W&CII test 2 - Labor and birth complications procedures, Maternal child nursing care/PP care PDF

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Labor and birth complications procedures, Maternal child nursing care/PP care & complications, Newborn nutrition...

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W&C II test 2 Labor and birth complications procedures – topic 5 Late pregnancy bleeding Placental abruption: occurs when part or all of the placenta detaches from the uterus - Risk factors: maternal HTN, cocaine use, trauma, smoking, hx of abruption, twins - S/S: sudden onset of vag bleeding, abdominal pain, uterine tenderness and contractions o Uterus is board like and hard in b/w contractions - US do not always detect placental abruption - Mgmt.: delivery (vag preferred but emergency c/s may be needed) Placenta previa: occurs when the placenta is implanted in the lower uterine segment, can be partial or complete – “placenta would be the first to come out” - Risks with placenta previa: hemorrhage, weight of fetus affects the placentas job, abnormal placental attachment - US detects this - S/S: painless vag bleeding (later in pregnancy) - Once diagnosed patient is placed on strict pelvic rest (NO sex or vag exams) - If present at birth  C/S Cord insertion and placental variations Vasa previa – blood vessels are implanted into the fetal membrane instead of the placenta, Vessels are at risk for rupture/compression b/c they aren’t protected, increases risk of fetal death and can be seen on US using color doppler - Velamentous insertion of the cord: when a fetal umbilical cord abnormally inserts on the edge of the placenta (on the chorioamniotic membrane), causes fetal blood vessels to travel unprotected from the placenta until they reach the umbilical cord - Battledore or marginal insertion of the cord: the umbilical cord is attached to the placental margin - Can go the entire preg without complications but fetus is at risk due to problems w/ the unprotected cord Preterm labor - Preterm labor is regular contractions along with a cervical change that occurs prior to 36 6/7 weeks or presenting with regular contractions and dilations of at least 2cm o Contractions may be painless - Risk factors: history PTL, mother had PTL, African descent, no prenatal care, smoking, infection, dehydration, stress, over distension of the uterus (twins or multiple births), placental changes - Fetal fibronectin or cervical length o Fetal fibronectin is a glycoprotein that is used as a diagnostic test for PTL  + test= a sign that mom may go into PTL (NOT definitive) may be r/t placental inflammation  - test= mom will not be going into labor soon o The test needs to be done prior to a vag exam and not within 24 hours of the patient having sex, swab is used to collect the glycoprotein from the cervical OS o Cervical length on a transvaginal US > 30mm in 2nd or 3rd trimester mom is unlikely to deliver early even if they have symptoms, mom could be dehydrated

Management of preterm labor in the hospital - Early recognition and treatment - Transfer of patient to facility with NICU - Monitor uterine activity, FHR, vitals, status of membranes - Medications for PTL: o IV fluid bolus, then maintenance fluid o Antibiotics to prevent GBS infection (given prophylactically)  We don’t know if she’s + b/c it is tested at 36wks o Tocolytics (all are off label uses)  Given to stop labor after uterine contractions and cervical change have occurred o Glucocorticoids  Given as IM injection, can help accelerate fetal lung maturity by stimulating fetal surfactant production Tocolytics Mag sulfate: offers neuroprotection for the premature newborn, can also be given for preeclampsia - Constantly assessing for s/s of mag toxicity. Mag levels would need to be drawn routinely (Q6), patient would be on strict bedrest with a foley and on strict I&O - Toxicity o Lethargy, muscle weakness, decreased or absent DTRs, double vision, slurred speech, maternal hypotension, bradycardia, bradypnea, or cardiac arrest  Decreased urine output can cause toxicity o If toxic, give antidote: calcium gluconate, 1 Gm given IV push over 3 min o Mag levels (5-8 mg/dl or 4-7 mEq/L)  For people not on Mag, normal mag level is 1-2 mg/dl - Mag sulfate is given as a loading dose of 4 gm in 100 ml IV over 30 minutes, Maintenance dose of 40 g in 1000ml of LR to run at rate of 1-4 g/hr - S/S: Hot flashes, sweating, burning at IV site, n/v, dry mouth, drowsiness, headache, ileus, dizziness, decreased variability in fetus - Interventions o Monitor reflexes, hourly urine output via foley with urimeter, vitals every 15 min, respiratory support for baby at delivery (bc mag crosses the placenta and helps baby relax  may cause a floppy baby) Terbutaline - Terbutaline helps relax the uterus (smooth muscle). This medication is often given SQ every 4 hours but can be given IV - Terbutaline can also be used to suppress uterine tachysystole during labor induction or augmentation or to suppress contractions before a C/S - S/S: tachycardia in mom and fetus (if maternal HR over 130, notify provider), palpitations, tremor, hyperglycemia in mom and baby - Do not use for more than 72 hours Nifedipine or Procardia

