Intrapartum Complications: Managing Dysfunctional Labor Risks

School

Chamberlain College of Nursing**We aren't endorsed by this school

Course

PA NR-327

Subject

Nursing

Date

Dec 12, 2024

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Uploaded by KidMetalReindeer30

1WEEK 6Chapter 16 – Intrapartum ComplicationsDysfunctional Labor – characterized by the progression of cervical, effacement, dilation, Problems with the PowersTwo patterns of Ineffective contractionsoLabor dystocia – difficult labor; that does not progress as expected “failure to progress”Contractions may be too weak to be effectiveLabor dystocia is tiring due to the duration of the labor process. Management includes IV fluids for electrolyte imbalances and hypoglycemia. Changing maternal position, therapeutic communication for anxiety, Aminotomy and oxytosin infusion maybe needed to promote labor progressRisk of amniotomy or augmentation includes umbilical cord prolapse, infection and placental abruptionoTachysystole – spontaneous or induced and is defined as excessive uterine activity. 5+ contraction in 10 mins averaged over 30 mins. Mother may be fatigue from constant discomfort. Lose confidence in her ability to give birth and cope with labor. Frustration and anxiety reduce her pain tolerance and interfere with normal processes of labor.Tocolytic drugs – inhibits uterine contractions maybe ordered to reduce uterine resting tone and improve placental blood flow. Ineffective maternal pushing – a reflexive urge to push with contractions usually occur as the fetal presenting parts reaches the pelvic floor during second-stage labor.oUse of non-physiological pushing techniques and positionsoFear of injury because of pain and tearing sensation felt by mother when she pushesoDecrease or absent urge to pushoMaternal exhaustionoAnalgesia or anesthesia that suppresses the women’s urge to pushoPsychological unreadiness to “let go” of her baby.Problems with the PassengerFetal sizeoMacrosomia – infant weighs more than 8lbs 13oz at birth = cephalopelvic disproportion oShoulder dystocia – delayed or difficult birth of the shoulder may impact above the maternal symphysis pubis. Occurs when mother has diabetes or the fetus is too large. Urgent situation because umbilical cord can be compressed between the fetal body and maternal pelvis. Turtle sign – surgical or repositioning of the knees to chest w/o fundal pressure.oRotation abnormalities – persistence OP or OT prevent the mechanism of labor from occurring normally. Management w/ Hands and knees—Rocking the pelvis back and forth while on hands and knees promotes rotation. The woman’s knees should be slightly behind her hips in this position. A peanut ball may aid in helping a patient feel supported. A dense epidural may interfere with the use of this position. Side-lying (on the opposite side of the fetal occiput)—Especially when in the farside-lying position with the posterior shoulder pulled behind the patient and the upper knee touching the bed. A peanut ball may be used in the side-lying position to open the pelvis. Squatting (for second-stage labor)—Sitting on a slightly underinflated birth ball gives a similar effect. Sitting, kneeling, or standing while leaning forward. If spontaneous rotation does not occur, then physicians will use forceps. Vacuum extractor can correct minor degree of malrotation. C-sections may be needed if methods are unsuccessful. oAbnormal fetal presentation or position – Deflexion abnormality – poorly flexed fetal head presents a larger diameter to the pelvis than if flexed with the chin on the chest. Breech presentation – cervical dilation and effacement often slower when the fetus is in breech presentation.Multifetal pregnancyFetal anomalies – hydrocephalus or large fetal tumor may prevent normal descent. Anomalies are discovered by US examination before labor. C-second is scheduled if vaginal birth is not possible or advisable. Pelvis – small contracted or abnormal shaped pelvis may retard labor and obstruct fetal passage. = Poor contractions, slow dilation, slow fetal descent and long labor. Gynecoid > Anthropoid (may born in OP position) is favorable than android or platypelloid.Maternal soft tissue obstructions – Full bladder is common soft tissue obstruction, bladder distention reduces available space in the pelvis and intensified maternal discomfort. Encourage to void every 1-2 hours. Catherization maybe needed if she cannot urinate or epidural analgesia depresses her urge to void.Problems of the PsycheAbnormal labor durationProlonged labor – is multifaceted and can lead to possible maternal and fetal problems; infection (maternaland neonatal), maternal exhaustion, higher level of anxiety during subsequent labor. Management:

