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Complication o Labor

Complication o Labor. Prolapsed Cord. Umbilical cord precedes presenting part May be visible or occult More common with Abnormal lie Low birth weight > previous births Amniotomy Long cord. Prolapsed Cord. Key interventions Relieve pressure on cord Trendelberg or knee chest position

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Complication o Labor

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  1. Complication o Labor

  2. Prolapsed Cord • Umbilical cord precedes presenting part • May be visible or occult • More common with • Abnormal lie • Low birth weight • > previous births • Amniotomy • Long cord

  3. Prolapsed Cord • Key interventions • Relieve pressure on cord • Trendelberg or knee chest position • Oxygen to increase maternal oxygen saturation • Pressure on the presenting part • Call for help, but do not leave mother • Expedite delivery

  4. Prolapsed Cord • Maternal Risk • No direct risk • Fetal-Neonatal Risk • Cord compression  ↓O2  possible death or neurologic compromise • Tx • Prevention! • If palpated, keep pressure off cord • ☺When ROM occurs, listen to FHTs for full minute; if decel heard, do vag exam to r/o cord prolapse

  5. Umbilical Cord Abnormalities • 2 vessel cord: associated with abnormalities, esp kidney • Check for 3 vessels at time of birth (2 arteries 1 vein)

  6. Amniotic Fluid-Related Complications • Embolism: bolus of amniotic fluid enters maternal circulation then lungs. • OB emergency! • High mortality.

  7. Amniotic Fluid-Related Complications • Hydramnios: >2000mL of fluid • Cause unknown but associated with congenital abnormalities (swallowing/voiding problems); also diabetes, Rh sensitization, infections such as CMV, Rubella, syphilis, toxoplasmosis, herpes • If severe (>3000mL) may experience severe edema, hypotension (from vena cava compression) and pain • Tx • Supportive • Corrective: may do amniocentesis, Indocin (to ↓ fetal urine output)

  8. Amniotic Fluid-Related Complications • Oligohydramnios • <500mL fluid or largest pocket of fluid on U/S is <5cm • Associated with postmaturity, IUGR, major renal problem in fetus (malformation, blockage) • If occurs early in preg, may cause fetal adhesions also fetal skin and skeletal abnormalities may occur, pulmonary hypoplasia, cord compression • Tx: • Monitor • Amnioinfusion • Fetal surgery

  9. Complications of 3rd and 4th stage • Retained placenta • ☺Lacerations: cervical or vaginal suspected when bright red bleeding in presence of well contracted uterus • 1st degree: fourchette, perineal skin, vag mucousa • 2nd degree: perineal skin, vag mucosa, underlying fascia, muscles of perineal body • 3rd degree: extends thru perineal skin, vag mucosa and perineal body and involves anal sphincter • 4th degree: same as 3rd degree, but extends thru rectal mucosa to the lumen of the rectum

  10. Intrauterine Fetal Demise (IUFD) • May be found prior to coming to hosp or at time of admission • May be unexplained or r/t materanal disease process or fetal insult • May be induced right away or wait for spontaneous labor. C/S not automatically done • Pain med give freely

  11. Intrauterine Fetal Demise (IUFD) • Provide privacy for families • Listen • Avoid inappropriate consolations • Give accurate info • Obtain mementos • Allow opportunity to see and hold • Provide information re: burial options • Provide support information

  12. Premature Rupture of Membrane(PROM) • Spontaneous break in the amniotic sac before onset of regular contractions • Mother at risk for chorioamnionitis, especially if the time between Rupture of Membranes (ROM) and birth is longer than 24 hours • Risk of fetal infection, sepsis and perinatal mortality increase with prolonged ROM. • Vaginal examinations or other invasive procedure increase risk of infection for mother and fetus.

  13. PROMSigns of Infection • Maternal fever • Fetal tachycardia • Foul-smelling vaginal discharge

  14. PROM Detecting Amniotic Fluid • Nitrazine • Ferning: Place a smear of fluid on a slide and allow to dry. Check results. If fluid takes on a fernlike pattern, it is amniotic fluid. • Speculum exam

  15. fernlike pattern

  16. PROM Treatment • Depends on fetal age and risk of infection • In a near-term pregnancy, induction within 12-24 hours of membrane rupture • In a preterm pregnancy (28 -34 weeks), the woman is hospitalized and observed for signs of infection. If an infection is detected, labor is induced and an antibiotic is administered

  17. PROMNursing Interventions • Explain all diagnostic tests • Assist with examination and specimen collection • Administer IV Fluids • Observe for initiation of labor • Offer emotional support • Teach the patient with a history of PROM how to recognize it and to report it immediately

  18. Signs of Preterm Labor • Rhythmic uterine contraction producing cervical changes before fetal maturity • Onset of labor 20 – 37 weeks gestation. • Increases risk of neonatal morbidity or mortality from excessive maturational deficiencies. • There is no known prevention except for treatment of conditions that might lead to preterm labor.

  19. Treatment of Preterm Labor • Used if tests show premature fetal lung development, cervical dilation is less than 4 cm, & there are no that contraindications to continuation of pregnancy. • Bed rest, drug therapy (if indicated) with a tocolytic

  20. Preterm Labor Pharmacotherapies • Terbutaline (Brethine), a beta-adrenergic blocker, is the most commonly used tocolytic • Side effects: maternal & fetal tachycardia, maternal pulmonary edema, tremors, hyperglycemia or chest pain, and hypoglycemia in the infant after birth • Ritodrine (Yutopar) is less commonly used.