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A calcium channel blocker that can reduce uterine contractions with low risk of side effects other than hypotension, headache, dizziness. Do not give with/near terbutaline - Do not give with Mag b/c both drugs block calcium and will cause a skeletal muscle blockade. Slowly change position due to orthostatic hypotension Indomethacin or Indocin - NSAID, not used longer than 48 hours and should not be given after 32 weeks due to it causing constriction of the ductus arteriosus - Indomethacin can also contribute to necrotizing enterocolitis and intraventricular hemorrhage. It can be given orally every 6 hours for up to 48 hours Glucocorticoids - Given to women in PTL between 24-34 weeks - Accelerates fetal lung maturity by stimulating fetal surfactant production - Reduces respiratory distress syndrome, intraventricular hemorrhage, necrotizing enterocolitis, and death in preterm babies - Betamethasone 12 mg IM for 2 doses 24 hours apart - Dexamethasone 6 mg IM for 4 doses 12 hours apart Premature rupture of membranes - PROM is the spontaneous rupture of the amniotic sac and leakage of amniotic fluid before labor begins - Preterm PROM is when this occurs before 37 weeks - Can be caused from inflammation, infection, or premature contractions - ROM doesn’t mean the woman is in labor! - Women may remain preg for days/wks if infection is not present and fluid is still around the baby & remain hospitalized with increased risk for infection, until baby is born Group Beta streptococcus colonization – found in normal vaginal flora - Risk factors: GBS with previous preg, positive vag culture, PROM 18+ hr, fever - Risk for baby: morbidity and mortality - Screening: done at 35-37 weeks using a rectovaginal culture (done at 36 wks) - Treatment: IV antibiotic prophylaxis o PCN G 5 million units (loading dose) then 2.5 million units Q4 during labor o Ampicillin, 2g (loading dose) then 1g Q4 Chorioamnionitis - Bacterial infection of the amniotic cavity - Most common maternal complication of PPROM - Can also occur with a tear in the amniotic membrane, STI’s or other infections in the vaginal canal - IV antibiotics required - Risks to baby= pneumonia, bacteremia, sepsis, and meningitis Post term pregnancy, labor, and birth - Post term= a preg that has reached 42 weeks - Risks caused by post term preg= fetal macrosomia, meconium in amniotic fluid, decreased amniotic fluid, advanced bone maturation of the fetal skull, placental aging - Teach post term moms it is important to count fetal movements  10 in 1 hour Dysfunctional labor, AKA, dystocia

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Abnormal uterine activity, Secondary powers, Abnormal labor patterns, Precipitous labor, Alterations in pelvic structure, Fetal causes, Dysfunctional labor is long, difficult, or abnormal labor - It is the most common reason for primary C/S (moms first c/s) - Causes: ineffective uterine contractions, fetal causes, or abnormalities in maternal bony structure (mom’s pelvis) Abnormal uterine activity - Hypertonic uterine activity: occurs in the latent phase, painful frequent contractions that are ineffective, uterus is not relaxing completely  give mom something to rest - Protraction disorders: labor progression is slower than normal. After some progression mom’s cervix fails to dilate in the active phase  hypotonic uterine activity o Common causes=cephalopelvic disproportion and fetal malposition - Arrest disorders: contractions slow down or stop, dilation doesn’t continue, IUPC is placed (if membranes are ruptured) for internal evaluation of contractions Secondary powers - Bearing down efforts can be decreased after analgesics have been given - Anesthesia can also prevent the bearing down effort entirely - Maternal exhaustion can affect labor and birth efforts: mom should only push w ctx’s - Maternal position can work against the forces of gravity Abnormal labor patterns - Prolonged latent phase, protracted active-phase dilation, secondary arrest, protracted descent, arrest of descent, failure of descent - Abnormal labor patterns increase risk of requiring a c/s, uterine rupture, infection, dehydration, and PP hemorrhage - Advanced maternal age and maternal obesity increase risk of having abnormal labor patterns Precipitous labor - Labor that lasts less than 3 hours from the onset of contractions to the time of birth - Can result from hypertonic uterine contractions - Can occur with placental abruption, uterine tachysystole and recent cocaine use - Rapid births increase the risk of intracranial trauma to baby: doesn’t allow the fetus to get used to the birth canal as it is descending Alterations in pelvic structure - Pelvic dystocia occurs when the bony pelvis is too narrow in any of the planes the fetus must pass through: more common in adolescent moms or after someone has had tailbone/pelvic injury - Soft tissue dystocia occurs when there is obstruction by anything other than the bony pelvis: can be due to placenta previa, uterine fibroids, full bladder, cervical edema o Cervical edema can occur if mom pushes before she is 10cm dilated and could result in mom needing a c/s Fetal causes of dystocia - Anomalies: tumors, open neural tube defects - Cephalopelvic disproportion: baby does not fit through the pelvis o Ex: macrosomia or small pelvis

