Intrapartum+Complication (1)

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Intrapartum ComplicationN420 Childbearing Family Nursing Week 13 April 13, 2000

PERINATAL GRIEFA 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 Kbler Ross, 1969

Denial (Shock) Anger Bargaining Depression Acceptance

Tasks of GrievingParkes & Weiss, 1983

Intellectual Recognition Emotional Acceptance Assumption of New Identity

Perinatal Loss Nursing Interventions Perinatal Grief ProtocolEffort 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 GriefFrequently Unacknowledged Interventions Case Study Peer/ Administration Support Resolution

Be aware of your own experiences of loss


Intrapartal ComplicationsPsychological Adaptations Fear Influence of Sympathetic Nervous System Response

Unmet expectations Grief-like response Family Support Needs

Labor DystociaDifficult Labor: prolonged or abnormal labor Problem with Four Ps: Passage, Passenger, Power, Psyche

Risks Related to Labor DystociaMaternal- Infection - Exhaustion - Dehydration - Ketosis - Lacerations - Hemorrhage perfusion Psychological trauma

Fetal- Infection - Asphyxia - Cord prolapse - Insufficient - Placental - Shoulder dystocia - Birth trauma

Labor DystociaProlonged 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 inmultip.

Precipitous Labor: < 3 hours

Labor DystociaProblem with Powers Abnormal Uterine Contraction Pattern Hypertonic Contractions Hypotonic Contractions Precipitous Labor and Birth

Labor DystociaProblem with Passage Pelvic Contracture Non-Gynecoid Pelvis.

Problem with Passenger Malpresentation Macrosomia Fetal Anomalies

Intrapartal ComplicationsMalposition Occiput Posterior

Malpresentation Breech Transverse Lie Brow Face Asynclitism

Management of Labor DystociaAugmentation of Labor Amniotomy Oxytocin Augmentation

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

Induction or Augmentation of LaborProstaglandin E2 for cervical ripening

Amniotomy artificial rupture of membranes

Oxytocin (Pitocin) induction of uterine contractions

Cytotec Controversy

Induction or Augmentation of LaborRequires 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 Augmentation of LaborBishop ScoreEvaluation of Readiness for Labor 0 1 2 Dilatation (cm) 0 1-2 3-4 Effacement (%) 0-30 40-50 60-70 Station -3 -2 -1,0 +1 Cervical Firm Med. Soft Consistency Cervical Position Post. ML Ant 3 5-6 80+

Augmentation of LaborPitocin 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 DeliveryVacuum - Assisted Delivery Mechanism: Suction and Traction used to assistdelivery of presenting part.

Indication: Most commonly related to prolonged2nd Stage of Labor. Takes up less space and causes less injury that forceps. (CPD); Most malpresentations and malpositions; extreme prematurity.

Contraindications: Cephalopelvic Disproportion Nursing Responsibility: FHR checks q 5 minutes;Hand held suction pump. Pressure release between UCs; Assess neonatal head for caput resolution after delivery.

Assisted and Operative DeliveryForceps Delivery Mechanism: Traction and rotation of fetalpresenting part with curved metal tongs.

Indication: Prolonged 2nd stage (> 3 hrs); maternal Contraindications: Cephalopelvic Disproportion(CPD); Most malpresentations and malpositions; < +2 station.

exhaustion; Outlet: > +2 station and visible at vaginal introitus; low: > +2, but not visible.

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

Cesarean Birth25% 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 BirthTypes 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 BirthEpidural Anesthesia Spinal Anesthesia General Anesthesia

Epidural Anesthesia for CesareanMechanism: Variety of Caine drugs administered in theepidural 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 ofspinal injuries

Adverse Effect: Maternal Hypotension; Inadvertent Spinal or systemic administration; Incomplete pain relief.

Spinal Anesthesia for CesareanMechanism: Variety of Caine drugs administered in thesubarachnoid 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, hxof spinal injuries; meningitis.

Adverse Effect: Maternal Hypotension; Inadvertent Spinal or systemic administration; Incomplete pain relief.

General Anesthesia for CesareanMechanism: Inhalation anesthesia such as nitrous oxide incombination 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 LaborS/ O: 24 y.o. G1 P0 with ruptured membranes x 17hours. Normal Pregnancy. EFW: 8 1/2 lbs.. Cervix on admission: 2cm, 50% effaced, -1 station, ROM in elevator. Reports UCs x 2 hours

After 11 hours of labor:UCs 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 LaborAfter 17 hours of labor: S/ O: UCs q 4 - 5 minutes x 45 seconds, strength: moderate to palpation. UCs 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 LaborS / O: Oxytocin (Pitocin) begun at 1 mu/min per O:infusion pump and increased 1-2 mu every 20 minutes until strong labor pattern established. After 20 Hours of Labor (3 hrs of augmentation): UCs 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: 150-160s, average variability, early decelerations.

A / P: ________________________

Case Study: Labor DystociaAfter 24 Hours of Labor: S/O: VS: T 100.2, P100, RR20, BP98/52 (BaselineBP 115/68). Epidural Effective as evidenced by _________ UCs q 3 min x 50-80 secs. IUPC in place. Cervix: Complete Dil. & Effaced, O station FHR: Decelerations resolved, Baseline increased at 160s with minimal variability maybe. r/t __________

A/P: ____________________

Case Study: Labor DystociaAt 27 Hours of Labor

S / O: Sonya has been pushing for 3 hoursUCs 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 ComplicationsIntrauterine Fetal Death Diagnosis Medical Management Psychological Impact

Obstetrical Emergencies

Fetal Distress Cord Prolapse Shoulder Dystocia Uterine Rupture Amniotic Fluid Embolism

Obstetrical Emergency: Shoulder DystociaFailure 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 DystociaObstetrical Maneuvers Suprapubic Pressure McRoberts Maneuver Rotation and Delivery of Posterior Shoulder Maternal Position Change Issue of Fundal Pressure