high - -¶ risk labor and delivery 2
TRANSCRIPT
Peripartum Careof High Risk Pregnancy
MYRNA P. DE GUZMAN, M.D.R.N.
HIGH-RISK LABOR AND DELIVERY
• PASSENGER• PASSAGEWAY• POWERS• PLACENTA• PSYCHE/PSYCHOLOGICAL STATE
PROBLEMS WITH THE PASSENGER• FETAL MALPOSITION - Occipitoposterior position• FETAL MALPRESENTATION - Vertex- brow, face, sincipital - Breech- complete, frank, footling - Shoulder• FETAL DISTRESS• PROLAPSED UMBILICAL CORD
FETAL MALPOSITION
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FETAL FACTORS IN LABOR AND DELIVERY
OCCIPITOPOSTERIOR
VERTEX MALPRESENTATION
• BROW PRESENTATION - part of the fetal head between the orbital
ridge and the anterior fontanel presents at the pelvic inlet.
- midway between full flexion and full extension
- unstable >>> face or occiput - fetal head cannot engage if this persists
FACE PRESENTATION
• HYPEREXTENDED HEAD• CHIN – PRESENTING PART• PREDISPOSING FACTORS: - Big Baby - Contracted Pelvis - Multiparity - Cord coil about the neck
SINCIPITAL PRESENTATION
• Partially flexed head
• Anterior fontanel presents
BREECH PRESENTATION
• TYPES• RISKS• Fetal: - Prolapsed Cord - Injury to the aftercoming head - Spine or arm fracture - Dysfunctional labor• Maternal
Breech Birth
• Maternal implication – CS may be required, especially in primigravida
• Fetal implications 1. Increased mortality 2. Prolapsed cord 3. Birth trauma: brachial palsy, fracture of upper
extremities
BREECH DELIVERY
BREECH DELIVERY
Nursing Care of Clients During Breech Birth
• Assessment - LM; IE - Location of FHT - (+) meconium w/o signs of fetal distress• Analysis1. Risk for injury r/t difficult birth2. Knowledge deficit r/t complications associated with
breech birth3. Risk for suffocation of fetus r/t interruption of blood
flow secondary to cord compression
Implementation• Monitor FHT• Watch for prolapsed cord; if it occurs: - push presenting part/trendelenburg - keep prolapsed cord moist with sterile saline• Observe for frank meconium• Add Piper forceps for the delivery set-up if vaginal
birth is anticipated• Prepare for CS Evaluation1. Birth is safe for mother2. Fetus remains free from complications
• VAGINAL EVOLVING OF BREECH
• EXTERNAL PODALIC VERSION
SHOULDER PRESENTATION
• TRANVERSE LIE
• CS
TRANSVERSE LIE
COMPOUND PRESENTATION
FETAL DISTRESS
• CAUSES
• SIGNS/SYMPTOMS
• NURSING INTERVENTIONS
UMBILICAL CORD PROLAPSECauses:
a. breech presentation b. transverse liec. unengaged presenting part d. hydramniose. small fetus
S/S: cord is protruding from vagina cord can be palpated in the vagina or
cervix fetal distress
Variable Deceleration
• Prolapsed Umbilical Cord - loop of the umbilical cord w/c descends along
or beyond the presenting part.
2 Types:
a. Occult Prolapse – the cord may be contained w/in the uterus.
- cord often compressed by shoulder.
- membranes may be intact or ruptured
b. Overt Prolapse • – protrusion of the cord in
advance of the presenting part through the cervical os or into the vagina.
- fetal membranes ruptured
- cord is visible or palpable on examination.
Management :
T- position or knee chest
O2 – prevent fetal hypoxia
push presenting part upward
apply moistened sterile towel
delivery ASAP
PASSAGEWAY PROBLEMS
1. Passagea. Gynecoid
- normal female pelvis - ideal for childbirth - round shape pelvic inlet
b. Android - male pelvis - heart shaped pelvic inlet
c. Anthropoid - “ape like” pelvis - oval shaped pelvic inlet
d. Platypeloid - flattened pelvis - reverse oval shaped
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PELVIC BONE
CEPHALOPELVIC DISPROPORTION
SHOULDER DYSTOCIA
McROBERT’S MANEUVER
• Hypotonic Uterus - contraction is weak; dilatation and effacement does not progress.
- oxytocin stimulation will be beneficial.
