OB 3 pt 1

• Dystocia

• Abnormal or difficult labor

• Abnormal progression of labor

  • Early admissions

    • Sedentary, early epidural, decreases labor progression

    • Encourage natural upright position

• Requires medical or surgical deliver

  • Leading cause of cesarean deliveries

Dystocia causes

• Problems with powers

  • Expulsive force

• Problems with passageway

  • Pelvis/birth canal

• Problems with passenger

  • Position/fetus

• Problems with psyche

  • Maternal stress

• problems with powers: Hypotonic uterine dysfunction

• Causes: Oxytocin, fetal malpresentation

  • Never relaxes between contractions

    • More contractions to compensate for ineffective contractions

  • Ineffective contractions, low placental perfusion

  • Longer latent phase, exhausted mother

• 0-6cm dilated

  • During active labor

  • Weak contractions, softer fundus with contraction

• Risk factors

  • Overstretching of uterus

    • Multiple fetus

    • One large fetus

    • Lots of fluid

    • Bowle or bladder distention

    • Excessive analgesia

      • Risk of hemorrhage

problems with powers:precipitate labor

• Abnormally rapid

• Less than 3 hours

• Manifestations

  • Genetically Soft/stretchy tissues

  • Abnormally strong contractions

  • A lot of Braxton hicks

• Complications

  • Maternal anxiety, injury, bleeding

  • Fetal hypoxic injury, trauma

problems with passenger

• Vertex but not flexed (face), OP

• Breech

  • Usually stuck by 35-36 wks

  • Risk for prolapsed cord, difficult birth

  • undo with External cephalic version

problem with passenger: shoulder dystocia

Obstruction of fetal decent of shoulder after head is delivered

• Obstetric emergency

• Occurs due to large fetus

• Fetal injury

  • Asphyxia, brachial plexus injury, fractures from purposefully broken ckavicle

• Maternal injury

  • Hemorrhage dt uterine atony, rupture, lacerations

Nursing care

• Call for help

• Assist with McRoberts maneuver or suprapubic pressure

• No fundal pressure! Call NICU team!

problems with passageway

• Pelvis

  • Pelvic inlet

  • Pelvic outlet

  • Pelvic shape

    • Best gynecoid, anthropoid ok

• Cephalopelvic disproportion (CPD)

• Can all lead to dystocia

problems with psyche

• Negative emotions

  • Anxiety

  • Fear

  • Helplessness

• Impact on dystocia

  • Uterine dysfunction

  • Uncoordinated contractions

  • Pain

  • Surgical birth

dystocia nursing assessment and management

• Nursing assessment

  • Hx of risk factors

  • VS (infection)

  • Uterine contractions

  • FHR, positioning (Leopolds)

    • Check to see if baby in good position and see where fhr can be assesed htrough leopolds

• Nursing management

  • Promoting labor progress

    • Active phase: 1cm/ hr

    • Bowel/bladder distention

      • Keep empty

    • Pitocin (oxytocin) augmentation

      • For protracted contractions

• Providing physical and emotional comfort

preterm labor

• Regular uterine contractions with cervical effacement and dilation before 37 weeks’ gestation

• Preventative progesterone for high risk @16 weeks

• Always had preterm

preterm risk factors

• Infection is huge! (dental, UTI)

• Uterine anomalies

• Multiple gestations/ ART

• Polyhydramnios

• Genetics

• Prenatal care

• ETOH/Drugs

• Extreme age

• Ethnicity

• Obesity

preterm fetal risk

• Neurodevelopment

• Respiratory Distress Syndrome (RDS), surfactant deficiency, stay in house

• Infections

• Thermoregulation issues, not enough fat

• Brain bleeds, micro premies 23-28 wks

• Jaundice, immature liver, pathologic jaundice

• High risk of developmental delays/disabilities

• Feeding issues

• Hypoglycemia

preterm Tx

• Bedrest-??

  • With bathroom privleages

  • Prevent dvt

• Tocolytic medications (Drug Guide 21.1)

  • Breaks down contraction

  • Won't stop preterm labor only delays it

• For preterm labor up to 34 weeks

  • Dilation of >2cm, 80% for nulliparous mom

• Purpose: Delay not Prevent!

