Nursing Care during Labor and Birth at Risk

maternal risk factors for preterm labor

low socioeconomic status

age below 16 or over 40

lack of social support, intimate partner violence

non-caucasian race

less than high school education

previous preterm birth/family hx

increased parity (6 deliveries or more, but increases with each one)

obesity

medical and obstetrical complications

uterine fibroids

perceived stress

infections

substance abuse/smoking

poor nutrition

work conditions

short spacing

when is preterm labor

20-37 weeks

what could cause preterm labor?

hx of preterm burth

bacterial vaginosis

intramniotic infection

prom

multiple gestation

bleeding

uterine/cervical abnormalities

bacterial vaginosis s/sx

vaginal discharge, foul odor, presence of "clue cells"

must be treated in pregnancy

intervention for intraamniotic infection

treat and deliver

s/sx of preterm labor

uterine activity

rhythmic discomfort --> indigestion, crampy, lower back pain

vaginal discharge

biochemical markers of preterm labor

FFN

Endocervical length

fFN (fetal fibronectin)

protein believed to help adhere amniotic sac to the lining of the uterus

how to test for ffn

speculum exam, swab cervix

what do the neg/positive results of the ffn test mean

if a woman is positive, poor predictor that she will deliver

if negative, 97% chance that she won't

home care after ffn test

if stable and negative

- education --> prevention is key!

- assessment --> stress management, home contraction management with toco

- interventions --> progesterone supplement

what can we give to women in her first trimester with a history of preterm birth

progesterone

hospital care after ffn test

positive, need to intervene fast

- medications

- steroids

medications for preterm birth

tocolytics

steroids

tocolysis

meds to stop contractions

great med for tachysystole

not great to stop pre-term, but long enough to get to tertiary care (NICU)

main tocolytic

terbutaline

terbutaline method of action

anti-asthmatic bronchodilator relaxes smooth muscles

terbutaline adverse reactions

tachycardia, tremors, fetal tachycardia, hyperglycemia

fluid overload symptoms from terbutaline

possible chest pain, dysrhythmias, hypotension, pulmonary edema

what med can reverse cardiac symptoms

propanolol

terbutaline administration

q15

subq- cannot get dose back

take pulse before and after

*clear lung fields before

*if 120 bpm or above, do not administer

first choice med to stop pre term labor

magnesium sulfate (MgSO4)

What does magnesium sulfate do?

slows contractions, neuroprotection, prevents cerebropalsy

antidote for mgso4

calcium gluconate

adverse reactions

mag toxicity, flushing, n/v, drowsiness, headache

how long can you use mgso4 for?

48 hours

- risk for fetal bone density issues

therapeutic range of mgso4

4-7.5 mEq/l

expected mgso4 levels when pt is slurring words and somnolance

10-12 mEq/l

expected mgso4 levels when pt is experiencing muscle paralysis, cardiac arrest, and death

15+

how often to check deep tendon reflexes with mgso4

q2

normal deep tendon reflexes

+2

what could depressed or absent deep tendon reflexes indicate

mag toxicity

first action if suspected mag toxicity

shut off drip

nifedipine

po antihypertensive, calcium channel blocker

prevents Ca from entering uterus

drug to use after 48h of mgso4

nifedipine

IM injection given as soon as she comes in for preterm labor

betamethasone

What does betamethasone do?

accelerates fetal lung maturity

crosses placenta to improve L:S ratio

1:1 --> 2:1

when is betamethasone given

between 24-24 weeks

betamethasone dosing

12mg IM

2 doses, given 24 hours apart

When is mom considered "beta complete"?

24h after 2nd dose

Premature Rupture of Membranes (PROM)

rupture of membranes before the onset of labor at any gestation (cervical dilation and regular contractions)

Preterm Premature Rupture of Membranes (PPROM)

PROM before 37 weeks

prolonged rupture of membranes

rupture of membranes for more than 24 hours prior to delivery

risks associated with PPROM

maternal and fetal infection

prematurity

low birth weight

cord prolapse

maternal and fetal infection from PPROM s/sx

fetal + maternal tachycardia

odor to amniotic fluid

fundal tenderness

maternal fever over 100.4

care of patients with premature rupture of membranes

if > 37 weeks, maybe be induced or discharged if stable

frequent vital signs (temp q4)

hygiene (peri care) and comfort

no vaginal exams

restricted activity

close observation for labor/abruption/infection

medications for premature rupture of membranes

antenatal corticosteroids if >24 and <34 weeks

administer 7 day course of antibiotics

precipitous labor

less than 3 hours from first contraction to birth

maternal risks from precipitous labor

uterine rupture

postpartum hemorrhage

amniotic fluid embolism

tears

infant risks from precipitous labor

decreased oxygen - baby didn't have enough rest between contractions

intracranial hemorrhage

facial bruising

dystocia

difficult labor

hypertonic uterine dysfunction

uncoordinated uterine activity. Contractions are frequent and painful but ineffective in promoting dilation and effacement.

