Maternal-Newborn Final Pt 4

unit 4 material

what is version? when is version done (indications)?

turning of the fetus, can either be done externally or internally

what are the indications for an external version?

baby is breech, transverse, or in oblique lay (diagonal, the fetus’ shoulder in pelvis)

• must be one baby

• amniotic fluid amount is enough

• reactive NST (FHR and movement is reassuring)

what meds are given before external version?what is the purpose of these meds?

Tocolytics are given — either terbutaline or magnesium sulfate

• these are given to relax the uterus so that it doesn’t contract

what nursing interventions done before and after external version?

• get labs (CBC)

• ultrasound has been done to check fetal position, umbilical cord and placenta placement, and enough amniotic fluid is present

• IV is put in, in case of an emergency or fluids need to be given

• nurse should monitor baby and mother before and after procedure

• position pt supine, trendelenburg, pillow behind the knees, and gel is available to decrease friction

• give RhoGam to prevent incompatibility issues and decrease risk of maternal-fetal hemorrhage

list tocolytics

• magnesium sulfate

• terbutaline

• indomethacin

• nifedipine

internal version occurs when?

only in twin deliveries, with the second twin’s birth

what are contraindications for external version?

• ROM (rupture of membranes)

• nuchal cord (umbilical cord around the neck)

• C/S indicated

• suspected IUGR (could indicate placental abnormalities)

• multiple gestation (more than one fetus)

• amniotic fluid abnormalities

• maternal problems like HTN, Gestational diabetes, and preeclampsia

what are indications for labor induction?

• post-term gestation (greater than 40 wks)

• macrosomia (baby greaser than 8lbs and 13 oz)

• pre-eclampsia and pregnancy induced HTN

• Diabetes Mellitus

• Fetal Compromise — IUGR and Oligo

• fetal demise

• non-reassuring FHR

• PROM

• Chorioamnionitis —infection in the uterine lining from GBS or MRSA

• maternal compromise

what is Bishop score used for?

calculate readiness for labor by checking if the cervix is favorable, done by checking cervical dilation, effacement, consistency, position, and the station of the fetal presenting part

• for a pt who is 38 wks a bishop score of eight means successful induction

• the higher score = successful labor induction

what are contraindications to labor induction?

• placenta previa (can’t have a vaginal delivery since the placenta either covers the entire cervix or part of it - C/S required)

• transverse lie

• prolapsed cord

• fetal distress

• classical uterine scar — increases risk of uterine rupture

• active genital herpes

• CPD (baby cannot fit though pelvis)

what are the methods used for labor induction?

• cervical ripening - using outside agents to prepare the cervix for delivery

• Stripping membrane

• sexual intercourse

• herbs — i.e. evening primrose oil

what are some examples of cervical ripening methods for labor induction?

• prostaglandin gel — releases prostaglandins that softens the cervix and stimulates contractions

• misoprostol (cytotec) - inserted either vaginally, sublingual, or oral

• transcervical catheter — mechanical dilation occurs with a foley catheter — pressure on the cervix causes prostaglandins to release and begin contractions

what is “stripping membrane”? how does it induce labor?

stimulates labor within 24-48 hours

• finger swept in cervical os to strip amniotic membranes — though to release prostaglandins

• may cause bloody discharge and painful

what are indications for labor augmentation?

• prolonged labor

• no progress

• dysfunctional labor (problem with one of the 3P’s

• CPD (cephalopelvic disproportion)

• if not CPD then - AROM or oxytocin may be required

what are nursing interventions for labor augmentation?

• monitor maternal VS

• FHR and NST

• have pt void every 2 hours

• keep pt calm, educate, and stay with couple

• NPO

AROM

Artificial rupture of membranes — amniotomy done

Amniotomy

shortens labor by using amnihook

what should be assessed before amniotomy?

• check that pt is 2cm dilated

• know dilation and station of fetus before performing

THIS IS ALL DONE BY DOING A sterile vaginal exam BEFORE

what are nursing interventions after amniotomy?

• take temperature every 2 hours

• check FHR before and after — are they tolerating the labor well?

• have pt be on bed rest

• assess fluid — using COAT

what are risks of amniotomy?

increased risk for infection and trauma to fetus

prolapsed cord risk or compression of cord

• no research shown to confirm that is does quicken labor

amnioinfusion

instillation of LR or NS into uterus

why is amnioinfusion done?

• oligohydramnios (low amount of amniotic fluid present)

• to dilute meconium and decrease fetal aspiration of meconium (with NS)

• decrease risk of fetal chord compression

how do you administer oxytocin (Pitocin)?

• given with a separate IV pump

• 30 units with 500 mL of IV fluid***

• begin with 1-2 mL/hr and increase by 1-2 mU every 30 minutes if needed until good contraction pattern**

• monitor contraction pattern and FHR

• FOR POSTPARTUM: 10 units IM or IV push or IV fluid rate of 100 mL/hr of 30 units/500mL bag

what are nursing interventions when administering oxytocin (pitocin)

• monitor fetus (is fetus tolerating labor?)

• monitor maternal BP

• monitor contractions

• assess and adjust dose accordingly

what are the contraindications of oxytocin/pitocin?

increased BP in pt

distressed fetus

prolapsed cord

(BASICALLY ANY pt THAT NEEDS C/S)

what should nurse do if fetal distress is noticed during oxytocin administration?

