labor and delivery (part2)

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LABOR AND DELIVERY ALEJANDRO S. MENDOZA, R.N., M.D. LABOR AND DELIVERY OVERVIEW Five Factors of Labor (5 P’s) 1. Passenger The size, presentation and position of the fetus A. Fetal head Usually the largest part of the baby; it has found effect on the birthing process Bones of the skull are joined by membranous sutures, which allow for overlapping or “molding” of cranial bones during birth process. Anterior and posterior fontanels are the points of intersection for the sutures and are important landmarks 4. Fontanels are used as landmarks for internal examinations during labor to determine position of fetus B. Fetal shoulders: may be manipulated during delivery to allow passage of one shoulder at a time LABOR AND DELIVERY 1. Passenger continue… C. Presentation: that part of the fetus which enter the pelvis in the birth process Types of Presentation are: Cephalic: head is presenting part; usually vertex (occiput), which is the most favorable for birth. Head is flexed with chin on chest.

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Page 1: Labor and Delivery (Part2)

LABOR AND DELIVERYALEJANDRO S. MENDOZA, R.N., M.D.

LABOR AND DELIVERYOVERVIEWFive Factors of Labor (5 P’s)1. Passenger

The size, presentation and position of the fetusA. Fetal head

– Usually the largest part of the baby; it has found effect on the birthing process– Bones of the skull are joined by membranous sutures, which allow for

overlapping or “molding” of cranial bones during birth process.– Anterior and posterior fontanels are the points of intersection for the sutures

and are important landmarks4. Fontanels are used as landmarks for internal examinations during labor to

determine position of fetus

B. Fetal shoulders: may be manipulated during delivery to allow passage of one shoulder at a time

LABOR AND DELIVERY1. Passenger continue…

C. Presentation: that part of the fetus which enter the pelvis in the birth processTypes of Presentation are:

– Cephalic: head is presenting part; usually vertex (occiput), which is the most favorable for birth. Head is flexed with chin on chest.

– Breech: buttocks or lower extremities present first. Types are:a. Frank: thighs flexed, legs extended on anterior body surface, buttocks

presentingb. Full or complete: thighs and legs flexed, buttocks and feet (baby is

squatting position)c. Footling: one or both feet are presenting

– Shoulder: presenting part is the scapula and baby is in horizontal or transverse position. Cesarean birth indicated.

LABOR AND DELIVERY1. Passenger continue…

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VERTEX PRESENTATION – When the head is well flexed, the subocciptobregmatic diameter and the biparietal diameter present. When the head is not flexed but erect, the presenting diameters are occipitofrontal, and the biparietal. (95%)

BROW PRESENTATION – When the head is partially extended, the mento vertical diameter, 13.5 cm, and the bitemporal diameter, 8.2 cm. If this presentation persist, vaginal delivery is extremely unlikely.

FACE PRESENTATION – When the head is completely extended, will distend the vaginal orifice the presenting diameters are the SOB – 9.5 cm, BT – 8.2 cm, the SMV diameter 11.5 cm,

LABOR AND DELIVERY1. Passenger continue…

D. Position: relationship of reference point on fetal presenting part to maternal bony pelvis

I. Maternal bony pelvis divided into four quadrants (right and left anterior; right and left posterior). Most common positions are:

– LOA (left occiput anterior): fetal occiput is on maternal left side and toward front, face is down. This is a favorable delivery position

– ROA (right occiput anterior): fetal occiput on maternal right side toward front, face is down. This is a favorable delivery position

– LOP (left occiput posterior): fetal occiput is on the maternal side and toward back, face is up. Mother experiences much back discomfort during labor; labor may be slowed; rotation usually occurs before labor to anterior position or health care provider may rotate at the time of delivery.

LABOR AND DELIVERY1. Passenger continue…

4. ROP (right occiput posterior): fetal occiput is on maternal side and toward back, face is up. Presents problem similar to LOP

II. Assessment of fetal position can be made by:– Leopold’s maneuvers: external palpitation (4 steps) of maternal abdomen

to determine fetal contours or outlines. Maternal obesity; excess amniotic fluid, or uterine tumors may make palpitation less accurate.

– Vaginal examination: location of sutures and fontanels and determination of relationship to maternal bony pelvis

– Rectal examination: now virtually completely replaced by vaginal examination

– Auscultation of fetal heart tones and determination of quadrant of maternal abdomen where best heard. (Correlate with Leopold maneuvers)

LABOR AND DELIVERY1. Passenger continue…

LEOPOLD’S MANEUVER – done to a. estimate fetal size, b. locate parts, and c. determine - presentation,

- position,

Page 3: Labor and Delivery (Part2)

- engagement and - attitude.

Presentation of client: • place in dorsal recumbent position to relax the abdominal muscle• palpate with warm hands because cold hands cause muscle contraction• use palm not finger (will tickle the ptx.)

LABOR AND DELIVERY1. Passenger continue…

LEOPOLD’S MANEUVER 1st Maneuver: Facing the head part, palpate for fetal part found in the fundus ( a hard, smooth balotable in the fundus means breech)

2nd Maneuver: Palpate sides of the uterus to determine location of fetal back

3rd Maneuver: Grasp lower portion of the abd. just above symphysis pubis to determine the degree of engagement.

4th Maneuver: Facing the feet part. Cross fingers downward on both sides of the uterus above the inguinal ligaments above the inguinal ligaments to determine attitude.

LABOR AND DELIVERY2. Passageway

- Shape and measurement of maternal pelvis and distensibility of birth canalA. Engagement: fetal presenting part enters true pelvis (inlet). May occur two

weeks before labor in Primipara; usually occurs at beginning of labor for Multipara.

B. Station: measurement of how far he presenting part has descended into the pelvis. Referrant is ischial spines, palpated through lateral vaginal walls. When presenting part is :

• at ischial spines, station is “0”

• above ischial spines, station is negative number

• below ischial spines, station is positive number

• “High” or “floating” terms used to denote unengaged presenting part.

LABOR AND DELIVERY2. Passageway continue…

C. Soft tissue (cervix, vagina): stretches and dilates under the force of contractions to accommodate the passage of the fetus.

3. PowersForces o labor, acting in concert, to expel fetus and placenta. Major forces are:

A. Uterine Contractions (involuntary)– Frequency: timed from the beginning of one contraction to the beginning

of the next– Regularity: discernable pattern; better established as pregnancy progresses

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– Intensity: strength of contraction; May be determined by the “depressability” of the uterus during a contraction. Describe as mild, moderate or strong.

– Duration: length of contraction. Contraction lasting more than 90 seconds without a subsequent period of uterine relaxation may have severe implications for the fetus and should be reported.

LABOR AND DELIVERY3. Powers continue…

B. Voluntary bearing down efforts– After full dilatation of the cervix, the mother can use her abdominal muscles

to help expel fetus– These efforts are similar to those for defecation, but the mother is pushing

out the fetus from the birth canal– Contraction of levator ani muscles

4. Placenta• As the placenta usually forms in the fundus of the uterus, it seldom interferes

with the progress of labor.• A low-lying, marginal, partial or complete placenta previa may require

medical intervention to complete the birth process LABOR AND DELIVERY

5. Psychologic response

A woman who is relax, aware and participating in the birth process usually has a shorter, less intense labor.

A woman who is fearful has high levels of adrenaline which slows uterine contractions.

LABOR AND DELIVERYThe Labor Process

CausesActual cause unknown. Factors involved include:

– Progressive uterine distension

– Increasing intrauterine pressure

– Aging of the placenta

– Changes in the levels of estrogen, progesterone, and prostaglandins

– Increasing myometrial irritability

LABOR AND DELIVERYThe Labor ProcessTHEORIES OF LABOR (Onset of Labor)• Prostaglandin Theory – initiation of labor is said to result from the release of

arachidonic acids produces by steroid action on lipid precursors. Arachidonic acid is said a increase prostaglandin synthesis which is turn causes uterine contractions.

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• Oxytocin Theory – release of oxytocin from the posterior pituitary glands causes contraction of the smooth muscles. Eg. Uterine muscles will necessarily contract and empty.

• Uterine Stretch Theory – releases of oxytocin from the posterior pituitary.

• Placental Degeneration Theory – because of decreased blood supply and functional capacity, the uterus starts to contract.

• Progesterone deprivation theory – decreased amount of progesterone initiates uterine motility.