2Promote comfort, conservation of energy, emotional support, position changes that favor normal progress and assessment for infection. Nursing care for fetus include observation for intrauterine infection and compromised fetal oxygenation. Precipitous – birth occurs within 3 hours of its onset. Usually when it is at a location of no one trained to assist. Can lead to placental abruption, fetal meconium, infection, maternal cocaine use, postpartum hemorrhage, low APGAR score. Priority nursing care is promotion of fetal oxygenation and maternal comfort. Side lying position enhances placental blood flow and reduces the effect of aortocaval compression and slow the rapid fetal descent and minimize perineal tear. O2 delivery for adequate blood volume and nonaddictive IV fluids, D/C oxytocin and tocolytic maybe ordered. Application of the Nursing Process: Intrauterine Infection – Triple I (intrauterine inflammation or infection) (chorioamnionitis, intra-amniotic infection or intra-uterine infection). Maternal fever, Fetal tachycardia, maternal WBC greater than 15,000, purulent fluid emanating from cervical, cloudy yellowish thick discharge with speculum examination of the cervical canal, amniotic fluid result with +gram stain for bacteria, low amniotic fluid glucose. [Fever+ 1 indicator = sus Triple I][ Fever + confirmed testing = confirmed Triple I]Assessment oAssess maternal temperature every 2 to 4 hours and every 2 hours if membrane have ruptured.oAssess maternal pulse, respiration and blood pressure hourly if elevated temp.oAssess amniotic fluid for normal clear color and mild odor. Small flecks of white vernix are normal in AF.Yellow and cloudy sus infection. Strong odor maybe noted before birth or afterwards on infant skin.Identification of patient problemsoMoms without signs of infection, ID potential problems for infection because of favorable conditions for development.Planning/EvaluationoMaternal temperature will remain below 38 C (100.4 F)oFHR will remain near the baseline with an avg baseline of no higher than 160 bpmoAF will remain clear and w/o foul or strong odor.InterventionsoReduce risk of infectionoIdentify infectionApplication of the Nursing Process: Maternal ExhaustionAssessmentoVerbal expression of tiredness, fatigue, or exhaustion.oVerbal expression of frustration with prolonged, unproductive laboroIneffective or inability to use coping techniques.oChanges in her pulse rate, respiration and blood pressure.Identification of patient problemsoIntense energy demands of dysfunctional labor may exceed a woman’s physical and psychological ability to meet them.Planning/EvaluationoRest between contractions with her muscle relaxedoCoping skills such as breathing and relaxation techniques effectivelyInterventionsoConserving maternal energyoPromoting coping skillsPremature Rupture of the Membranes – Rupture of the amniotic membrane before onset of true labor is (PROM) earlier than 37 weeks with or w/o contractions. PPROM (preterm premature rupture of the membrane) associated with preterm labor and birthEtiologyoTriple IoInfectionoAmniotic sac with a weak structureoPrevious preterm birthoFetal abnormalities or malpresentationoIncompetent cervix or short cervical lengthoOverdistention of the uterus = multiple gestation or polyhydramniosoMaternal hormone changes, stress or low socioeconomic status, nutritional deficiencies and diabetes.ComplicationsoMembranes that rupture before term may form a seal stopping the fluid leak and allowing amniotic fluid to become reestablished, however membrane may continue to leak, Oligohydramnios, prolonging

3the loss of amniotic fluid cushion for the fetus. Umbilical cord compression, reduced lung volume, and deformities resulting from compression may occur. Therapeutic managementoDetermining time of membrane ruptureoMaternal antibioticsNursing considerationsoAvoid sexual intercourse, orgasm, insertion of anything in the vagina which increase the risk for infection oAvoid breast stimulation of gestation is preterm because it may cause a release of oxytocin from posterior piutution. Preterm LaborAssociated factorsSigns and symptomsPreventing preterm birthTherapeutic managementoPredictingoIdentifyingoStoppingoAccelerating fetal lung maturityApplication of the Nursing Process: Preterm LaborPsychosocial concernsAssessmentIdentification of patient problemsPlanningInterventionsEvaluationManagement of home careAssessmentIdentification of patient problemsPlanningInterventionsoCaring for childrenoMaintaining the householdEvaluationBoredomAssessmentIdentification of patient problemsPlanningInterventionsoIdentifying appropriate activitiesoChanging the physical surroundingsEvaluationPost-term PregnancyComplicationsTherapeutic managementNursing considerationsIntrapartum EmergenciesPlacental abnormalitiesProlapsed umbilical cordUterine ruptureUterine inversionAnaphylactoid syndrome (amniotic fluid embolism)Trauma Intrapartum Emergencies: Prolapsed Umbilical CordCausesSigns of prolapseTherapeutic managementNursing considerationsIntrapartum Emergencies: Uterine RuptureCausesSigns and symptomsTherapeutic managementNursing considerations

