nurs 3560 compromised labor and delivery fall 10 sv

8/8/2019 NURS 3560 Compromised Labor and Delivery Fall 10 SV

1/97

Integrated, Compensated and CompromisedIntegrated, Compensated and CompromisedLabor and DeliveryLabor and Delivery

y NURS 3560

y Donna Wilsker, MSN, RN


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Analgesia/AnesthesiaAnalgesia/Anesthesia

y Analgesia

Two individuals to consider

A

dministration of meds


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Discomfort During Labor and BirthDiscomfort During Labor and Birth

y Pain and discomfort experienced duringlabor have two neurologic origins: visceraland somatic

y Neurologic origins Visceral pain: from cervical changes, distention

of lower uterine segment, and uterineischemia

Located over lower portion of abdomenx Referred pain: originates in uterus, radiates to

abdominal wall, lumbosacral area of back, iliaccrests, gluteal area, and down thighs


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Discomfort During Labor andDiscomfort During Labor and

BirthBirthcontdcontdy Neurologic origins

Somatic pain: pain described as intense, sharp,burning, and well localized

x Stretching and distention of perineal tissues andpelvic floor to allow passage of fetus fromdistention and traction on peritoneum anduterocervical supports during contractions and

lacerations of soft tissue


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BirthBirthcontdcontdy Perception of pain

Threshold remarkably similar in all, regardlessof gender, social, ethnic, or cultural differences

Differences play definite role in personsperception of and behavioral responses topain


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BirthBirthcontdcontdy Expression of pain

Pain results in physiologic effects and sensoryand emotional (affective) responses

Emotional expressions of suffering often seenx Increasing anxiety

x Writhing, crying, groaning, gesturing (hand clenchingand wringing), and excessive muscular excitability

x Cultural expression of pain varies


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BirthBirthcontdcontdy Factors influencing pain response

Physiologic factors

Culture

Anxiety and fear Previous experience

Gate-control theory of pain

Comfort and support

Environment


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Fig. 16-1. Discomfort during labor. A, Distribution of labor pain during first stage. B, Distribution of

labor pain during later phase of first stage and early phase of second stage. C, Distribution of

labor pain during later phase of second stage and during birth. (Gray shadingindicates areas of

mild discomfort; light-colored shadingindicates areas of moderate discomfort; dark-colored

shadingindicates areas of intense discomfort.)


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NonpharmacologicNonpharmacologic ManagementManagement

of Discomfortof Discomforty Nonpharmacologic measures often simple,

safe, and inexpensive

y Provide sense of control over childbirthand measures best for woman

y Methods require practice for best results

y Try variety of methods and seekalternatives, including pharmacologic

methods, if measure used is not effective


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y Childbirth preparation methods

Dick-Read method

Lamaze method Bradley method

HypnoBirthing

Birthing fromw

ithin Childbirth and Postpartum Professional

Association


of Discomfortof Discomfortcontdcontd


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y Relaxing and breathing techniques Relaxation

Imagery and visualization Music

Touch and massage

Conscious breathing

Energy work Effleurage and counterpressure

Water therapy (hydrotherapy)




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y Relaxing and breathing techniques

Transcutaneous electrical nerve stimulation

Acupressure and acupuncture Applications of heat and cold

Hypnosis

Biofeedback Aromatherapy

Intradermal water block




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The Coalition to Improve MaternityThe Coalition to Improve Maternity

ServicesServicesy Adopted Lamaze Institute for Normal

Birth principles

Labor to begin on its own

Freedom of movement throughout labor

Continuous labor support

No routine interventions

Nonsupine No separation of mother and baby


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Pharmacologic ManagementPharmacologic Management

of Discomfortof Discomforty Sedatives

y Analgesia and anesthesia

Anesthesia

Systemic analgesia

x Opioid (narcotic) agonist analgesics

x Opioid (narcotic) agonistantagonist analgesics

x Opioid (narcotic) antagonists


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Sedatives andAntiemeticsSedatives andAntiemetics

y Induce sleep for a few hours

y Should not be administered during active

labor

y May augment the use of analgesics andreduce nausea after the administration of

opiods


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BarbituratesBarbiturates

y May have undesirable effects respiratory and

vasomotor depression; these effects may beintensified if administered with another CNS

depressanty If administered without an analgesic to awoman experiencing pain, pain will increase

y Rarely used in labor


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BenzodiazepinesBenzodiazepines

y When given with opiod analgesic

enhance pain relief and reduce N/V

y Some may have undesirable amnesic effecton laboring mother


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SystemicAnalgesiaSystemicAnalgesia

y Given slowly in small doses during a

contraction (s).