Maternal Assessment

Premonitory Assessment

Physiologic changes preceding labor:– Lightening (engagement): – occurs up to two weeks before labor in Primipara; – at beginning of labor for Multipara

– Braxton Hick’s contractions: may become more noticeable; may play a part in ripening of cervix

– Easier respirations from decreased pressure on diaphragm

– Frequent urination, from increased pressure on bladder

– Restlessness/ poor sleeping patterns, “nesting behaviors”

Maternal Assessment

True vs. False Labor

LABOR AND DELIVERY

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Stages of Labor

I. DefinitionsStage 1: from onset of labor until full dilatation of cervix

Latent phase: 0-4 cmActive phase: 4-8 cmTransition phase: 8-10 cm.

Stage 2: from full dilatation of cervix to birth of baby

Stage 3: from birth of baby to expulsion of placenta

Stage 4: time after birth (usually 1-2 hours) of immediate recoveryLABOR AND DELIVERYStages of Labor

II. Cervical changes in first stage laborA. Effacement:

– Shortening and thinning of cervix– In Primipara, effacement is usually well advanced before dilatation

begins; in a Multipara, effacement and dilatation progress together

B. Dilatation:– Enlargement or widening of the cervical os and canal– Full dilatation is considered 10 cm.

LABOR AND DELIVERYDuration of Labor

A. Depends on– Regular, progressive uterine contraction– Progressive effacement and dilatation of cervix– Progressive descent of presenting part

B. Average lengthLength of Normal Labor:

PRIMI MULTIFirst Stage 12 ½ hours 8 hoursSecond Stage 80 minutes 30 minutesThird Stage 10 minutes 10 minutes

TOTAL 14 hours 8 hours

LABOR AND DELIVERYSTAGES OF LABOR:

FIRST STAGE (Stage of Dilatation) – begins with true labor contractions and ends with complete dilatation of the cervix.Power of forces at work: involuntary uterine contractionsPhases:

a. Latent – early time in labor• Cervical dilatation is minimal because effacement is occurring.

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• Cervix dilates 0-4 cm.

• Contractions are of shorts duration and are occurring regularly 5-10 mins apart hence admission can be done.

• The woman in this stage is excited with some degree of apprehension but still with the ability to communicate.

LABOR AND DELIVERYSTAGES OF LABOR:FIRST STAGE (Stage of Dilatation)Phases continue…

b. Active or accelerated – cervical dilatation reaches 4-8 cm. rapid increase in duration, frequency and intensity of contraction, woman fears losing of herself.

c. Transition Period – 8-10 cm cervical dilatation occursthe mood of the woman suddenly changes and the nature of

contractions intensify.

-If cervix is intact, this period is marked by a sudden gush of amniotic fluid as the fetus is pushed into the birth canal. Show becomes prominent.

-There is an uncontrollable urge to push with contractions (a sign that the second stage of

labor is very near).

-Duration of contraction – 60 to 70 seconds; -Interval – 30 to 90 seconds

LABOR AND DELIVERYPalpitation

Assess intensity of contraction by manual palpitation of uterine fundus

– Mild: tense fundus but can be indented with finger tips

– Moderate: firm fundus, difficult to indent with fingertips

– Strong: very firm fundus, cannot indent with finger tips

Maternal Assessment

FIRST STAGE OF LABORPRIMI MULTI

First Stage 12 ½ hours 8 hours

Latent Phase (0-4 cm)Assessment

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– Contractions: frequency, intensity, duration– Membranes: intact or ruptured, color of fluid– Bloody show– Time of onset– Cervical changes– Time of last ingestion of food– FHR every 15 minutes; immediately after rupture of membranes– Maternal vital signs– Temperature every 2 hours if membranes ruptured, every 4 hours if intact– Pulse and respirations every hour or prn as indicated – Progress of descent– Clients Maternal Assessment

FIRST STAGE OF LABOR

Latent Phase (0-4 cm)

AnalysisNursing diagnoses for the latent phase of first stage of labor may include

– Anxiety– Ineffective breathing pattern– Pain– Knowledge deficit

Planning and ImplementationA. Goals– Complete all admission procedures– Labor will progress normally– Mother/fetus will tolerate latent phase successfully

Maternal Assessment

FIRST STAGE OF LABORLatent Phase (0-4 cm)

B. Interventions• Administer perineal prep/enema if ordered/appropriate• Assess V.S., B.P., FHR, contractions, bloody show, cervical changes, descent of fetus as scheduled• Maintained bed rest if indicated or required• Reinforced/teach breathing technique as needed• Support laboring woman/couple based on their needs• Have client attempt to void every 1-2 hrs• Apply external fetal monitoring if indicated or ordered

Evaluation• Admission procedure complete

B. Progress through latent stage normal, cervix dilatedC. Labor progressing through latent phase well, mother as comfortable as

possible, vital sign normal. FHR maintained in response to contraction

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Maternal Assessment

FIRST STAGE OF LABORActive Phase (4-8 cm)

Assessment • Cervical changes

B. Bloody showC. MembranesD. Progress of DescentE. Maternal / fetal vital signF. Clients affect

AnalysisNursing diagnoses for the active phase of first stage of labor

may include:A. Ineffective individual copingB. Alteration in oral mucous membranesC. Knowledge deficitD. PainE. Altered tissue perfusionF. High risk for injury

Maternal Assessment

FIRST STAGE OF LABORActive Phase (4-8 cm)

Planning and Implementation• Goals• Progress will be normal through the active phase• Mother/ fetus will successfully complete active phase B. Interventions – Continue to observe labor progress– Reinforce/teach breathing techniques as needed– Position client for maximum comfort – Support client/ couple as mother becomes more involved in labor– Administer analgesia if ordered or indicated – Assist with anesthesia if given and monitor maternal/fetal vital signs– Provide ice chips or clear fluids for mother to drink if allowed or desired– Keep client/couple informed as labor progresses– With posterior position, apply sacral counter-pressure or have father do so.Maternal Assessment

FIRST STAGE OF LABORActive Phase (4-8 cm)

Evaluation– Labor progressing through active phase, dilatation progressing– Mother/fetus tolerating labor appropriately

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– No complications observed

Transition Phase (8-10 cm)Assessment– Progress of Labor– Cervical changes– Maternal mood changes: if irritable or aggressive may be tiring or unable to cope– Signs of nausea, vomiting, trembling, crying, irritability– Maternal/fetal vital signs– Breathing patterns, may be hyperventilating– Urge to bear down with contractions

Maternal Assessment

FIRST STAGE OF LABOR

Transition Phase (8-10 cm)

AnalysisNursing Diagnoses for transition phase if first stage of labor may include:– Ineffective breathing pattern– Powerlessness– Ineffective individual coping

Planning and ImplementationA. Goals– Labor will continue to progress through transition– Mother/fetus will tolerate process well– Complications will be avoidedMaternal Assessment

FIRST STAGE OF LABOR

Transition Phase (8-10 cm)B. Interventions– Continue observation of labor progress, maternal/

fetal vital signs– Give mother positive support if tired or discouraged– Accept behavioral changes of mother– Promote appropriate breathing patterns to prevent hyperventilation– If hyperventilation present, have mother re-breath the expelled carbon dioxide to reverse respiratory alkalosis– Discourage pushing efforts until cervix is completely dilated, then assist with pushing – Observe for signs of delivery

Evaluation– Mother/fetus progressed through transition– No complications observed– Mother/ fetus ready for second stage labor

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LABOR AND DELIVERYSTAGES OF LABOR:SECOND STAGE OF LABOR (STAGE OF EXPULSION) begins with the

complete dilatation and ends with the delivery of the infant.Primi- 80 minutes Multi- 30 minutes

Power/forces at work :Involuntary uterine contractions of the diaphragmatic and abdominal muscles.

Mechanisms of Labor/Fetal position. Changes: (ED FIRE ERE)

1.Engagement -The head is fixed in the pelvis2.Descent – fetus goes down in the birth canal3.Flexion – fetal chin bends toward the chest.4.Internal Rotation – from AP to transverse then AP to AP.5.Extension – the head extends, the forehead, nose mouth and chin appears.6.External Rotation – (restitution) anterior shoulder rotates externally to

AP position.7.Expulsion – delivery of the rest of the body.

