Childbirth at Risk

Childbirth at Risk Chapter 21

Dystocia • Disruption of labor • Emotional factors • Contractions • Fetus • Pelvis • Relation between pelvis and fetus

Contractions • Hypertonic (latent) labor- irregular in strength and timing • Do not change cervix. Tx- augmentation • Hypotonic (active) labor-less than 2-3 ucs in 10 minutes. • Due to overdistention

Nursing Assessment • Contractions • FHT • Coping • Dehydration • Fluid • Infection

Post term Pregnancy • Past 42 wks • Associate with LGA, assisted delivery, oligo, mec aspiration, decrease perfusion • After 40 weeks need NST, BPP X2 q week

Malposition • OP common malposition -most rotate • May visualize depression in maternal abdomen above symphysis • Change positions- pelvic rocking, hand knees • Assess for extreme back pain

Malpresentation • Brow-widest diameter. • Face • Breech-ECV @ 36-38 wks • Heart tones high • Risk for prolapse • T-lie- r/t multiparity, ECV • Compound presentation

Macrosomia • Greater than 4000 gms, risk for dystocia • McRoberts, suprapubic pressure • Greater than 4500 plan C/S • Assess for Erb’s, motor problem • Maternal risk for PPH • “Falling off” the labor curve

Multiple Gestation • High risk, type of multiple gestation determines risk • Associated with PIH, PTL, previa, malpresentation • Need NST, BPP, serial UTZ • Many need bed rest

Intrauterine Resuscitation • Decreased uterine placental flow • NSG- turn to L lat, IV fluids, give 02 • Correct maternal hypotension • Turn off pit • Explain to family

IUFD • Perinatal death after 20 weeks • Can cause DIC. • Thromboplastin activates clotting system • FIB., and factor V and VII are depleted • DX confirmed by Spaulding’s sign, estriol levels, no heart tones

Parents of Stillborn • Protest, refuse to believe. • Disorganization • Reorganization- time frame varies • Use checklist • Give mementos

Abruptio Placentae • Cause may be decrease in blood flow. • Marginal- at edges, may bleed vaginally • Central-separates centrally, concealed • Complete- massive bleed total separation • S/S include rigid abdomen, constant pain

Abruption • Retroplacental clotting can prompt release of thromboplastin, lead to DIC • With severe abruption mortality 100% • Eval. fibrinogen and platelets • Often uterine resting tone is elevated

Placenta Previa • Located in lower uterine segment, may cover whole os, or portion. NO VE • With dilatation and ucs villi are torn from uterus and leave sinus exposed • Hemorrhage can cause fetal hypoxia • Painless bright red blood • Assess fetal response to blood loss

Prolapsed Cord • Cord presents before fetus, vessels occluded • Monitor FHT following SROM or with amniotomy X 1min • If feel cord push up head to relieve pressure • Knee chest-Trendelenburg to OR • Preventative- make sure head is engaged

Amniotic Fluid Emboli • Break in chorion or amnion can allow amniotic fluid to enter maternal system • Uterus forces emboli from circulation to lung • S/S • Give 02, CPR, ABO

Hydramnios • Cause unknown, r/t with fetal anomalies. • Rh sensitization, DM, multiple gestations • Fetus swallows and urinates amniotic fluid • Associated with SOB, edema • Abruption if size of uterus reduced quickly • Nursing- increase in fundal hgt, FHTs

Oligohydramnios • Associated with IUGR, postmaturity, renal, kidney, uterine placental insufficiency • Restricts fetal movement, effects lungs, cord compression. • Increase fetal surveillance • Amnioinfusion • Reposition

CPD • Head larger than pelvis • Assess diagonal conjugate • Bulging perineum and crowning indicate imminent delivery • Fetus will not descend • Fall off the labor curve • Position change

Lacerations • First degree- perineal skin, fourchette, vaginal mucous • Second- skin underlying fascia, muscle • Third-anal sphincter, ant. wall of rectum • Fourth- through rectal mucousa to lumen

Childbirth at Risk