CHILDBIRTH%20AT%20RISK

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CHILDBIRTH AT RISK

• Chapter 21

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PSYCHOLOGICAL DISORDERS BEHAVIORS IN LABOR

• Depression decreased ability to concentrate, or
  process information feeling overwhelmed and
  hopeless
• Bipolar disorder may be depressed or hyper
  excited
• Anxiety disorder chest pain SOB, faintness, fear
• Clinical therapy goals decrease anxiety,
  maintain orientation to reality, promote optimal
  functioning in labor

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HYPERTONIC LABOR DYSTOCIA

• Characteristics increased contraction frequency
  and uterine resting tone prolonged latent phase
• Implications prolonged labor and discomfort
  reduced uteroplacental exchange resulting inn
  nonreassuring fetal status
• Prolonged pressure on fetal head resulting in
  molding, caput succedaneum and cephalohematoma

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Clinical therapy for Hypertonic labor

• Bed rest and relaxation measures
• Pharmacologic sedation
• Oxytocin
• amniotomy

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HYPOTONIC LABOR(fewer tan 3 contractions in 10
min)

• Usually in active phase after labor already
  established
• Clinical therapy oxytocin, amniotomy, IV fluids
• Nursing Plan
• Assess amniotic fluid for meconium
• Monitor VS, FHT, IO, minimize SVE, assess for
  signs of infection
• Ambulate, position changes, hydrotherapy
  relaxation exercises

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PRECIPITOUS LABOR(less than 3 hours)

• Contributing factors multiparity, large pelvis,
  previous precipitous labor, small fetus in a
  favorable position, strong contractions, uterine
  hyper stimulation from excess pitocin
• Implications loss of coping ability, laceration
  of cervix, vagina, perineum, postpartum uterine
  atony, hemorrhage, fetal stress or hypoxia from
  intense uterine ctx. Cerebral trauma from rapid
  descent, pneumothorax from rapid descent

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NURSING PLAN FOR PRECIPITOUS LABOR

• Anticipate r/t risk factors (be prepared)
• Frequent monitoring and assess for accelerated
  labor progress (intense ctx with little uterine
  relaxation), constant nursing attendance
• Prepare for delivery early keep Dr. informed
• Institute supportive measures for hyper
  stimulation d/c pitocin, side-lying, O2

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POSTTERM (more than 42 weeks gestation)

• Implications
• Probable labor induction
• Risk for large baby
• Decreased placental perfusion
• Oligohydramnios
• Meconium aspiration

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Nursing plan for Postterm Pregnancy

• Teach fetal kick counts antenatally
• Ongoing FHR assessment for signs of cord
  compression in labor
• Take corrective action for cord compression due
  to oligohydramnios position change, O2,
  amnioinfusion
• Carefully monitor labor progress
• Provide emotional support

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FETAL MALPOSITON

• Persistent occiput-posterior (OP)
• Fetal malpresentation
• Brow
• Face
• Breech
• Transverse
• Compound (two presenting parts)

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MACROSOMIA (infant weight of 4000g or 813oz)

• Predisposing factors male gender, offspring of
  large parents, maternal diabetes, prolonged
  gestation, previous large infant, grand
  multiparity.
• Implications dysfuntional labor, soft tissue
  laceration during birth, PP hemorrhage, CPD with
  subsequent cesarean, meconium aspiration,
  shoulder dystocia, brachial plexus injury,
  fractured clavicle, asphyxia

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NURSING PLAN FOR MACROSOMIC INFANT

• Continuous EFM assess for fetal stress (decels)
• Assess for labor dystocia
• Anticipate and assist with emergency measures
  during birth as needed such as McRoberts
  maneuver, suprapubic pressure, emergency CS
• Anticipate uterine atony postpartum
• Assess newborn for birth trauma

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MULTIPLE GESTATION (TWINS AND MORE)

• Predisposing factors infertility treatment,
  advanced maternal age, African American
  ethnicity, multiparity, tall, overweight women
• Early indicators two gestational sacs on early
  US, fundal ht greater than expected, auscultation
  of two or more heart rates differing by more than
  10 beats, elevated hCG with severe nausea and
  vomiting, elevated alph-fetoprotein

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Implications of multiple gestation

• Increased maternal discomfort
• Preeclampsia
• Preterm labor
• Placenta previa
• Abnormal fetal presentation
• Dysfunctional labor
• Ten times greater perinatal mortality
• Increased IUGR, fetal anomalies, cerebral palsy,
  and sequelae of prematurity