  • reduce severity of RDS and other complications, delay delivery until corticosteroids can be given

• Contraindications

  • Abruption

    • Detaching from uterus

  • Fetal distress

  • Pre/Eclampsia

  • Dilation> 6cm

    • Too late

    • Active labor

  • Maternal instability

preterm medical tx

• magnesium sulfate ( smooth muscle relaxer)

• indomethacin (prostaglandin inhibitor) NSAID

• nifedipine/ Procardia (Ca+ channel blocker inhibits muscle Contrax)

• betamimetics (Terbutaline)

• corticosteroids (betamethasone)

all tocolytics except for steroid

• its-indomethacin

• not-nifedipine

• my-magnesium

• time-terbutaline

preterm labor nursing assessment

• History/Assessments Risk factors

  • Subjective:

    • Change in Discharge or spotting, ROM

    • Pelvic pressure, backache, cramps, GI

    • Heaviness or aching in the thighs

    • Uterine contractions with or without pain

    • More than six contractions per hour

• Objective:

  • Contractions

  • Effacement/Dilation

  • Fetal descent/station

  • Laboratory:

    • CBC, Urinalysis

    • Amniotic fluid analysis

    • Fetal fibronectin:

      • Glycoprotein from chorion

        • Glue that helps hold structure of membranes

        • Stuck between chorion and embrion

      • Good for triaging/admitting

      • Shouldn’t be present after 23 weeks

      • If present: delivery w/in 14 days

      • If absent: predictor of no delivery

        • Good sign

  • Diagnostic testing:

    • Cervical length measurement (U/S)

      • Good predictor after 16 weeks

      • If cervical length >30mm = no delivery soon

preterm support

• Multifactorial

• Working

  • Assessment

  • Education

  • Stress reduction

• Nonworking

  • Full family support

  • Nicu

preterm prevention

• Avoid traveling long distances

• Avoid lifting heavy objects

• Avoid performing hard, physical work

• Mild to moderate levels of exercise

• Appropriate weight and nutrition.

• Wait 18 months between pregnancies.

• Visit a dentist in early pregnancy

• Avoid sexual activity preterm labor

• Avoid cannabis, cocaine, tob, heroine

• Use stress management techniques

• Seek help with IPV

• Teaching of Symptoms:

  • Contraction pattern frequency

  • Backache

  • GI issues

  • Pelvic pressure

  • Leaking

postterm labor

• Pregnancy >42 weeks’ gestation

  • Incorrect dates 

• Unknown etiology

• Pregnancy issues: uteroplacental insufficiency, Fluid levels

post term labor assessment and management

• Nursing assessment:

  • Estimated date of delivery

  • Daily fetal movement counts,

  • NST, BPP, AFI twice weekly

  • Weekly cervical examinations

  • Client needs: education, anxiety, and coping ability

• Nursing management:

  • Fetal surveillance

  • Decision for labor induction

  • Support; education

  • Intrapartum care; pain management!

postterm labor maternal and fetal risks

• Maternal risks: Exhaustion!

  • C/S

  • Dystocia/ birth trauma

  • Postpartum hemorrhage

  • Infection

• Fetal risks: problems with big babies, FGR

• TX

  • induction and augmentation

Induction

stimulating contractions via medical or surgical means

augmentation

enhancing ineffective contractions after labor has begun

labor induction and augmentation

• All-time high!

  • Fetal distress, C/S , instrumental delivery, epidurals, infections, NICU

• Recommendations:

  • After CPD is ruled out , clear medical indication

  • Close monitoring

• Contraindications:

  • Previa, abruption, prolapsed cord, classical incision, Abn FHR

• Reasons:

  • PPROM, HTN, infection, dystocia, IUFD, Diabetes

• Many interventions required:

  • IV

  • Bed rest

  • Continuous FHR monitoring

  • PAIN!

  • Prolonged stay

labor induction and augmentation: assessment

• Maternal & Fetal status

• Cervical Assessment for Ripeness

  • Ripe cervix: 1st step in before effacement/dilation

  • Bishop Score

    • likely successful induction

    • Short, centered, soft, partially dilated is good!