Maternal Assessment

SECOND STAGE OF LABOR

Assessment– Signs of imminent delivery– Progress of descent– Maternal/fetal vital signs– Maternal pushing efforts– Vaginal distension– Bulging of perineum– Crowning– Birth of baby

AnalysisNursing diagnoses for the second stage of labor may include– High risk for injury– Noncompliance related to exhaustion– Knowledge deficit

Maternal Assessment

SECOND STAGE OF LABOR

Planning and ImplementationA. Goals– Safe delivery of living, uninjured fetus

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– Mother will be comfortable after tolerating delivery

B. Interventions – If necessary, transfer mother carefully to delivery table or birthing chair; support legs equally to prevent/ minimize strain on ligaments– Carefully position mother on delivery table, in delivery chair or birthing bed to prevent Popliteal vein pressure– Help mother use handles or legs to pull on as she bears down with contractions– Clean vulva and perineum to prepare for delivery– Continue observation of maternal/fetal vital signs– Encourage mother in sustained (5-7 seconds) pushes with each contractionMaternal Assessment

SECOND STAGE OF LABOR

Planning and Implementation7. Support father’s participation if in delivery area

8. Catheterize mother’s bladder if indicated

9. Keep mother informed of delivery progress

10. Note time of delivery of baby.

Evaluation– Delivery of healthy viable fetus

– Mother comfortable after procedure

– No complications during procedure LABOR AND DELIVERYSTAGES OF LABOR:THIRD STAGE (PLACENTA STAGE)

Begins with the delivery of the baby and ends with the delivery of the placenta.Primi- 10 minutes Multi- 10 minutes

Signs of placental separation:1. Calkin’s sign – the uterus becomes round and firm, rising up to the level of the umbilicus. Earliest Sign.2. Sudden gush of the blood from the vagina3. Lengthening of the cord.

Types of placenta delivery:– Schultz – the placenta separates first at the center and presents the shiny fetal surface. Most common (80%)– Duncan – placenta separates first at the margin presents the maternal side.(20%)

LABOR AND DELIVERYSTAGES OF LABOR:THIRD STAGE (PLACENTA STAGE)

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Primi- 10 minutes Multi- 10 minutes– Avoid tugging at the cord as it can cause uterine inversion. Just watch for the sings of placental separation.– Perform Brandt Andrew Maneuver– Take note of the time of placental delivery; it should be delivered within 20 minutes after the baby. Otherwise, refer stat to the M.D.– Inspect for completeness of cotyledons; retained placental fragments cause severe bleeding and possible death.– Palpate the uterus to determine degree of contraction. Massage gently, ice cap is also allowed.

Medical management: Methergin is injected IM post- placental delivery to maintain uterine contraction.

LABOR AND DELIVERYSTAGES OF LABOR:THIRD STAGE (PLACENTA STAGE)

Inspect the perineum for lacerations.Categories: 1st degree : involves the vaginal mucus

membrane and perineal skin. 2nd degree : plus the muscles 3rd degree : plus the external sphincter of

the rectum 4th degree : plus the mucus membrane of

the rectum

Episiorrhaphy – repair of the episiotomy or lacerations.

Vaginal pack is sometimes inserted to prevent bleeding. Removed pack 24-48 hours.- Make the pt. comfortable by doing perineal care and applying clean sanitary napkins. Place flat on bed.

Maternal Assessment

THIRD STAGE OF LABOR

AssessmentA. Signs of placental separation– Gush of blood – Lengthening of cord– Change in shape of uterine (discoid to globular)B. Completeness of placentaC. Status of mother/ baby contact for first critical 1-2 hrs– Baby’s Apgar scores – Blood pressure, pulse, respirations, lochia, fundal status of mother

AnalysisNursing diagnoses for the third stage of labor may include:– Pain– Potential fluid volume deficit

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Baby’s Apgar scores (1 min & 5 mins.)Interpretation:

7-10 the baby is in the best possible health4-6 the baby’s condition is guarded the needs more extensive

clearing of airway.0-3 the baby is in serious danger and needs immediate

resuscitation.

Maternal Assessment

THIRD STAGE OF LABORPlanning and ImplementationA. Goals– Placenta will be delivered without complications.– Maternal blood loss will be minimized– Mother will tolerate procedures well.B. Interventions– Palpate fundus immediately after delivery of placenta; massage gently if not firm– Palpate fundus at least every 15 minutes for first 1-2 hours– Observe lochia for color and amount– Inspect perineum– Assist with maternal hygiene as needed.

a. Clean gownb. Warm blanketc. Clean perineal pads.

– Offer fluids as indicated– Promote beginning relationship with baby and parents through touch and privacy– Administer medications as ordered/needed (pitocin added to IV if present)

Maternal Assessment

THIRD STAGE OF LABOR

Evaluation– Placenta delivered without complications

– Minimal maternal blood loss

– Mother tolerated procedure well

LABOR AND DELIVERYSTAGES OF LABOR:FOURTH STAGE (RECOVERY STAGE)

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- first 2 hours post partum is the most crucial stage of the mother due to unstable vital signs.

Assessment:– Fundus – should be checked q 15 mins for 1 hour and q 30 mins for the next 4 hours.– Lochia – should be moderate in amount.– Bladder – full bladder is evidenced by the shifting of the uterus to the right.– Perineum – normally tender, discolored and edematous. It should be cleaned with intact sutures.– BP & HR – should be monitored closely: 15 mins during the 1 hr, q 30 mins for the next 2 hours.– Rooming – in concept – the mother and the baby stays in the same room in the hospital to promote the bonding at the same time encourages breastfeeding.

Maternal Assessment

FOURTH STAGE OF LABORAssessment

– Fundal firmness, position– Lochia; color, amount

The endometrial surface is sloughed off as lochia, in three stages:• Lochia rubra: dark red color, days 1-3 after delivery; consists of blood and

cellular debris from decidua.• Lochia serosa: pinkish brown, days 4-10; mostly serum, some blood,

tissue debris• Lochia alba: yellowish white, days 11-21; mostly leukocytes, with decidua,

epithelial cells, mucus.3. Perineum4. Vital signs5. IV if running6. Infant’s heart rate, airway, color, muscle tone, reflexes, warmth, activity state7. Bonding/ family integration

Maternal Assessment

FOURTH STAGE OF LABOR

AnalysisNursing diagnoses for the fourth stage of labor may include– Pain– High risk for fluid volume deficit– High risk for altered family processes

Planning and ImplementationA. Goal: critical first hour after delivery will pass without complications for

mother/baby.Maternal Assessment

FOURTH STAGE OF LABOR

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B. Interventions– Palpate fundus every 15 minutes for first 1-2 hours; massage gently if not firm– Check mother’s blood pressure, pulse, resp. every 15 min. for first 1-2 hrs. or until stable– Check lochia for color and amt. Every 15 min. for the first 1-2 hrs.– Inspect perineum every 15 min. for first 1-2 hrs.– Apply ice to perineum if swollen or if episiotomy– Encourage mother to void, particularly if fundus not firm or displaced

Evaluation– Mother’s vital signs stable, fundus and lochia within normal limits– Evidence of bonding: parents cuddle, touch, talk to baby– No complications observed for mother or baby during crucial timeLABOR AND DELIVERYASSESSMENT DURING LABORFetal Assessment AuscultationAuscultate FHR at least every 15-30 minutes during first stage and every 5-

15 minutes during second stage (depends on the risk status of the client)– Normal range 120-160 beats/minute– Best recorded during the 30 seconds immediately following a contraction

PalpitationAssess intensity of contraction by manual palpitation of uterine fundus

– Mild: tense fundus but can be indented with finger tips– Moderate: firm fundus, difficult to indent with fingertips– Strong: very firm fundus, cannot indent with finger tips

LABOR AND DELIVERYASSESSMENT DURING LABORFetal Assessment

Electronic fetal monitoringA. Placement of ultrasound transducer and tocotransducer to record fetal heart

beat and uterine contractions and display them on special graph paper for comparison and identification of normal and abnormal patterns.