  21. Preterm Labor Pharmacotherapies • Magnesium Sulfate • Acts as a smooth muscle relaxant and leads to decreased blood pressure • Many side effects including flushing, nausea, vomiting and respiratory depression • Should not be used in women with cardiac or renal impairment • Excreted by the kidneys

  22. Perterm Labor Pharmacotherapies • Corticosteroids • Help mature fetal lungs • Betamethasone or dexamethasone • Most effective if 24 hours has elapsed before delivery

  23. Nursing Interventions with Preterm Labor Nursing Intervention in Premature labor • Observe for signs of fetal or maternal distress • Administer medications as ordered • Monitor the status of contractions, and notify the physician if they occur more than 4 times per hour.

  24. Nursing Interventions with Preterm Labor Nursing Intervention in Premature labor • Encourage patient to lie on her side • Bed rest encouraged but not proven effective • Provide guidance about hospital stay, potential for delivery of premature infant and possible need for neonatal intensive care

  25. Nursing Interventions with Preterm Labor Discharge teaching for home care: • Avoid sex in any form • Take medications on time • Teach to recognize the signs of preterm labor and what to do

  26. Birth Related Procedures

  27. Procedures • Version • External • Internal • Cervical Ripening • Cervidil • Cytotec • Amnioinfusion • ~250-500 mL warmed saline or LR is infused into uterus via IUPC over 20-30 min • Used to correct variables, dilute mec stained fluid

  28. Labor Induction • Stimulation of U/C before spontaneous onset of labor • Prior to starting induction • Verification of gestation age • Confirmation of fetal presentation • Assessment of risk factors • Well-being assessment of mom and baby • Cervical Assessment

  29. Labor Induction • Cervical Assessment (Bishop’s Score) • Higher the score, more successful the induction will be • Favorable cervix is most important criteria for successful induction

  30. Bishop’s Score)

  31. Labor Induction • Methods • Stripping membranes • Oxytocin • ☺Always given via IV pump (may be given IM after del) • Site closest to insertion • Continuous EFM • Risks • Hyperstimulation • Uterine rupture • Water intoxication • Fetal risks associated with maternal problems, hyperbilirubinemia, trauma from rapid birth

  32. Episiotomy • Decline over the years • May make it more likely will have deep tears • Lacerations heal more quickly in absence of epis • 3rd or 4th degree lacerations more likely with epis

  33. Episiotomy • Midline • from vag orifice to fibers of rectal sphincter • Less blood loss, easier to repair, heals with less discomfort • Mediolateral • From midline of posterier forchette to 45° angle to right or left • Provides more room but has > blood loss, longer healing time and more discomfort • Tx • Pain relief measures • Ice • Inspect!

  34. Operative Assisted Deliveries • Forceps • Maternal complications • Trauma • Increased pain in pp period • Weakening of the pelvic floor • Fetal-neonatal complications • Caput • Caphalohematoma • Transient facial paralysis • trauma

  35. Operative Assisted Deliveries • Vacuum Extractor • Longer duration of suction, more likely scalp injury • Maternal complications • Perineal trauma • Edema • Genital tract and anal sphincter probs (< than with forceps) • Neonatal complications • Scalp lacerations • Bruising/subdural hematoma • Cephalohematoma • Jaundice • Fx clavicle • Retinal hemorrhage • death

  36. Cesarean Birth • 1970 - ~5% • 1988 – 24.7% • 2001 – 21% • 2005 - ? But higher • Indications • Failure to progress/descend • Previa/abruption/prolapse cord • Non-reassuring fetal status • Malpresentation • Previous C/S • Maternal morbidity and mortality is > than vag delivery

  37. Cesarean Birth • Technique • NOTE: Skin incision NOT indicative of uterine incision • Transverse (Pfannenstiel)-lower uterine segment • Adv: below pubic hair line, less bleeding, better healing • Disadv: difficult to extend if needed, requires more time, if adipose fold difficult to keep clean and dry • Vertical-between naval and symphysis • Adv: quicker, more room • Disadv: scar obvious, longer

  38. Cesarean Birth

  39. Cesarean Birth

  40. Cesarean Birth • Technique • Uterine incision (type depends on need for C/S) • Transverse-lower uterine segment • Adv: thinnest  less blood loss, only mod dissection of bladder, easier to repair, site less likely to rupture during subsequent pregnancies, less chance of adherence of bowel or omentum to incision line • Disadv: takes longer, limited in size due to major blood vessels, greater tendency to extend into uterine vessels

  41. Cesarean Birth • Technique • Lower Uterine Segment Vertical Incision • Preferred for multiple gestation, abnormal presentation, previa, preterm, macrosomia • Adv: more room • Disadv: may extend into cx, more extensive dissection of the bladder is necessary, if extends upward hemostasis and closure more difficult, higher risk of rupture in subsequent pregnancies

  42. Cesarean Birth • Technique • Classic incision • Upper uterine segment • Adv: more room, quicker to do • Disadv: more blood loss, difficult to repair, higher risk of rupture in subsequent pregnancies

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