• lay pt on left side

• stop oxytocin (pitocin)

• increase IV fluids

• administer oxygen at 8-10L per nonrebreather mask

• may admin turbutaline subq

what are the nursing cares for an episiotomy and laceration?

• ensure perineal hygiene is being performed —> educate pt to wipe from front to back, pat to dry, use peribottle (rinsing with water)

• ice packs or sitz baths

• change pad frequently — it could become breeding ground for bacteria

• increase water intake, fiber, and take stool softeners

• give pain meds (analgesics)

• educate on when sexual intercourse can resume

why is laceration better than episiotomy?

• quicker healing time than episiotomy

• decreased sexual dysfunction

• less anal sphincter damage

what types of patients are at high risk for forceps-assisted delivery?

• nullipara (first time mom)

• maternal age greater than 35

• short women < 4ft 11in)

• pregnancy wt gain > 35 lbs

• postdate gestation = bigger fetus

• epidural anesthesia (decreased sensation and unable to push effectively)

vacuum extraction indications and what should pt be?

indications:

• prolonged second stage of labor

• fatigue

• non-reassuring FHR

PT MUST BE:

• completely dilated

• engaged and low

• empty bladder

when should vacuum extraction be discontinued?

• greater than 3 pop-offs

• longer than 30 min of attempted use

what are contraindications for vacuum extraction?

less than 34 wks.

CPD (cephalopelvic disproportion)

non-vertex position

what are indications for C/S?

• CPD

• cervical cerclage

• tumors

• active genital herpes

• complete placenta previa

• placental abruption

• umbilical cord prolapse

• failure to progress (dystocia)

• fetal distress

• repeat C/S

• breech

• PIH (pregnancy induced HTN)

what are risk factors for C/S?

increased risk of maternal mortality

• risk of infection and bleeding/hemorrhage

• blood clots D/T anesthesia and no ambulation

• respiratory depression

• dehiscense

• longer recovery period

how do you prepare pt for C/S?

** all depends on whether this is scheduled, repeat, emergency

• pt should be NPO night before

• abdomen shaved

• foley

• abdominal scrub

• meds

• fetal monitoring

• education: pt will be given anesthesia - either general, spinal, or epidural

• they will feel pulling or tugging but it should be painless

• POST C/S: regular VS monitoring, look for bleeding, watch for “wet lungs” in fetus

what are characteristics for optimal VBAC or TOLAC candidate?

VBAC:

• previous low transverse cut

• vaginal dilation without induction

• healthy pregnancy

• a woman in her 20s

• a pt with hx of an induction with fetal distress that led to a C/S

• spontaneous rupture at 40 wks

• women laboring in a low-stress environment

what should be prepared before epidural?

• signed informed consent on file

• IV bolus given

what is the biggest disadvantage for epidural?

maternal hypotension

• caused when peripheral vasodilation occurs - decreases venous return - decreases cardiac output - and lowers BP/causes SOB/chest pressure reported

what are S&S of maternal hypotension?

• BP drops

• SOB

• chest pressure

what should be done if maternal hypotension occurs?

give another fluid bolus

what are contraindications for epidural?

• allergy

• lack of consent

• risk of localized infection

• increased intracranial pressure

• bleeding disorders

• low PLT count

what are nursing interventions before epidural?

• have crash cart ready and nearby

• obtain baseline VS (of mom and baby)

• have pt empty bladder

• give IV bolus (500 or 1,000mL of IV fluid 15-30 min BEFORE procedure occurs)

what are nursing interventions AFTER epidural procedure?

• don't leave pt alone for 20 min after procedure

• re-assess VS (every 5 min until stable and then every 15 min), bladder (may need to get an order for a foley)

• reposition from side to side

• observe for accidental total spine

how do you know accidental total spine has occurred?

• increased numbness to upper body

what are the disadvantages of a spinal block?

• maternal hypotension —> fetal hypoxia

• spinal headache R/T cerebral-spinal leak

contraindications for spinal block

• hypovolemia

• CNS disease

• local infection

• allergy

what are the disadvantages of using general anesthesia?

• impact mother and infant — fetal respiratory depression

• increases risk of mortality and morbidity

• b/c it relaxes everything - it increases the risk of hemorrhage for mother

when is general anesthesia typically used?

last resort

in emergencies

what is the primary risk with narcotics for fetus?

baby will look blue D/T lack of Oxygen

risk of respiratory depression

what is the rule when giving narcotics during labor?

DO NOT GIVEN AN HOUR BEFORE BIRTH

what is nalaxone?

NARCAN

used for respiratory depression D/T narcotics

what should be assessed after C/S?

• VS every 15 min x8

• VS every 30 min x2

• VS q4h if stable

• monitor that SpO2 is greater than 90%

• auscultate lungs

• check dressing are clean and dry (could have steristrips — look for HEALING AND DISCHARGE)

• whtauscultate bowel sounds — at risk for peristalsis, blockage, and perilitic ileus

• check for S&S of blood cots per shift

what are C/S delivery post care?

• Activity: bedrest, can dangle legs after 8hrs BUT should lay flat if spinal anesthesia used

• Nutrition: NPO 8 hours then cleared by provider

• monitor I&O

• elimination: Foley catheter every 4-8 hours

• give oxytocin, anti-emetics, anti-flatulents, analgesics

• can shower 24 hours after delivery

• SCD use to prevent DVTs