Intrapartum Complication

N420 Childbearing Family Nursing

Week 13

April 13, 2000

PERINATAL GRIEF

“A friend asked if we had named our stillborn baby. After telling her the name, we both began referring to the baby by name, Sarah. It felt good to call her by name.”

–When Pregnancy Fails

Stages of GriefElizabeth Kübler Ross, 1969

Denial (Shock) Anger Bargaining Depression Acceptance

Tasks of GrievingParkes & Weiss, 1983

Intellectual Recognition Emotional Acceptance Assumption of New

Identity

Perinatal LossNursing Interventions

Perinatal Grief Protocol–Effort to move family into or through the first stages of grief–Set up follow up support and assessment for later stages of grief

Perinatal Provider Grief

Frequently Unacknowledged Interventions

–Case Study–Peer/ Administration Support–Resolution

Be aware of your own experiences of loss

IntrapartumComplications

Intrapartal Complications

Psychological Adaptations–Fear

» Influence of Sympathetic Nervous System Response

–Unmet expectations–Grief-like response–Family Support Needs

Labor Dystocia

“Difficult Labor”: prolonged or abnormal labor

Problem with Four P’s:Passage, Passenger, Power, Psyche

Maternal Fetal- Infection - Infection

- Exhaustion - Asphyxia

- Dehydration - Cord prolapse

- Ketosis - Insufficient

- Lacerations - Placental

- Hemorrhage perfusion - Shoulder dystocia

– Psychological trauma - Birth trauma

Risks Related to Labor Dystocia

Labor Dystocia Prolonged Latent Phase:

– > 20 hrs in nullip; > 14 hrs in multip. Protracted Active Phase:

– < 1.2 cm dilation q hr in nullip.; < 1. 5 cm. q h multip

Active Phase Arrest:– No cervical change in 2 - 4 hours

Aberrant Fetal Descent Patterns:– > 1 - 2 cm descent / hour

Prolonged 2nd Stage: > 3 hrs in nullip; > 2 hrs in multip.

Precipitous Labor:– < 3 hours

Labor Dystocia

Problem with Powers–Abnormal Uterine Contraction Pattern

–Hypertonic Contractions–Hypotonic Contractions–Precipitous Labor and Birth

Labor Dystocia

Problem with Passage–Pelvic Contracture –Non-Gynecoid Pelvis.

Problem with Passenger–Malpresentation–Macrosomia–Fetal Anomalies

Intrapartal Complications

Malposition– Occiput Posterior

Malpresentation– Breech– Transverse Lie– Brow– Face– Asynclitism

Management of Labor Dystocia

Augmentation of Labor– Amniotomy– Oxytocin Augmentation

Assisted and Operative Delivery– Vacuum - Assisted Delivery– Forceps Delivery– Cesarean Birth

Induction or Augmentationof Labor

Prostaglandin E2– for cervical ripening

Amniotomy– artificial rupture of membranes

Oxytocin (Pitocin)– induction of uterine contractions

Cytotec– Controversy

Requires Maternal or Fetal Indication

Favorable Cervix– Bishop Score 5 or greater

Necessary Equipment/Supplies– EFM (Toco & US)– Mainline IV Start– Pitocin IV Solution (10 - 20 U / L)– Infusion Pump– Terbutaline Rx

Induction or Augmentationof Labor

Bishop Score Evaluation of Readiness for Labor

0 1 2 3

Dilatation (cm) 0 1-2 3-4 5-6

Effacement (%) 0-30 40-50 60-70 80+

Station -3 -2 -1,0 +1

Cervical Firm Med. Soft

Consistency

Cervical Position Post.ML Ant

Induction or Augmentationof Labor

Augmentation of Labor

Pitocin Induction:– Informed consent– Discuss with family.– Mainline IV– Continuous maternal toco.– Continuous fetal monitoring– IV Solution: LR or D5LR with 10 - 20 Units

pitocin– Start Pitocin drip at 1 mu/ min per infusion

pump.– May increase every 20 - 60 minutes

Assisted and Operative Delivery

Vacuum - Assisted Delivery– Mechanism: Suction and Traction used to

assist delivery of presenting part.

– Indication: Most commonly related to prolonged 2nd Stage of Labor. Takes up less space and causes less injury that forceps.

– Contraindications: Cephalopelvic Disproportion (CPD); Most malpresentations and malpositions; extreme prematurity.

– Nursing Responsibility: FHR checks q 5 minutes; Hand held suction pump. Pressure release between UC’s; Assess neonatal head for caput resolution after delivery.

Assisted and Operative Delivery

Forceps Delivery– Mechanism: Traction and rotation of fetal

presenting part with curved metal tongs.

– Indication: Prolonged 2nd stage (> 3 hrs); maternal exhaustion; Outlet: > +2 station and visible at vaginal introitus; low: > +2, but not visible.

– Contraindications: Cephalopelvic Disproportion (CPD); Most malpresentations and malpositions; < +2 station.

– Disadvantages: Maternal and fetal trama.

– Nursing Responsibility: FHR checks q 5 minutes; obtain forceps; assess neonate and mother for trauma. Increased legal liability.

Cesarean Birth

25% of all births in U.S. Indication For Cesarean Birth

– Unsafe vaginal birth r/t maternal or fetal factors.

Complications – Infection– Pain– GI Dysfunction– Bladder Injury– Coagulopathy– Risks r/t Anesthesia (Epidural vs General)– Psychological Trauma– Risk to Maternal/ Infant Attachment

Cesarean Birth

Types of Cesarean Incisions–Lower Uterine Segment (Low Transverse)–Classical (Vertical Midline)

Only L. Uterine Segment Cesareans allow a trial of labor with the next pregnancy.

