Childbirth at Risk

1. Childbirth at Risk

2. Care of the Woman at Risk Because of Psychological Disorders • Prevalence of psychological disorders of adults in the U.S. is 26.2% • Alteration in thinking, mood or behavior

4. Depression • More women are affected than men • CNS imbalance in serotonin & other neurotransmitters • Unable to process information • Unable to concentrate • Fatigue, sleep deprivation • Overwhelmed by labor process • Unworthy of motherhood • Hopelessness

5. Effect on Labor • Unable to concentrate/process info from healthcare team • May begin labor fatigued or sleep deprived • Labor process may overwhelm the woman physically & emotionally-no energy • May appear irritable or withdrawn due to inability to articulate feelings of hopelessness or “unworthiness of motherhood”

7. Bipolar Disorder • Higher risk of suicide • Women with a previous diagnosis of bipolar depression are at greater risk for developing a mood disorder in the postpartum period • Postpartum psychosis is more common in women with bipolar disorder

8. Anxiety Disorders • Panic disorder, OCD,PTSD, generalized anxiety disorder, phobias • Cause a wide range of sx in the laboring woman: terror, SOB, CP, weakness, faintness, dizziness (exclude other dx) • Labor may trigger flashbacks, avoidance behavior, anxiety sx. • Severe sx to vague feeling “something is wrong”

9. Clinical Therapy • Provide support • Decrease anxiety • Orient to reality • Sedatives/analgesia (decrease pain may decrease psychological sx) • Psychiatric support

10. Dystocia • Abnormal labor pattern • Problem with the 3 Ps • Most common problem is dysfunctional uterine contractions resulting in prolonged labor • Friedman curve: 4cm in active labor-1cm/hr for primips, 1.5 cm/hr for multips • Variations: protracted labor & arrest of labor (no change for 2 hours)

11. Hypertonic Labor Pattern • Ineffectual uterine contractions of poor quality occur in the latent phase and resting tone of the myometrium increases • Painful, ineffective contractions become more frequent prolonging latent phase • Management: bed rest and sedation to promote relaxation and reducpain • Nursing comfort measures: position change, hydrotherapy, mouthcare, linen change, relaxation exercises, education

12. Clinical Management • Consider CPD (station) “out of the pelvis” • If no CPD, consider amniotomy and Pitocin augmentation

13. Active vs Expectant Management • AMOL: amniotomy, timed cervical checks, augmentation of labor with IV pitocin • Expectant management: Labor considered a normal process and allowed to progress without automatic intervention

14. Nursing Care and Management • VS • Labor pattern • Cervical progress • Fetal status • Vtx pressing down on cx without descent = caput, caput increases with no progress • Maternal hydration: I & O • Monitor for infection

15. Precipitous Labor and Birth • L & D occurs within 3 hours • Maternal risks: abruptio placenta, lacerations, PPH • Fetal risks: oxygenation may be poor-meconium stained AF may be aspirated, low Apgar scores, trauma • Know hx, assess laboring woman for rapid dilatation

16. Postterm Pregnancy • Extends beyond 42 completed weeks of pregnancy • 7% of all pregnancies in the U.S. • Cause – unknown, wrong dates • ? Dates: early sono • Maternal risks: labor induced, LGA, macrosomia, forceps, vacuum, perineal damage, hemorrhage, c/s doubled (endometritis, hemorrhage, thromboembolic disease)

17. Postterm Pregnancy • Fetal risks: placental changes, increased perinatal mortality, oligohydramnios, if decreased placental perfusion-SGA; • IF no compromise-LGA or macrosomic, birth trauma, shoulder dystocia, prolonged labor, hypoglycemia seizures, respiratory distress, meconium staining-aspiration

18. Management of Postterm Pregnancy • Starting at 40 wks: NST, BPP, AF index + NST usually twice weekly • In labor, ongoing assessment, continuous EFM, note AF,

19. Fetal Malposition - POP • Early labor 15%, at birth 5% • Maternal risk: intense back pain til rotation, 3rd or 4th degree laceration if born OP, higher incidence of operative deliveries (60% of women will have a c/s) • Nursing assessment: back pain, abdominal depression, protracted labor, FHR heard laterally • Nursing care: Position change! pelvic rocking

22. Face presentation. Mechanism of birth in mentoposterior position. Fetal head is unable to extend farther. The face becomes impacted.

23. Types of cephalic presentations. A, The occiput is the presenting part because the head is flexed and the fetal chin is against the chest. The largest anteroposterior (AP) diameter that presents B, Military (sinciput) presentation. C, Brow presentation.D, Face presentation.