    • Good score:

      • 8-10 good

      • 6-7 give some time, middle rnage

      • 0-5 give meds to rippen

labor induction and augmentation: therapeutic management

• NonPharm:

  • Herbal agents

  • Castor oil, hot baths, enemas

  • Sexual intercourse with breast stimulation

• Mechanical methods

  • Foley

  • Dilators (laminaria)

  • Rolled up Seaweed

• Surgical methods

  • Stripping of membranes

  • Amniotomy

labor induction and management: pharmacological management

• Bishop score of 5 or less

  • Prostaglandins- promotes cervical ripening and contractions

  • Dinoprostone (Cervidil, etc.)

    • Directly softens cervix

    • Cervical insert

  • Oxytocin (Pitocin)

    • Uterotonic Agent- very popular!

    • IV:POTENT

    • No placental crossing

    • Watch out for uterine hyperstimulation = FHR!!

      • Tachysystole more than 6 contraction in 10 min period not enough resting tone for good placental perfusion, maternal exhaustion.

      • Stop Pitocin

    • 10 units/1 L of isotonic solution, titrated to achieve stable contractions every 2 to 3 minutes lasting 40 to 60 seconds

    • 1cm/hr dilation progress is good!

    • Misoprostel (Cytotec)

      • Prostaglandin and Uterotonic

      • Not as potent as oxytocin

      • Ripens cervix

      • Oral, vaginal, rectal

      • Can also cause uterine overstimulation

tocolytics

• Magnesium Sulfate (smooth muscle relaxer)

  • IV

  • Assessment: RR, DTR, renal fx, FHR, infant RR,

  • Also treats preeclampsia

• Indomethacin (prostaglandin inhibitor)

  • NSAID

  • Oral/Rectal

  • Risk: oligohydramnios

  • Assessment: Urine output, mat temp, AFI

• Nifedipine/Procardia (Ca+ Channel blocker that inhibits muscle contractions

  • Better effectiveness

  • Oral or sublingual

  • Assessment: Cardiac SSX (hypotension, tachycardia, HA, N/V, flushing)

• Betamimetics ( Terbutaline) Not in book

  • Derived from epinephrine

  • Assessment: racing HR! Fetal arrythmias

uterotonics

• Dinoprostone (Cervidil, etc.)

  • Directly softens cervix

  • Cervical insert

• Oxytocin (Pitocin)

  • Uterotonic Agent- very popular!

  • IV:POTENT

  • No placental crossing

  • Watch out for uterine hyperstimulation = FHR!!

  • 10 units/1 L of isotonic solution, titrated to achieve stable contractions every 2 to 3 minutes lasting 40 to 60 seconds

  • 1cm dilation progress is good!

• Misoprostel (Cytotec)

  • Ripens cervix

  • Oral, vaginal, rectal

  • Can also cause uterine overstimulation

corticosteroids

• Corticosteroids (Betamethasone) before 34 weeks

  • IM; 2 doses 12 hours apart

  • Helps Increase production of surfactant earlier and faster

obstetrical emergencies

• umbilical cord prolapse

• placental previa

• placental abruption

• uterine rupture

• amniotic fluid embolism

umbilkical cord prolapse

• Obstetric emergency!!

• Partial or total occlusion of cord with rapid fetal deterioration

• Nursing assessment

  • Prevention- Knowing Risk factors

    • Malpresentation

    • IUGR, Prematurity

    • Rom with high station

    • Polyhydramnios

  • Continuous assessment of client and fetus

• Nursing management

  • Prompt recognition- sudden bradycardia

  • Measures to relieve compression

    • Manual

    • Position – Trendelenburg, knee to chest, Sims

placental previa

• Diagnosed with ultrasound

• Placental implantation in the lower uterine segment over or near internal os of cervix

• 1^st thought with painless bleeding

• Causes:

  • Direct cause with # of C/S

• Risks:

  • Separation, bleeding or hemorrhage

  • Barrier

  • 2^nd or 3^rd trimester of pregnancy

  • No Vaginal Exam!! For fear of abruption

  • C/S

placental abruption

• Obstetric emergency involving premature separation of placenta

• At risk for no perfusion needs circulation

• Risk factors

  • Illicit drugs (cocaine)