B. Can be applied externally to mother’s abdomen or internally within uterus.

a. External application• Less precise information collected • May be affected by maternal movements• Noninvasive: rupture of membranes not required, can be widely used• Little danger associated with use

LABOR AND DELIVERYFetal Assessment Electronic fetal monitoring continue…

b. Internal application• More precise information collected• Cervix must be dilated and membranes ruptured to be utilized• Physician applies scalp electrode and uterine catheter• Sterile technique must maintained during application to reduce risk of

intrauterine infection

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• Can yield specific short-term variability LABOR AND DELIVERYFetal Assessment

Pattern Recognition– Nurse is responsible for assessing FHR patterns, implementing appropriate

nursing interventions and reporting suspicious patterns to physician– Baseline FHR: 120-160, no uterine contraction– Variability is normal, indicative of intact fetal nervous system. Variability is

result of interaction of sympathetic and parasympathetic nervous systems. Two types of variability are:a. Short-term (beat to beat): absent/presentb. long term (rhythmic fluctuations): cycle/min ave. 6/minute

4. Tachycardia– FHR more than 160 beats/minute lasting longer than 10 minutes – May have multiple causes– Oxygen may be administered

LABOR AND DELIVERYFetal Assessment

Pattern Recognition5. Bradycardia

– FHR less than 120 beats/minute lasting longer than 10 minutes– May have multiple causes– Oxygen may be administered

6. Early deceleration– Deceleration of FHR begins early in contraction, stays within normal range,

returns to baseline by end of contraction– Believed to be the result of compression of fetal head against cervix– Not an ominous pattern, no nursing interventions required

LABOR AND DELIVERYFetal Assessment Pattern Recognition continue…

7. Late deceleration– Deceleration of FHR begins late in contraction; depth varies with strength

of contraction; does not return to baseline by end of contraction– May be occasional or consistent. Gradual increase in number is always

suspicious and MUST be reported/charted.– Believed to be the result of utero-placental insufficiency– An ominous pattern– Nurse should change maternal position, administer oxygen, discontinue

any oxytocin infusion, assess variability, prepare for immediate delivery if patterns remain uncorrected.

LABOR AND DELIVERYFetal Assessment Pattern Recognition

8. Variable deceleration – Onset of deceleration not related to uterine contraction– Swings in FHR abrupt and dramatic, return to baseline frequently rapid– Believed to be the result of compression of the umbilical cord

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– Although not an ominous pattern, continued nursing assessment required– Nurse should change maternal position to relieve pressure on the cord; if no

improvement seen, administer oxygen, discontinue oxytocin if infusing, prepare client for vaginal exam to assessed for prolapsed cord

– If cord is prolapsed, relieve pressure on cord; do not attempt to replace cord.– Cesarean delivery will be noted

COMPLICATIONS OF LABOR AND DELIVERYPremature/Preterm LaborGeneral information

– Labor that occurs before the end of the 37th week of pregnancy– Cause is frequently unknown, but the ff conditions are associated with

premature labor– Cervical incompetence– Preeclampsia/eclampsia– Maternal injury– Infection– Multiple births– Placental disorders

3. Preterm labor; Prevention– Minimize or stop smoking; a major factor in preterm labor and birth– Minimize or stop substance abuse/chemical dependency– Early and consistent prenatal care.– Appropriate diet/ weight gain– Minimize/prevent exposure to infections– Learn to recognize signs and symptoms of preterm labor

COMPLICATIONS OF LABOR AND DELIVERYPremature/Preterm LaborGeneral information continue…

4.Incidence of preterm labor is between 5% and 10% in all pregnancies and is a major cause of perinatal mortality

Medical management1. Unless labor is irreversible, or a condition exists in which the mother or fetus

would be jeopardized by the continuation of the pregnancy, or the membranes have ruptured, the usual medical intervention is to attempt to arrest the premature labor (tocolysis)

2. Medications used in the treatment of premature labora. Magnesium sulfate

– Stops uterine contractions with fewer side effects than beta adrenergic drugs.

– Interferes with muscle contractility.– Administered IV for 12 to 24 hrs. PO form of magnesium may be used

for maintenance– Loading dose of 4-6 grams IV over 20-30 minutes

COMPLICATIONS OF LABOR AND DELIVERYPremature/Preterm Labor continue…

5. 1-4 g maintenance dose IV (2-3 g/hr)6. Must monitor patient for magnesium toxicity7. Few serious side effects; initially patient feels hot, flushed, may c/o

headache, nausea, diarrhea, dizziness, nystagmus, and lethargy.8. Most common fetal side effect is hypotonia.

b. Beta-adrenergic drugs-Terbutaline and Ritodrine– Decreases effect of calcium on muscle activation to slow or stop uterine

contractions– Initially given, IV, then p.o. brethine (terbutaline) for maintenance

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– Terbutaline– 1-8 mg/min x 8-12 hrs– 2.5 to 5 mg PO q 4-8 hrs.

– Ritodrine– 0.05-0.1 mg/min increase to 0.35 mg/min until contractions stop– 10-20 mg. q 2 h for 24 hours

COMPLICATIONS OF LABOR AND DELIVERYPremature/Preterm Labor continue…

5. Side effects: increased heart rate, nervousness, tremors, nausea and vomiting, decrease in serum K+ level, cardiac arrythmias, pulmonary edema.

c. Nifedifine– Calcium channel blockers– 10-30 mg loading dose; oral or sublingual; second dose may be given in

30 min if contractions persist; 10-20 mg orally or 4-6 hour for maintenance

– Side effects facial flushing, mild hypotension, reflex tachycardia, headache, nausea

d. Indomethacin– Prostaglandin synthetase inhibitor– Loading dose: 50-100 mg PO or rectally; 25 mg q 4-6 hr for 24-48 hr

maintenance– Side effects: nausea, vomiting, dyspepsia

COMPLICATIONS OF LABOR AND DELIVERYPremature/Preterm Labor continue…3. When premature labor cannot or should not be arrested and fetal lung maturity

needs to be improved, the use of betamethosone (Celestone) can improve the L/S ratio of lung surfactants. It is administered IM to the mother, usually q 12 hrs times 2, then weekly until 34 weeks gestation.

Nursing Intervention– Keep client at rest, side-lying position.– Hydrate the patient and maintain with IV fluids or PO fluids– Maintain continuous maternal/fetal monitoring– Administer drugs as ordered/ indicated– Keep client informed of all progress/ changes– Identify side effects/ complications as early as possible– Carry out activities designed to keep client comfortable

COMPLICATIONS OF LABOR AND DELIVERYPostmature/Prolonged PregnancyGeneral information

• Defined as those pregnancy lasting beyond the end of the 42nd week• Fetus at risk due to placental degeneration and loss of amniotic fluid (cord

accidents)• Decreased amounts of vernix also allow the drying of the fetal skin, resulting

in a dry, parchment-like skin condition

Medical management• Directed towards ascertaining precise fetal gestational age and condition and

determining fetal ability to tolerate labor• Induction of labor and possibly cesarean birth

Assessment findings

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• Measurements of fetal gestational age for fetal maturity• Biophysical profile

COMPLICATIONS OF LABOR AND DELIVERYNursing interventions

• Perform continual monitoring of maternal/fetal vital signs• Support mother through all testing and labor• Assist with amnio-infusion if ordered to increase cushion for cord

Prolapsed Umbilical CordGeneral information

• Displacement of the cord in a downward direction, near or ahead of the presenting part or into the vagina

• May occur when membranes rupture or with ensuing contraction• Associated with breech presentation, unengaged presentations and

premature labor • Assessment findings: vaginal exams identifies cord prolapse into vagina

COMPLICATIONS OF LABOR AND DELIVERYNursing intervention

– Check fetal heart tones immediately when membranes rupture and again after next contraction or within 5 minutes; report deceleraton

– If fetal Bradycardia; perform vaginal examination and check for prolapsed cord

– If cord prolapsed into vagina, exert upward pressure against presenting part to lift part off cord, reducing pressure on cord

– Get help to move mother into a position where gravity assists in getting presenting part off cord (knee-chest position or severe trendelenburg’s)

– Administer oxygen and prepare for immediate cesarean birth– If cord protrudes outside vagina, cover with sterile saline while carrying out

above tasks. Do not attempt to replace cord– Notify physician

COMPLICATIONS OF LABOR AND DELIVERYPremature Rupture of MembranesGeneral information

– Loss of amniotic fluid, prior to term, unconnected with labor– Dangers associated with this event are prolapsed cord, infection and the

potential need for premature delivery

Assessment findings– Report from mother/family of discharge of fluid– pH of vaginal fluid will differentiate between amniotic fluid (alkaline) and

urine or purulent discharge (acidic)

Nursing intervention– Monitor maternal/fetal vital signs on continuous basis, especially maternal

temperature– Calculate gestational age– Observe for signs of infection and for signs of onset of labor

– If signs of infection, administer antibiotics as ordered and prepare for immediate delivery

– If no maternal infection, induction of labor may be delayedCOMPLICATIONS OF LABOR AND DELIVERY

