± rare complication of pregnancy characterized by the
sudden, acute onset of hypoxia, hypotension, or cardiac arrest and coagulopathy that can occur either
during labor and during birth, or immediately after birth; also known as amniotic fluid embolism
± medications administered to the mother for the purpose of accelerated to the
mother for the purpose of accelerating fetal lung maturity when an increased risk exists for preterm birth
24-34 weeks of gestation
± stimulation of ineffective UCs after labor has started spontaneously but is not
progressing satisfactorily
± Rating system to evaluate inducibility (ripeness) of the cervix; a higher score increases
the likelihood of a successful induction of labor
- condition in which the infant¶s head is of such a shape, size, or
position, that it cannot pass through the mother¶s pelvis, or maternal pelvis is too small, abnormally
shaped, or deformed to allow the passage of a fetus of average size
± birth of a fetus by an incision through the abdominal wall and uterus
± inflammatory reaction in fetal membranes to bacteria and viruses in the amniotic fluid,
which then become infiltrated with polymorphonuclear leukocytes
± abnormal UC that prevent normal progress of cervical dilation, effacement, or
descent
± prolonged, painful, or otherwise difficult labor caused by various condition associated with
the five factors affected by labor (powers, passage, passenger, maternal position, and maternal emotions)
!"!#
± turning of the fetus to a vertex presentation by external exertion of
pressure on the fetus through the maternal abdomen
$ ± vaginal birth in which forceps are used to assist in the birth of the fetal head
%
&
± uncoordinated, painful, frequent UCs that do not cause cervical
dilation and effacement; primary dysfunctional labor
%
&
± weak, ineffective UCs, usually occurring in the active phase of labor,
often r/t cephalocaudal disproportion or malposition of the fetus; secondary uterine inertia
'#
± hormone produced by the posterior pituitary gland that stimulates UC and the release of milk
in the mammary glands (let-down reflex); synthetic oxytocin is a medication that mimics uterine
stimulating action of oxytocin
'c ± rupture of amniotic sac and leakage of fluid before the onset of labor at any
gestational age
± UC causing cervical change that occurs between 20 and 37 weeks of pregnancy
± condition in which the head is born, but the anterior shoulder cannot pass under the
pubic arch
(
± administration of analgesics and implementation of comfort or relaxation measures
to decrease pain and induce rest for management of hypertonic uterine dysfunction
(
± medications used to suppress uterine activity and relax the uterus in cases of
hyperstimulation or preterm labor
" $ ± birth involving attachment of vacuum cap to the fetal head (occiput) and
application of negative pressure to assist in the birth of the fetus
" ± Vaginal birth after cesarean ± giving birth vaginally after having had a previous cesarean birth
!(!c')(%
preterm labor defined as cervical changes and UCs occurring 20 weeks ± 37 weeks of pregnancy
preterm birth ± any birth that occurs before completion of 37 weeks gestation
rate increasing for the last several years, major unsolved problem in perinatal medicine today
approximately 75% of preterm births are considered late preterm births (occurring between 34-36 weeks)
majority of infant deaths, and most serious morbidity occur 16% infants born before 32 weeks gestation
!(!c)(% *'+)(%+!),%(
preterm birth describes LENGTH of gestation (less than 37 weeks, regardless of weight)
low birth weight describes only WEIGHT at the time of birth (<2500g)
Preterm birth ü more dangerous health condition because a decreased time in utero correlates with
immaturity of body systems.
