Intrapartum & IP Complications 1

Covers slides 1-34

“Four Ps”

• Powers

• Passage

• Passenger

• Psychologic

What are the components of the birth process?

Powers

Uterine contractions in the first stage of labor

• Frequency

• Duration

• Intensity

• Resting interval

Maternal pushing during second stage of labor

Passageway

Pelvic shape and soft tissues of the pelvis

• Best shape: gynecoid

• Okay shape: anthropoid

Passenger

Fetus

9 ½ in

What is the average head size for fetus?

1. Cephalic (best)

2. Breech (butt and legs first)

3. Transverse (across)

What are the different ways a baby might come out?

• First letter

  • Left or Right side of pelvis

• Second letter

  • Presenting part

  • Occiput (back of head), Mentum (chin), Sacrum (back of pelvis)

• Third letter

  • Front or back of woman’s pelvis

  • Anterior, Posterior, Transverse

How might the hospital refer to fetal position?

LOA and ROA

What is the best position a baby should come out?

LOP and ROP

What positions indiate the baby is coming out face upward?

• Give mother control; allow her to assume any position of comfort

  • Encourage movement

  • SQUATTING enlarges pelvis

    • assist gravity for fetal descent

  • Hands and knees, side lying, or side lunge positions can help to ROTATE fetus

  • Frequent position changes

What are the positions to promote rotation to OA (occiput, anterior)?

Birthing ball/ peanut ball

What is a device that is used to help promote fetal rotation to OA?

• Reduce length of labor, incidence of assisted deliveries

• Reduce tears and use of episiotomies

Why are FREQUENT position changes good for mothers intrapartum?

• Prepre for childbirth

• Trust in staff and partner to help and support

• Clear info of process and procedures

• Control over decisions being made

• Control over breathing and pushing

What are the nursing interventions to help with mothers PSYCHE intrapartum?

• Increased, clear vaginal secretions

• Braxton Hicks contractions

• Lightening, “dropping”

• Increased energy level, “nesting”

• Bloody show (release of mucus plug)

• Full term 38-42 weeks

What are the premonitory signs of LABOR?

• Contraction timing

  • REGULAR

  • BECOME CLOSER TOGETHER

  • 4-6 min apart, lasting 30-60 sec

• Contraction strength

  • Become STRONGER over time

  • Vaginal pressure usually felt

• Contraction discomfort

  • Starts in BACK and RADIATES to FRONT

• Change in activity

  • Contractions CONTINUE no matter what positional change is made

• Cervix

  • PROGRESSIVE EFFACEMENT AND DILATION (best indication)

What are contraction signs of TRUE labor?

Progressive effacement and dilation

What is the best indication of TRUE labor?

• Contraction timing

  • Irregular

  • NOT becoming closer together

• Contraction strength

  • WEAK; not getting stronger

• Contraction discomfort

  • Braxton Hicks, felt in FRONT of ab

• Change in activity

  • STOP or SLOW with walking or positional change

• Cervix

  • No significant change, drink fluids and walk, ok to go home

What are contraction signs of FALSE labor?

Labor

Uterine contractions resulting in cervical change (dilation or effacement)

cm dilated / % effaced / station

CES

How is a cervical assessment reported/documented?

• Contractions: nullipara vs. multipara

• ROM, with or w/o contractions

• Bleeding

• Decreased fetal movement (low kick count)

• Other concerns

What should you educate patients on WHEN to go to the hospital intrapartum?

• Nullipara: regular 5 mins apart for one hour

• Multipara: 10 mins apart for one hour

What the differences of contractions nullipara vs. multipara?

• Date and time

• Color

• Odor

• How much?

What are the things to assess if ROM?

• PROM or PPROM

  • Risk for chorioamnionitis; longer rupture before delivery, increased risk >18hrs

Why assess DATE and TIME for ROM?

• Cloudy (infection)

• Green (meonium; stool fetus had in utero)

  • dangerous if fetus swallows or aspirates on it

• Foul odor (infection)

Why note the color and odor of ROM?

1. SROM (spontaneous ROM); on its own

2. AROM (artificial ROM); done by provider (AMNIOTOMY)

What are the types of ruptured amniotic fluid statuses?

• Prolapsed cord

• Infection

• Placental abruption

What is the complications of amniotomy?

• Cervical assessment

• Need baseline reassuring fetal HR (110-160 bpm)

• Cephalic position

• ZERO STATION or lower (+1 or +2)

• Supplies: white towels under buttocks, sterile gloves for provider, amnihook, lubricant

• Document time, color, odor, fetal HR

• Monitor for fetal tachycardia (popping can cause stress), maternal fever (infection)

• Keep linens dry

• Pt. teaching

What are the nursing interventions for amniotomy?

• Cephalic position

• ZERO STATION or lower (+1 or +2)

What position should the baby be in for amniotomy?

• Fetal HR and contraction pattern (fetal monitor)

• How many weeks is she? (could be premature)

• Pregnany hx? GTPAL

• Is the prenatal record available?

• Allergies, problems with anesthesia

• Current labor and amniotic fluid status, cervical dilation and effacement, fetal position

• Plans and desires for birth

• Plans and desires for the care of newborn

• Cultural preferences

What is the initial maternal assessment intrapartum?

• H/H and blood typing, Rh factor, AB screen

• Rubella

• PLATELETS (if they can have EPIDURAL)

• Hepatitis B surface antigen (HbsAg)

• VDRL (syphillis)

• Drug screen if hx supports use

• HIV with consent

• GROUP B STREPTOCOCCUS (deadly for baby)

• Urine (protein, glucose, ketones)

What are the labs to check intrapartum?