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Premature Rupture of Membranes5. Observe and record color, odor, amount of amniotic fluid6. Examine mother for signs of prolapsed cord7. Provide explanations of procedures and findings and support mother/family.8. Prepare mother/family for early birth if indicated

Fetal distressGeneral information: common contributing factors are:

– Cord compression– Placental abnormalities– Preexisting maternal disease

Assessment findings– Decelerations in FHR– Meconium-stained amniotic fluid with a vertex presentation– Fetal scalp sampling (may be needed for a definitive diagnosis)

COMPLICATIONS OF LABOR AND DELIVERYFetal distress

Nursing intervention– Check FHR on appropriate basis for presentation and position– Conduct vaginal exam for presentation and position– Place mother on left side, administer oxygen, check for prolapsed cord, notify

physician– Support mother and family– Prepare for emergency birth if indicated

COMPLICATIONS OF LABOR AND DELIVERYDystociaGeneral information

– Any labor or delivery that is prolonged and difficult– Usually results from a change in the interrelationships among the 5 Ps

(factors in labor and delivery): passenger, passage, powers, placenta and psyche of mother

– Frequently seen causes include– Disproportion between fetal presentation (usually the head) and

maternal pelvis (cephalopelvic disproportion [CPD])– if disproportion is minimal, vaginal birth may be attempted if fetal

injuries can be minimized or eliminated– cesarean birth is needed if disproportion is great

– Problems with presentation– any presentation unfavorable for delivery (e.g. breech, shoulder,

face, transverse lie)– posterior presentation that does not rotate or cannot be rotated

with ease– cesarean birth is the usual intervention

COMPLICATIONS OF LABOR AND DELIVERYDystocia

3. Problems with maternal soft tissue– a full bladder may impede the progress of labor, as can myomata

uteri, cervical edema, scar tissue, and congenital anomalies– emptying the bladder may allow labor to continue; the other

conditions may necessitate cesarean birth

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4. Dysfunctional uterine contractions – contraction may be too weak, too short, too far apart, ineffectual– progress of labor is affected; progressive dilatation, effacement and

descent do not occur in the expected pattern– classification

a. primary: inefficient pattern present from beginning of labor; usually prolonged latent phaseb. secondary: efficient pattern that changes to efficient or stops; may occur in any stage

COMPLICATIONS OF LABOR AND DELIVERYDystociaAssessment findings

– Progress of labor is slower than expected rate of dilatation, effacement, descent for specific client

– Length of labor prolonged– Maternal exhaustion/distress– Fetal distress

Nursing intervention– Individualized as to cause– Provide comfort measures for client– Provide clear, supportive descriptions of all actions taken– Administer analgesia if ordered– Monitor mother/fetus continuously– Prepare for cesarean delivery if needed

COMPLICATIONS OF LABOR AND DELIVERYPrecipitous Labor and Delivery

General Information– Labor of less than 3 hours– Emergency delivery without clients physician/midwife

Assessment findings– As labor is progressing quickly, assessment may need to be done rapidly– Client may have history of previous precipitous labor and delivery– Desire to push– Observe status of membranes, perineal area for bulging and for signs of

bleeding

Nursing intervention (see Table)COMPLICATIONS OF LABOR AND DELIVERYPrecipitous Labor and DeliveryNursing intervention Emergency Delivery of an Infant• If you have to deliver the baby yourself• Assessed the client’s affect and the ability to understand directions, as well as

other resources available (other physicians, nurses, auxiliary personnel).• Stay with client at all times; mother must not be left alone if delivery is

imminent• Do not prevent birth of baby• Maintain sterile environment if possible

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• Rupture membranes if necessary• Support baby’s head as it emerges, preventing too rapid delivery with gentle

pressure• Check for nuchal cord, slip over head if possible• Use gentle aspiration with bulb syringe to remove blood and mucus from nose

and mouth• Deliver shoulders after external rotation, asking mother to push gently if needed• Provide support for baby’s body as it is deliveredCOMPLICATIONS OF LABOR AND DELIVERYPrecipitous Labor and DeliveryNursing intervention Emergency Delivery of an Infant• Hold baby in a head down position to facilitate drainage of secretions• Promote cry by gently rubbing over back and soles of feet • Dry to prevent heat loss• Place baby on mother’s abdomen• Check for signs of placental separation • Check mother for excess bleeding, massage uterus prn• Hold placenta as it is delivered• Cut cord when pulsation cease, if cord clamp is available, if no clamp, leave

intact• Wrap baby in dry blanket, give to mother, put to breast if possible• Check mother for fundal firmness and excess bleeding• Record all pertinent data• Comfort mother and family as needed

COMPLICATIONS OF LABOR AND DELIVERYAmniotic Fluid EmbolismGeneral Information

– Escape of amniotic fluid into the maternal circulation, usually in conjunction with a pattern of hypertonic, internse uterine contractions, eithe naturally or oxytocin involved

– Obstetric Emergency: may be fatal to the mother and the baby Assessment findings

– Sudden onset of respiratory distress, hypotension, chest pain, signs of shock– Bleeding DIC– Cyanosis– Pulmonary edema

Nursing interventionsinitiate emergency life support activities for motherestablish IV line for blood transfusion and monitoring of CVPadminister medications to control bleeding as orderedprepare for emergency birth of babykeep client/family informed as possible

COMPLICATIONS OF LABOR AND DELIVERYInduction of LaborA. General Information: deliberate stimulation of uterine contractions before the

normal occurrence of labor.

B. Medical management: may be accomplished by– Amniotomy (the deliberate rupture of membrane– Oxytocin, usually Pitocin– Prostaglandin (PGE2) in gel/ suppository form

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C. Assessment findings• Indication for use

– Post mature pregnancy– Preclampsia/ eclampsia– Diabetes– Premature rupture of membrane

• Condition of fetus: mature, engaged vertex fetus in no distress• Condition of mother: cervix “ripe” for induction , no CPD

COMPLICATIONS OF LABOR AND DELIVERYInduction of LaborNursing interventions

– Explain all procedures to client– Prepare appropriate equipment and medications

– Amniotomy: a small tear made in amniotic membrane as part of sterile vaginal exam– explain sensation to client– check FHR immediately before and after procedure; marked changes

may indicate prolapsed cord– additional care as for woman with premature rupture of membranes

– Oxytocin (Pitocin): IV administration, “Piggy backed” to main IV– usual dilution 10 mU/100ml fluid delivered via infusion pump for

greatest accuracy in controlling dosage– usual administration rate is 0.5-1.0 mU/min at 40-60 minute intervals

until regular patterns of appropriate contractions is established (every 2-3 minutes, lasting less than 90 seconds, with 30-45 seconds rest period between contractions)

COMPLICATIONS OF LABOR AND DELIVERYInduction of LaborNursing interventions

3. Know that continuous monitoring and accurate assessments are essential– Apply external continuous monitoring equipment– Monitor maternal condition on a continuous basis; blood pressure, pulse,

progress of labor

6. Discontinue oxytocin infusion when– Fetal distressed is noted– Hypertonic contractions occur– Signs of other obstetric complications (hemorrhage/shock, abruptio

placenta, amniotic fluid embolism) appear

10. Notify physician of any untoward reactions

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COMPLICATIONS OF PREGNANCYPregnancy can be complicated by situations unique to child bearing (e.g. placenta

bleeding), or by long standing conditions predating pregnancy and continuing into the child bearing process (e.g. age socioeconomic status, cardiac problems); for common discomforts of pregnancy,

Common discomforts During Pregnancy

COMPLICATIONS OF PREGNANCY

General Nursing Responsibilities:– Teach danger signals of pregnancy early in prenatal period so that client is aware of

what needs to be reported to health care provider on an immediate basis

– Be aware that early teaching allows the client to participate in the identification and reporting symptoms that can indicate a problem in her pregnancy.

– Early recognition and reporting of danger signals that usually results in diminishing the risk and controlling the severity of maternal/ fetal complications.

– Interventions are specific for the individual risks.

– Evaluation centers around whether or not the risk was controlled or eliminated and how the maternal/fetal reaction was controlled.

COMPLICATIONS OF PREGNANCYFirst Trimester Bleeding ComplicationsAbortion• General information

• Loss of pregnancy before viability of fetus; may be spontaneous, therapeutic or elective (clients may use term “miscarriage” for spontaneous abortion.)