low birth weight babies can be, but are not necessarily preterm
LBW babies can be caused by conditions such as; IUGR, condition of inadequate fetal growth, not
necessarily correlated w/ initiation of labor
infants born at a preterm gestation can be more than 2500g at birth
-
)
± occur after early initiation of labor process
) - occur as a means to resolve maternal or fetal risk related to continuing pregnancy
25% are indicated because of medical or obstetric conditions that affect the mother, fetus, or both
increase in the number of indicated preterm births account for much of the recent rise in late preterm
births
#$
-preeclampsia
-fetal distress
-IUGR
-abruptio placentae
-intrauterine fetal demise
-pregestational or gestational diabetes
-renal disease
-Rh sensitization
-congenital malformalities
*history of previous preterm birth, multiple gestation, bleeding after 1st trimester, and low maternal BMI
major risk factors for sponatenous preterm birth
others: non-caucasian, low SES and educational status, living with chronic stress, smoking, substance
abuse, physically demanding work conditions, periodontal disease
*because at least 50% of all women who give birth prematurely have NO identifiable risk factors«
women should be educated about prematurity early, also in preconceptional period
±
changes in cervical length occur before UA
women whose cervical length is more than 30mm are UNLIKELY to give birth prematurely, even if they
have sx
± Infection is the only factor that has been definitely shown to cause preterm labor
bleeding at the placental implantation site in 1st or 2nd trimester ± possible
resulting uteroplacental ischemia or hemorrhage at the decidual layer of the placenta may somehow
activate the preterm labor process
Intrauterine inflammation is associated with infection, uterine vascular compromise, decidual hemorrhage
ü may contribute to preterm labor
Maternal/Fetal stress, uterine overdistention. allergic reaction, decrease in progesterone may play a part
2 recent studies ü recurrent preterm birth can be prevented in some women (who have previously given
birth prematurely ONLY) by administering prophylactic progesterone supplementation (1 vaginal, 1 IM
weekly)
risk of preterm reduced by 1/3
? how much is needed ü further studying.
-lower abdominal cramping, similar to gas pains; may be accompanied by diarrhea
-dull, intermittent low back pain (below the waist)
-painful, menstrual like cramps
-suprapubic pain or pressure
-pelvic pressure or heaviness
-urinary frequency
"
-change in character and amount of usual discharge; thicker (mucoid) or thinner (watery); bloody, brown,
or colorless; increased amount; odor
-rupture of amniotic membranes
1 3
1. Gestational age between 20 and 37 weeks
2. Uterine Activity (UCs)
3. Progressive cervical changes (effacement of 80%, or cervical dilation of 2 cm or greater)
If fetal fibronectin is used as another diagnostic criteria, a sample of cervical mucus for testing should be
obtained before an examination for cervical changes because lubricant can reduce the accuracy of the test
for fetal fibronectin
+
-empty your bladder
-drink 2-3 glasses of water or juice
-lie down on your side for 1 hour
-palpate for contractions
-if sx continue, call your PCP, or go to hospital
-if sx go away, resume light activity but not what you were doing before sx occurred
-if sx return, call your PCP, or go to hospital
)/!(5!c')/)()'
commonly prescribed intervention for prevention of preterm birth
*bed rest should not be routinely recommended
has many adverse physical effects, risk of thrombus formation, muscle atrophy, osteoporosis, and CV
deconditioning, also effects psychologically, emotionally, socially, and financially
"!!!//!('/!!(
c 6 7
-weight loss
-muscle wasting, weakness
-bone demineralization and calcium loss
-decreased plasma volume and cardiac output
-increased clotting tendency, risk for thrombophlebitis
-cardiac deconditioning
-alteration in bowel function
-sleep disturbances, fatigue
-prolonged postpartum recovery
c !6
7
$loss of control associated w/ role reversal
-dysphoria-anxiety, depression, hostility, anger
-guilt associated w/ difficulty complying with activity, restriction and inability to meet the responsibilities
-boredom, loneliness
-emotional lability (mood swings)
!
