COMPLICATIONS OF PERINATAL PERIOD

• multiple gestation

• post date

• atypical presentation

• dystocia

• augmentation

• alterations in FHR

• shoulder dystocia

• cord prolapse

• c section

• hemmorage post partum

• disseminated intravascular coagulopathy

• amniotic fluid embolism

• perinatal loss

MULTIPLE GESTATION RISK FACTORS

• hyperemesis

• anemia

• preterm labour

• gestational hy[ertension

• placental abruption

• poly/oligohydramnious

• prolapsed cord

• uterine dysfunction

• cardiovascular complications

• hemmorage post partum

FETAL RISKS MULTIPLE GESTATION

• stillbirth

• preterm

• low birth weight

• intrauterine growth restrictin

• congenital abnormalities

• cord accident

• abnormal placentas

POST TERM PREGNANCY

• more common in primagravidas

• fetal mortality rate doubles at 42 weeks

• placental function deterioration

• oligohydramnious, poor fetal nutrition, oxygenation

RISK OF POST TERM

• meconium aspiration

• induction of labour

• large for gestational age

• tissue trauma

• c section

NURSING ASSESMENTS FOR POST TERM

• antepartum

  • fetal surveillance

  • amniotic fluid volume

• intrapartum

  • induction

  • pain management

ATYPICAL PRESENTATION

• 3 main presentation

  • cephalic (head first)

  • breech presentation (buttocks, feet, or both feet)

  • shoulder presentation

• internal or external version can be performed

• nurses role is to monitor fetus and support mom

• obtain maternal vital signs and assess comfort

UTERINE DYSTOCIA

• defined as abnormally slow progress in labour

  • caused by various conditions related to 5 ps

  • hypotonic, uncoordinated infrequent uterine contractions or ineffective bearing down efforts (power is most common cause)

  • alterations of pelvic structure (passageway)

  • fetal cause, abnormal presentation of position, anomalies, excessive size and number os fetuses (passenger)

  • maternal position during labour

  • psychological response of mother is related to experiences, and support system

• OTHER FACTORS INCREASE RISK FOR UTERINE DYSTOCIA

  • over weight, short stature, advanced maternal age, infertility difficulties, prior cephalic external version, uterine abnormalities (congenital malformations, over distension with polyhydramnious)

  • malpresentation and position of fetus

  • cephalopelvic disproportion (CPD)

  • uterine overstimulation with oxytocin

  • maternal fatigue, dehydration and electrolyte imbalance

LABOUR DYSTOCIA

• inadequate progression of labour

  • physician dx, CPD, medications, and nursing actions required

DYSTOCIA PREVENTION

• prenatal education

• management of labour

• ambulation

• continuous emotional support

• amniotomy

• augmentation with oxytocin

AUGMENTATION

• stimulation of uterine contractions after labour has stopped

• implemented of hypotonic uterine dysfunction resulting in slowing of labour

• augmentation methods are oxytocin infusion and amniotomy

• non invasive methods

  • bladder emptying, ambulation, position changes, relaxation measures, hydration

• freidman’s curve: graph that documents hours in labour are plotted against cervical dilation. measured in cm, increasing dilation indicated progress of fetus as it moves in birth canal. the curve is S shaped

OXYTOCIN INDICATIONS FOR INDUCTION OR AUGMENTATION OF LABOUR

• suspected fetal distress (IUGR)

• inadequate uterine contractions (dystocia)

• pre labour rupture of membranes

• post term pregnancy

• chorioamniomitis

• renal disease, diabetes, severe Rh isoimmunization

• preeclampsia, eclampsia

• fetal death

CONTRAINDICATIONS TO OXYTOCIN STIMULATION IN LABOUR

• prolapsed cord, cephalic disproportion

• abrominal fetal heart rate

• placenta previa/vasa previa

• prior classic uterine incision or uterine surgery

• genital infection

• cancer of cervix

• previous uterine rupture

NURSING CONSIDERATIONS FOR CONTRAINDICATIONS FOR OXYTOCIN

• oxytocin will be decreased or not given if tachystole resulting in abnormal fetal heart rate or if a pattern occurs

• the Friedman graph again is used to determine normal length and pace of labour. If cervix does not dilate accordingly, will be sent in for c section