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Malposition: baby is not in the correct position for birth o R occiput posterior is the most common problematic position. Women typically complain of severe back pain from fetal head pressing against her sacrum - Malpresentation: anything other than cephalic or headfirst o Ex: breech presentation - Multifetal pregnancy Procedures - External cephalic version, induction of labor, augmentation of labor, operative vaginal birth, cesarean birth, anesthesia, trial of labor, vaginal birth after cesarean External cephalic version - Attempt to externally turn fetus from malpresentation to vertex for vag delivery - Done in hospital after 37 weeks by provider - This is only done on healthy moms and babies by the use of gentle constant pressure on the abdomen - Preprocedure: NST, US, informed consent, terbutaline, possible epidural due to pain - Requires continuous monitoring of FHTs during and after for one hour - Assess for vag bleeding - If rh negative  give mom rhogam - Mom cannot be in labor, amniotic fluid must be intact, not ruptured, term, not engaged down low in the pelvis & mom cannot have placenta previa, not w/ multiple gestation Induction of labor - Chemical or mechanical initiation of uterine contractions before they begin spontaneously, goal is to start the labor process, may be elective after 39 weeks if cervix is favorable, may be indicated because of maternal or fetal health issues - Methods of induction include oxytocin or Pitocin infusion, amniotomy, and cervical ripening o Cervical ripening= meds placed in the cervix to soften it and get it ready  followed by pit o Amniotomy= provider goes in and breaks the water using amniohook  Labor doesn’t always follow, and this doesn’t mean mom is in labor - Risk w/ induction= having to have a c/s due to the body not being in natural labor - Medicaid/insurance will not pay for induction prior to 39 wks w/o medical need Pitocin for induction or augmentation - Induction = starting labor prior to labor starting itself, Augmentation = stimulation of contractions after labor has started (done to manage hypotonic uterine contractions) o Hypotonic uterine contractions: active phase, they become weak, seen with CPD and malposition, maternal exhaustion, increases risk for infection  Treatment: rule out CPD, insert IUPC, augment with pit, ambulation, ROM - Use of synthetic oxytocin/Pitocin to induce or augment labor, high alert med, use lowest dose possible to achieve adequate contraction pattern and avoid effects to mom and fetus - Begin at 1 milliunit and increase by 1-2 Q30-60min, works within 3-5min, half-life is 1012 min - Concentrations available  10U in 1000ml, 20U in 1000ml, 30Uin 500ml

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Given IVPB through the lowest port of the primary line Goal of 100-220 MVUs or consistent pattern of ctxs Q2-3 min, lasting 80-90sec, and strong to palpation - We also bolus Pitocin for/after the delivery of placenta  decreases risk of PP hemorrhage Cervical ripening - Used before induction with oxytocin to “ripen” the cervix when bishop score is 4 or less, mom may never need oxytocin with this - Meds o Prostaglandin E1 (PGE1) misoprostol (Cytotec)  25mcg vaginally w/o lubricant Q 3-6 hours up to 6 doses until effective contraction pattern or cervix is favorable o PGE 2 dinoprostone (cervidil insert/prepidil gel)  Cervidil: 10mg vaginally; remove after 12 hours or onset of active labor  Prepidil: 0.5mg vaginally through syringe and catheter; repeat Q 6 hours up to 3 doses Mechanical methods of induction - Balloon catheter: foley with 30-50ml of sterile water, goes in cervix and inflated, should fall out when pt is 3cm, done by provider o Goal= balloons constant pressure on the cervix causes dilation - Membrane stripping/sweeping: separation of the membrane from the wall of the cervix and lower uterine segment by inserting a finger into the internal cervical OS and rotating it 360 degrees o Works well when mom is primigravida at term and baby is in the right position, but the cervix isn’t ready yet, but she is dilated a little o Very uncomfortable and increases the risk of infection, ROM, bleeding, precipitous labor and birth - Nipple stimulation: releases oxytocin which causes contractions - Intercourse: sperm is filled with prostaglandins and can act as a cervical ripening agent - Alternative methods: castor oil and primrose are not recommended Amniotomy/artificial ROM - Can induce or augment labor and decrease duration by 2 hours - Could cause prolonged ROM and chorio, often used with oxytocin induction, painless, performed by provider with an amnio hook, not nurse - Presenting part should be engaged before procedure - Nursing interventions: assess color, odor, amount, and time (COAT), change pad, assess FHT for prolapsed cord, temp Q 2hr, watch for signs of chorio, limit vag exams once ROM occurred o Use sterile gloves for vag exams after ROM! Operative vaginal birth – a vag birth using either forceps or vacuum extractor to deliver baby - Forceps vaginal delivery o Indications: prolonged pushing, exhaustion, category 3 FHTs, malposition o Cervix fully dilated, bladder empty, presenting part engaged