-stress associated w/ role reversal, increased responsibilities, disruption of family routines
-financial stress associated w/ loss of maternal income, and cost of treatment
-fear and anxiety regarding the well-being of the mother and fetus
%
³taking it easy´ at home for a few week or months.
nurse can help with women and family to deal with many difficulties
keep items needed within reach (tv, radio, tapes, computer w/ internet, snacks, books, magazines, and bed
near window or bathroom is helpful)
egg crate cover may be comfortable
daily schedule of meals, activities, hygiene, and grooming helps w/ boredom, and maintains control and
normalcy
)
6)
7 ± a NSAID has been shown in some trials to suppress preterm labor by blocking
production of prostaglandins
serious maternal side effects Uncommon
3 serious s/e cause major concerns
-constriction of ductus arteriosus, oligohydramnios, and neonatal pulmonary hypertension
* use in short duration
:
± each woman should be assessed in their knowledge of:
-dangers of preterm birth
-sx of preterm birth
-what to do if sx occur
;
-psychosocial status
-emotional status
-impact of diagnosis and treatment on family dynamics
;
-risk for imbalanced fluid volume (maternal) r/t: the administration of tocolytics to suppress preterm labor
-interrupted family processes r/t: required limitation on maternal activity associated with preterm labor
-anticipatory grieving r/t: potential for birth of the preterm infant
-risk of impaired parent-infant attachment r/t: care requirements of preterm infant
!#
'
±
learn s/sx of preterm labor, be able to assess herself, and her need for intervention
follow teaching suggestions, call PCP if sx occur
not experience sx of preterm labor, if occurs able to take action
maintain pregnancy for at least 37 weeks
give birth to a healthy, full-term infant
PROMOTION OF LUNG MATURITY
Antenatal glucocorticoids
given as IM injection to the mother to accelerate fetal lung maturity * for preventing morbidity and
morality
reduce significantly the incidence of respiratory distress syndrome, IV hemorrhage, necrotizing
enterocolitis, and death in neonates w/o increasing the risk of infection to mother or newborn
NIH recommends all women 24-34 weeks gestation be given a single course when preterm is threatened,
unless corticosteroids will have an adverse effect on mother or birth is imminent.
*Optimal benefit begins 24 hours after injection
:
: stimulates lung maturation by promoting release of enzymes that induce production of lung
surfactant (NOT FDA approved)
:)
: accelerate lung maturity in fetuses 24-34 weeks
:
0
;Bethamethasone ± 12 mg IM for 2 doses, 24 hours apart
Dexamethasone: 6 mg IM for 4 doses, 12 hrs apart
give deep IM injection in gluteal muscle
teach signs of pulmonary edema
assess blood glucose levels and lung sounds
'c
spontaneous rupture of the amniotic sac and leakage of amniotic fluid beginning before the onset of labor
at any gestational age
'c
membranes rupture before 37 weeks is responsible for 1/3 of all preterm births
Preterm PROM most likely from pathologic weakening of fetal membranes, caused from inflamm, stress
from UC, or other factors causing increase in uterine pressure
diagnosed when woman feels gush of fluids, or slow leak from vagina
usually hospitalized to try to prolong pregnancy and allow time for fetal maturity
unless ± intrauterine infection, significant vaginal bleeding, placental abruption, preterm labor, or fetal
compromise
of preterm PROM ± daily fetal assessment, usually by non-stress test, and
biophysical profile BPP, monitored for labor, placental abruption, development of intrauterine infection
antenatal corticosteroids given to women less than 32 weeks given they have been proven to decrease the
risk of several neonatal complications, resp distress syndrome, Iv hemorrhage, and necrotizing
entercolitis.
also 7 days ABX broad spectrum to treat or prevent intrauterine infection
major part of nursing care and patient education after preterm PROM
5(')
long, difficult, or abnormal labor ; dysfunctional labor, or dystocia
caused by various conditions associated w/ 5 factors
occurs 8-11% of all births
*2nd most common indication for c-section, after previous cesarean birth
Contractions ± frequent, painfully strong, w/ hypertonic uterine activity, but ineffective at promoting
cervical effacement, and dilation
Hypotonic ± rise in uterine pressure generated during contractions is insufficient to promote cervical
dilation and effacement
%
&
± (primary dysfunctional labor)
anxious, 1st time mother,
contractions in latent stage (cervical dilation <4cm) and usually uncoordinated
uterus may not relax between contractions
contractions in the midsection of the uterus, unable to put pressure on cervix
%
&
$ *more common type (secondary uterine inertia)
normal progress into active phase, then contractions become weak and ineffective, or stop all together
insufficient for effacement and dilation
nursing
help woman find comfortable position for pushing, coaching her to push effectively
assisted vaginal birth using vacuum or forceps or cesarean birth will be necessary
variety of causes: ineffective UCs, pelvic contractures, cephalopelvic disproportion, abnormal fetal
presentation, early use of analgesics, nerve block anesthesia, anxiety, stress.