INDUCTION METHODS

• membrane sweeping

• medications

  • cervidil

  • prostaglandin gel

  • misoprostol

  • oxytocin

• ballon catheters

INDICATIONS FOR INDUCTION

• high priority

  • preeclampsia >37wks

  • maternal disease not responding to treatment

  • significant but stable antepartum hemmorage

  • chorioamnionitis

  • fetal compromise

  • pre labour rupture of membranes with GBS colonization

• other indications

  • postdates or post term pregnancy

  • uncomplicated twin pregnancy

  • glucose control may dictate urgency

  • autoimmune disease at or near term

  • intrauterine growth restriction

  • oligohydramnious

  • gestational hypertension >38wks

  • intrauterine fetal death

  • PROM near or at term (GBS) negative

  • intrauterine device prior to pregnancy

ALTERATIONS IN FHR

• 5 components

  • baseline

  • baseline variability

  • accelerations

  • decelerations

  • trends over time

• normal: are the characteristics within normal parameters

• atypical: further vigilant assessment is required

• abnormal: action is required

  • atypical: involves correction of reversible cause for compromise, intrauterine resuscitation and scalp stimulation or blood sampling

  • abnormal: review of overall clinical situation, intrauterine resuscitation and operative delivery (vaginal or section) indicated, or if there is evidence of normal oxygenation by scalp PH assessment

MANAGEMENT OF ATYPICAL OR ABNORMAL FETAL HEART RATE PATTERN

• intrauterine resuscitation

  • stop or decrease oxytocin, and change maternal position

  • improve maternal hydration with IV fluid bolus

  • perform vaginal examination to assess progress in labour and relieve pressure off cord

  • can condor using oxygen 0-10L but evidence shows that there is effectiveness on fetal compromise

  • prolonged maternal oxygen have negative implications of fetal cord blood gases at birth and should only be used in caution as part of intrauterine resusitation

  • consider amnioinfusion if variable decelerations present

SHOULDER DYSTOCIA

• condition where head is born but anterior shoulder cannot pass under pubic arch

  • turtle sign: involves appearance and retraction of baby’s head, occurs when baby’s shoulder is obstructed by maternal pelvis

  • mcroberts manœuvre: used to assist in child birth, employed in cases of shoulder dystocia during birth and involved hyper flexing the legs tightly to abdomen

  • suprapubic pressure: attempt to manually dislodge anterior shoulder from behind symphysis pubic during shoulder dystocia. Performed by making a fist, placing it above maternal pubic bone and pushing fetal shoulder in one direction or another

  • hands and knees: wood screw maneuver: this maneuver is used in shoulder dystocia, anterior shoulder is pushed towards baby’s chest, and posterior shoulder is pushed towards baby’s back, making the baby’s head face the mothers rectum

FACTORS THAT CAUSE SHOULDER DYSTOCIA

• fwtopelvic disproportion caused by excessive fetal size

• maternal pelvic abnormalities can be cause

• maternal diabetes (macrosomia)

• history of shoulder dystocia with pervious birth

FETAL INJURIES SHOULDER DYSTOCIA

• asphyxia

• trauma to brachial plexus

• phrenic nerve injuries

• fracture of humerus or clavicle

• brachial plexus injury (Erb Palsy)

NURSING ACTIONS FOR SHOULDER DYSTOCIA

• mcroberts manœuvre: romans legs are flexed to abdomen, causes sacrum to straighten, and symphysis pulls rotates towards mothers head: angle of pelvic inclination is decreased freeing the shoulder

• suprapubic pressure can be applied

• mcroberts is preferred methods when mother is receiving epidural anesthesia

positions that can resolve shoulder dystocia

• gaskin manouversL hands and knees position

• squatting or lateral recumbent position

fundal pressure can be used as a method of relieving shoulder dystocia is avoided, it is associated with neurological complications

• when shoulder dystocia is diagnosed, nurse helps patient assume position that facilitate birth of shoulders, and monitor fetal response. Nurse also provides encouragement and support to reduce anxiety and fear

• newborn assessment should indicate examination for fracture of clavicle or humorous, brachial plexus injuries and asphyxia

• maternal assessmentt should focus on detection of hemmorage and trauma to soft tissue of birth canal