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Chapter 36
INTRAPARTAL COMPLICATIONS
Interference with normal processes & patterns of labor/birth resulting in maternal or fetal jeopardy. Preterm labor; dysfunctional labor patterns; prolonged labor; hemorrhage uterine ruputure/inversion; amnioticfluid embolus.
Dysfunctional Labor:
Possible Causes:
Catecholamines (response to anxiety/fear), increase physical/psychological stress, leads to myometrial dysfunction; painful & ineffective labor. Premature or excessive analgesia, particularly during latent phase. Maternal factors. Fetal factors. Placental factors. Physical restrictions (position in bed).
ASSESSMENT:
Antepartal history. Emotional status. Vital signs, FHR. Contraction pattern (frequency, duration, intensity). Vaginal discharge.
Preterm Labor:
Occurs after 20 weeks gestation and before 38 weeks. Causes may be from maternal, fetal, or placental factors. Prevention:
Primary: close observation and eduction in S&S of labor. Secondary: prompt, effective Rx of associated disorders. Tertiary: suppression of preterm labor.
Signs of infection:
Emotional status: denial, guilt, anxiety, exhaustion. Signs of continuing & progressing labor:
Effacement Dilation Station (vaginal exam ONLY if indicated by other signs of continuing labor progress)
Status of membranes. FHR, activity (continuous monitoring). Ctx: frequency, duration, strength.
Intermittent back and thigh pain. Rupture of membranes. Vaginal bleeding. Fetal distress. IF LABOR CONTINUES:
GOAL = facilitate infant survival; emotional support; support comfort measures; health teaching.
Chapter 26
HYPERTONIC DYSFUNCTION:
Increased resting tone of uterine myometrium; diminished refractory period; prolonged latent phase.
Nullipara: more than 20 hours. Multipara: more than 14 hours.
Contractions:
Continuous fundal tension, incomplete relaxation. Painful. Ineffectual no effacement or dilation.
HYPOTONIC DYSFUNCTION:
After normal labor at onset, ctx diminish in frequency, duration, & strength. Lowered uterine resting tone; cervical effacement & dilation slow / cease. Etiology:
Premature or excessive analgesia / anesthesia (epidural, spinal block). CPD. Overdistention (hydramnios, fetal macrosomia, multifetal pregnancy). Fetal malposition / malpresentation. Maternal fear / anxiety.
Assessment:
Onset (latent phase & most common in active phase). Contractions - normal previously, will demonstrate:
Decreased frequency. Shorter duration. Diminished intensity (mild to moderate). Less uncomfortable.
Maternal VS (elevated temperature) may indicate infection. Medical diagnosis procedures: vaginal examination, x-ray pelvimetry, ultrasonography. To rule out CPD (most common cause).
Management:
Amniotomy (artificial ROM). Oxytocin augmentation of labor. If CPD, prepare for c/s. Emotional support, comfort measures, prevent infection.
Precipitate Labor
Labor that progresses rapidly and ends with the delivery occurring less than 3 hours after the onset of uterine activity. Rapid labor and delivery.
Chapter 26
Breech Presentations
Fetal descent in which the fetal buttocks, legs, feet, or combination of these parts is found first in the maternal pelvis. Labor tends to be longer and more difficult due to a softer presenting part, that does not fill the birth canal completely. Increase risks for fetal outcome.
Shoulder Presentation
Fetal descent in which the shoulder precedes the fetal head in the maternal pelvis alone or along with the ftal arm and hand. Vaginally undeliverable.
Face Presentation
Fetal descent in which hyperextension of the fetal head and neck allows the fetal face to descend into the maternal pelvis, as opposed to flexion that results in fetal vertex presentation. Brow presentation = occurs when the area between the anterior fontanelle and the fetal eyes descends first.