chart on partogram, compare with intervals of normal labor times of nulli or multi, notify PCP
( $.
c
Prolonged Latent Phase > 20 hrs >14 hrs
Protracted active phase dilation <1.2cm/hr <1.5cm/hr
Secondary arrest, no change >2 hr > 2 hr
Protracted descent < 1cm/hr <2cm / hr
Arrest of descent; no change >1hr > ½ hr
Failure to descent No change during deceleration phase and 2nd stage
Precipitous Labor > 5 cm / hr 10 cm / hr
labor that lasts less than 3 hours from onset of contractions to time of birth
abnormal labor occurs in 2% of births
not usually associated w/ significant maternal or infant morbidity or morality
$(
obstruction of birth passage by an anatomic abnormality other than the bony pelvis
placenta previa (low lying placenta) that partially obstructs that internal os of the cervix
leiomyomas (uterine fibroids) in the lower uterine segment, ovarian tumors, a full bladder or rectum, may
prevent the fetus from entering the pelvis.
cervical edema can occur during labor when cervix is caught between presenting part and symphysis
pubis, or when woman begins bearing down efforts prematurely, inhibiting complete dilation
STDS ± (HPV) can alter cervical tissue integrity and thus interfere w/ adequate effacement and dilation
gross ascites, large tumors, open neural tube defects, hydrocephalus can cause dystocia
anomalies affect the relationship of the fetal anatomy to the maternal pelvic capacity, interfering with
ability of fetus to descend through birth canal
/
disproportion between the size of the fetus, and the size of the mother¶s pelvis
fetus cannot fit through the pelvis to be born vaginally
often CPD is related to excessive fetal size (macrosomia) (4000g or more), but often malposition is the
case
! ! can be associated with maternal diabetes, obesity, multiparity, large size of one or both
parents
maternal origin- when maternal pelvis is too small, abnormally shaped, deformed
unfortunately CPD cannot accurately be predicted
c
-most common fetal malposition is persistent occiptoposterior position (right occipitoposterior or left
occipitoposterior) occurring in 15% of labors during latent phase of 1st stage of labor
5% are in this position in 2nd stage
labor prolonged *especially in 2nd stage
** Severe Back Pain from the head pressing on sacrum
Counterpressure ± apply fist or heel of hand to sacral area
Heat/Cold ± apply to sacral area
Double Hip Squeeze ± knee chest position, partner or nurse places hands over gluteal muscles, presses
with palms and hands up and inward toward the pelvis
Knee Press ± sitting position w/ knees a few inches apart, feet flat on floor or stool
partner or nurse cups a knee in each hands, presses knees straight back toward the woman¶s hips while
learning forward toward the woman
/
/ %
-lateral abdominal stroking ± stroke abdomen in direction the head should rotate
-all 4¶s
-squatting
-pelvic rocking
-stair climbing
-lie on side which fetus should turn
-lunges ± in the direction of occiput
c
commonly reported complication
breech most common 3-4% of labors
associated w/ multifetal gestation, preterm birth, maternal anomalies, hydramnios, and oligohydramnios
genetic disorders
neuromuscular disorders ± b/c they have less ability to move in utero
diagnosis ± made by palpation, and vaginal examination, usually confirmed by US
risk for head being stuck after body is delivered (especially in footling
prolapse of umbilical cord
emotional support, expression of feelings, full explanation of events ü reduce anxiety and stress
hormones, and NT released in response to stress ( catecholamines) can cause dystocia
stress, pain, absesnce of support, confinement to bed or restriction of movement
anxiety is excessive, inhibit cervical dilation, prolonged labor, increased pain
increased stress level hormones released ± betaendorphin, adrenocorticotropic hormone, cortisol,
epinephrine) cause dystocia by reducing UCs
-document all assessment findings, interventions, patient responses in the patient¶s record according to
policy
-assess whether woman and family is fully informed about the procedures she is giving consent to
-provide full explanations regarding events that are taking place and interventions that are needed to help
mom and baby
-maintain safety by administering meds and treatments correctly
-have telephone orders signed ASAP
-provide care at acceptable standards
- if short staffing occurs ± nurse should document that rejecting this additional assignment would have
placed patients in danger as a result of abandonment
-maternal and fetal monitoring continues until birth, according to policies, even when decision to carry
out c-section is made