o Performed by physician, assess mom for perineal trauma; assess baby for facial bruising and palsy - Vacuum vaginal delivery o Same indications from forceps, vacuum cup to top of head, NOT used prior to 34 wks gestation o Assess baby for cephalhematoma, subdural hematoma Cesarean birth - Birth of baby through surgical abdominal incision of the uterus - Elective: moms choice r/t fear - Scheduled: medical indication to have c/s o Placenta previa, active HSV, positive HIV, maternal health condition that can’t withstand labor, repeat cesarean  We give prophylactic acyclovir to prevent HSV if she has a hx of it - Unplanned, primary – originally planned on vag birth o CPD (cephalopelvic disproportion), FTP (failure to progress) o Stat unplanned C/S – category 3 FHTs - Incision on skin o Vertical: up and down o Transverse (pfannenstiel): down low on bikini line - Incision on uterus o Low (vertical) o Classic (vertical)  After up and down incision on the uterus the patient can no longer have a vag delivery o Low transverse (horizontal) – can do VBAC Cesarean section - Preop o NPO for 8 hours, informed consent, IV fluids (bolus before), foley (moves bladder out of surgical field and helps monitor bleeding in urine), preop meds, antibiotics, clip pubic hair, SCDs o Explain to the patient that she should only feel pressure, let her know she will hear sounds  suctioning - Intraop o Staff, support person, hip wedge, strap legs to table, ground pad, foley after anesthesia, neonatal nurse team, timeout, FHTs after anesthesia - PACU o Skin to skin/breastfeeding - Document decision to incision time (depends on type of c/s) Anesthesia for c/s - Epidural: unplanned and already had one for labor - Spinal: scheduled - General: emergency & no time for spinal or mom chooses to be sedated r/t fear (RARE) o More risk to fetus – have respiratory support available

o Significant other cannot be in OR o Mom wakes up hurting immediately Trial of labor/vaginal birth after cesarean (VBAC) - TOL: observing active labor for 4-6 hours if vaginal birth is questionable - Previous c/s with low transverse uterine incision – only type of incision that could have VBAC - Dysfunctional labor, breech presentation, category 3 FHTs are often nonrecurring - Major risk= uterine rupture at scar - PGE 1 and 2 contraindicated Obstetric emergencies - Meconium stained amniotic fluid: fetus has a BM in utero, risk of meconium aspiration syndrome in newborn at first breath - Shoulder dystocia: head of fetus is born but shoulders can’t fit, can cause delay of completing birth or trauma to fetus o McRoberts maneuver is used to help with this - Prolapsed umbilical cord: occurs when the cord lies below the presenting part of the fetus, riskiest time is right after ROM  assess FHT o Mgmt.: hold presenting part of umbilical cord manually, put mom in Trendelenburg, vag delivery with forceps, emergency c/s - Rupture of the uterus: uterus opens up, prevention is the best treatment (only do VBAC with low transverse, be cautious with prolonged pit) o Emergency c/s, possible hysterectomy - Amniotic fluid embolism: patient presents with sudden onset of hypoxia, hypotension, cardiovascular collapse and coagulopathy o Cause=unknown Maternal child nursing care/PP care & complications – topic 6 Assessment - Assessment and client education assist in meeting needs of childbearing families – assist in detecting risk and treating possible complications - Easy way to remember BUBBLE-HEE B-breast U-uterus B-bowel B-bladder L-lochia/legs(DVT) E-episiotomy/incision Hhemorrhoids E-edema E-emotion Uterine, VS, and CV status - Monitor o Every 15 minutes for first hour after birth, every 30 minutes for the next hour, then hourly for approximately 2 more hours, then every 8 hours or more frequently if there is bogginess, position out of midline, heavy lochia flow Vital signs and blood values - Temperature – afebrile (except for 1st 24 hours) o Low grade temp right after labor  dehydration=make sure mom is hydrated - Pulse – bradycardia rates of 50-70 commonly during first 6-10 days o If mom has elevated pulse= something is going on, mom anxious, pain, infection, hypovolemia

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Respirations – normal rate, monitor with narcotics BP – consistent with BP baseline during preg; orthostatic hypotension for 48 hours o If mom had preeclampsia, it may take longer for her BP to go down o Orthostatic hypotension is due to blood loss or moving too quickly WBC count elevated after delivery – should go back to normal by the end of 1st week Risk of thromboembolism – lots of clotting factors circulating after placenta comes off o Goes back to normal 3-4 wks PP

Breasts - Assess if mom is breast or bottle feeding – inspect nipples and palpate for engorgement or tenderness (we want breasts to be soft) - Assess breasts for cracking, plugged ducts, and signs of mastitis - Teach mom proper latching on techniques and breast care: mom needs a nursing bra (about 1 size...