- occur during the active phase of labor
PROBLEMS WITH POWERS
Induction or Stimulation of Labor
• Elective Induction: 1. Pharmacologic means: - Vaginal insertion of Prostaglandin E2 cervix
softens and effaces - 8-12 hrs after prostaglandin E2, oxytocin infusion 2. Mechanical means: - amniotomy - laminaria insertion - nipple stimulation
• Augmentation of Labor:
- assisting client when labor process is not progressing normally ( prolonged labor ) by pharmacologic or mechanical means
Nursing Care of Clients During Induction of Labor
• Assessment - Obstetric history - Maternal status: - Uterine contractions - Status of cervix, membranes - ultrasound findings - Level of anxiety - Fetal status: - Gestational age - (-) CPD - fetal monitor results
• Nursing Diagnoses: 1. Anxiety r/t uncertainty of labor and birth process
2. Risk for infection r/t ruptured membranes
3. Pain r/t use of oxytocics
4. Risk for trauma r/t possibility of sustained contractions from oxytocin or fetal cord prolapse following amniotomy
Planning/Implementation• Prepare mother and labor coach for induction - explain all procedures - obtain informed consent• Remain with the patient at all times• Obtain and record baseline v/s, FHR,
contractions • Monitor pitocin administration - gradual increase drip rate till contractions
occur every 2 – 3 mins. - slow rate if (+)hypotension or tachycardia
- D/C pitocin drip if: - sustained uterine contractions occur - fetal accelerations/decelerations persist - urinary flow decreases to 30 ml/hr - signs of abruptio placenta appear• Monitor effect of prostaglandin• Assist with amniotomy - maintain asepsis - monitor FHR immediately after rupture - Note time, color, amount of AF
• Maintain hydration• Prepare for “E” CS if necessary
• Evaluation/Outcome1. Labor begins or increases and progresses to birth2. Pitocin causes no adverse effects3. Anxiety is decreased4. Client shows no signs of infection
• Hypertonic Uterus – contractions are painfully strong and frequent
• but ineffective in producing effacement and dilatation. - Reposition patient and
administer analgesic. - Tocolytic drugs (ritodrine) may
be effective. - occur in the latent phase of labor.
• Pelvic Dystocia - abnormalities in any of the 3 planes of the pelvis, inlet contraction, midplane and outlet contraction.
- Contraction is low
- Cervical dilatation and effacement does not
progress
- Fetus fails to descent in the pelvic planes.
ABNORMAL PROGRESS IN LABOR
LENGTHS OF PHASES & STAGES OF NORMAL LABOR IN HOURS
• NULLIPARA MULTIPARA
PHASE AVERAGE - UPPER NORMAL AVERAGE- UPPER NORMAL
LATENT: 8.6 20 5.3 14
ACTIVE 5.8 12 2.5 6
2ND STAGE 1 1.5 0.25
LABOR CURVES
PATHOLOGIC RETRACTION RING
• PROLONGED LABOR
• PELVIC DYSTOCIA
PATHOLOGIC RETRACTION RING
CESAREAN DELIVERY
D. CAESAREAN DELIVERY
Indications:1. CPD2. malposition3. malpresentation 4. previous CS5. complete or partial placenta previa6. abruptio placenta7. prolapsed umbilical cord
8. fetal distress
Types:1. Low Segment
incision done on lower uterine segment blood loss is minimal possibility of later uterine rupture is lessened
2. Classic incision is made on the wall of the body of the
uterus done for anterior placenta previa done for transverse lie
PFANNENSTIEL ( “BIKINI” ) INCISION
PFANNENSTIEL
VERTICAL ABDOMINAL INCISION
Indications of Cesarean Section
Nursing Care:
a. monitor vital signs closelyb. check dressing sitec. inspect perineal padd. check uterine fundus for firmnesse. breathing exercisesf. out of bed 1st post-op day g. have the woman hold the baby ASAP
A. PREMATURE LABOR & BIRTH
Contributing Factors:a. multiple gestation b. polyhydramniosc. PROMd. incompetent cervixe. placenta previa / abruptio placenta f. previous preterm laborg. infection
Management :1. Prevention of Premature Delivery- if woman is currently in preterm labor, she is