"
turning of fetus from one presentation to another
externally, or internally by physican
!"!#
used in attempt to turn the fetus from a breech or shoulder presentation to a vertex presentation for birth
it may be attempted in a labor and birth setting after 37 weeks
exertion of gentle, constant pressure on abdomen
US needs to be done 1st to determine position, rule out placenta previa, evaluate the adequacy of maternal
pelvis, assess the amount of amniotic fluid, gestational age, presence of anomalies
NST performed to confirm well being, FHR monitored
informed consent obtained
A tocolytic agent often given to relax the uterus to facilitate maneuver.
Contraindications ± Uterine anomalies, 3rd trimester bleeding, multiple gestation, oligohydramnios,
evidence of uteroplacental insufficiency, nuchal cord, previous c-section, obvious CPD
*Most successful in multiparous woman who has normal amount of amniotic fluid, whose fetus is not yet
engaged.
IF EVC not successful, recommendation for C-Section
during ± nurse continuously assesses FHR (esp. for brady, or variable decels), maternal VS, comfort,
uterine activity, and vaginal bleeding
FHR continue for 1 hour
Women who are RH- should receive RH (D) immune globulin because manipulation could cause
fetomaternal bleeding
) "
physician inserts hand into uterus and changes presentation to cephalic (head) or podalic (foot)
rarely used ±
sometimes in twin pregnancies to help deliver the 2nd fetus
safety is not documented, fetal injury is possible
C-section is usual method for managing malpresentation
*nurse ± monitor status of fetus, support woman
induction of labor is indicted if continuing pregnancy could be dangerous for mother or fetus, and if no
contraindications exist to artificial ROM or augmenting UCs.
Success rates are increased when the condition of the cervix is favorable, or inducible
± can evaluate inducilibility
when it is 8 or more, induction is more successful
)%''!
Dilation (cm) o 1-2 3-4 >5
Effacement 0-30 40-50 60-70 >80
Station -3 -2 -1,0 +1,+2
Cervical Consistency firm med soft soft
Cervix Position post mid-post ant ant
prostaglandin E1 and E2 shown to be effective before induction to ³ripen´ (soften, and thin) cervix
advantage ± decrease need for oxytocin, decreased oxytocin induction time, decrease in amount
*E1 though less expensive, and more effective«. increased risk for hyperstimulation of uterus with FHR
changes and meconium-stained amniotic fluid
%
(substances that absorb fluid from surrounding tissues and then enlarge) can be
used
± (artificial rupture of membranes) can be used to induce labor when the condition of the
cervix is favorable (ripe) to augment labor if progress begins to slow
amniotomy decreases the length of some labors, even w/o oxytocin
risks ± itnraamniotic infection, variable FHR decelerations
umbilical cord prolapse, and fetal injury
*assess FHR before and immediately after to detect any changes (transient tachycardia is common.. but
brady and variable decels are not) that may indicate cord compression, or prolapse
women¶s temperature needs to be checked at least q 2 hours or per policy
more frequently if sx of infection are present
temp 38 degrees or higher, notify PCP
sx: chills, uterine tenderness on palpation, foul-smelling vaginal discharge, fetal tachycardia
Comfort measures * - frequently changing underpads, and perineal cleansing
$
-time and rupture
-color, odor, and consistency of fluid
-FHR before and after
-maternal status (how well tolerated)
'>5(')
hormone normally produced by the posterior pituitary gland that stimulates UC and aids in milk let down
Synthetic oxytocin (Pitocin) may be used to either induce labor, or augment a labor that is progressing
slowly b/c of inadequate UCs
*most commonly used« but also most commonly associated w/ A/E during childbirth
*high-alert medication²when used inappropriately
maternal hazards ± pain, abruption placentae, uterine rupture, unnecessary cesarean birth caused by non-
reassuring FHR patterns, postpartum hemorrhage, and infection
contractions too frequent, or prolonged, fetus can experience hypoxemia, academia
ü late decels, & minimal or absent baseline variability
GOAL * produce UCs of normal intensity, duration, and intensity while using the lowest dose of
medication possible
Recommendation ± starting dose of 1 milliunit/min and increasing by 1-2 milliunits no more frequently
than every 30 to 60 minutes
High-dose protocols ± initial dose is larger, and dose level is increased more rapidly
have been found to result in reduced lengths of labor, and fewer forceps-assisted and c-section births
caused by dystocia.
