High Risk Labor and Delivery (NURS 368)

dysfunctional labor

dysfunctional or ineffective labor due to abnormalities of the powers (forces, uterine contractions), passenger (fetus), passage (pelvis)

dystocia

general term for any difficult labor or birth and can be caused from any of the P’s

labor and associated complications (dysfunctional powers)

problems with “powers” or contractile forces which involve abnormalities with frequency, duration, intensity of contractions, resting tone of uterus between contractions 

stages of labor

stage one labor, stage two birth, stage three delivery of placenta

latent phase

hypertonic labor occurs in which phase

hypertonic labor

prodromal labor, resting tone of myometrium increases, often with constant pain

hypertonic labor contractions

painful, erratic, and with poor intensity, Cx duration may decrease while freq may increase (not same as tachysystole)

hypertonic labor maternal risks

may lead to maternal exhaustion

hypertonic labor fetal risks

fetal intolerance of labor due to decreased placental perfusion, lead to hypoxia/asphyxia

nursing care of hypertonic labor

promote rest, relaxation, PO or IV hydration, assess FHR, UCs, vaginal exam, administer tocolytic or pain meds as ordered

active phase of labor

hypotonic phase occurs in which phase

hypotonic labor contractions

contractions may weaken in intensity/duration, not strong enough to result in dilation/effacement

maternal risk of hypotonic labor

exhaustion, infection if membranes ruptured

fetal risks of hypotonic labor

fetal intolerance of labor, decrease in variability or late decels

nursing care of hypotonic labor

administer pitocin, amniotomy, encourage voiding, prevent dehydration, position changes, evaluate FHR, contractions, limit vaginal exams if ROM, emotional support, consider sedative to promote rest and relaxation

arrest disorder: stage 1

>6cm (active phase) AND >4hrs of adequate cxs/6hrs inadequate cxs

stage 2 arrest disorder

after 2-3 (or 4) hours of pushing

arrest disorders are

failure to progress or failure to descend (closely watch fetal-maternal status)

precipitous labor and birth

lasting <3hrs, UCs more frequent, longer duration, more intense, delivery is sudden, unexpected, and often unattended

risk factors of precipitous labor and birth

grand multip, history of precip delivery

maternal risks of precipitous labor and birth

postpartum hemorrhage, lacerations, placental abruption

fetal risks of precipitous labor and birth

hypoxia, CNS depression

precipitous labor and birth nursing care

monitor closely, stay with patient, perform SVE if patient has need to push, bear down, comfort measures, monitor FHR, maternal oxygen, IV fluids, tocolytic drug, prep for delivery (possibly nurse delivery)

nursing delivery for precipitous labor and birth

GET HELP, include NICU staff, keep bed together, keep newborn from popping out (gentle counter pressure on head to control delivery), dry and stimulate infant, bulb syringe if needed, assess infant (APGAR), skin-to-skin with cord intact

fetal (passenger) dystocia

difficult labor due to malpresentation of fetus or excessive size (macrosomia), multiple, fetal anomaly, vaginal birth difficult, CPD, failure to progress or descend

fetal (passenger) malpresentation

persistent OP or OT, brow, face, breech, shoulder (transverse lie)

cephalopelvic disproportion (CPD)

fetal head is larger than pelvic diameter (in given fetal position), abnormal position/presentation may occur as presenting part tries to pass through pelvis

nursing care of CPD

position changes (squatting, turning, hands and knees), comfort care, monitor FHR, prepare instrument assisted or C section

shoulder dystocia

EMERGENCY!, shoulders become impacted under symphysis after delivery of fetal head, may result in neonatal morbidity and potentially mortality

turtle sign

retraction of head in perineum (shoulder dystocia)

shoulder dystocia affect on fetus

respiratory exchange ceases as chest, neck, and cord compressed- asphyxia starts after ~5 minutes, brachial plexus injury, broken clavicle, neurological injury, asphyxia, death

shoulder dystocia nursing care

request additional staff, suprapubic pressure (and downward traction of fetal head), McRoberts maneuver, midline episiotomy- increase visualization, empty bladder, anticipate neonatal resuscitation, explain situation

pelvic dystocia

presence of contractions (narrowing) in one or more of the three planes of pelvis (inlet, midpelvis, oulet)