admitted to the hospital Bedrest monitoring of contractions IE Tocolytic drugs ( Ritodrine, Terbutaline
SO4)
Patient Teaching- teach woman symptoms of preterm labor
uterine contractions irregular pattern for more than 1 hour while at rest
intermittent or constant uterine cramps low, dull backache & abdominal cramping rupture of membrane
Nursing Care of Clients with Preterm Labor with Tocolytic Therapy:
A. Assessment1. Number of weeks of gestation2. Presence of live and viable fetus3. Presence of labor: - 2 contractions lasting 30 seconds in a 15-minute period - cervical dilatation less than 4 cms. - effacement of 50% or less4. No signs of hemorrhage or infection5. Presence of severe PIH6. Prolonged rupture of membranes7. Emotional impact on mother
Analysis/Nursing Diagnoses:1. Anxiety r/t uncertainty of labor and birth process2. Ineffective family coping r/t need for specialized care and continued hospitalization of the newborn3. Fear r/t acute status of baby and potential for death4. Knowledge deficit r/t cause and treatment for preterm labor5. Altered parenting r/t the physical condition of the baby6. Situational low self-esteem r/t failure to carry pregnancy to full term7. Risk of trauma r/t use of medications
Intervention:
1. Monitor VS, FHR, contractions and progression of labor2. Maintain bed rest3. Inform client about the medication; obtain consent.4. Provide emotional support; reduce anxiety and prepare for possible loss of baby5. Provide special care related to the administration of tocolytic drugs6. Prepare for use of glucocorticoid therapy for the fetus7. Prepare for premature birth if labor continues8. Provide home instructions for halting preterm labor
Evaluation/Outcome:
1. Labor ceases
2. FHT and FM satisfactory
3. No adverse effects from tocolytic drugs
4. Anxiety decreases
5. Client and partner able to state recurring signs of preterm labor
PRECIPITATE DELIVERY- characterized by very strong contractions & delivery that occurs less than 3 hours of labor
Predisposing Factors: multiparity history of rapid labor premature or small fetus large bony pelvis
Risks: perineal lacerations hemorrhage cerebral trauma
Management:
fetal monitoring-fht..
analgesia –nubain (nalbuphine); demerol
assess for birth injury
assess for cervical, vaginal & perineal lacerations
Nursing Care of Clients During Precipitate Labor:
A. Assessment 1. Rapid cervical dilatation 2. Accelerated fetal descent 3. History of rapid labor 4. Frequent uterine contractions with decreased relaxationB. Analysis/Nursing Diagnoses 1. Risk for maternal injury r/t rapid expulsion of fetus resulting in lacerations and hemorrhage 2. Risk for fetal trauma r/t cranial battering during rapid birth
Planning/Implementation:
1. Remain with mother and monitor closely
2. Keep emergency birth pack at bedside
3. Keep mother and partner informed throughout process of labor and birth
Evaluation/Outcomes:
1. Mother is safe throughout labor and birth*baby’s are nose breathers2. Neonate remains injury free during birth
UTERINE INVERSION*baby out. Placenta next.. Delivered w/in 30mins.
Check for placental separation*gushing of blood
*involution of uterus*rising of fundus
*lenghtening of the cord
*BRANT –ANDREW’S MANUEVER-movement: up-down, right-left placenta
UTERINE INVERSION CORRECTION
UTERINE PROLAPSE/inversion= buwa
can happen to old women; multigravida.. ; who didn’t give birthkyawa=h-mole
UTERINE RUPTURE*prolonged labor due to cephalopelvic disproportion
*previous CS*primigravida with prolonged cpd
PLACENTAL PROBLEMS
• PLACENTA PREVIA
• ABRUPTIO PLACENTA
Abnormally Adherent Placenta
• Accreta - attachment of the placental villi to the myometrium.
• Increta - invasion of the placental villi into the myometrium.