24. Breech • Overall incidence 4%, directly related to gestational age • Frank breech most common 50-70%(term) • Single or double footling breech 10-30% (preterm) • Complete breech 5%

25. Frank breech

26. Incomplete (footling) breech

27. , Complete breech

28. On vaginal examination, the nurse may feel the anal sphincter. The tissue of the fetal buttocks feels soft.

29. Breech • Associated with: placenta previa, oligo, hydrocephaly, anencephaly,multiples • Higher incidence of cord prolapse, neonatal & infant mortality, mec aspiration • Entrapment, head trauma, spinal injury • ECV (external cephalic version) attempted at 37- 38 weeks • Passage of mec normal in vag breech

30. Transverse Lie Common in mutliples More common in multips Many convert to cephalic or breech by term If still transverse ECV may be done Persistent transverse lie requires a c/s after determining fetal lung maturity

31. Transverse lie. Shoulder presentation

32. Macrosomia • More than 4500 g. (differs according to ethnic group) • Obese women 3-4 times more likely • Association with pregestational and gestational diabetes • Distention of uterus, overstretching leads to dysfunctional labor & increased PPH • Increased risk perineal trauma, PPH, infections, forceps, vacuum

33. Shoulder Dystocia • ID macrosomic infant infant in labor • McRoberts maneuver, lower mom’s head, apply suprapubic pressure • Recognize: slow descent, turtle sign, excessive molding • After the birth: examine for cephalhematoma, Erb’s palsy, fractured clavicle. Neuro/cerebral damage

34. McRoberts maneuver. A, The woman flexes her thighs up onto her abdomen

35. B, The angle of the maternal pelvis before McRoberts maneuver. C, The angle of the pelvis with McRoberts maneuver.

36. Multiples • Twins 3.2% of all pregnancies • Triplets and higher 1.8% • 33% monozygotic twins: genetically identical-highest risk for fetal demise, cord entanglement, twin-to-twin transfusion • 25% of all twins are lost before the end of the first trimester • Higher incidence of preterm birth

39. Complications Common with Multiples • Spontaneous abortion • Gestational diabetes • Hypertension or preeclampsia 2.6x • HELLP • Acute fatty liver (severe coagulopathy, hypoglycemia, hyperammonemia • Pulmonary embolism 6x • Maternal anemia • Hydramnios • PROM, incompetent cx, IUGR • Labor cx: PTL, uterine dysfunction, abn presentations, operative delivery (forceps, c/s) PPH

41. Management • Goals: promote normal fetal development, prevent maternal complication, prevent PTD, diminish fetal trauma • US: frequent surveillance • PTL prevention: cervical checks start at 28 wks & cervical measurements, fetal fibronectin equivocal. Bed rest and hospitalization to prevent PTL not supported by EBP • Expect fundal height greater than wks gestation • Auscultate 2 heart beats • Wt gain 35-44# • Diet 135g protein & 1mg folic acid

42. Labor Management of Multiples • c/s if presenting twin is not vertex • External monitor A & B • Internal monitor A & external monitor B • Correctly identify A & B • Anticipate PPH

43. Nonreassuring Fetal Status • O2 supply insufficient to meet physiological demands of fetus • Causes: cord compression, uteroplacental insufficiency, maternal/fetal disease • Most common initial signs=meconium stained AF (vertex) changes in FHR( late, severe variable decelerations; rising baseline)

44. Interventions • Change mother’s position • Increase rate of IV infusion • O2 via mask at 6-10 L/min • Continuous EFM • D/C pitocin if running • Provide emotional support to woman, her partner, family-explanations: unexpected c/s

45. Placental Problems • Abruptio placenta • Placenta previa • Accreta

46. Abruptio Placentae • Premature separation of a normally implanted placenta: 0.5%-2% • Risk factors: smoking, PROM, HTN, previous abruptio=10x higher risk • Cause unknown: maternal HTN(44%), trauma ( 2-10%),fibroids, cocaine, high parity, short cord • Marginal, Central (concealed bleeding), Complete • Retroplacental clot, blood invades myometrium, uterus turns blue couvelaire uterus- hysterectomy • Large amts of thromboplastin are released triggering DIC, fibrinogen plummets

47. Abruptio placentae. A, Marginal abruption with external hemorrhage. B, Central abruption with concealed hemorrhage. C, Complete separation

48. Management • Risk of DIC- evaluate coagulation profile • In DIC fibrinogen and platelet counts are decreased, PT and PTT are normal to prolonged, fibrin split produces rise with DIC • IV access (16 or 18 gauge), continuous EFM, c/s usually safest, T and X-M at least 3 units of blood, treat hypofibrinogenemia with cryo or FFP before surgery, may need CVP monitoring. • Consider 2 IV lines, watch I & O, worrisome if output below 30 mL/hour • Clot observation test at bedside (red top tube) if clot fails to form in 6 minutes fibrinogen level of less than 150 mg/dL is suspected, clot not formed in 30 minutes fibrinogen less than 100 possible

49. Placenta Previa • The placenta is improperly implanted in the lower uterine segment. Implantation may be on a portion of the lower uterine segment or over the internal os. • As the lower uterine segment contracts and dilates in the later weeks of pregnancy, the placental villae are torn from the uterine wall. Bleeding