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NCM 102 COMPLICATIONS OF LABOR AND DELIVER

PROBLEMS WITH THE POWER HYPOTONIC UTERINE CONTRACTIONS UTERINE INERTIA Infrequent contractions with decreased intensity Commonly occurs in the active phase of labor Etiology and Pathophysiology: Overstretching of the uterus Bowel or bladder distention preventing descent Excessive use of analgesia Signs and Symptoms of HYPOTONIC UTERINE INERTIA: Weak contractions become mild Infrequent (every 10 15 minutes +) and brief, Can be easily indented with fingertip pressure at peak of contraction. Prolonged ACTIVE Phase Exhaustion of the mother Psychological trauma - frustrated

Therapeutic Interventions: Ambulation Nipple Stimulation --release of endogenous Pitocin Enema--warmth of enema may stimulate contractions Amniotomy--artificial rupture of the membranes Augmentation of labor with Pitocin Amniotomy is the artificial rupture of the amniotic sac with a tool called the amniohook (a long crochet type hook, with a pricked end) or an amnicot (a glove with a small pricked end on one finger). One of these will be placed inside the vagina, where the caregiver will rupture the amniotic sac or membrane.

AMNIOTOMY Advantages of doing this before Pitocin Contractions are more similar to those of spontaneous labor Usually no risk of rupture of the uterus Does not require as close surveillance Disadvantages of an Amniotomy Delivery must occur Increase danger of prolapse of umbilical cord Compression and molding of the fetal head (caput) Amniotomy Nursing Care: # 1-Check the fetal heart tones Assess color, odor, amount Provide with perineal care Monitor contractions Check temperature every 2 hours Cervical Ripening Cervical ripening is the process of effecting physical softening and dilatation of the cervix in preparation for labor and delivery. Cervical Ripening: prostaglandin E2 Medications Prepidil gel Cervodil Prostaglandin E1 Medication Cytotec Nursing Care Monitor maternal vital signs, cervical dilatation and effacement Monitor fetal status for presence of reassuring fetal heart rate Remove medication if hyperstimulation occurs PITOCIN Augmentation of Labor Assess first to make sure CPD is not present, then start procedure: Give 10 units / 1000 cc. fluid and hang as a secondary infusion, never as primary

Nursing Care: Assess contractions--are they increasing Assess dilation and effacement Monitor vital signs and FHTs Make sure no signs of hyperstimulation before increasing dose HYPERTONIC UTERINE CONTRACTIONS Contractions are ineffectual, erratic, uncoordinated, and of poor quality that involve only a portion of the uterus Increase in frequency of contractions, but intensity is decreased, do not bring about dilation and effacement of the cervix. Most often occur in first-time mothers, Primigravidas Signs and Symptoms: PAINFUL contractions RT uterine muscle anoxia, causing constant cramping pain Dilation and effacement of the cervix does not occur. Prolonged latent phase. Stay at 2 - 3 cm. dont dilate as should Fetal distress occurs early uterine resting tone is high, decreasing placental perfusion. Anxious and discouraged Treatment of Hypertonic Uterine Contractions: Provide with COMFORT MEASURES Warm shower Music imagery Back rub, therapeutic touch

Mild sedation Bedrest or position changes Hydration Tocolytics to reduce high uterine tone

Ineffective Maternal Pushing Results from: Incorrect pushing techniques Fear of injury Decreased urge to push Maternal exhaustion Treatment Teaching

INDUCTION OF LABOR The stimulation of uterine contractions before the spontaneous onset of labor, for the purpose of accomplishing birth refers to measures used for the deliberate initiation (stimulation) of uterine contractions before the spontaneous onset of labor for the purpose of achieving a vaginal birth. Augmentation of labor refers to the stimulation of ineffective uterine contractions after spontaneous onset of labor to manage labor dystocia.