• Percreta - penetration of the placental villi through the myometrium to the
serosa
PLACENTA ACCRETA
PROBLEMS WITH THE PSYCHE FACTORS
1. First Trimester - ambivalence; focuses more on self - fear - possible decrease in sex driveTASK:Accepting the pregnancy, “I am pregnant”
2. Second Trimester
- increased awareness and interest in fetus - acceptance of reality of pregnancy - feeling of well-being - preoccupation with selfTASK:Accepting the baby, “A baby is growing inside me
3. Third Trimester - anticipation of labor and delivery - fears (impending labor) and fantasies (motherhood) about
pregnancy - heightened introversion - view infant as reality vs. fantasy - spurt of energy during the last month
TASK:Preparing for parenthood, “I am a mother”
COUVADE SYNDROME – group of physiological & behavioral manifestation experienced by the husband- are often the results of stress, anxiety & empathy for the pregnant women
Onset: 3-5 days after birthSymptoms: sadness, fearsIncidence: 75% of all birthsEtiology: probable hormonal
changes, life changes Therapy: support, empathyNursing Role: offer compassion
& understanding
*taking in –centered on mother’s feelings
*taking hold –return demo*letting go: holding the baby
Onset: 1-6 months after birthSymptoms: anxiety, feeling of
loss, sadnessIncidence: 10% of all birthsEtiology: history of poor
parental relationship, hormonal response
Therapy: counselingNursing Role: refer for
counseling
Onset: within 1st month after birth Symptoms: delusions, hallucinations Incidence: 2% of all birthEtiology: possible activation of previous
mental illness, hormonal changesTherapy: psychotherapy, drug
therapyNursing Role: refer for counseling,safeguard mother from injury to self or
newborn
•HIGH RISK POSTPARTAL CLIENTS:BLEEDINGINFECTION
THROMBOEMBOLISMPSYCHIATRIC DISORDERS
Postpartum Complications: Subinvolution
Description– Incomplete involution or failure
of uterus to return to its normal size and condition
Assessment– Pelvic pain or heaviness – Backache – Uterus is larger and softer than
expected – Prolonged lochial discharge – Irregular or excessive uterine
bleedingInterventions
– Monitor fundal height and lochia
– Prepare to administer methylergonovine maleate (Methergine) as prescribed
Postpartum Complications: Hemorrhage
Description• Blood loss exceeding 500 ml. after vaginal childbirth or 1000 ml.
after cesarean birth
Assessment• Early• Occurs during 24 hours after delivery• Caused by uterine atony or laceration or inversion of uterus• Late• Occurs after the 24 hours following delivery• Caused by retained fragments of placenta
Postpartum Complications: Hemorrhage
Signs of Uterine Atony– Uterine fundus is difficult to locate – Soft or boggy fundus – Uterus becomes firm when massaged but loses tone when massage is
stopped – Uterine fundus located above expected level – Excessive lochia, especially if it is bright red – Expulsion of excessive number of clots
Postpartum Complications: Hemorrhage
Interventions – Notify health-care provider if
hemorrhage occurs – Assess client for uterine atony – If uterus is not firmly contracted,
massage fundus until it is firm and to express clots that may have accumulated in the uterus (but do not push on uterus)
– Monitor client's vital signs and fundus every 5 to 15 minutes
– Prepare to administer intravenous fluids, blood transfusions, and medications such as oxytocin (Pitocin) to maintain firm contraction of uterus
– If bleeding is due to a laceration, prepare client for repair of laceration
Postpartum Complications: Infection
Description– Any infection of the
reproductive organs that occurs within 28 days of delivery or abortion
Assessment– Chills and fever– Anorexia– Pelvic discomfort or pain– Vaginal discharge– Increased white blood cell
count
Interventions– Check client's vital signs and
temperature every 2 to 4 hours– Make mother as comfortable as
possible; position her for comfort and to promote vaginal drainage
– Keep mother warmed if chilled– Isolate newborn from the mother
only if mother is infectious– Provide a high-calorie, high-protein
diet and encourage fluids to 3000 to 4000 ml/day if not contraindicated
– Encourage frequent voiding and monitor client's intake and output
– Monitor results of cultures if they were prescribed
– Administer antibiotics according to organism, as prescribed
Postpartum Complications: Endometritis
• Description– Infection of uterine lining after
delivery; caused by bacteria that invade uterus at site of attachment of placenta
– Infection may spread, involving entire endometrium and causing peritonitis, paralytic ileus, or pelvic abscess
• Assessment– Chills and fever – Uterine tenderness and
enlargement – Foul odor or purulent lochia; may
increase or decrease in volume – Malaise, fatigue, tachycardia
Postpartum Complications: Endometritis
• Interventions– Monitor client's vital signs– Obtain cultures of blood and lochia– Assist client into Fowler's position to facilitate drainage of
lochia– Administer antibiotics and pain medication as prescribed– Instruct client in proper handwashing techniques– Initiate wound (contact) precautions as necessary– Breastfeeding may be restricted during infectious period;
if woman is breastfeeding, she may need to pump her breasts to establish and maintain lactation
Postpartum Complications: Thrombophlebitis
Description– A condition in which a clot forms in
a vessel wall as a result of inflammation of the wall
– Partial obstruction of vessel may occur
– Increased levels of clotting factors in postpartum period place client at risk
Assessment – Heat, tenderness, and pain in
affected leg – Swelling of affected leg [Figure] – Homans' sign [Figure] – Chills and fever
Swelling/Homan’s signpain is felt when the foot is dorsiflexed on the affected area. Do not massage.