Summary of nagle\'s rule PDF

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Chapter 32 labor and birth complications ● Preterm labor (PTL) ○ Cervical changes and uterine contractions occurring 20 to 37 weeks of pregnancy ● Preterm birth ○ Delivery of baby that occurs before 37 and 0/7 ● Preterm birth or prematurity: length of gestation regardless of birth weight ○ More dangerous than having JUST a low birth weight alone because of immaturity of body systems ● Low birth weight: less than 2500 grams at birth ○ Many causes ● Preterm birth ○ Spontaneous: 75% of preterm births ■ Happens on own ○ Indicated: 25% of preterm births ■ Due to fetal or maternal complications ● Predicting spontaneous preterm labor and birth ○ Risk factors ■ Familial or personal history of preterm birth ■ Non-white race ■ Genital infections ■ Multiple gestation ■ 2nd trimester bleeding ■ Low pre pregnancy weight of mom ○ Cervical length ■ Not predictive of preterm birth ■ BUT cervical length>30mm are unlikely to give preterm birth ○ Fetal fibronectin test ■ Glycoprotein glue found in the vagina to try and indicate likelihood of birth in the next 2 weeks ● PTL care management ○ Teach patient about warning signs ○ Tell moms what labor feels like ○ Interventions ■ Prevention ■ Early recognition and diagnosis ○ Lifestyle modifications ■ Don’t have sex while having contractions ● PTL care management ○ Suppression of uterine activity ■ Not very effective at STOPPing labor, but can delay it long enough to transfer them to another hospital or get them betamethasone ■ Tocolytic medications (smooth muscle relaxants) ● Magnesium sulfate is a CNS depressant, neuroprotective for

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cerebral palsy and for babies before 32 weeks ● Terbutaline ● Indomethacin (NSAID) ● Nifedipine ■ Promotion of fetal lung maturity ● Given up to 36 weeks (any preterm baby) ● Betamethasone (antenatal glucocorticoids) promotes lung maturity in the baby. Works to prevent respiratory issues, NEC, and death ○ Management of inevitable preterm birth ■ Begin treatment (betamethasone) ■ Try and prolong the delivery ■ Plan for resuscitative measures ■ Prepare for a transport to higher acuity facility Premature rupture of membranes (PROM) ○ PROM: spontaneous rupture of amniotic sac prior to the onset of labor at any gestational age ○ PPROM: preterm rupture of membrane before 37 and 0/7 weeks of gestation ■ Responsible for 10% of all preterm births ■ Often preceded by chorioamnionitis (infection) ■ If PPROM before 20 weeks = pulmonary hypoplasia ● Lungs can’t form because there’s no liquid in the womb PROM and PPROM management of care ○ Once the membrane is confirmed to be ruptured, the big thing to worry about is infection because the womb is no longer sterile ■ Be vigilant for signs of infection ■ Be careful not to introduce infection ■ Limit vaginal exams ■ Check temperatures VERY frequently Chorioamnionitis ○ Bacterial infection of amniotic fluid and cavity ○ Clinical finding ■ Maternal fever ■ Maternal and fetal tachycardia ■ Uterine tenderness ■ Foul odor of amniotic fluid ○ Neonatal risk ■ Pneumonia ■ Bacteremia - sepsis - death ○ Treatment ■ IV broad spectrum antibiotics ■ Ampicillin and gentamicin Postterm pregnancy, labor and birth ○ Post Term pregnancy is pregnancy > or equal to 42 weeks ○ Maternal risks

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■ Dysfunctional labor and birth canal trauma ■ Labor and birth interventions are more likely ■ Fatigue and psychological reactions as the estimated date of birth passes ○ Fetal risks ■ Macrosomia ■ Prolonged labor ■ Shoulder dystocia because they get stuck ■ Birth trauma like breaking the clavicle, a bruised head ■ Aging placenta calcifies and doesn’t work that well so there’s an increased likelihood of fetal demise ■ Postmaturity syndrome ● Dry, cracked peeling skin (ran out of vernix) ● Long nails ● meconium (can be inhaled and get pneumonia) ○ Care management post term ■ Perinatal morbidity and mortality increase greatly after 42 weeks of gestation ■ Try and convince her to deliver but if she absolutely refuses ● More frequent monitoring, NST, and BPP Dysfunctional labor (dystocia) ○ Long, difficult, or abnormal labor (8-11% of all births) ○ Most common reason for C-section (60%) Fetal causes of dysfunctional labor ○ Anomalies ■ Tumor, hydrocephalus ■ Cephalopelvic disproportion ● Macrosomia or maternal pelvic shape ■ Malposition ● ROP or LOP (sunny side up) ● Severe back pain and stalled labor ■ Malpresentation ● Breech ● Transverse ○ Multifetal pregnancy ■ Only 40-45% of twins are both vertex ■ Can try vaginal delivery in the OR Psychological reasons for dysfunctional labor ○ Increased stress with pain or lack of support person Obesity ○ Higher incidence of C-section with obese moms External cephalic version ○ Attempt to turn the baby around from the outside of the baby Internal cephalic version ○ Turn baby from the inside