Labor Readiness Fetal Maturity Cervical Readiness with utilization of the PreLabor Status Evaluation Scoring System/ Bishops score Assesses cervical dilatation, effacement, consistency, position, and fetal station. A score of 8-9 is favorable for induction Methods of Inducing Labor Stripping the Membranes With a gloved finger, the amniotic membranes lying against the lower uterine segment are separated. This causes release of prostaglandins that stimulate uterine contractions Other Methods of Induction Ambulation Nipple Stimulation --release of endogenous Pitocin

Enema--warmth of enema may stimulate contractions Herbs Insertion of balloon catheter

Dystocia An abnormal, long, or difficult labor or delivery Dystocia is abnormal labor resulting from abnormalities of uterine contractions or maternal expulsive forces (power), the fetal position, size, or presentation (passenger), or the pelvis or soft tissues (passage). PREMATURE LABOR Definition: Labor that occurs after 20 weeks but before 37 weeks Etiology: urinary tract infections Premature rupture of membranes

Goal -- STOP THE LABOR ! suppress uterine activity Risk factors : Mult. first trimester abortions Uterine anomalies: malformations, fibroids, cervical incompetence Medical complications: DM, HTN, Multiple gestation Polyhydramnios TOCOLYTIC MEDICATIONS -adrenergic agonist Examples: Yutopar (ritodrine) or Brethine (terbutaline sulfate) SIDE EFFECTS or WARNING SIGNS: Palpitations Tachycardia - pulse ~120 Tremors, nervousness, restlessness Headache, severe dizziness Hyperglycemia TOXIC EFFECTS - PULMONARY EDEMA rales, crackles, dyspnea noted on routine nursing chest assessment every shift Tocolytic Drugs Give ANTIDOTE: INDERAL Tocolytic Medications Magnesium Sulfate Decreases frequency and intensity of uterine contractions Given via IV infusion pump Side effects Lethargy and weakness Sweating, flushing, N/V, headache, slurred speech

Nursing Care: Stop the medication Start oxygen

Loading dose 4-6 g in 100 ml given over ~20 minutes Maintenance dose 1-4 g per hour.

Toxic effects Absences of reflexes Respiratory depression

Tocolytic Medications Calcium Channel Blocker nifedipine Decreases smooth muscle contraction by blocking the slow calcium channels at cell surface. Administration Orally or sublingually Side Effects Hypotension, tachycardia Facial flushing Headache Tocolytic Medications prostaglandin synthesis inhibitor indomethacin (Indocin) Action: Inhibits prostaglandin synthesis thus reducing uterine contractions. (Prostaglandins stimulate uterine contractions) Used for pregnancies <32 weeks gestation and not given for more than 72 hours. Not a widely used medication to treat preterm labor. Self Care Measures Rest Drink plenty of fluids 2-3 quarts /day Empty bladder every 2-3 hours when awake

Avoid lifting heavy objects Avoid overexertion Modify sexual activity

Preterm labor NURSING CARE: Teach how to take medication -- on time Teach patient to check pulse, call Dr. if > 120 140 (dehydration increases contractions) Teach to assess fetal movement daily, kick counts Drink 8-10 glasses of water per day Monitor uterine activity -- Home monitoring -- call dr. if has contractions Decrease activity Lie on side Keep bladder empty

Preterm Prematurely Ruptured Membranes (PPROM) PPROM Incidence 1.7% of pregnancy Risk Factors Preceding preterm birth Twins Abruptio placentae Chorioamnionitis Antibiotics for Chorioamnionitis Vaginal delivery 1. Ampicillin 1 g iv. q 6 hrs 2. Gentamicin C/S Add Metronidazole 500 mg. iv. Q 8 hr. Antibiotics Ampicillin 1 g. iv. every 6 hrs. X 2 days then Amoxicillin (500 mg.) 1X3 or 1X4 / 5 days Erythromycin (500 mg.) 1X4 / 7 days PRECIPITATE LABOR Precipitate Delivery. This refers to a delivery which results after an unusually rapid labor (less than three hours) and culminates in the rapid, spontaneous expulsion of the infant. Delivery often occurs without the benefit of asepsis. b. Emergency Delivery. This refers to an unplanned, non delivery room, non-hospital birth which occurs as a result of precipitous labor, geographical distance from the hospital, or other cause for the unexpected delivery.

PRECIPITIOUS LABOR OR DELIVERY Labor that last less than 3 hours Unexpected fast delivery Etiology Lack of resistance of maternal tissue to passage of fetus Intense uterine contractions Small baby in a favorable position Complications/ Risks: If the baby delivers too fast, does not allow the cervix to dilate and efface which leads to cervical lacerations Uterine rupture Fetal hypoxia and fetal intracranial hemorrhage Nursing Care: Do NOT leave the mother alone Try to make the place clean Try to get the mother in control -- Have mom pant to decrease the urge to push Apply gentle pressure to the fetal head as it crowns to prevent rapid change in pressure in the fetal head which can cause subdural hemorrhage or dural tears Deliver the baby BETWEEN contractions to control delivery Suction or hold babys head low and place on mom/s abdomen, tie off cord Allow to breast feed, Document!

