High Risk Labor and Delivery

dystocia/ dysfunctional labor

dysfunctional or ineffective labor due to abnormalities of the powers, passenger, passage

dystocia

general term for any difficult labor or birth and can be caused from any of the Ps

dysfunctional powers

problems with the contractile forces which involve abnormalities with freq, duration, intensity, and resting tone of the uterus between cxs

freq

in minutes (how many cxs)

duration

seconds (how long cxs last)

hypertonic labor

latent phase

resting tone of the myometrium inc often with constant pain

cxs are painful, erratic, and with poor intensity

duration may dec while fre of cx increases

not the same as tachysystole

not the same as prodromal labor which is a type of false labor

hypertonic mom and baby risks

mom- exhaustion

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

hypertonic NC

promote rest

promote relaxation

PO or IV hydration

assess FHR, UCs, vag exam

adminster tocolytic or painmedications as ordered

hypotonic labor

active phase of labor

less than 2-3 cxs in 10 min (normally want 3-5)

cx not strong enough to result in dilation or effacement

hypotonic maternal risks

exhaustion

infection (if membranes ruptured)

fetal risks

eventually- not common

fetal intolerance of labor

dec in variability or late decels

hypotonic NC

administer pitocin

amniotomy

encourage voiding, empty bladder

prevent/treat dehydration- PO or IV fluids

encourage position changes

evaluate FHR, cxs

limit vag exams if rom

provide emotional support/info

consider a sedative to promote rest and relaxation

arrest disorders- prolonged labor

occur in stage 1 or stage 2

stage 1 arrest

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

stage 2 arrest

after 2-3 (or 4) hours of pushing

failure to progress or failure to descent

closely watch fetal-maternal status

precipitous baor and labor

lasting < 3 hours

UCs occur more freq, longer duration , and more intense

delivery is sudden, unexpected,, and often unattended (nurse delivery)

precipitous baor and labor risk factors

grand multip, hx of precip delivery

precipitous baor and labor maternal risk

PPH, lacerations, placental abruption

precipitous baor and labor fetal risks

hypoxia, CNS depression

precipitous baor and labor NC

monitor closely

stay with patient

perform sterile vag exam if patient feels the urge to push, bear down

comfort measures- breathing techniques to delay pushing

monitor FHR for distress

Maternal oxygen, IV fluids, tocolytic drug (turbutaline)

prepare for delivery- possible nurse delivery

nurse delivery

get help- including NICU staff

do not try to prevent the birth by holding legs together

keep bed together

keep the NB from popping out- gentle counter pressure on head to control the delivery

dry and stimulate the infant, bulb syringe if needed

assess the infant- APGAR score

place skin to skin with cord intact

fetal (passenger) dystocia

difficult labor due to malpresentation of fetus- persisten occipital (OP) or occipital transverse (OT) , brow, face, breech, shoulder (transverse lie)

only OA presentation is favorable

or due to excessive size (macrosomia), multiple, fetal anomaly

vaginal birth is difficult

cephalopelvic disproportion CPD

fetal head is larger than the pelvic diameter (in the given fetal position)

abnormal position/ presentation may occur as the presenting part tire to pass through the pelvis

failure to progress or failure to descend

CPD NC

position chnages- squatting, turning, hands and knees

comfort care- support and encouaragement

monior GFR

prepare for instrument-assisted or c/s

shoulder dystocia

emergency; shoulder become impacted under the symphysis after the delivery of the fetal head

may result in neonatal morbidity and potentially mortality

respiratory exhange ceases as chest, neck, and cord is compressed

turtle sign

retraction of the fetal head against the perineum

shoulder dystocia aspyxia?

starts after 5 minutes

shoulder care/medical NC

request additional staff/notify the neonatal team

suprapubic pressure (and downward traction of fetal head)

McRoberts maneuver

midline episiotomy- inc visualization

empty bladder

anticipate neontal resuscitation

explain the istuation to the mother and fam

shoulder dystocia complications

brachial plexus injury

broken clavicle

neurological injury

asphyxia

death

Passage: pelvic dystocia

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

pelvic shapes most to least favorable

gynecoid, antropoid, android, platypelloid

post-term labor

pregnacy 42- 0/7 weeks and beyon NST’s 2-3 x a week

AFI- oligohyrdamnios?

induction at 41 weeks or greater

assess for signs of fetal distress?

provide emotional support and encouragement

post maturity syndrome- affects 5-20% of post-term infants

Umbilical cord prolapse

umbilacal cord precedes the presenting part -emergency

pressure on the cord from the presenting part and maternal pelvis—> compress the cord

FHR drops and does not recover (prolonged variable deceleration —> bradycardia )

Umbilical Cord Prolapse rf

malpresentation (breech or shoulder)

presenting part not engaged in pelvis

preterm, sm fetus

multiple gestation

polyhydramnios

Umbilical Cord Prolapse NC

relieve the pressure immediately

call for help, notify the provider

lift the presenting part off the cord with gloved hands

position cganges- knee-chest, elevating hips and trendelenburg position

DC oxytocin

adminster o2, iv fluid bolus

adminster tocolytic (terbutaline) to dec the uterine activity

prepare for a vag or instrumental delivery if birth is imminent

prepare for c-section

Anaphylactoid syndrome

amniotic fluid embolism

emergency

anaphylactoid syndrome patho

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

anaphylactoid syndrome RF

preciptious delivery

AMA

placenta previa or abruption

preeclampsia

instrumental or c/s

cervical lacerations

grand multips

anaphylactoid syndrome causes

resp failure and cardiogenic shock-starting from pulmonary vasospasm and occlusion

resp arrest and cardiac arrest

uterine atony, massive hemorrhage

can progress to severe coagulaphy- disseminated intravascular coagulation

s/s of resp failure

acute dyspnea, severe hypoxia, cyanosis, hypotension

anaphylactoid syndrome interventions

call code

CPR as needed

adminster O2

ensure IV access

adminster RBCs, platelets as ordered

transfer to the ICU

often fatal- 60-80% mortality rate . survivors typically have permanent neurological injury

disseminated intavascular coagulation rf

anaphylactoid syndrome

abruptio placenta

preeclampsia

HELLP syndrome

sepsis

PPH

disseminated intavascular coagulation patho

abnormal activation of blood clotting/coagulation mechanisms, probably due to severe inflammatory response to initial event (anaphylactoid syndrome or pph)

this leads to fibrin blood clot formation in sm vessels—> depletion of the clotting factors leading to massive hemorrhage

excessive clotting and excessive bleeding at the same time

disseminated intavascular coagulation s/s

severe uterine bleeding

bleeding from IV site, incision, gums, and signs of shock

disseminated intavascular coagulation tx

administer massive blood/blood products

transfer to ICU

placental and umbilical cord abnormalities

umbilical cord proplapse

anaphylactoid syndrome

dissem