• Types:a. Threatened abortion

• cervix closed• some bleeding and contractions• fetus is not expelled

b. Inevitable• cervix open• heavier bleeding and stronger contractions• loss of fetus usually not avoidable

COMPLICATIONS OF PREGNANCYFirst Trimester Bleeding ComplicationsAbortion: Types continue…

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c. Incomplete1. expulsion of fetus complete2. membranes or placenta retained

d. Complete: all products of conception expelled

e. Missed: fetus dies in uterus, but is not expelled

f. Habitual • three pregnancy in a row culminating in spontaneous abortion• may indicate need for investigation into underlying causes

COMPLICATIONS OF PREGNANCY

First Trimester Bleeding ComplicationsDanger Signals of Pregnancy:

• Any bleeding from vagina

• Gush of fluid from vagina (Clear, not urine)

• Regular contractions occurring before due date

• Severe headaches or changes in vision

• Epigastric pain

• Vomiting that persists and is severe

• Change in fetal activity patterns

• Temperature elevation, chills or “sick” feeling indicative of infection

• Swelling in upper body, especially face and fingers

COMPLICATIONS OF PREGNANCY

First Trimester Bleeding Complications

Assessment findings:– Vaginal bleeding (observing carefully for accurate determination of amount,

saving all perineal pads).

– Contractions; pelvic cramping, backache

– Lowered hemoglobin if blood loss significant

– Passage of fetus/tissue

COMPLICATIONS OF PREGNANCYFirst Trimester Bleeding ComplicationsNursing interventions:

– Save all tissue passed (Histopathology examination).

– Keep client at rest and teach reason for bed rest.

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– Increased fluids PO or IV as ordered.

– Prepare client for surgical intervention (D & C or suction evacuation) if needed

– Provide discharge teaching about limited activities and coitus after bleeding ceases.

– Observe reaction of mothers and others, provide emotional support and give opportunity to express feelings of grief and loss.

– Administer Rhogam if mother is Rh negative. COMPLICATIONS OF PREGNANCY

First Trimester Bleeding ComplicationsIncompetent Cervical Os(Premature Dilatation of Cervix)

General information: painless condition in which the cervix dilates without uterine contractions and allow passage of the fetus usually the result of prior cervical trauma

Medical Management: may be treated surgically to cerclage (placement of fascia or artificial material to constrict the cervix in a “purse-string” manner). When client goes into labor, choice of removal of suture and vaginal delivery or cesarean birth.

COMPLICATIONS OF PREGNANCYFirst Trimester Bleeding ComplicationsIncompetent Cervical Os

Assessment findings– History of repeated, relatively painless abortions– Early and progressive effacement and dilatation of cervix– Bulging of membranes through cervical os

Nursing interventions – Continue observation for contractions, ruptures of membranes and monitor

fetal heart tones– Position client to minimize pressure on cervix

COMPLICATIONS OF PREGNANCYFirst Trimester Bleeding ComplicationsEctopic PregnancyGeneral information

– Any gestation outside the uterine cavity– Most frequent in the fallopian tubes, where the tissue is incapable of the

growth needed to accommodate pregnancy, so rupture of the site usually occurs before 12 weeks.

– Any condition that diminishes the tubal lumen may predispose a woman to ectopic pregnancy.

Assessment findings– History of missed periods and symptoms of early pregnancy– Abdominal pain, may be localized on one side– Rigid, tender abdomen; sometimes abnormal pelvic mass– Bleeding: if severe may lead to shock– Low hemoglobin and hematocrit, rising white cell count

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– HCG titers usually lower than in intrauterine pregnancy

COMPLICATIONS OF PREGNANCYFirst Trimester Bleeding ComplicationsEctopic Pregnancy

Nursing interventions – Prepare client for surgery

– Institute measures to control/ treat shock if hemorrhage severe; continue to monitor postoperatively

– Allow client to express feelings about loss of pregnancy and concerns about future pregnancies.

COMPLICATIONS OF PREGNANCYFirst Trimester Bleeding Complications

Hydatidiform Mole (Gestational Trophoblastic Disease)

General information– Proliferation of trophoblast: embryo dies. Unusual chromosomal patterns

seen (either no genetic material in ovum or 69 chromosomes). The chorionic villi change into a mass of clear, fluid-filled grape like vessels

– More common in oriental women and women over 40.

– Cause essentially unknown

COMPLICATIONS OF PREGNANCYFirst Trimester Bleeding ComplicationsHydatidiform Mole (Gestational Trophoblastic Disease)

Assessment findings– Size of the uterus disproportionate to the length of pregnancy

– High levels of HCG with excessive nausea and vomiting

– Dark red to brownish vaginal bleeding after 12th week

– Anemia often accompanies bleeding

– Symptoms of preeclampsia before usual time of onset

– No fetal heart sounds or palpitation of fetal parts

– Ultrasounds shows no fetal skeleton

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COMPLICATIONS OF PREGNANCYFirst Trimester Bleeding ComplicationsHydatidiform Mole (Gestational Trophoblastic Disease)

Nursing interventions – Provide Pre- and Postoperative care for evacuation of uterus (usually suction

curettage).

– Teach contraceptive use so that pregnancy is delayed for at least one year

– Teach client need for follow-up lab work to detect rising HCG levels indicative of choriocarcinoma

– Provide emotional support for loss of pregnancy

– Teach about risk for future pregnanciesCOMPLICATIONS OF PREGNANCY

Second Trimester Bleeding Complications

There are few unique causes of bleeding in the second trimester. Bleeding may be late manifestation of condition usually seen in first trimester, such as

a. spontaneous abortion

b. incompetent cervical os.COMPLICATIONS OF PREGNANCYThird Trimester Bleeding Complications

Placental problems are the most frequent cause of bleeding in the third trimester

Placenta Previa

General information– Low implantation of the placenta so that it overlays some or all of the internal

cervical os

– Cause uncertain, but uterine factors (poor vascularity, fibroid tumors, multiple pregnancies) may be involved

– Amount of cervical os involved classifies placenta previa as marginal, partial or complete

COMPLICATIONS OF PREGNANCYThird Trimester Bleeding ComplicationsPlacenta Previa

Assessment findings– Painless bright red vaginal bleeding after seventh month of pregnancy is

cardinal indicator. Bleeding may be intermittent, in gushes or continuous.

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– Uterus remains soft

– FHR usually stable unless maternal shock present

– No vaginal exam by nurse, may result in severe bleed, if done by physician, double set-up used

– Diagnosis by sonography

COMPLICATIONS OF PREGNANCYThird Trimester Bleeding ComplicationsPlacenta Previa

Nursing interventions – Ensure complete bed rest.

– Maintain sterile conditions for any invasive procedures (including vaginal examination)

– Make provisions for emergency cesarean birth (double set-up procedure)

– Continue to monitor maternal/fetal vital signs

– Measure blood loss carefully

– Assess uterine tone regularlyCOMPLICATIONS OF PREGNANCYThird Trimester Bleeding ComplicationsAbruptio PlacentaGeneral information

– Separation of placenta from part or all of normal implantation site, usually accompanied by pain

– Usually occurs after 20th week of pregnancy– Seen frequently in women with hypertension, previous abruptio

placentae, late pregnancies and multigravidas, but cause essentially unknown

Assessment findings– Painful vaginal bleeding– Tender, board-like uterus (especially if concealed hemorrhage, then no

vaginal bleeding)– Fetal bradycardia and late decelerations absent FHT in complete abruption– Additional signs of shock

COMPLICATIONS OF PREGNANCYThird Trimester Bleeding ComplicationsAbruptio Placenta

Nursing interventions – Ensure bed rest

– Check maternal/fetal vital signs frequently

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– Prepare fir IV infusions of fluids/blood as indicated

– Monitor urinary output

– Anticipate coagulation problem (DIC)

– Provide support to parents as outlook for fetus is poorCOMPLICATIONS OF PREGNANCYHyperemesis Gravidarum

General information– Excess nausea and vomiting of early pregnancy leads to dehydration

and electrolyte disturbances, especially acidosis– Causes: possible severe reaction to HCG levels increased. HCG levels

peak around 6 weeks after conception, plateau, then begin to decline after the 12th week. Symptoms often improve later in pregnancy, but may last entire time.