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OpioidAgonistAnalgesicsOpioidAgonistAnalgesics

y No amnesic effects; promote feelings of

euphoria

y Delay normal gastric emptying time N/Vmay result

y Bowel and bladder elimination slowed.

y Research results

y Administer < 1 hr or >4 hrs prior to

birth


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OpiodAgonistOpiodAgonist--AntagonistAntagonist

AnalgesicsAnalgesicsy Satisfactory pain reliefwithout causing

neonatal or maternal respiratorydepression

y Less N/V

y Not administered to a woman with an

opiod dependence


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y Nerve block analgesia and anesthesia

Local perineal infiltration anesthesia

Pudendal nerve block Spinal anesthesia (block)

x Disadvantages

x Marked hypotension

x Impaired placental perfusionx Ineffective breathing patterns

x Headache

x Autologous epidural blood patch




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Epidural anesthesia/analgesia

xLumbar epidural anesthesia/analgesia

x Caudal epidural block

x Walking epidural analgesia

x Epidural and intrathecal opioids




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Epidural anesthesia/analgesia

xContraindications to epidural blocksx Maternal refusal or inability to cooperate

x Maternal cardiac conditions

x Antepartum hemorrhage

x Anticoagulant therapy or bleeding disorder

x Infection at injection site

x Allergy to anesthetic drug




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x Epidural anesthesia/analgesiax

Effects of epidural block on neonatex Paracervical (uterosacral) nerve block rarely

used

x Nitrous oxide for analgesia self administered




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Epidural/SpinalAnesthesiaEpidural/SpinalAnesthesia

y Fluid Pre-Loady Positioning

y Epidural pump

y Vital Signs Monitoring


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Spinal HeadacheSpinal Headache

y When a patient receives a spinal for a c-section or inadvertently during an epidural,a spinal headache may occur.

y Care to reduce the effects includes: Forcing large amounts of fluid including

drinks with caffeine.

Bedrest, ice pack, quiet, darkened room Blood patch


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Fig. 16-10. C, Levels of anesthesia necessary for cesarean and vaginal births.


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y General anesthesia

Used rarely for vaginal births

Infrequently for elective cesareansection

May be necessary if indicationsnecessitate a rapid birth




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Nursing Care ManagementNursing Care Management

y Plan of care and

implementation

Nonpharmacologic interventions Informed consent

Timing of administration

Preparation for procedures


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Nursing Care ManagementNursing Care Managementcontdcontd

y Plan of care and implementation

Administration of medication

x Intravenous route

x Intramuscular routex Spinal nerve block

Signs of potential problems

Safety and general care

Anesthesia in obese woman


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Nursing Care ManagementNursing Care Managementcontdcontd

y Plan of care and implementation

Maternal hypothermia after analgesia andanesthesia

x Defined as core body temperature of less than 35 Cx Caused by effects of analgesia and anesthesia

x May result in cardiovascular, pulmonary, circulatory,hematologic, neurologic, or renal complications


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GeneralAnesthesia

y GeneralAnesthesia

Implications for delivery

y Post Delivery Care

Turn, cough, deep breath

Incentive Spirometer

Increase diet slowly


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Preparations for Delivery

yOxygen and suction set up for baby.

y If meconium stained fluid-suction set up

from the maternal side of the room.yOver bed warmer on to full power (should

already have been pre-warming).

y

Baby medications in room


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y Delivery Table

y Breaking the bed and bucket to catch

secretions from delivery

y Maternal Meds

y Perineal cleansing


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DeliveryDelivery

y Local anesthesia Pudendal Block

y Episiotomy/lacerations

Medline Mediolateral

y Normal SpontaneousVaginal Delivery

(NSV

D)


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y Forceps


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y Vacuum Extractor


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y Fundal pressure vs Suprapubic

pressure


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After Delivery CareAfter Delivery Care

yOnce the baby has been delivered and

handed off to the baby nurse to begin itstransition, the doctor/midwife may deliver

the placenta. However, at times they maybegin the repair of the episiotomy and/or

lacerations and deliver the placenta when

they are finished.