Malpositions
Persistent occipitoposterior position. Persistent occipitotransverse position. Result from fetal rotation as the fetus descends through the pelvis. Possible precipitating factors are macrosomia and pelvic abnormalities. Results in increased discomfort (particularly back labor), prolonged, abnormal labor, soft tissue injury, lacerations, or an extensive episiotomy incision.
Chapter 26
DYSTOCIA:
Difficult labor. Causes:
3 Ps for mother: Psych, Placenta, Position. 3Ps for fetus: Power, Passageway, Passenger.
FETAL:
1. Hypoxia, anoxia, demise. 2. Intracranial hemorrhage.
Placental Abnormalities
Placenta previa Abruptio placentae Other placental abnormalities
Chapter 26
PLACENTA PREVIA
Abnormal placement of placenta so that it partially covers the cervix; dilatation results in bleeding, which can be of hemorrhagic proportions. The placenta is located over or very near the internal cervical os. Severe hemorrhage can result from digital palpation of the internal os. Previa is a serious but uncommon complication, occurring in .3-.5% of pregnancies.
Advanced maternal age and multiparity increase the risk. Painless hemorrhage is symptomatic of previa, often around the end of the 2nd trimester. Clinical diagnosis is reached through ultrasound examination in which the placenta is localized in relationship to the cervix. Manual examination is contraindicated! Management of pregnancy depends on gestational age.
PLACENTAL ABRUPTION
Premature separation of the placenta from the uterine wall; usually results in maternal hemorrhage and fetal compromise. Classified as partial or total. Total Abruption fetal death is inevitable. Partial Abruption the fetus has a chance of survival. Separation of >50% is incompatible with fetal survival.
Grading of Placental Abruptions: Grade I: Slight vag.bleeding & some uterine irritability. Maternal BP is unaffected & there are normal fibrinogen levels. FHR has a normal pattern. Grade II: External bleeding is mild to moderate. The uterus is irritable. Tetanic ctx may be present. Maternal BP is maintained. FHR shows signs of distress. Maternal fibrinogen level is decreased.
Grade III: The bleeding may be severe & may be concealed in some instances. Uterine ctx are tetanic and painful. Maternal hypotension may be present. The fibrinogen level is greatly decreased & there are coagulation problems.
Diagnosis: may be made by ultrasound, but frequently the diagnosis is made and confirmed at delivery, by inspection of the placenta.
Chapter 26
PROLAPSED UMBILICAL CORD: Cord descent in advance of presenting part; compression interrupts blood flow, exchange of fetal / maternal gases. Leads to fetal hypoxia, anoxia, death (if unrelieved). Etiology:
SROM or AROM. Excessive force of escaping fluid (hydramnios). Malposition (breech, compound presentation, transverse lie). Preterm or SGA fetus allows space for cord descent.
Assessment:
Visualization of cord outside (or inside) vagina. Palpation of pulsating mass on vaginal exam. Fetal distress variable deceleration and persistent bradycardia.
Nursing interventions:
Reduce pressure on cord. Increase maternal / fetal oxygenation (O2 per mask @ 8-10 liters). Protect exposed cord (continuous pressure on presenting part to keep pressure off cord).
Identify fetal response to these measures, reduce threat to fetal survival: moniotr FHR continuously. Expedite termination of threat to fetus (prepare for immediate vaginal or c/s). Support mother and significant other (try to explain things while mobilizing delivery team).
Chapter 26
Baseline FHR:
Bradycardia (<100 bpm) Tachycardia (>160 bpm)
Amniotic fluid:
Amount: excessive; diminished. Odor Color: meconium stained or particulate; port-wine; yellow. 24 hr or more since ROM.
Maternal hypotension.
POSTPARTUM COMPLICATIONS
Chapter 37
Postpartum Hemorrhage:
Definition:
More than 500cc of blood loss after vaginal birth. More than 1000cc of blood loss after C/S.
Blood loss is often underestimated by up to 50% (ACOG, 1998). Subjective. #1 cause of PP Hemorrhage = Uterine Atony.