Assessment findings– Nausea and vomiting, progressing to retching between meals– Weight loss

COMPLICATIONS OF PREGNANCYHyperemesis Gravidarum

Nursing interventions– Begin NPO and IV fluid and electrolyte replacement. (Correction of F&E

balance will decrease nausea, NPO will rest the stomach)– Monitor I&O– Gradually re-introduce PO intake, monitor amounts taken and retained– Monitor TPN and central line placement if unable to eat– Provide mouth care– Offer emotional support- very demoralizing and depressing client – Refer to home health as appropriate for continued IV or TPN therapy

COMPLICATIONS OF PREGNANCYPregnancy-Induced HypertensionGeneral information

a. Refers to condition unique to pregnancy where vasospastic hypertension is accompanied by proteinuria and edema; maternal or fetal condition may be compromised

• Probable cause: Gradual loss of normal pregnancy-related resistance to angiotensin II

• May also be related to decreased production of some vasodilating prostaglandins

b. Onset after 20th week of pregnancy, may appear in labor or up to 48 hours postpartum.

c. Characterized by widespread vasospasmd. Cause essentially unknown, but incidence is high in primigravidas, multiple

pregnancies, H. mole, poor nutrition, essential hypertension; familial tendency.

COMPLICATIONS OF PREGNANCYPregnancy-Induced HypertensionGeneral information continue…

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e. Occurs in 5%-7% of all pregnant womenf. Usual clinical classification of hypertensive disorders in pregnancy is as

follows:1. Pregnancy-induced hypertension (PIH)

1.1 Hypertension1.2 Preeclampsia

a. Mildb. Severe

1.3 Eclampsia2. Chronic Hypertension3. Chronic hypertension with superimposed PIH

3.1 Superimposed preeclampsia3.2 Superimposed eclampsia

COMPLICATIONS OF PREGNANCYPregnancy-Induced HypertensionGeneral information continue…

– Classic triad of symptoms includes edema/weight gain, hypertension and proteinuria. Eclampsia includes convulsion and coma

– Possible life threatening complications. HELLP syndrome (Hemolysis, elevated liver enzymes, lowered platelets).

i. Only known cure is deliveryCOMPLICATIONS OF PREGNANCYPregnancy-Induced Hypertension

A. Mild Preeclampsia

Assessment findings– Appearance of symptoms between 20th and 24th week pregnancy– Blood pressure of 140/90 or +30/ +15 mmHg on two consecutive occasions

at least 6 hours apart– Sudden weight gain (+3 lb/month in second trimester; +1 lb/week at

any time)– Slight generalized edema, especially of hands and face– Proteinuria of 300 mg/liter in a 24-hour urine specimen (> +1)

COMPLICATIONS OF PREGNANCYPregnancy-Induced Hypertension

A. Mild Preeclampsia

Nursing interventions – Promote bed rest as long as signs of edema or proteinuria are minimal,

preferably side-lying.

– Provide well-balanced diet with adequate protein and roughage, no Na+ restriction.

– Explain need for close follow-up, weekly or twice-weekly visits to physicianCOMPLICATIONS OF PREGNANCYPregnancy-Induced Hypertension

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B. Severe Preeclampsia

Assessment findings – Headaches, epigastric pain, nausea and vomiting, visual disturbances,

irritability

– Blood pressure of 150-160/100-110 mmHg

– Increased edema and weight gain

– Proteinuria (5g/24hours)(4+)COMPLICATIONS OF PREGNANCYPregnancy-Induced HypertensionB. Severe Preeclampsia

Medical Management: Magnesium Sulfate– Magnesuim sulfate acts upon the myoneural junction, diminishing

neuromuscular transmission.

– It promotes maternal vasodilatation, better tissue perfusion and has anticonvulsant effect

– Nursing responsibilities– Monitor client’s respirations, blood pressure and reflexes, as well as

urinary output frequently.– Administer medications either IV or IM

4. Antidote for excess levels of magnesium sulfate is calcium gluconate or calcium chloride

COMPLICATIONS OF PREGNANCYPregnancy-Induced Hypertension

B. Severe Preeclampsia

Nursing interventions– Promote complete bed rest, side-lying. – Carefully monitor maternal/fetal vital signs– Monitor I&O, results of laboratory tests– Take daily weights– Do daily fundoscopic examination– Institute seizure precautions– Instruct client about appropriate diet– Continue to monitor 24-48 hours post delivery– Administer medications as ordered; Peripheral vasodilator of choice usually

Hydralazine (Apresoline)COMPLICATIONS OF PREGNANCYPregnancy-Induced Hypertension

C. EclampsiaMedical management (see Severe Preeclampsia)

Assessment findings

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– Increased hypertension precedes convulsion followed by hypotension and collapse

– Coma may ensue

– Labor may begin, putting fetus in great jeopardy

– Convulsion may recur COMPLICATIONS OF PREGNANCYPregnancy-Induced Hypertension

C. Eclampsia

Nursing Intervention– Minimize all stimuli– Check vital signs and lab values– Have airway, oxygen and suction equipment available– Administer medication as ordered– Prepare for C-section when seizures stabilized– Continue observations 24-48 hours postpartum

PRE- AND COEXISTING DISEASES OF PREGNANCY

Cardiac ConditionsGeneral Information

• May be the result of congenital heart disease or the sequelae of rheumatic fever/ heart disease.

• May affect pregnancy, but are definitely affected by pregnancy.

C. Classification• Class 1: no limitation of activity• Class 2: slight limitation of activity• Class 3: considerable limitation of activity• Class 4: symptoms present even at rest

PRE- AND COEXISTING DISEASES OF PREGNANCY

Cardiac ConditionsPrenatal Period

Assessment findings– Evidenced of cardiac decompensation especially when blood volume peaks

(weeks 28-32).

– Cough and Dyspnea

– Edema

– Heart Murmurs

– Palpitations

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– RalesPRE- AND COEXISTING DISEASES OF PREGNANCY

Cardiac ConditionsPrenatal Period

Nursing Intervention– Promote frequent rest periods and adequate sleep, decreased stress.– Teach client to recognize and report signs of infection, importance of

prophylactic antibiotics– Compare vital signs to baseline and normal values expected during

pregnancy.– Instruct in diet to limit weight gain to 15 lbs., low Na+.– Explain Rationale for anticoagulant therapy (heparin use in pregnancy) if

ordered– Teach danger signals for individual client

PRE- AND COEXISTING DISEASES OF PREGNANCY

Intrapartal PeriodLabor increases risk of congestive heart failure: milking effect of contractions and

delivery increases blood volume to heart

Nursing Interventions– Monitor maternal EKG and FHT continuously.– Explain to client that vaginal delivery is preferred over C-section– Monitor client’s response to stress of labor and watch for signs of

decompensation– Administer oxygen and pain medication as ordered, epidural preferable– Position client in side-lying/ low semi-Fowler’s position.– Provide calm atmosphere– Encourage “open-glottal” pushing during second stage labor, forceps or

vacuum extractor used to minimize pushingPRE- AND COEXISTING DISEASES OF PREGNANCY

Cardiac ConditionsPostpartal Period

• Nursing Interventions1. Monitor vital signs, any bleeding, strict I&O, lab test values, daily weight, rest and diet.

2. Promote bed rest in appropriate position

3. Assist with ADL

4. Prevent Infection

5. Facilitate nonstressful mother/baby interactions

6. Help mother plan for rest and activity pattern at home.

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PRE- AND COEXISTING DISEASES OF PREGNANCY

Endocrine ConditionsDiabetes MellitusGeneral Information

– Chronic disease caused by improper metabolic interaction of carbohydrates, protein, fats and insulin

– Interaction of pregnancy and diabetes may cause serious complications of pregnancy

– Classifications of Diabetes mellitus:– Type 1: formerly called juvenile-onset or insulin-dependent

diabetes; onset before age 40– Type 2: formerly called maturity-onset or non-insulin-dependent;

onset after age 40– Type 3: formerly called gestational; onset during pregnancy; reversal

after termination of pregnancy– Type 4: formerly called secondary; occurs after pancreatic infections

or endocrine disorder– Significance of Diabetes in pregnancy

PRE- AND COEXISTING DISEASES OF PREGNANCY

Endocrine ConditionsDiabetes MellitusGeneral Information

5. Interaction of estrogen, progesterone, HPL and cortisol raise maternal resistance to insulin (inability to use glucose at the cellular level).

6. If the pancreas cannot respond by producing additional insulin, excess glucose moves across placenta to fetus, where fetal insulin metabolizes it and acts as growth hormone, promoting macrosomia.

7. Maternal insulin levels need to be carefully monitored during pregnancy to avoid widely fluctuating levels of blood glucose.