4Intrapartum Emergencies: Uterine InversionCausesSigns and symptomsTherapeutic managementNursing considerationsChapter 10 – Complications of PregnancyHemorrhagic Conditions of Early PregnancyAbortionSpontaneousThreatenedInevitableIncompleteCompleteMissedRecurrent spontaneous Ectopic pregnancyImplantation of a fertilized ovum outside of uterine cavity; 97% occur in fallopian tubeIncidence and etiologyClinical manifestationsDiagnosisTherapeutic managementNursing considerationsGestational trophoblastic diseaseHydatidiform mole trophoblasts develop abnormallyCharacterized by proliferation and edema of the chorionic villiIncidence and etiologyClinical manifestationsDiagnosisTherapeutic managementNursing considerationsApplication of the Nursing Process: Hemorrhagic Conditions in Early PregnancyHemorrhagic Conditions of Late PregnancyPlacenta previaImplantation of the placenta in the lower uterusIncidence and etiologyClinical manifestationsTherapeutic managementHome and inpatient careAbruptio placentaeSeparation of a normally implanted placenta before the fetus is bornIncidence and etiologyClinical manifestationsTherapeutic managementNursing considerationsHemorrhagic Conditions of Late Pregnancy: Application of the Nursing ProcessDisseminated Intravascular Coagulation (DIC)Life-threatening defect in coagulation May occur with pregnancy complications such as abruptio placentae or hypertensionInappropriate coagulation occurring in microcirculationTiny clots form in the tiny blood vessels, blocking blood flow to organs causing ischemiaClotting mechanisms are initiated inappropriatelyHyperemesis GravidarumEtiologyUnknownTherapeutic managementDiphenhydramine (Benadryl)Histamine-receptor antagonists (Pepcid/Zantac)Gastric acid inhibitors (Nexium/Prilosec)Metoclopramide (Reglan)Pyridoxine/doxylamine (Diclegis)Nursing considerationsHypertensive Disorders of PregnancyGestational hypertensionPreeclampsia-eclampsiaEclampsia

5Chronic hypertensionChronic hypertension with superimposed preeclampsiaHypertensive Disorders of Pregnancy: PreeclampsiaIncidence and risk factorsPathophysiologyPreventive measuresClinical manifestationsTherapeutic management of preeclampsiaHome care: Activity restrictions, blood pressure, weight, urinalysis, fetal assessment, dietHypertensive Disorders of Pregnancy: Severe PreeclampsiaDiagnostic criteriaManagementAntepartumBed rest and fetal monitoringAntihypertensive medicationsAnticonvulsant medicationsMagnesium sulfateIntrapartumPostpartumAnticonvulsant medicationsMagnesium sulfateActionIndicationsDosage and routeOnset of actionExcretionContraindications and precautionsReactionsNursing implicationsHypertensive Disorders of Pregnancy: EclampsiaTherapeutic managementPotentially preventable extension of severe preeclampsia marked by one or more seizuresWoman’s blood volume severely reduced in eclampsia, increasing risk for poor placental perfusionWoman should be monitored for ruptured membranes, signs of labor, or abruptio placentaeApplication of the Nursing Process: PreeclampsiaAssessmentPatient symptomsMagnesium toxicityPsychosocial assessmentIdentification of patient problemsPlanningInterventionsEvaluationHELLP SyndromeHemolysis, Elevated LLPiver enzymes, ow lateletsLife-threatening Complicates about 10% of pregnanciesSymptomsTherapeutic managementChronic HypertensionDiagnosisEvidence suggests that hypertension preceded the pregnancy. When a woman is hypertensive before 20 weeks of gestation Effects Therapeutic managementIncompatibility Between Maternal and Fetal BloodRh incompatibilityTwo conditions must exist: Mother is Rh-negative, and fetus is Rh-positive.PathophysiologyFetal/neonatal implicationsPrenatal assessment/managementPostpartum managementRhogam: Action, indications, dosage and route, nursing implicationsABO incompatibilityDiabetes Mellitus: EtiologyComplex disorder of carbohydrate metabolism