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Postpartum CarePostpartum Care

y Pitocin IV

y Perineal cleansing

y Ice Pack to Perineum

y Vital signs/fundal massage


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y If an epidural has been done, discontinueepidural pump. D/C foleywhen feeling returns

y Fluids and food

y Feeding the baby

y Ambulate with assistance.


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Indications forInduction ofIndications forInduction of

LaborLabor

y Suspected fetal

jeopardy (IUGR)

y Premature rupture of

membranesy Post date pregnancy

y Maternal medical

problems (Diabetes,

renal disease,respiratory problems

y Chorioamnionitis

y Multiparous woman with

a history of fast labors or

who live a distance fromthe hospital.

y Fetal Demise (death).


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Stimulation of LaborStimulation of Labor

y Prostaglandin gel may be used to ripen

cervix - esp. if low Bishop score

y Bishops score based on

dilatation

effacement

station

cervical consistency position of cervix


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Complications ofOxytocin UseComplications ofOxytocin Use

y Uterine rupture

y Precipitous L & D

y Fetal hypoxia

y Prolapsed cord


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Oxytocin ProtocolOxytocin Protocol

y With hyperstimulation of uterus (non-

tetanic contractions with no fetal distress)decrease dosage by 2 increments

y If fetal distress - discontinue oxytocin,position on L side, give O2 if distress

related to uteroplacental perfusion,

change position if distress due toprolapsed cord, notify physician


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Oxytocin Protocol ContinuedOxytocin Protocol Continued

y If contractions are tetanic with no fetal

distress - discontinue oxytocin, notifyphysician, observe for signs of placental

abruption and/or uterine rupturey Oxytocin may be used for induction or

augmentation


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Contraindications forContraindications for PitocinPitocin

UseUse

y Placenta previa

y Vasa previa

y Prolapsed cord

y Pelvic contracture

y Malpresentation or

position of fetus

y

Premature labory Unripe cervix

y Uterus likely to

rupture

y Non-reassuring

fetal heart rate.

y CPD

y Active genital

herpes infectiony Invasive cancer of

the cervix


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PitocinPitocin should be used withshould be used with

cautioncautiony In multifetal

presentations

y Breechpresentations

y Presenting partabove the pelvicinlet

y Abnormal fetalheart rate notrequiringemergency

deliveryy Polyhydramnios

y Grand multiparity

y Maternal cardiacdisease

y Hypertension


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Methods ofInductionsMethods ofInductions

y Amniotomy

y Prostaglandin Gel 1-3 mg insertedintra-vaginally.

y Cervidil/Prepidil

y Prostin E2 Suppositories


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y Pitocin Induction Protocol

Obtain a 20 minute baseline FHR monitorstrip.

10 - 20 Units Pitocin in 1000 mLs of LR

Usually started at 1 mU (3 mLs ) per hour

Increase every 30-60 min by 1-2 mU to amaximum of 20 - 40 mU/min.

Vital Signs every 30-60 minutes and with

dose increased In hyperstimulation may decrease dose by 2

increases; might need to DC pitocin and runmainline


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Active Management of LaborActive Management of Labor

ProtocolProtocol

y Obtain a 20 minutes baseline monitor strip

y 20 Units Pitocin in 1000 mls LR

y Generally used with Primigravidas

y Usually started at 6 mU (18 mls) and

increased by 6 mU (18 mls) up to a

maximum of 36 mU (108 mls) every 15

minutes.

y If hyperstimulation occurs decrease rate by

6 mU (18 mls) increments.