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NURSING PLAN

• Prenatal
• educate on lifestyle modifications
• nutrition 4000 cal daily, 135 g protein,
  40-50lb wt gn
• increased prenatal visits weekly NST at 30 wks,
  weekly BPP,
• educate on danger signs

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• Nursing Plan
• Continuous EFM
• 18 g IV catheter
• Double setup for delivery of newborn
• Alert additional staff for help with birth and
  newborn care
• Be prepared for CS

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FETAL DISTRESS

• Common causes cord compression, uteroplacental
  insufficiency, placental abnormalities,
  preexisting maternal or fetal disease
• Fetal implications chronic hypoxia, permanent
  organ damage, potential emergent CS

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• Common initial signs of fetal stress
  meconium-stained amniotic fluid, persistent late
  decels, persistent severe variable decels
• Institute Intrauterine Resuscitation measures
• Correct maternal hypotension and enhance
  uteroplacental blood flow
• Change position that improves FHR,
• Increase rate of IV
• O2 via face mask
• Decrease uterine activity stop pitocin, adm
  tocolytic
• Perform vaginal exam (prolapsed cord?)

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ABRUPTIO PLACENTAE (premature separation of
placenta)

• Contributing factors hydramnios, twins, smoking,
  street drugs, trauma
• Significant symptoms pain, uterine irritability,
  and a firm, hard abdomen
• Types
• Marginal
• Central
• Complete

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• Maternal implications intrapartum hemorrhage,
  DIC, ruptured uterus, fatal hemorrhagic shock
• Fetal-neonatal implications sequelae of
  prematurity, hypoxia, anemia, brain damage, fetal
  demise

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Nursing plan

• Maintain two large bore IV sites
• Monitor frequently
• Monitor for signs of DIC
• Monitor IO hourly
• Measure abdominal girth hourly as well as vital
  signs q 15 minutes
• Prepare for CS and neonatal resuscitation

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Placenta Previa (placenta implanted in lower
uterine segment

• Categories total, partial, marginal, low-lying
• Most accurate diagnostic sign is painless,
  bright-red vaginal bleeding.
• Implications changes in FHR, meconium staining,
  fetal hypoxia, cesarean birth, neonatal anemia

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NURSING PLAN

• No vaginal exams!
• Assess blood loss, pain, uterine contractions
• Continuous external monitoring
• Monitor VS and IO often
• Maintain IV access
• Provide emotional support
• Promote neonatal adaptation resuscitate as
  needed, evaluate H/H, administer oxygen and blood
  as needed

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UMBILICAL CORD PROLAPSE (cord precedes the fetal
presenting part and gets trapped)

• Implications extreme maternal emotional stress,
  CS, hypoxia, brain damage, fetal death
• Nursing Plan perform a vaginal exam to establish
  engagement or rule out prolapse,
• Maintain hand in vagina to relieve cord
  compression, assist to knee-chest position,
  prepare for stat CS.

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Amniotic Fluid Embolism

• SS dyspnea, cyanosis, frothy sputum, chest
  pain, tachycardia, hypotension, mental confusion,
  massive hemorrhage
• Nursing Plan summon emergency team, O2, large
  bore IV, CPR as needed, prepare for CS birth,
  administer blood

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HYDRAMNIOS

• Greater than 2000ml of amniotic fluid
• Cause unknown but major fetal anomalies are
  present in 20
• Implications for Mother shortness of breath,
  edema, uterine dysfunction, abruptio placenta, PP
  hemorrhage
• Implications for fetus malformations, preterm
  birth, increases mortality rate, prolapsed cord,
  malpresentation

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OLIGOHYDRAMNIOS

• Amniotic fluid reduced or concentrated to less
  than 50 of normal or less than 500 ml at term
• Found in postmaturity , and associated primarily
  with fetal renal defects or placental
  insufficiency
• Implications dysfunctional labor with slow
  progress
• Umbilical cord compression, head compression
• May need amnioinfusion during labor

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CEPHALOPELVIC DISPROPORTION (CPD)

• A contracture or narrow diameter in birth passage
  especially if fetus is larger than the maternal
  pelvic diameters.
• Implications Maternal prolonged labor, arrest
  of descent, uterine rupture, forceps-assisted
  birth with trauma
• Implications Fetal cord prolapse, excessive
  molding of head, birth trauma to skull and CNS