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Induction of labor ○ Chemical or mechanical initiation of UC before spontaneous onset of birth ○ Cannot induce before 39 weeks Elective induction of labor ○ No medical indication ○ Convenience of mom or physician Bishop’s score ○ Rating system used to evaluate the inducibility or cervical ripeness ○ Higher score means more inducible Cervical ripening methods ○ Chemical agents ■ Misoprostol (cytotec) and dinoprostone (cervidil) ● Ripens the cervix ■ Mechanical methods ● Membrane stripping ● Have sex (cuz semen has prostaglandins) or nipple stimulation (oxytocin) ● Walking (gravity) ■ Alternative methods ● Herbs and acupuncture ○ Amniotomy ■ Breaking the water!! ● Watch the baby ● Get the baby on the monitor, consider starting an IV line ○ Pitocin (oxytocin) ■ Comes after the cervical ripening ■ Stimulates UC Augmentation of labor ○ Stimulation of uterine contraction after labor has started spontaneously ○ Common augmentation methods include oxytocin and amniotomy (breaking the water) Operative vaginal birth ○ Forceps assisted ○ Vacuum assisted ■ Watch the baby for trauma (bruises, lacerations, hematomas) ■ Vacuum - hematoma ■ Forceps - bruises laceration C section ○ VBAC - vaginal birth after cesarean ○ TOLAC - trial of labor after cesarean Elective ○ Choose a cesarean birth Scheduled ○ For repeat c sections

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Unplanned ○ Wasn’t planned Complications of C-section ○ Anesthesia stuff - spinal ○ Hemorrhage - bleeding from being cut ○ Bladder or bowel injury ○ Infection is the biggest one ○ UTI from foley catheter use ○ Scalp or body laceration (from surgeon accidentally knicking the baby) Anesthesia ○ Spinal is the most common ○ Can use epidural ○ General is the last option Pre Op care ○ NPO ○ Pre-op meds ○ IV, shave her belly, TED hose (SCD after) ○ Baseline labs Intra op care ○ Circulating RN - help w/anesthesia, positioning, time out ○ Fetal heart tones ○ Foley after the delivery Trial of labor after cesarean birth (TOLAC) ○ Contraindications ■ Multiple C section (more than 1 prior) ■ C section where scar is vertical (not horizontal) ○ Risks ■ Uterine rupture Shoulder dystocia ○ Head is delivered but anterior shoulder cannot pass ○ 0.34% of vag births ○ Mcroberts maneuver ■ Throw legs back ○ Suprapubic pressure ■ Push the baby out ○ Deliver in less than 5 minutes before brain damage occurs Prolapsed cord ○ Cord comes through before baby ○ Put hand in to try and push head up so it doesn’t occlude the cord ○ Prep mom for emergency c section Rupture of the uterus ○ Rare and life threatening obstetric injury ○ Hole in uterus ○ Extremely rare but at an increased risk if c section has occurred

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Causes ● Separation of scar of previous cesarean birth ● Uterine trauma ○ During labor ■ Intense spontaneous uterine contractions ■ Overdistended uterus ■ Quick fetal deceleration ■ Pain ■ Hypovolemic shock ● If mom has a cardiac emergency ○ Give her CPR!! ○ Call a code too Postpartum ● Postpartum hemorrhage ○ Major cause of obstetric morbidity and mortality ● Hemorrhagic shock (hypovolemic) ○ Emergency situation ○ Perfusion of body organs can become severely compromised ○ Can lead to death ● Definition and incidence ○ 500ml or more after vaginal birth ○ 1000ml or more after c section ○ A 10% change in Hct between labor and postpartum ● Often goes unrecognized until mother has profound symptoms ● You can hemorrhage right after delivery or you can go home after delivering and still hemorrhage (up to 6 weeks) ● Uterine atony ○ Most common cause ○ Uterus is not firm ○ Boggy fundus and heavy bleeding ■ Massage and medicine ● Retained placenta ○ Placenta doesn’t get delivered ○ Needs to be manually removed ● Lacerations ○ Bright bleeding despite a firm fundus ■ Report to HCP and stop the bleeding ● Hematomas ○ Internal bleeding that looks like a big, purple golf ball ○ Like a bruise ● Uterine atony ○ Associated with ■ Overdistention of uterus (big baby) ■ Lots of babies (high parity)

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■ Multifetal gestation Retained placenta ○ Should come out with 30 minutes of birth ■ Accreta - vessels of placenta either frew into the uterus or around it Lacerations of genital tract ○ Uterus is firm but theres still bright red blood ○ Episiotomies Inversion of the uterus ○ Uterus turns inside out ○ Rare but life threatening ○ Don’t pull on the cord it could invert uterus Early recognition and treatment ○ Initial intervention = firm massage of fundus Methergine and hemobate and cytotec ○ Commonly used after delivery for contracting the uterus (hemorrhage) ○ Can’t give methergine if mom is HTN ○ Hemobate can’t give to moms with asthma Hemorrhage (hypovolemic) shock ○ Mom’s bleeding out ■ Assess that vital organs are properly perfused ● Urine output (30ml/hr) ● Unconsciousness ■ Management ● Restore volume ● IVF ● Blood products DVT ○ SCDs after C section or any type of prolonged bed rest ○ Prevention is key Postpartum infections ○ 2% vaginal ○ 10-15% c sections ○ Educate S&S infection ■ Mastitis ● In boobs ○ Report any flu like symptoms, pain, reddened area on breast, fever, tachycardia, anorexia, foul smelling bleeding UTI ○ Catheter use and vaginal exams and trauma during labor ■ Notify doc of UTI symptoms...