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Binnece J. Green MSN APNC
Complications due to Anxiety and Fear
Individuals ineffective coping Ineffective family coping and expectations Fear of pain Fear of change in family dynamics Fear due to educational deficit Support systems
Anxiety and Fear
Support the laboring woman Education Modeling and relaxation techniques Support partner in relaxation techniques, and maintaining control Establish confident rapport
Abnormal labor attributed to three factors:
inefficient uterine action persistent posterior presentation cephalopelvic disproportion
Dystocia Uterine contractions normal: occur regularly 2 to 4 contractions per 10 minutes. mean applitude 35mmHG in early labor progresses to: 4 to 5 contractions per 10 minutes mean amplitude 40-50mmHG .
Interventions by physician evaluate size of maternal pelvis position and presentation fetus fetal weight . slow Progress.Dystocia Dysfunctional : contractions are irregular. cervical dilations slow or arrested. low amplitude.
contractions. (CPD) If no CPD. fetal ht. Assess vs. Pitocin (1mU/min): goal is to obtain 8 contractions per 20 minutes. dilation. rate . decent.Dystocia continued Do not give Oxytocin (Pitocin) if woman has cephalopelvic dysproportion. amniotomy.
Dystocia Continued Encourage changing position Ambulation Warm Showers Relaxation (visualization) Mouth care Encourage Voiding Nipple stimulation .
Umbilical Cord Prolapse Etiology 1-275 deliveries Definition: umbilical cord that lies below/beside presenting part Usually immature gestation Results in fetal hypoxia & death > 5 min results in CNS damage/ death .
Umbilical Cord Prolapse Precipitating factors: Long umbilical cord Abnormal location on placenta Small or preterm infant Polyhydramnios Multiple gestation Amniotomy before fetal head is engaged .
Umbilical Cord Prolapse Clinical Manifestations: Cord observed or palpated Bradycardia following ROM Repetitive. variable decelerations that do not respond to medical intervention Prolonged decelerations (>15 bpm lasting 2 mins or longer yet <10 mins) .
Umbilical Cord Prolapse Nursing interventions: Apply gentle upward pressure on presenting part Knee chest position Medical management: Immediate delivery of viable infant C-section .
0.0% of all NSVDs When the anterior shoulder does not fit under the pubic arch.Shoulder Dystocia Etiology Occurs in approx. Cephalic presentation: head has been delivered by extension problem with external rotation (shoulders unable to be delivered) Highly associated with macrosomic infants (> 4000gms) .15-2.
Shoulder Dystocia Clinical Manifestation: Turtle sign Head presents on perineum and then retracts Other signs and symptoms during labor Excessive molding Prolonged fetal rate of descent (<1cm/hr in nulliparas/<2.1cm/hr multiparas) .
Shoulder Dystocia Nursing interventions: OB emergency Assist with positioning to expand pelvic space for delivery of infant Wood¶s maneuver McRobert¶s maneuver Stop maternal pushing Call for assistance Lower bed Empty bladder via catheterization .
Shoulder Dystocia Nursing Interventions: Anticipate fetal complications Erb¶s Palsy: (brachial plexus palsy) Facial paralysis Respiratory depression Fractured clavicle Anticipate maternal complications: Early postpartum hemorrhage r/t uterine atony Hematomas (cervical/uterine/vaginal) Hematuria Infection Hypovolemia .
Meconium Stained Amniotic Fluid Appearance of meconium in AF Staining r/t amount of meconium passed in utero Vernix stains yellow within 12-14 hours of exposure Fetal fingernails stain yellow within 4-6 hours of exposure Placental surface stains within 3 hours Umbilical cord stains within 1 hour .
if preterm Bolus of 200-250 ml over 20 minutes. odor of AF Report to CNM. then 100cc/hr Monitor FHR. uterine activity and resting tone . color.Meconium Stained Amniotic Fluid Observe amount. MD Amnioinfusion 1000cc NS at room temperature/ blood warmer esp.
Meconium Stained Amniotic Fluid Prepare Labor and delivery room Anticipate fetal respiratory depression at delivery Notify neonatal team: will gentle oropharyngeal/nasopharyngeal suctioning with mechanical suctioning of head on the perineum Laryngoscopy. tracheal intubation and suctioning for depressed infants .
4 hours No known risk factors . 86% Short interval between onset and death 10 minutes-32 hours One quarter of the clients die r/t cardiopulmonary arrest within 1 hour 50% of survivors develop acute DIC within 30 mins.000 deliveries Maternal mortality rate of approx.Amniotic Fluid Embolism Etiology: 1-80.
frothy sputum No chest pain Convulsions Apprehension Extreme anxiety CNS: .Amniotic Fluid Embolism Clinical Manifestations:Medical Emergency Respiratory: Dyspnea Acute cyanosis Pink.