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Nursing Plan for CPD

• Assess cervical change and fetal descent
  frequently
• Continuously monitor FHT
• Be alert for signs of fetal stress
• Assist with optimal positioning during labor such
  as squatting, hands and knees

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Complications of 3rd and 4th stages of Labor

• Retained Placenta beyond 30 minutes after birth
• Lacerations first, second, third (extends
  through the perineal body and involves the anal
  sphincter and fourth (extends through the rectal
  mucosa to the lumen of the rectum.
• Placenta accreta the chorionic villi attach
  directly to the myometrium of the uterus

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Fetal Death
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REVIEW

• Dystocia/hypotonic difficult, often prolonged
  labor caused by dysfunctional or uncoordinated
  uterine activity
• Irregular in timing, strength or both and arrest
  cervical change
• Pharmocologic sedation will frequently stop these
  contractions
• If rest doesnt improve the pattern, labor
  stimulation with pitocin may be used if CPD ruled
  out

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• Precipitous birth is not the same as precipitous
  labor. Precipitous labor is simply a rapid labor
  followed by anticipated birth., Precipitous birth
  is unexpected, sudden and often unattended.
• There are both maternal and fetal risks with
  precipitous labor

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• Implications of postterm primarily stem from
  decreasing placental function and concerns abut
  fetal size and well-being
• Meconium is more common in postterm pregnancies,
  possibly due to fetal maturity, or stress related
  to suboptimal placental functioning
• Careful assessment of labor progress is warranted
  due to the risk of CPD from macrosomia

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MALPOSITION

• Occiput posterior is the most common fetal
  malposition
• During labor, 90 to 95 of OP fetuses rotate to
  OA position
• Maternal position such as hands and knees may
  facilitate fetal rotation and relieve back pain

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Malpresentations

• Brow, face, breech shoulder and compound
• Many brow presentations convert to occipital or
  face with fetal descent
• Reassure the couple that the edema and bruising
  are temporary and will be markedly improved in
  3-4 days, though complete resolution may take
  several weeks.

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• The nurse is frequently the first to recognize
  breech presentation through Leopolds maneuvers
  and vaginal exam.
• Footling breech, nurse must be alert for
  prolapsed cord. The danger is greater if there is
  a small fetus and membranes are ruptured
• If transverse lie persists at term, external
  cephalic version may be useful

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Macrosomia

• Primary risks are CPD and shoulder dystocia
• Dysfunctional labor or lack of fetal descent
  could indicate CPD
• Birth trauma associated with this are
• Erbs palsy
• Fractured clavicle
• cephalohematoma

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More than one fetus

• Clinical monitoring usually begins in 3rd
  trimester and continues until nonreassuring
  findings are obtained or birth occurs

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Abruptio Placentae

• Separation of normally implanted placenta
• Occurs more frequently in pregnancies with
  hypertension and cocaine abuse. Also smoking and
  alcohol ingestion are contributing factors
• Clotting disorders (DIC) result when uterine wall
  damage and retroplacental clotting from central
  separation trigger release of a large amount of
  thromboplastin into maternal circulation

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• If separation is mild and pregnancy near term,
  labor induction may be feasible
• Signs are painful, board like distended abdomen
  and uterine irritability

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Placenta Previa

• Signs are painless bleeding. Abdomen is soft
• Management based on gestational age at first
  bleeding episode and the amount of bleeding
• No vaginal exams should be done by nurse
• Preterm can usually be managed with bed rest with
  bathroom privileges only as long as there is no
  bleeding, pain and uterine contractions until
  fetus is mature.

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Umbilical cord Prolapse

• Compresses the blood vessels to and from the
  fetus. Labor ctx further compress the cord
• A drop in fetal heart rate accompanied by
  variable decelerations is consistent with
  prolapse cord. And a vaginal exam is the best way
  to confirm.
• The number one priority is to relieve compression
  to allow blood flow to reach fetus. A c-section
  is imminent.

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Polyhydramnios

• Occurs in 10 to 20 of pregnant diabetics
• Major fetal anomalies are present in 20 of cases
• Uterine over distention may result in labor
• dysfunction and postpartum hemorrhage
• Rupture of membranes increases risk of cord
  prolapse
• An abnormally taut abdomen with difficulty
  palpating the fetus may be suspicious for
  hydramnios

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