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Preterm LaborPreterm Labor

y Preterm Labor

after 20 weeks, before 37 weeks

incidence - 10 %

responsible for 83% of infant deaths, notcounting those associated with anomalies


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Diagnosis of Preterm LaborDiagnosis of Preterm Labor

y Presence of uterine contractions that result inprogressive effacement and dilatation of thecervix

y

Biochemical Factors to predict pre-term labor: Fetal Fibronectin

Salivary estriol

Cervical length - < 30 mm (3 cm) in singleton

pregnancy


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RiskFactors for PreRiskFactors for Pre--termterm

LaborLabory African American race

y Maternal age of Less than 17 or above 34

years.

y History of previous pre-term labors.y History of multiple abortions

y Uterine anomalies

y

Physiologic problemsy Multiple gestation/uterine over distention


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y Maternal Infection/chorioamnionitisy Incompetent cervix/uterine surgery

y Bleeding, placenta previa or abruptio

y Fetal anomalies

y Premature rupture of membranesy Short intervals between pregnancy

y Smoking

y Cocaine

y Late or no prenatal carey Dehydration

y Psychological stress, fatigue, long workinghours


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Symptoms of PreSymptoms of Pre--TermTerm

LaborLabor

y Pelvic pressure

y Low, dull backache

y Menstrual like cramps

y Change and increases in vaginal discharge

y Uterine contractions occurring every 10

minutes or more often with or without

pain, lasting for 1 hour or longery Intestinal cramping with or without

diarrhea


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Prevention MeasuresPrevention Measures

y Adequate nutrition and fluid intake

yGetting adequate rest

y Appropriate weight gain

y Avoidance of smoking, non-

therapeutic drugs, alcohol and

strenuous activity.

y Stress Reduction techniques

y Treatment ofInfections


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Hospital AdmissionHospital Admission

y Initial assessment of cervical status byhealth care provider

y Assessment of amniotic fluid leakage

y Fetal monitoring

y Cervical/vaginal cultures

y Assessment of maternal temperature

y I.V. TherapyyUltrasound exam


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y Suppression ofUterine Activity

Tocolytic Therapy-theadministration of pharmaceutical

agents that suppress uterine activity.

Early methods of slowing orinhibiting pre-term labor

x Liquor (Vodka,Gin, orRum)Oral

xI.V. Alcohol administration


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Most common agentsx Brethine/Terbutaline (BetaAdrenergics)

x Magnesium Sulfate (CNS depressant)

x Yutopar/Ritodrine not used much anymore


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x Indomethicin ProstaglandinInhibitor

xNifedipine (Calcium Channel

Blocker-Procardia


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y The use ofTocolytic agents may not be

effective as a means to totally suppress pre-

term labor or prevent pre-term birth butthey are valuable in suppressing labor long

enough to facilitate:


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The administration of corticosteroids tomother to stimulate fetal lung maturity.

Treat contributing medical problems

Transfer to higher level facilities if NICUservices are not available in the hospital.


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Additional care of theAdditional care of the

PrePre--Term Labor PatientTerm Labor Patienty Bedrest

y IVTherapy

y Fetal monitoring of FHR and

Contractions

y Vaginal exams should be kept at a

minimum.


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y When labor cannot be arrested: Analgesics should be kept at a minimum

or avoided if possible.

AROM not usually done until the patient

is at least 6 cms and the head is pushingagainst the cervix to prevent a cordprolapse.

Depending on the severity of

prematurity, a c-section may beperformed to prevent head trauma fromdelivery.


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Ruptured UterusRuptured Uterus

y Occurs in 1 - 1,500 - 2,000 births

y Occurs more often in multigravida

y May be caused by:

intense spontaneous uterine contractions

labor stimulation (oxytocin)

overdistended uterus

malpresentation version

difficult forceps assisted birth


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Classification of Ruptured UterusClassification of Ruptured Uterus

y Complete

extends through entire uterine wall intoperitoneal cavity or broad ligament

y Incomplete

extends into peritoneum


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Signs and Sx of RuptureSigns and Sx of Rupture

y Excruciating pain with complete rupture

y Cessation of contractions

y Vaginal bleeding (possibly)