action --> sedate patient

hypotonic uterine dysfunction

too few contractions (usually due to big baby), admin pitocin or prepare for c/s

lack of secondary powers

no energy to push --> forceps/vaccuum

action for dystocia - breech

external version

external version

md tries to turn the fetus from outside

monitoring for external version

tocolytic, ultrasound, EFM

considerations for external version

must have adequate fluid and small baby

rhogam if -

1 hr monitor post procedure

if baby doesn't tolerate it --> emergent c-section

induction of labor is determined by

bishop score

bishop score

Determines maternal readiness for labor by evaluating whether the cervix is favorable by rating

cervical dilation, effacement, consistency, position, and station

what bishop score requires a cervical ripening agent

6-8 --> prostaglandin

at what bishop score can you induce a woman

9

agents to induce labor

cervical ripening

amniotomy

oxytocin

how do we encourage cervical ripening

chemical agents: prostaglandins

mechanical agents: balloon

how can do we conduct an amniotomy to induce labor

artificial rupture of membranes: amniohook

yellow, painless hook

what criteria needs to be met for an amniotomy to occur

station must be at 0

head must be engaged

when does pitocin start to work?

when she is 9cm dilated

there are absolute contraindications for induction of labor. these would include all of the following except:

a. active herpes infectoin

b. previous horizontal incision during a c section

c. acute fetal distress

d. umbilical cord prolapse

b. previous horizontal incision during a c section

- she can labor

c. is wrong because acute fetal distress indicates a category 3 reading which results in immediate c section

d. umbilical cord prolapse results in an immediate c section

indications for labor induction

post-date pregnancy, IUGR, PROM with infection, maternal health risks

contraindications for labor induction

- Known CPD

- Floating fetal head

- Malpresentation

- Placenta previa

- Previous vertical uterine incision

- herpes outbreak

when to stop pitocin

late and variable decels

tachysystole

contractions lasting longer than 2 min

less than 30 seconds of rest between contractions

what is happening to the fetus when contractions last longer than 2 min?

not getting enough oxygen

interventions for operative vaginal delivery

forceps

vacuum

indications for operative vaginal delivery

forceps

vacuum

forceps assisted delivery

used to deliver fetal head

outlet for forceps

introitus

risks associated with forceps

fetal skull or neck injury, bruising, maternal lacerations, hematomas

conditions for forceps delivery to happen

water broken

fully dilated

bladder empty

Occiput Anterior

No CPD

cpd

cephalopelvic disproportion

(head too big for birth canal)

who is there for every vacuum delivery?

NICU

vaccuum delivery

suction applied to fetal scalp, rather than pulling on entire head

thought to be less traumatic

possible vacuum complications

scalp injury and hematoma

nursing role for vacuum

explain procedure

inform parents of risks: possible bruising

monitor FH

if needed generate vacuum pressure in "green zone"; document number of pulls pressure used and pop-offs

observe neonate for jaundice, anemia

how many pop offs before c-section in vacuum

3

indications for c sections

prior c section; fetal distress

pre-operative nursing care during a c-section

desire NPO x 6 hours

bicitra

foley

shave lower abdomen

IV

strip on fetus

bicitra

sodium citrate/citric acid

neutralizes stomach acid incase of general anesthesia

postoperative nursing care during a c section

vs q15 min, temp q1, o2 one hour pp

assess uterus and bleeding

help splint incision

ekg within the first hour

vaginal birth after a c-section/labor after a c-section

~75% succesful

contraindicated in women with previous vertical uterine incisions

risk associated with vbac

uterine rupture d/t previous scar

in order to attempt vbac:

md must be available (OB and anesthesia)

must be able to preform stat c-section

25 minutes to c section but asap

post date pregnancy

after 40 weeks

post term pregnancy

pregnancy/birth after 42 weeks

risks for post term pregnancy

excessive fetal size (macrosomnia)

post maturity syndrome d/t placental insuffiency

meconium aspiration syndrome

manifestations of post maturity syndrome

weight loss, decreased afv, meconium staining/aspiration, fetal distress, respiratory distress, hypoglycemia

meconium aspiration syndrome

neonate inhales meconium mixed with amniotic fluid upon first breath or while in utero

pneumonia

management of post term pregnancy

close fetal monitoring after 40 weeks

labor induction

fetal monitoring after 40 weeks

non stress tests biweekly

- if non reactive --> contraction stress test

amniotic fluid index

why induce labor after 40 weeks?

prevent stillbirth

avoid meconium aspiration

shoulder dystocia

emergency

head is delivered but shoulders are too large