but, have been associated w/ increased uterine hyperstimulation, increased c-section births r/t fetal stress
OXYTOCIN
action ± hormone produced in the posterior pituitary gland that stimulates uterine contractions, and aids in
milk let down. Pitocin is a synthetic form of this hormone
secondary line ± connected to the main line at the proximal port (closest to the IV insertion site)
always administered by pump
Nursing:
Explain reasons for using oxytocin to patient and family
inform the women as to the reactions to expect concerining the nature of contractions, intensity of the
contraction increasing more rapidly, holds the peak longer, and ends more quickly; will come regularly,
and more often
Everyone is different on the amount they need, some need very little, others need larger doses
Assess FHR every 15 minutes, or change in dose
Monitor UC pattern, and resting tone every 15 minutes, or change in dose
Monitor BP, R, P, every 30-60 minutes, or change in dose
Assess I&O, limit IV to 1000mL / 8 hours; output more than 120mL / 4 hours
Vaginal exam
Monitor side effects, n/v, hypotension, headache
Uterine Tachysystole ± ( know treatment)
Standard concentration of Oxytocin to minimize risk of patient harm
Rate needs to be continuously titrated to the lowest dose that achieves acceptable labor progress
(usually can be decreased, or d/c after ROM or in the active stage of 1st stage of labor)
Document time infused, each time increased, decreased, or discontinued
Document interventions for uterine tachysystole, and nonreassuring FHR and women¶s response to
interventions
Document notification of PCP and that person¶s response
!c!,!5
&(
42'#
more than 5 contractions in 10 minutes
series of single contractions lasting more than 2 minutes
contractions of normal duration occurring within 1 minute of eachother
)
642 /%7
reposition or maintain women in side-lying position
administer IV bolus w/ 500 mL of LR
if uterine activity does not return to normal after 10 minutes ± decrease oxytocin by ½
if uterine activity does not return after this, d/c oxytocin until fewer than 5 contractions / 10 mins
'#
(
If oxytocin infusion has been d/c for less than 20-30 mins, resume at no more than ½ rate that has caused
tachysystole
if oxytocin infusion has been d/c for more than 30-40 mins, resume at the initial starting dose
stimulation of UC after labor has started spontaneously but progress if unsatisfactory
usually for management of hypotonic uterine dysfunction, resulting in slowing of labor
active management of labor ± aggressive use of oxytocin so that woman gives birth within 12 hours
intervening early, with higher than normal amounts, given at frequent intervals, shortens labor
Forceps-Assisted Birth
instrument with 2 curved blades us used to assist birth of the fetal head
cephalic-like curve similar to shape of fetal head, with pelvic curve to the blades conforming to the curve
of the pelvic axis
locks prevent the forceps from compressing fetal skull
** FHR is assessed, reported, and recorded before and after application of the forceps
assess for vaginal/cervical lacerations, urinary retention, hematoma formation
infant ± bruising or abrasions at site of blade application, facial palsy from pressure on facial nerve, or
subdural hematoma
*newborn and postpartum providers should be told forceps were used
" $
attachment of vacuum cap to the fetal head, using negative pressure to assist in the birth of the head
generally not used before 34 weeks
easier, less anesthesia, easier to learn to use
risk ± cephalohematoma, scalp laceration
maternal ± perineal, vaginal, cervical lacerations, soft-tissue hematomas
documentation
pass on information to post-partum and newborn providers
observe application site
cerebral irritation (poor sucking, or listlessness)
caput succedaneum usually disappears 3-5 days
;
Assess FHR frequently during the procedure