Amniotic Fluid Embolism Clinical Manifestations:Medical Emergency Cardiovascular: Hypotension Sudden.profound shock dysrhythmias .
PT. platelet count . fibrinogen. Liver enzymes.PTT. and fresh plasma to treat bleeding r/t DIC Lab studies:CBC. dopamine infusion if indicated Fresh whole blood or packed RBCs.Amniotic Fluid Embolism Medical Management: CPR prn Oxygen at high concentrations Rapid volume infusion.
1% all pregnancies Unknown cause but is seen in conjunction with major congenital anomalies Types: Chronic Acute .Hydramnios Occurs when >2000ml of amniotic fluid.
Shortness breath edema pain .Hydramnios Chronic : fluid gradually rises. >3000ml Sx. becomes problem 3rd trimester Acute: rapid increase over days Often diagnosed between 20-24 wks.
syphilis Treatment supportive If severe hospitalization. removal fluid through AROM or amnio. Indomethacin shown to decrease amniotic fluid by decreasing fetal urine output. .Hydramnios (cont) Maternal disorders Diabetics RH sensitization Infection ex. CMV.
Oligohydramnios Less than normal amount of amniotic fluid norm is 500ml. Unknown cause Found in cases of postmaturity with intrauterine growth restriction secondary placental insufficiency Fetal conditions: renal malformations .
) Concern with fetal adhesions One part of fetus adhere to another Fetal skin and skeletal abnormalities Due to decrease in fetal movement Pulmonary: pulmonary hypoplasia Complications in birthing process due to decrease fluid for cushioning .Oligohydramnios (cont.
) Monitor uterine growth (suspect if uterus doesn¶t increase in size. Fetus easily palpated Fetus not ballottable (fetus floats away and returns when pushed) Monitor cord compression due to decrease cushioning during birth Fetal monitoring Amniofusion: infuse sterile fluid(NS)through intrauterine catheter .Oligohydramnios (cont.
multiparas->5 Lower socioeconomic .Placental Complications Abruptio Placentae Premature separation of placenta (prior to 3rd stage labor) Source.maternal from uterine surface More common with HX HTN.
Abruptio Placentae: symptoms Severe pain Fetal distress Dark bleeding Rigid abdomen Sx shock .
Management L lateral recumbant O2 100% IV Assess for Coagulation abnormalities Monitor mother and fetus .
maternal Placenta usually larger .Placenta Previa Placenta implanted in lower region of uterus Placenta precedes fetus More common multiparas Source.
Placenta Previa Symptoms Painless Vaginal bleeding Bleeding bright red Bleeding may not begin until labor begins .
Management No vaginal exam HOB 20-30 degrees 100% O2 IV Monitor mother and fetus .
Breech Presentation 4% births Gestational age 25-26weeks incidence increases to 25% Frank Breech most common Often associated with placenta previa. multiple gestation. hydramnios. fetal anomalies Cord prolapse more common .
Cesarean Births Indications: Dystocia Cephlopelvic disproportion Maternal disease as diabetes Active genital herpes Benefit of the Fetus Malpresentations. multiple gestation Placental abnormalities Cord Prolapse Emergency conditions .
) Cesarean birth preferred due to increase in mortality and morbidity rate due to cord prolapse. Contraindications for vaginal birth fetal weight less than 1500g hyperextention of fetal neck of more than 90 degrees anomalies ie hydrocephalus maternal pelvic measurements .Breech Presentation (cont. birth trauma. fetal cervical trauma.
Cesarean Risks Maternal: Infection Hemorrhage Urinary tract trauma Thrombophlebitis Atelectasis Aspiration Fetal: Inadvertant preterm birth Transient tacypnea Persistent pulmonary hypertension Injury as laceration .
Care During Aversion A procedure used to change the fetal presentation by abdominal or Intrauterine manipulation External version May be very painful .
PE. injuries. respiratory distress .Cesarean Birth (cont.) Surgical techniques: Vertical vs. injury. thrombophlebitis. emotional trauma Fetal Risks: Prematurity. Horizontal incisions Maternal Risks: Aspiration. Infections. risks related to anesthesia.
Nursing Management Provide emotional support Use therapeutic communication to promote positive childbirth experience Stress management techniques Support person should be encouraged to remain with her during the birth Provide teaching r/t cesarean experience .
IV fluids.Nursing Considerations Preoperative care: VS. or attachments Assess emotional preparation of both woman in labor and support persons . Retention Catheter. FHR. removal of jewelry. shaving. Informed consent.
Birth Related Interventions Amniotomy Prostagalandin Administration Misoprostol Administration Induction of Labor Amniofusion Episiotomy Forceps-Assisted Birth Cesarean Birth .
>10cm/hr in multips Complications of precipitous labor include trauma to birth canal.Precipitous Delivery Precipitous labor is on the other end of the spectrum of labor abnormalities >5cm/hr dilatation in nullips. and postpartum hemorrhage . fetal distress.
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