y Pathologic retraction ring (Bandls ring)

y Signs of shock


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Nurses Role in Ruptured UterusNurses Role in Ruptured Uterus

y Administering and monitoring IV fluids

y Transfusing blood

y Administering oxygen

y Assisting with surgical prep. of

client/family

y Emotional support


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Prolapse of Umbilical CordProlapse of Umbilical Cord

y Occurs in 1:400 births

y Contributing factors

long cord (>100 cm)

malpresentation (breech)

transverse lie

unengaged presenting part (CPD, placenta

previa, multiparity) small fetus


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Care Management of ProlapsedCare Management of Prolapsed

CordCordy New technique - if can be done with

rapidity - amnioinfusion

y If the cervix is fully dilated, and the fetusis in cephalic presentation - forceps or

vacuum assisted delivery; otherwise C-

section


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Emergency Interventions for ProlapsedEmergency Interventions for Prolapsed

CordCordy Call for assistancey Notify Healthcare provider immediately

y Glove examining hand and apply reverse pressure

y Position extremeTrendelenburg, modified Sims orknee-chest

y If cord is protruding from vagina cover with steriletowel warmed with sterile normal saline

y O2 by mask 10-12 L/min.

y Start IV fluids or increase rate

y

Monitor FHRy Emotional support to mom and support person


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DystociaDystocia

y Abnormal labor progression

Labor is longer, more painful, or

abnormal because of problems withthe mechanics of labor-powers,

passage, passenger or psyche.

Dystocia occurs in approx. 8-11% of

women during the first or second

stage of labor.


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Freidmans CurveFreidmans Curve


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Advanced maternal age

Excessive analgesia/epidural

Pathologic retraction ring

The patients psychologic response

to labor can have an effect on the

duration and intensity of labor.


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Dysfunctional LaborDysfunctional Labor

y Nullipara

More prone to early labor dysfunction -hypertonic uterine dysfunctiion, primary

inertia, and prolonged latent phasey Multigravida

More prone to late labor dysfunction -hypotonic contractions, secondary inertia,

protraction or arrest of active phase


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Etiologic Factors in DysfunctionEtiologic Factors in Dysfunction

y Most common causes:

pelvic contracture

fetal malposition

y Other possible causes:

uterine overdistention

cervical rigidity (cervical fibrosis, laser surgery orelderly nullipara

advanced maternal age excessive analgesia/epidural

pathologic retraction ring


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Hypertonic Labor PatternHypertonic Labor Pattern

y Contractions are painful but ineffective; may lead to fetaldistress; maternal exhaustion; intense pain and lack ofcontrol

y Prolonged latent phase

y Treatment Warm bath; rest/sedation to halt labor; may use

tocolytic agent to rest uterus

Administration of fluids

May give morphine, meperidine, or Nubain to reduce

abnormal tissue excitabilityy Usually returns to normal pattern following 4-6 hour

rest


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Hypotonic Uterine PatternHypotonic Uterine Pattern

y Secondary uterine inertia

y Usually occurs in active phase, but may occur during Stage II

y Need to rule out CPD or malposition

y Management:

rest if exhausted; ambulate to augment labor

Ultrasound/x-ray to R/O CPD

Monitor FHR pattern

fluids

enema

stripping or rupture of membranes (amniotomy)

oxytocin administration/nipple stimulation slowing or discontinuing epidural if inhibiting urge to push

Premature Rupture of MembranesPremature Rupture of Membranes


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Premature Rupture of MembranesPremature Rupture of Membranes

(PROM)(PROM)

y Membranes rupture at least 1 hour prior

to the start of labor; labor typically beginswithin 24 hours

y If PROM occurs during weeks 28 - 34,labor may take up to 1 week to begin

y Rupture of membranes before term is

PPROM


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Etiology of PROMEtiology of PROM

y While unknown, contributing factors maybe: amnionitis

placenta previa multifetal gestation

malpresentation

polyhydramnios

bacterial vaginal/cervical infections UTIs

maternal smoking


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Care Management of PROMCare Management of PROM

y Sterile speculum exam:

visualization of amniotic fluid from cervix

positive nitrazine test

presence of ferning on slide

y Treatment:

controversial - may be hospitalized until birthor return home

C M t f PROMC M t f PROM


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Care Management of PROMCare Management of PROM