Ecourage woman to push during contractions
Do not exceed the ³green zone´ indicated on pump, verify amount of pressure w/ physician
Document # of pulls attempted, maximal pressure used, and any pop-offs that occurred
birth of a fetus through a transbdominal incision
loss of experience may have negative effect on women¶s self concept
focus on birth of child, rather than operative procedure
/
$
when mother refuses to undergo c-section when indicated for fetal reasons (maternal-fetal conflict)
providers are ethically obliged to protect the well-being of mother and fetus
if woman refuses, health care providers need to find out why, provide info to help persuade her decision
? still refuses ± obtain court order?
uterine incision are the low transverse and the vertical which may be low, or classic
*higher incidence of uterine rupture in vaginal births after classic uterine incision
0
aspiration, hemorrhage, atelectasis, endometritis, abdominal wound, dehiscence or infection, UTI, injuries
to bowel or bladder, complications r/t anesthesia
$
if vaginal birth is contraindicated
complete placenta previa, active gential herpes, HIV positive w/ high viral load
&
$
psychosocial more pronounced and negative than compared w/ scheduled/planned
abrupt changes occur; experience is traumatic for all involved
tired, discouraged after ineffective/difficult labor
fear own safety, as well as fetus¶
dehydrated, low glucogen reserves
pre-op : little time is available ± may feel unprepared, uninformed
anxiety high ± may forget what people said
anger, guilt, fatigue in postpartum
no woman can be guaranteed a vaginal birth
women need to be prepared of possibility of c-section
continuing presence and support of partner helped them respond positively to their experience
;
family centered
same as any other elective or emergency procedure
discussed need for c-section, and prognosis
anesthesiology will assess cardiopulmonary system
informed consent
blood tests, CBC, blood type, Rh status
maternal VS and FHR assessment per hospital policy
IV fluids ± hydration
catheter
Abx
check consents
shave / clip pubic hair if needed
TED hose / SCD boots to prevent blood clots
remove jewelry (depending) polish, dentures, nail polish
*make sure bring glasses in OR so she can see infant
uterus displaced laterally & wedge placed under hip during procedure to prevent decreased
placental perfusion
women¶s legs may be strapped to ensure proper positioning
mother transferred to PACU
postpartum & postop needs that must be met! (surgical patients, also new mothers)
airway*
VS q 15 mins for 1-2 hours until stable
positioning
incisional dressing, fundus, lochia assessed
IV intake, and UO from foley
TCDB, leg exercises
bonding
breastfeeding
transferred when stable, and when anesthesia wears off (she is alert, able to feel and move
extremities)
medication given promptly, before pain is severe
*Postpartum/Postop care
mother 1st, post-op patient 2nd
physiologic concerns may be dominated by pain at incision site, and intestinal gas
first 24 hours pain relief by epidural opiods, pca, IV or IM injections ü oral
position changes, splinting of incision w/ pillows, breathing, relaxation
*temperature greater than 38 (100.4)
*painful urination
*lochia heavier than a normal period
*wound separation
*redness or oozing at incision site
*severe abdominal pain
('(
observance of woman for reasonable time period (4-6 hours) of spontaneous active labor to
assess the safety of vaginal birth for mother and fetus
most common -- * mother wants VBAC
women is evaluated for occurrence of active labor, contractions, engagement and descent of
presenting part, effacement and dilation
assesses VS and FHR, contractions, alert for signs of complications
appropriate actions ü responses to interventions, notifying PCP, evaluation / documentation
support and encouragement, provide information