most favorable pelvic shape for vaginal delivery

gynecoid

least favorable pelvic shape for vaginal delivery

platypelloid

pot-term pregnancy

42-0/7 weeks and beyond, NSTs 2-3x a week, AFI- oligohydramnios, induction at 41 weeks or greater, asses for signs of fetal distress, post maturity syndrome

placenta and umbilical cord abnormalities

umbilical cord prolapse, anaphylactoid syndrome, abnormal placentation, pre-e, placenta previa, placental abruption

umbilical cord prolapse

EMERGENCY- umbilical cord precedes presenting part, pressure on cord from presenting part and maternal pelvis compress cord- FHR drops and does not recover (a prolonged variable deceleration → bradycardia)

risk factors of umbilical cord prolaps

malpresentation (breech or shoulder), presenting part not engaged in pelvis, preterm small fetus, multiple gestation, polyhydramnios)

nursing care umbilical cord prolapse

relieve pressure on cord ASAP, call for help, lift presenting part off cord with gloved hand or position changes (knee chest position or elevating hips and trendelenberg position)

medical care umbilical cord prolaps

DC oxytocin, administer oxygen, IV fluid bolus, administer a tocolytic to decrease uterine activity, prepare for vaginal or instrumental delievery if birth is imminent, prep for C section

anaphylactoid syndrome other name

amniotic fluid embolism

pathophysiology anaphylactoid syndrome

amniotic fluid enters into maternal circulation and causes a massive anaphylactic-like, inflammatory response to the fetal fluid/particulate occurs

risk factors of anaphylactoid syndrome

precipitous delivery, AMA, placenta previa or abruption, preeclampsia, instrumental or c section delivery, cervical laceration, grand multips

anaphylactoid syndrome is an…..

EMERGENCY

why is anaphylactoid syndrome an emergency

it causes respiratory failure and cardiogenic shock (starting from pulmonary vasospasm and occlusion), acute dyspnea, severe hypoxia, cyanosis, hypotension, respiratory arrest, cardiac arrest, uterine atony, massive hemorrhage, can progress to sever coagulopathy

coagulopathy

disseminated intravascular coagulation

anaphylactoid syndrome interventions

call code, CPR as needed, administer oxygen, ensure IV access, administer RBCs, platelets ordered, transfer to ICU, often fatal 60-86% mortality rate (survivors typically have permanent neurological injury

risk factors for DIC

anaphylactoid syndrome, abruptio placenta, preeclampsia, HELLP syndrome, sepsis, PPH

pathophysiology of disseminated intravascular coagulation

abnormal activation of blood clotting/coagulation mechanisms, probably due to severe inflammatory response to initial event (aka anaphylactoid syndrome or PPH), this leads to fibrin blood clot formation in small vessels then depletion of clotting factors (platelets, prothrombin, fibrinogen), leads to mass hemorrhage

-excessive clotting and bleeding at same time

disseminated intravascular coagulation s/s

severe uterine bleeding, bleeding from IV site, incision, gums, signs of shock

disseminated intravascular coagulation treatment

administer massive blood/blood products, transfer to ICU

placenta accreta

79%, chorionic villi attach directly to myometrium

placenta increta

14%, myometrium is invaded by chorionic villi

placenta percreta

7%, myometrium penetrated by chorionic villi

abnormal placentation greatest risk factor

previous c-sections, may result in hysterectomy

abnormal placentation nursing care

anticipate and be prepared for hemorrhage

uterine rupture

tearing of uterine muscles either complete, incomplete, or dehiscence

uterine rupture causes

weakened uterine scar (after c-section) vertical incisions worst, most common in VBACs, mismanagement of pitocin (avoid use in TOLAC), obstetric trauma

signs of uterine rupture

(depends on degree of tear) tearing sensation, vaginal bleeding, fetal compromise/loss of fetal heart tones, maternal hemorrhage, hypovolemia, shock

uterine rupture medical and nursing care

notify provider, monitor vitals, assess bleeding, pain, administer oxygen, IV fluids, prepare for surgical repair and/or c section, administer blood, support/educate patient and family

uterine inversion (prolapse)

may occur at time of birth or later in life, uterus replaced manually or surgically, assess for bleeding, shock

first degree laceration

skin, subcutaneous tissue

second degree laceration

extends into perineal body and muscle

third degree laceration

extends into some of external anal sphincter

fourth degree laceration

extends through sphincter and into rectum

nursing care lacerations

assess for bleeding, swelling, bruising, approximation, ice packs for 24 hrs/sitz bath after 24 hrs