  • Trauma

    • IPV, CAR ACCIDENT

  • HTN

  • Smoking

• Management dependent on gestational age, extent of hemorrhage, and maternal–fetal oxygenation perfusion

  • Less than 20 wks SAB

• Maintenance of maternal cardiovascular status

• Prompt delivery of fetus

• Cesarean birth if fetus still alive; vaginal birth if fetal demise

• S/S:

  • Vaginal bleeding (but also may not see any)

  • Hypertonic contractions

  • Maternal hypovolemia (shock, oliguria, anuria)

    • Coagulopathy

  • Pain mild to severe – usually localized over one region, but could be diffuse and feel like a board

  • “Silent Abruption” – may not have any pain or tenderness

    • Still see other signs

  • Maternal risk: hemostasis related

  • Perinatal mortality/Neonatal mortality and morbidity is 15-30% - because of:

    • Hypoxia, preterm birth, SGA

    • Risk of neuro defects is increased

uterine rupture

Obstetric emergency; onset marked by sudden fetal bradycardia

Nursing assessment

• Risk factors: previous uterine surgery, hyper stimulation 

• Onset of sudden fetal distress

Nursing management 

• Preparation for urgent cesarean birth

• Continuous maternal and fetal monitoring

amniotic fluid embolism

Obstetric emergency- 20% mortality and 50% survivors have neurologic injury

Sudden onset of hypotension, hypoxia, and coagulopathy d/t amniotic fluid (or particles) enter maternal circulation

Nursing assessment:

• difficulty breathing,

• cardiac arrest

Nursing management:

• hemodynamic function

• critical care monitoring 

external cephalic version

36-38 weeks

Rotation of fetus done manually In patient, with ultrasound and FHR

monitoring

cesarian birt

• Reasons?

• Classic or low transverse incision

• Incisions:

  • Low transverse

  • Classical/Vertical

• Blood loss

• Skin closures:

  • Sutures/Surgical

  • Glue

  • Sutures/staples

• Nursing management

  • Preoperative care

  • Blood work

  • Prepare surgical site

  • IV

  • Foley

  • Meds

• Postoperative care

  • Frequent VS

  • Fundal/Lochia Assessments

  • Dressing/wound assessment

  • Perineal Care/hygiene

  • Pain management

  • IS/Movement/GI

  • Help with baby

vaginal birth after cesarean VBAC

• Controversy related to risk of uterine rupture and hemorrhage

• Contraindications

  • Prior classical incision

  • Other uterine surgery

  • Emergent birth

• Special areas of focus: consent, documentation, surveillance, and readiness for emergency

instrumental deliveries

• Application of traction to fetal head

• Forceps: similar to tongs

• “Guided pushing”

• Indications:

  • nonreassuring FHR pattern, presumed fetal jeopardy or fetal distress

  • Risk of tissue trauma to mother and newborn

• Prevention as key

terms

• “Failure to Progress”

• Protracted Disorders (slower)

  • Hydration, reassurance, position changes

• Arrest Disorders (cessation)

perinatal loss

Perinatal loss- pregnancy loss/neonatal death up

to 1 month of age

• Numerous causes, some unknown

• Post-term

• Substance abuse

• Infection, HTN, diabetes, obesity

• Congenital anomalies

• Cord, Uterine Rupture, AMA

• Trauma

• Social determinants of health

• Devastating effects on family and staff

• Nursing assessment/management

• Inability to obtain fetal heart sounds

• Ultrasound to confirm absence of fetal

activity

• Labor induction

• Assistance with grieving process/seeing

baby

• Referrals

Multiple Gestations

• Increased incident

  • People having babies later, IVF puts multiple embryos into patient

• Increased mortality, morbidity

• Vaginal delivery is twins are vertex/vertex

• No vaginal delivery > twins

• Vaginal delivery done in OR

• Must monitor both fetus'

• Maternal risks: Uterine rupture, hemorrhage d/t uterine atony

• Fetal risk: Prematurity, IUGR intrauterine growth restrictions, C/S

  • Excessive fetal size

• Macrosomia (LGA) > 4000g

• Risk for dystocia

• Increased use of instrument delivery

• May be scheduled C/S to avoid

  • Dystocia

  • Maternal hemorrhage

  • Maternal laceration injury