Lacerations:
Cervix, vagina, perineum. Suspected when bleeding continues despite a firm, contracted uterine fundus. Characteristics: bleeding can be a slow trickle, an oozing, or frank hemorrhage. Influencing factors: structural, maternal, fetal Lacerations = the most common cause of injuries in the lower portion of the genital tract.
Retained Placenta:
Causes:
Partial separation of normal placenta Entrapment of the partially or completely separated placenta by uterine constriction ring Mismanagement of the 3rd stage of labor Abnormal adherence of the entire placenta or a portion of placenta to the uterine wall
Types:
Nonadherent retained placenta Adherent retained placenta
Uterine Subinvolution
Causes:
Retained placental fragments Pelvic infection
Coagulopathies
Idiopathic Thrombocytopenic Purpura: (ITP) von Willebrand Disease: a type of hemophilia, factor VIII deficiency, most common congenital clotting defect of women in childbearing years. Disseminated Intravascular Coagulation: (DIC) a pathologic form of clotting, diffuse. Includes platelets, fibrinogen, prothrombin, and factors V and VII. Thromboembolic Disease: formation of clot(s) in blood vessels caused by inflammation or partial obstruction of the vessel.
Postpartum Infection
Antepartal factors:
Hx of previous venous trhombosis, UTI, mastitis, pneumonia Diabetes mellitus Alcoholism Drug abuse Immunosuppression Anemia Malnutrition
Intrapartal Factors
Cesarean birth PROM Chorioamnionitis Prolonged labor Bladder catheterization Internal fetal or uterine pressure monitor Multiple vaginal exams after ROM
Types of PP Infection
Endometritis (most common usually begins as a localized infection at the placental site, but can involve entire endometrium) Wound infections (c/s incision, episiotomy, repaired laceration site) UTIs (2-4 % of PP women) Mastitis (1% of BF moms, usually 1st)
PP Psychologic Complications
Mood Disorders: with or without psychotic features, if the onset occurs within 4 weeks of childbirth.
Baby Blues occurs in up to 70% of PP moms Postpartum Depression Postpartum Psychosis
Chapter 26
High-Risk Infants
May need resuscitation at birth. Most institutions require AHA Certification in Neonatal Resuscitation of all personnel at deliveries Requirements may include:
Warmth Oxygen Intubation Suctioning
Preterm Infants
Definition: born before 37 weeks of gestation. Particular problems: respiratory function, anemia, jaundice, persistent patent ductus arteriosus, & intracranial hemorrhage. Low-birthweight infants = those weighting 1500-2500 grams.
Very-low-birthweight infants = those weighing 1000-1500 grams. Extremely-very-low-birthweight infants = those weighing between 500-1000 grams. All such infants need intensive care from the moment of birth. Risks: neurologic after-effects caused by being so critically close to the age of viability.
Postterm Infants
Definition: born after 42 weeks gestation. Particular problems: establishing respirations, meconium aspiration, hypoglycemia, temperature regulation, and polycythemia.
Transient Tachypnea
A temporary condition caused by slow absorption of lung fluid at birth. Close observation of the infant is necessary until the fluid is absorbed and respirations slow to a normal rate.
Apnea:
Definition: a pause in respirations longer than 20 seconds, with accompanying bradycardia. Occurs in preterm infants who have secondary stresses such as: infection, hyperbilirubinemia, hypoglycemia, or hypothermia.
Hyperbilirubinemia
Results from: destruction of RBCs, due either to a normal physiologic response or an abnormal destruction of the RBCs. Hemolytic disease of the newborn is destruction of RBCs from Rh or ABO incompatibility. Phototherapy or exchange transfusion is used to prevent kernicterus.
Retinopathy of Prematurity
Definition: destruction of the retina due to exposure of immature retinal capillaries to oxygen. Monitoring oxygen saturation via arterial blood gases is an important prevention measure.