Rapid Delivery - Delivery Outside Normal Setting Everything is OUT OF CONTROL! mom is frightened, angry, feels cheated

NURSING CARE TO PREPARE FOR ANTICIPATED PRECIPITATE BIRTH a. Assess Patient for an Impending Precipitous Delivery Situation. (1) Patient has previous obstetric history of rapid labor/delivery. (2) Patient complains of a sudden, intense urge to push. (3) Notable increase in bloody show. (4) Sudden bulging of the perineum. (5) Sudden crowning of the presenting part.

b. Call for Help. Do not leave the patient unattended. c. Obtain a Sterile Obstetric or Precipitate Delivery Pack, if Available. The pack contains a variety of supplies to include towels, drapes, sanitary pads, and so forth. Priority equipment includes: (1) Gloves - sterile gloves are preferred as they help promote asepsis, however, if non-sterile gloves are available they should be utilized as protection for the nurse. (2) Towel/cloth-to provide a friction surface for control of delivery of the fetal head. (3) Bulb syringe-for aspiration of amniotic fluid from the infant's mouth. (4) Hemostats or cord clamps-to clamp the umbilical cord. (5) Scissors-to cut the episiotomy/cord. (6) Dry blanket/towel-to wrap the infant after delivery. d. Provide the Cleanest Environment Possible. If no sterile equipment is available this should include: (1) Paper, towel, blanket, or coat to place under the patient's buttocks. (2) Ligating material such as string, yarn, or shoelaces to tie the cord. (3) A sharp instrument such as scissors, a knife, or a razor to cut the cord. (4) A dry cloth to wrap infant after delivery. e. Provide for Asepsis to the Greatest Extent Possible. (1) Pour Betadine over the patient's perineum if time does not permit for perineal prep. (2) Wash your hands and glove, if possible. f. Support the Patient. (1) Keep the patient informed of plans for delivery. (2) Speak in a calm tone and provide direction to available assistants (e.g., significant other). (3) Encourage the patient to pant or blow through contractions to slow the delivery process and to decrease the force of expulsion. (4) Provide for privacy, but do not leave the patient alone. NURSING CARE AFTER A PRECIPITATE DELIVERY a. Assist the mother into a comfortable position with her legs extended. b. Provide a clean surface under the patient's buttocks. c. Check uterine fundus every 10 to 15 minutes during the first hour to assure contraction of myometrium and normal lochial flow. (1) Gently massage the uterus if the fundus is soft or boggy. (2) Avoid overstimulation as myometrium will fatigue and result in severe atony. d. Assess the amount of blood loss from the delivery. Normally, blood loss is less than 500 cc. Save all evidence of blood loss. e. Assess for intactness of the placenta. f. Provide for comfort and warmth of both patients. Promote fluids in the mother as tolerated. g. Encourage the mother to void to prevent bladder distention

PELVIC ORGAN PROLAPSE Genital Prolapse Genital prolapse or pelvic organ prolapse is the protrusion of the pelvic organs into or out of the vaginal canal. Most cases are the result of damages to the vaginal and pelvic support tissues due to childbirth or due to chronically elevated intra-abdominal pressure. Definitions Complete Genital Prolapse (Total procidentia): Protrusion of entire female organ out of vagina. Uterine Prolapse: Protrusion of the uterus into or through the vagina.