37 WEEKS (35-37 usually)

At how many weeks should GBS swab be done?

Immunoglobulin

What should be given to the newborn if mom has HbsAg (Hep B)?

• Positive GBS swab (vaginal, rectal)

• Hx newborn GBS infection

• GBS bacteriuria during current pregnancy

• GBS status unknown

What are the indications for GBS prophylaxis?

Penicillin (AB)

• q4HR until delivery (at least 2 DOSE before delivery)

• If inadequate prophylaxis; newborn watched for s/s illness, tested and treated of necessary

What is the tx for GBS?

• Placenta previa

• Umbillical cord prolapse

• Transverse lie

• CPD (big head)

• Genital herpes

• HIV

• Maybe STIs (clamydia, gonorrhea)

What are the conditions that warrant C-section?

Effacement and dilation

THINNING and WIDENING of cervix

Fetal station

Measurement in labor to describe how far down baby’s presenting part has descended into pelvis

Negative station: high

0 station: middle (ischial spine)

Positive station: low

Ischial spine (midpoint of pelvis)

What anatomical structure is at 0 station?

• Leopold’s maneuver’s (determine fetus position)

• Analysis of FHR

• Uterine contraction pattern (how often, how strong)

• GTPAL

• Analysis amniotic fluid status (intact, ruptured)

• Cervical exam (c/e/s)

What are the nursing interventions in intrapartum?

Preterm Labor (PTL)

Labor that begins <37 weeks

• Uterine contractions, cramping or low back pain

• Vaginal discharge (loss of mucus plug)

• Leaking fluid from vagina (PROM)

What are the s/s PTL?

Fetal fibronectin (fFN)

What test is done to determine the risk of preterm birth?

Fetal fibronectin (fFN)

Test for specific proteins in vaginal secretions

• Negative result = less than 1% chance delivery within 2 weeks

• Hx preterm labor and/or birth

• Diabetes and/or chronic HTN

• Pregnancy w/ multiple fetuses

• PPROM and/or late or no prenatal care

What are the risk factors of PTL?

• MAGNESIUM SULFATE (MgSO4) IV

• NIFEDIPINE ORAL

• AB

• Corticosteroids

• FHR monitor

• Pain manage

• Pt. edu

What is the management for PTL?

• Relaxes uterine muscles to STOP and PREVENT contractions (off label use)

• Neuroprotective in early preterm gestations

• Main use for preeclampsia

What is MgSO4 used for in PTL?

Calcium channel blocker that INHIBITS contractions

• TOCOLYTIC

• May have less adverse reactions

Why give nifedipine oral in PTL?

Prolonged pregnancy

Pregnancy lasting >42 weeks

• Placental insufficiency (low nutrient, O2)

• Fetal macrosomnia

• Shoulder dystocia (brachial plexus injuries)

• Cephalopelvic disproportion (CPD) (big head)

What are the complications of prolonged pregnancy?

• TWICE a week NST AND/OR BIOPHYSICAL PROFILE

• Daily fetal movement (kick counts)

  • At least 10 in 2 HOURS

• Induction of labor after cervical ripening if needed

What is the management for prolonged pregnancy?

1. Evaluation of cervical readiness (ripening) first with BISHOP SCORE

2. OXYTOCIN (if cervix ripe, used w/o cervical ripening agent

3. Amniotomy (AROM, done once in active labor and if no rupture)

What are the steps when inducing labor?

Bishop Score

Determines the ripeness of cervix and how ready cervix is for birth

• Lower the score, the longer the anticipated labor

≤ 6: ripening agent should be used

≥ 8: none needed

7: up to provider

What do each of the scores mean in bishop score?

• Misoprostol (Cytotec) or dinoprostone (Cervadil)

• Provider may insert a transcervical catheter (cook balloon) into endocervical canal

What are the ripening agents used to help SOFTEN CERVIX to dilate and efface?

• Monitor FHR and contraction pattern closely

  • can cause hypertonicity of uterus (tight/contracted muscle)

What should be monitored when giving misoprostol or dinoprostone?

q4-6HR

• Buccal PO

• Into cervix

How is misoprostal administered?

Low cost, minimal restrictions

What are the advantages to misoprostol?

GEL to cervix with string (topical)

How is dinoprostone administered?

• Advantage: can be quickly removed/reversed

• Disadvantage: cautious use in women with asthma, HTN, renal/liver problems

What are the advantages and disadvantages to dinoprostone?

Oxytocin (Pitocin)

Stimulates uterine smooth muscle (uterotonic hormone)

• Used for INDUCTION and AUGEMENTATION of labor (causes contractions)

• CONTROLS BLEEDING after expulsion of placenta

• Stimulates MAMMARY GLAND smooth muscle

• VASOPRESSOR and ANTIDIURETIC

• INCREASES pain

What are the uses for Oxytocin in pregnancy?

• Increases contraction strength, duration, frequency

• Support descent of fetal head

• Rapidly metabolized and excreted (HALF LIFE 3 MINS)

  • easy to reverse

What are the benefits of oxytocin?

• Hypertonic uterine activity

• Water intoxication (anti-diuretic)

• Hypotension

• Fetal hypoxia

• Placental abruption

What are the complications of oxytocin?

• Hypertonic contractions; hyperstimulation of uterus (impaired blood flow, leads to fetal distress)

• Labor is too rapid

  • cervical lacerations, placental abruption, uterine rupture

• s/s fluid retention and hyponatremia

• monitor BP, FHR

What should you monitor for oxytocin?

• Headache

• Muscle spasm/cramping

• Fatigue/drowsy

• N/V

• Seizures

What are the s/s water intoxication (hyponatremia)?