8. Dose may drop during first trimester, then rise during second and third trimesters.

9. Higher incidence of fetal anomalies and neonatal hypoglycemia (good control minimizes)

PRE- AND COEXISTING DISEASES OF PREGNANCY

Endocrine ConditionsDiabetes MellitusAssessment Findings

– Polyuria– Polydipsia– Weight loss– Polyphagia– Elevated glucose levels in blood and urine. Urine tests for elevated blood

glucose less reliable in pregnancy. Blood tests (more accurate) used as follows:• 1-hour glucose tolerance test: usually done for screening on all

pregnant women 24-28 weeks pregnant.• 3-hour glucose tolerance test: used where results from 1hour GTT>

140 mg/dl.• HbAlc: glycosylated hemoglobin; reflects past

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4-12 week blood levels of serum glucose. PRE- AND COEXISTING DISEASES OF PREGNANCY

Endocrine ConditionsDiabetes MellitusNursing Interventions

– Teach client the effects and interactions of diabetes and pregnancy and signs of hyper- and hypoglycemia

– Teach client how to control diabetes in pregnancy, advise of changes that need to be made in nutrition and activity patterns to promote normal glucose levels & prevent complications.

– Advice client of increased risk of infection and how to avoid it.– Observe and report any signs of preeclampsia– Monitor fetal status throughout pregnancy– Assess status of mother and baby frequently

• Monitor carefully fluids; calories, glucose and insulin during labor and delivery

b. Continue careful observation in post delivery.PRE- AND COEXISTING DISEASES OF PREGNANCY

Renal Conditions Urinary tract infection (UTI)General Information

– Affect 10% of all pregnant women– Dilated, flaccid and displaced ureters are a frequent site.– E. coli is the usual cause– May cause premature labor if severe, untreated or pyelonephritis develops.

Assessment Findings– Frequency and urgency of urination– Suprapubic pain– Flank pain (if kidney involved)– Hematuria– Pyuria– Fever and chills

PRE- AND COEXISTING DISEASES OF PREGNANCY

Renal ConditionsUrinary tract infection (UTI)

Nursing Interventions– Encourage high fluid intake

– Provide warm baths to relieve discomfort and promote perineal hygiene

– Administer and monitor intake of prescribed medications (antibiotics, urinary analgesics)

– Stress good bladder-emptying schedule

– Monitor for signs of premature labor from severe or untreated infectionPRE- AND COEXISTING DISEASES OF PREGNANCY

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Other InfectionsGeneral Information

– Pregnancy is not a prevention against pre- or coexisting infections– Toxoplasmosis, other infections, rubella, cytomegalovirus and herpes

(TORCH infections) are especially devastating to the fetus, causing abortions, malformations and even fetal death.

– Rubella titer is assessed during early prenatal visit.

General Nursing Interventions– Instruct the pregnant woman in signs and symptoms that indicate infection,

especially fever, chills, sore throat, localized pain or rash– Caution pregnant women to avoid obviously infected persons and other

sources of infection, as danger exists for the fetus in all maternal infections– May affect delivery options.

PRE- AND COEXISTING DISEASES OF PREGNANCY

AIDS and PregnancyGeneral Information

– Transmission of the HIV authenticated through blood, semen, vaginal secretions and breast milk

– Can be transmitted from mother to fetus during pregnancy– C/S delivery will not avert mother-to-fetus transmission– Breast feeding not currently recommended for seropositive mothers– Increased in prematuriy, premature rupture of membranes, low birth weight,

and coexistent STD’s– Pregnancy-altered immune states may result in the acceleration of

opportunistic diseases, such as Candida albicans, herpes, and toxoplasmosis– Treatment of the mother with AZT during pregnancy decreases the risk of

transmission of the virus to the fetusPRE- AND COEXISTING DISEASES OF PREGNANCY

AIDS and PregnancyNursing implications

– Through review of history and any physical symptoms

– Close attention to lab studies, especially CBC, leukocyte count, T-cell count, and urinalysis indicated.

– Strict attention to universal precautions as appropriate

– Protective coverings in the delivery room

– Wear gloves to handle all infants until they are bathed

– Suction new born with bulb or wall suction devices only

– Special assessments: respiratory, neurologic, psychosocial

Other Conditions of Risk in Pregnancy

Adolescence

General information– Pregnancy is a condition of both physical and psychologic risk

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– Adolescent is frequently undernourished and not yet completely matured either physically or psychosocially

– Adolescents is uniquely unsuited for the stresses of pregnancy

– Frequency of serious complications increases in adolescent pregnancy, particularly toxemia and low-birth-weight infants.

Other Conditions of Risk in PregnancyAdolescence

Nursing Interventions– Encourage adequate prenatal care

– Provide health teaching to prepare for pregnancy, labor and delivery and motherhood

– Provide nutritional counseling

– Teach coping skills for labor and delivery

– Teach child care skillsOther Conditions of Risk in PregnancyDisseminated Intravascular Coagulation (DIC)

General information– Also known as consumptive coagulopathy– A diffuse, pathologic, form of clotting secondary to underlying disease/

pathology– Occurs in critical maternity problems such as abruptio placenta, dead

fetus syndrome, amniotic fluid embolism, preeclampsia/ eclampsia, hydatidiform mole and hemorrhagic shock

– Mechanism:a. Precoagulant substances release in the blood trigger microthrombosis

in peripheral vessels and paradoxical consumption of circulating clotting factors

b. Fibrin-split products accumulate, further interfering with the clotting process

c. Platelet and fibrinogen levels dropOther Conditions of Risk in PregnancyDisseminated Intravascular Coagulation (DIC)Assessment findings

– Bleeding may range from massive, unanticipated blood loss to localized bleeding (purpura and petechiae)

– Presence of special maternity problems– Prolonged prothrombin and partial thromboplastin

Nursing Interventions– Assist with medical mgt. of underlying condition.– Administer blood component therapy (white blood cells, packed cells,

fresh frozen plasma, cryoprecipitate) as ordered.– Observe for signs of insidious bleeding (oozing IV site, petechiae,

lowered hematocrit).– Institute nursing measures for severe bleeding /shock if needed.

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– Provide emotional support to client and family as needed.Other Conditions of Risk in PregnancyAnemiaGeneral information

– Low red cell count may be underlying condition– May or may not be exacerbated by physiologic hemodilution of pregnancy– Most common medical disorder of pregnancy

Assessment findings– Client is pale, tired, short of breath, dizzy– Hgb is less than 11 g/dl; hct less than 37%

Nursing Interventions– Encourage intake of foods with high iron content– Monitor iron supplementation.– Teach sequelae iron ingestion.– Assess need for parental iron.

Other Conditions of Risk in PregnancyPrenatal Substance AbuseGeneral information

– Incidence: probably underestimated in our society– Morbidity/mortality: related to chemical used, timing , and route of

administration.Assessment findingsA. Alcohol

– elevates the mood, depresses the central nervous system– affects every other system in the body of the mother– displaces other nutritional food intake– greatest risk from high blood alcohol levels– no safe level of maternal alcohol use in pregnancy has been established– fetus may display IUGR (Intrauterine Growth Retardation), CNS

dysfunction, craniofacial abnormalities (fetal alcohol syndrome).Other Conditions of Risk in PregnancyPrenatal Substance Abuse

Cocaine– powerful stimulant; very addictive

– causes vasoconstrictions, elevated BP, tachycardia

– may precipitate seizures

– affects ability to transport O2 into the blood

– may cause spontaneous abortion, fetal malformation, placenta abruptio, neural tube defects

– newborn may display irritability, hypertonicity, poor feeding patterns, increased risks of SIDS

Other Conditions of Risk in PregnancyPrenatal Substance AbuseOpiates

– produce analgesia, euphoria, respiratory depression

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– if used IV, foreign substance contamination may cause pulmonary emboli or infections

– if used IV, places mother at greater risk of contracting HIV, then passing it on to fetus

– newborns experience withdrawal within 24-72 hours after delivery – high pitch cry, restlessness, poor feeding seen in the newborn

Other Chemicals– may include tranquilizers, prescription medications, paint thinners, other

aerosols, etc.– major danger in overdose, with accompanying cardiac/ respiratory arrest.

Other Conditions of Risk in PregnancyPrenatal Substance Abuse

Nursing interventions– Treatment during pregnancy include in- or outpatient care. Alcoholics

Anonymous-Base Programs are widely utilized

– Treatment may include family therapy

– Efforts to treat the chemical abuse/dependency should be maximized during pregnancy. Withdrawal is the best accomplished with competent, professional help