(contd)(contd)y If no signs of infection or fetal distress:

daily assessment ofVS - esp. temp.; FHTs andfetal movement

palpation to determine if uterine tendernesspresent

assess vaginal discharge for odor, color, andamount

assess for preterm labor

biophysical profiles every 2 days to weekly

antibiotics - if infection exists


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Precipitous LaborPrecipitous Labor

y Labor < 4 hoursy Cervical dilatation of 5 cm/hr in nullipara and

10 cm/hr in multigravida

y Contractions may be very intense and frequent

y Danger to fetus - hypoxia, cerebral trauma,unattended birth

y Danger to mother - cervical and vaginal tears,ruptured uterus, amniotic fluid emboli,postpartum hemorrhage


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Precipitous LaborPrecipitous Labor -- continuedcontinued

y May be induced to control the labor

y At greater risk for postpartal hemorrhage


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OP PositionOP Position

y Marked back labor

y Must rotate 135 degrees

y Labor more prolonged - not good fit of

presenting party May need deeper episiotomy

y May need manual or forceps rotation - whichcomplicates the delivery

y Scanzoni maneuver - forceps rotation followedby reapplication and forceps delivery


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External CephalicVersionExternal CephalicVersion


90/97

Breech PresentationBreech Presentation

y Danger of early placental separationy Danger of uterus contracting down around

necky Increased fetal risk of fractures or DDH

(hip)y Breech positions:

Complete - Indian fashion Frank - legs extended against chest

Incomplete breech - single or double footling,knee presenting part


91/97

Cesarean BirthCesarean Birth

y Whether elective or emergency - mayimpact self-concept

y Review maternal and fetal implications

y Nursing care - combination of surgicalcare and postpartal care


92/97

A. Classic:

vertical incisions of skinand uterus. Limits births.

B. Low cervical:

horizontal incision ofskin; vertical incision ofuterus

C. Low transverse:

horizontal incisions ofskin and uterus. Popular!

y Frequently used!

Group B StrepGroup B Strep


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Group B StrepGroup B Strep

y Significance-Considered normal in non-pregnant.

However, during pregnancy can become a

dangerous factor to the health and welfare of the

baby.y Protocol

If patient has positive cultures-History of

previous positive cultures

If patient has had no prenatal care If pre-term.


94/97

Heart DiseaseHeart Disease

y Bearing down efforts of Stage II avoided ifpossible

y Class II - IVwill probably receive

prophylactic antibiotics following deliveryy Ergot products CONTRAINDICATED!

(Methergine or Ergot)

DiabetesDiabetes


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DiabetesDiabetes

y

Hourly blood sugars during labor.y Mainline IV usually D5 LR

y After delivery every hour x2, thenevery 2 hours x2, then every 4 hours

x1, then ac and hs orpostprandial as ordered by theendocrinologist.

y

Keep in mind that many times noinsulin is needed but close monitoringis the key element.

PreeclampsiaPreeclampsia HELLP SyndromeHELLP Syndrome


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PreeclampsiaPreeclampsia -- HELLP SyndromeHELLP Syndrome

y Foley catheter with urimetery Vital signs, DTRs, Intake and output

y Monitoring of serial Magnesium levels,

liver enzymes.y Calcium gluconate antidote for Mag

toxicity

y Quiet, dark environment, limitation of

visitors.

y Seizure precautions

Amniotic Fluid EmbolusAmniotic Fluid Embolus


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Amniotic Fluid EmbolusAmniotic Fluid Embolus

yOccurs when amniotic fluid withparticles enters the maternalcirculation and obstructs pulmonary

vessels, causing respiratory distressand circulatory collapse.

y Caused by and opening in theamniotic sac or an opening in the

maternal uterine veins, accompaniedby enough intrauterine pressure toforce the fluid into the veins.

nurs 3560 compromised labor and delivery fall 10 sv

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