/S incision, active HSV, pelvic abnormalities

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