spontaneous labor more likely to result in a successful labor than has been induced or augmented
<35 years old, fetus weight less than 4000g, previous C- section was performed for some other
reason than failure to descent in 2nd stage of labor
after being informed of risks/benefits ± about 25% of potential candidates choose repeat c-
section
*emotional support needed during TOL b/c increased anxiety can lead to release of
catecholamines, inhibiting release of oxytocin ü delay in labor. therefore another c-section
) c
4
4 c
/
-assess amniotic fluid for presence of meconium after ROM
-if it is stained, gather equipment necessary for neonatal resuscitation before birth
-have someone capable of performing resuscitation ± and endotracheal intubation
)
-assess baby¶s respiratory efforts, HR, muscle tone
-suction baby¶s mouth and nose if the baby has:
strong resp. efforts, good muscle tone, HR > 100 bpm
-suction below vocal cords using endotraceal tube to remove any meconium present before many
spontaneous respirations have occurred, or assisted ventilation has been initiated if the baby has:
-depreseed resp, decreased muscle tone, HR <100 bpm
uncommon obstetric emergency that increases the risk for fetal / maternal morbidity and morality
during the attempt to deliver the fetus vaginally
condition where the head is born, but the shoulder cannot pass under the pubic arch
fetopelvic disproportion r/t excessive fetal size or maternal pelvic abnormalities may cause the
shoulder dystocia, although up to half of all cases occur w/ fetuses of smaller size
other risk factors ± maternal diabetes, history in previous birth, prolonged 2nd stage of labor
in half of all cases ± no risk factors
complications r/t trauma brachial plexus and phrenic nerve injuries, fx of humerus or clavicle
*most serious brachial plexus injury (erb palsy) which occurs in 10-20%
if recognized early, and treated properly 80-90% resolve
Management ±
suprapubic pressure can be applied, maternal position changes to free anterior shoulder
McRobert¶s maneuver woman¶s knees flexed apart, knees on her abdomen.
causes sacrum to straighten, symphysis pubis rotates toward mother¶s head
suprapubic pressure can be applied also
*preferred when given epidural anesthesia
factors ± long cord (> 100 cm), malpresentation (breech), or unengaged presenting part
if the presenting part does not fit snugly in the lower uterine segment (hydramnios), the gush of
fluids may cause cord to be displaced downward
or during amniotomy
or small fetus who does not fit snugly
*prompt recognition b/c fetal hypoxia can result from prolonged cord compression
(occlusion of blood flow to and from fetus for more than 5 minutes) usually results in CNS
damage, or death of fetus
pressure may be relieved by examiner putting sterile gloved fingers in to keep fetus off cord
s/sx vary
most common ± reassuring FHR, variable & late decelerations, bradycardia, absent/minimal
variable
loss of fetal station may occur
constant abdominal pain, uterine tenderness, change in uterine shape, cessation of contractions
sx of hypovolemia r/t hemorrhage (hypotension, tachycardia, pallor, cool, clammy skin)
placenta seperates ± FHR will be absent
fetal parts may be palpable through abdomen
aka: amniotic fluid embolism
maternal factors ± multiparity, tumultuous labor, placental abruption, oxytocin, fetal problems ±
macrosomnia, death, meconium passage ± increased risk of development
Immediate interventions ±
CPR
perimortem c-section within 5 minutes
transfer to ICU
replace blood, clotting factors, hydrate, ventilator
!$
;
Respiratory Distress:
restlessness, dyspnea, cyanosis, pulmonary edema, respiratory arrest
Circulatory Collapse:
hypotension, tachycardia, shock, cardiac arrest
Hemorrhage:
coagulation failure ± bleeding from incisions, venipuncture sites, trauma, petechiae, ecchymoses,
purpura, uterine atony