Vaginal Vault Prolapse: Protrusion of the top of the vagina into the lower portion of the vagina or through the vagina totally inverting it. This occurs in post-hysterectomy patients. Cystocele: Protrusion of the bladder into or through the vagina. Rectocele: Protrusion of the rectum into or through the vagina. Enterocele: Protrusion of bowel into or through the vagina. Urethrocele: Protrusion of the urethra into the vagina. Treatment of Pelvic Organ Prolapse 1. Pessary: A device inserted into the vagina to support the prolapsed organs. 2. Pelvic floor muscle exercises: May be done in conjunction with pessary use. The exercise strengthens the muscles in the pelvic floor, and may enhance the ability to retain the pessary in the vagina. 3. Hormone replacement therapy: Improves the quality of the vaginal tissue. UTERINE PROLAPSE w/ or w/o cystocele or rectocele Vigorous massage of the fundus & pulling on the umbilical cord to speed placental separation may cause prolapse of the cervix & lower uterine segment through the introitus

INVERSION OF THE UTERUS Inversion of the uterus is a potentially life-threatening complication in which the uterus turns inside out during the third stage of delivery. Inversion may be: 1. Spontaneous - occurs with increased abdominal pressure, as seen with forceful coughing or bearing down 2. Forced - occurs with pulling on the umbilical cord 3. Complete - fundus inverts and passes through the cervical os into the vagina 4. Partial - fundus of uterus partially inverts but not beyond the cervical os Pathophysiology and Etiology Inversion is more commonly seen with fundal placental implantation and with a thin uterine wall at the site of implantation. Predisposing factors include: Excessive traction on the cord while the placenta is still attached to the uterine wall Fundal pressure Lax or thin uterine wall Abnormally short umbilical cord

Uterine atony Fundal placentation Abnormally adherent placental tissue (placenta accreta or increta) Fetal macrosomia Use of oxytocin

Clinical Manifestations: Primary sign is hemorrhage and sudden agonizing pelvic pain. Maternal bleeding and shock, with symptoms seeming out of proportion for the blood loss. A complete inversion may appear protruding from vagina. Inability to palpate fundus in association with clinical manifestations. Confirmed with bimanual examination. Management: Prevention is the most effective therapy. Goal is to immediately restore the uterus to its normal position, manually. If attempts to restore uterus immediately are unsuccessful, use of general anesthesia and tocolytic therapy (terbutaline or MgSO4) is recommended. After the uterus has been restored to its normal position, oxytocin is given to contract the uterus. Abdominal or vaginal surgery may be necessary if manual replacement fails. Additionally, the woman is treated with broad-spectrum antibiotics.

Complications Infection, anemia Potential for a hysterectomy if uterus cannot be returned to its normal position Potential for paralytic ileus (Obstruction of the intestine due to paralysis of the intestinal muscles) UTERINE RUPTURE Spontaneous or traumatic rupture of the uterus Uterine rupture is tearing of the uterus, either complete (rupture extends through entire uterine wall and uterine contents spill into the abdominal cavity) incomplete (rupture extends through endometrium and myometrium, but the peritoneum surrounding the uterus remains intact). 2. Small tears may be asymptomatic and may heal spontaneously, remaining undetected until the stress and strain or a subsequent labor. Dehiscence is the partial separation of the old uterine scar; the fetus usually stays inside the uterus and the bleeding is minimal when dehiscence occurs.

Etiology: Rupture of a previous C-birth scar Prolonged labor Injudicious use of Pitocin -- overstimulation Excessive manual pressure applied to the fundus during delivery C. PATHOPHYSIOLOGY 1. The most common pathologic factors is a preexisting scar that results in a weakened or defective myometrium that does not stretch; this is most frequently identified in spontaneous uterine rupture. 2. Some episodes of rupture are due to traumatic disruption of the uterine surface. 3. More severe ruptures pose the risk of irreversible maternal hypovolemic shock of subsequent peritonitis, consequent fetal anoxia, and fetal or neonatal death. Signs and Symptoms: Sudden sharp abdominal pain, abdominal tenderness Cessation of contractions Absence of fetal heart tones Shock Therapeutic Interventions: Deliver the baby ! / Cesarean Deliver

NCM-102 COMPLICATIONS OF LABOR AND DELIVERY PROBLEMS WITH THE PSYCHE COMPLICATIONS OF THE PSYCHE Etiology and Pathophysiology: Hormones released in response to anxiety can cause DYSTOCIA Intense anxiety stimulates Sympathetic nervous system which releases Norepinephrine and epinephrine lead to uncoordinated or increased uterine activity Factors influencing the psyche of the client in labor Fear & anxiety Perception of problems Self-image Preparation for childbirth Support systems Copping ability Nursing Care Assess support available and be there for the patient Patient Teaching- breathing/relaxation Provide with non-pharmacological measures Keep informed Provide quiet calm environment