Classical is used for emergency Cesareans or for some mal presentations.

Pre-0p Activities and Prep Ethical/ Legal Issues

Anesthesia for Cesarean Birth

Epidural Anesthesia Spinal Anesthesia General Anesthesia

Epidural Anesthesia for Cesarean Mechanism: Variety of Caine drugs administered

in the epidural space at L-2 to L-4 with a T-8 to S-5 block

Nursing Responsibilities:– Informed Consent– Pre-hydration by IV bolus– Assisting Anesthesiology with placement– Comfort the patient.– Monitor maternal / /fetal physiologic response

including level of anesthesia.

Contraindications: Clotting disorders, agent allergies, hx of spinal injuries

Adverse Effect:– Maternal Hypotension; Inadvertent Spinal or systemic

administration; Incomplete pain relief.

Spinal Anesthesia for Cesarean

Mechanism: Variety of Caine drugs administered in the subarachnoid space at L-3 to L-4 a block up to T-6.

Nursing Responsibilities:– Informed Consent– Pre-hydration by IV bolus– Assist anesthesiology with positioning patient– Comfort to patient.– Monitor maternal / /fetal physiologic response including level

of anesthesia. Protect from injury.

Contraindications: Clotting disorders, agent allergies, hx of spinal injuries; meningitis.

Adverse Effect:– Maternal Hypotension; Inadvertent Spinal or systemic

administration; Incomplete pain relief.

General Anesthesia for Cesarean Mechanism: Inhalation anesthesia such as nitrous

oxide in combination with an IV short-acting barbiturate, such as thiopental sodium, rendering patient unconscious.

Nursing Responsibilities:– Informed Consent– Pre-hydration by IV bolus– Assisting anesthesiology with cricoid pressure for

intubation– Circulation Nurse for the Cesarean.

Contraindications: Allergies, fetal compromise

Adverse Effect:– Neonatal respiratory depression– Maternal response to general anesthesia

Case Study:Augmentation of Labor

S/ O: 24 y.o. G1 P0 with ruptured membranes x 17 hours. Normal Pregnancy. EFW: 8 1/2 lbs..

Cervix on admission: 2cm, 50% effaced, -1 station, ROM in elevator. Reports UC’s x 2 hours

After 11 hours of labor: UC’s q. 4 minutes x 40 seconds, moderate to

palpation Cervix: dilated 3-4 cm, 60-70% effaced, -1

station, soft, anterior (Bishop Score 10) : Prolonged Latent Phase (?).

Case Study:Augmentation of Labor

After 17 hours of labor: S/ O: UC’s q 4 - 5 minutes x 45

seconds, strength: moderate to palpation. UC’s painful.

Cervix dilated 5 cm, 90% effaced, -1 station, soft anterior

FHR tracing reassuring A: Labor Dystocia (See Partogram):

P: Obtain Informed Consent for Oxytocin Augmentation

Case Study:Augmentation of Labor

S / OS / O:: Oxytocin (Pitocin) begun at 1 mu/min per infusion pump and increased 1-2 mu every 20 minutes until strong labor pattern established.

After 20 Hours of Labor (3 hrs of augmentation):

UC”s q 3 min. x 50 secs, strong to palpation.

Sonya c/o UC pain/ wants an epidural. Cervix: 8 cm dilated, 100% effaced, -1

station. FHR: 150-160’s, average variability, early

decelerations. A / P: ________________________

Case Study:Labor Dystocia

After 24 Hours of Labor: S/O: VS: T 100.2, P100, RR20, BP98/52

(Baseline BP 115/68). Epidural Effective as evidenced by

_________ UC’s q 3 min x 50-80 secs. IUPC in place. Cervix: Complete Dil. & Effaced, O station FHR: Decelerations resolved, Baseline

increased at 160’s with minimal variability maybe. r/t __________

A/P: ____________________

Case Study:Labor Dystocia

At 27 Hours of Labor S / O: Sonya has been pushing for 3

hours UC’s q 2 - 3 mins. x 60-80 secs,

adequate forces. Station: +4 IV antibiotics given. Temp. 99.8. FHR reassuring Head Delivers w/o restitution: “Turtle

Sign” A/ P: _________________

Intrapartum Complications

Intrauterine Fetal Death–Diagnosis–Medical Management–Psychological Impact

Obstetrical Emergencies

Fetal Distress Cord Prolapse Shoulder Dystocia Uterine Rupture Amniotic Fluid Embolism

Obstetrical Emergency:Shoulder Dystocia

Failure of anterior shoulder to deliver spontaneously after delivery of fetal head.

Incidence: Less than 1 % (1.6% if than 4 Kg)

Risk Factors:– Hx large Infants, maternal obesity, maternal diabetes

Maternal Morbidity:– Perineal trauma, PP hemorrhage, endometritis

Perinatal Morbidity/Mortality:– High mortality rate r/t asphyxia– Developmental delay, brachial plexus Injury, clavicle/ humerus

fx

Shoulder Dystocia

Obstetrical Maneuvers–Suprapubic Pressure–McRobert’s Maneuver–Rotation and Delivery of Posterior Shoulder

–Maternal Position Change– Issue of Fundal Pressure

Case Study:Obstetrical Emergency

S / O: Silvia is a 28 y.o. G2P1 in active labor.

Cervix: 4 cm dilated, 90% efface, -3 station.

Resting in bed. SROM with immediate FHR bradycardia to the 70’s.

A / P: ________________