6Caused by a partial or complete lack of insulin secretion by the beta cells of the pancreasWithout insulin, glucose accumulates in the blood (hyperglycemia).Classic symptoms of diabetesPolydipsia Polyuria Polyphagia Diabetes Mellitus: Effect of Pregnancy on Fuel MetabolismEarly pregnancyLittle change in maternal metabolic needInsulin release in response to serum glucose levels accelerates May experience hypoglycemiaLate pregnancyFetal growth acceleratesRise in placental hormone levelsHormones create resistance to insulin.BirthMaintaining normal maternal glucose levels essential during birth to reduce neonatal hypoglycemiaPostpartumNeed for additional insulin fallsBreastfeeding encouraged The added calorie intake by the mother helps lower the amount of insulin needed in women with types 1 and 2 diabetes mellitus. The woman with gestational diabetes mellitus (GDM) usually needs no insulin after birth. Diabetes Mellitus: ClassificationType 1Insulin deficientType 2Insulin resistantGestational (GDM)Onset of glucose intolerance during pregnancyDiabetes Mellitus: IncidenceCommon medical condition that often affects pregnancyType 1 accounts for about 5% of diagnoses.Type 2 accounts for 90% to 95% of diagnoses.Approximately 9.2% of all pregnancies are affected by GDM. About half of women with GDM will develop Type 2 DM later in life.Diabetes Mellitus: PreexistingMaternal effectsDuring first trimester Hypoglycemia, hyperglycemia, ketosisIncreased incidence of spontaneous abortion or major fetal malformations Preeclampsia more likely to develop if preexisting diabetesKetoacidosisPremature rupture of the membranes (PROM)MacrosomiaShoulder dystociaFetal effectsCongenital malformation Variations in fetal sizeSmall for gestational age (SGA)Intrauterine growth restriction (IUGR)Neonatal effectsHypoglycemiaHypocalcemiaHyperbilirubinemia Respiratory distress syndrome Diabetes Mellitus: Maternal AssessmentHistoryOnset and management of diabetic conditionMay need insulin to control (injection; no oral agent)Physical examBaseline electrocardiogram (ECG)Ophthalmology referralWeight and blood pressure (BP)

7Laboratory tests24 hour urineHemoglobin A(HbA)1c 1cDiabetes Mellitus: Fetal SurveillanceSurveillance should begin early for women with preexisting diabetes.Testing for anomalies Frequent ultrasoundFetal echocardiogram at 20 to 22 weeksMaternal assessment of fetal movementDoppler velocimetryDiabetes Mellitus: Therapeutic ManagementMaintain normal blood glucose levelsFacilitate the birth of a healthy babyAvoid accelerated impairment of blood vessels and other major organs Preconception careDietSelf-monitoring of glucoseInsulin therapyGestational Diabetes Mellitus: Risk FactorsOverweight Maternal age older than 25 yearsPrevious birth outcome often associated with GDMGDM in previous pregnancyHistory of abnormal glucose toleranceHistory of diabetes in a close relativeMember of a high-risk ethnic groupHistory of prediabetesHistory of polycystic ovary syndromeGestational Diabetes Mellitus: ScreeningGlucose challenge test (24 to 28 weeks)1 hour test, 50 g of oral glucose solutionIf abnormal (>140 mg/dL)3 hour oral glucose tolerance test Oral glucose tolerance test (OGTT)Fasting, 95 mg/dL1 hour,180 mg/dL2 hours,155 mg/dL3 hours,140 mg/dLGestational Diabetes Mellitus: Therapeutic ManagementDietRegistered dietitian, registered dietary technician, or diabetes educatorNonobese pre-pregnancy weight, an average of 30 to 35 kcal/kg/day is recommended Obese: 25 kcal/kg/day ExerciseBlood glucose monitoringPharmacologic treatment Fetal surveillance Gestational Diabetes Mellitus: Nursing ConsiderationsIncrease effective communication. Provide opportunities for control.Provide normal pregnancy care.Application of the Nursing Process: Pregnant Woman with Diabetes MellitusCardiac Disease: IncidenceHeart disease complicates about 1% to 4% of pregnancies. It remains a significant cause of maternal mortality.The two major categories of heart disease are acquired heart disease and congenital heart disease. Cardiac Disease: ClassificationAcquired heart disease RheumaticSometimes follows a streptococcal pharyngitis May cause scarring of the heart valvesThe mitral valve is the most common site of stenosis.May lead to pulmonary hypertension, pulmonary edema, or congestive heart failure

8Valvular stenosisMost commonly caused by infection or blockage of the heartSome types must be surgically repaired.Acquired heart disease (cont.)Myocardial infarctionAffects 1 in 10,000 pregnancies Highest incidence in third trimesterCardiomyopathyRare and often fatal disorder of heart muscle structureMay be considered a diagnosis of exclusionCongenital heart disease Left-to-right shuntAtrial septal defect Ventricular septal defect Patent ductus arteriosus Right-to-left shuntTetralogy of FallotEisenmenger syndrome Other congenital lesionsTransposition of the great vesselsMitral valve prolapseCoarctation of the aortaCardiac Disease: Diagnosis and ClassificationAssessment for specific signs and symptoms of heart disease is part of every initial prenatal visit. Signs and symptoms Dyspnea, syncope (fainting) with exertionHemoptysis Paroxysmal nocturnal dyspneaChest pain with exertionAdditional signsThe severity of the disease is determined by ability the specific cardiac lesion, the functional status of the woman, and the development of complications.Cardiac Disease: Therapeutic ManagementClass I or II heart diseaseClass III or IV heart diseaseDrug therapyAnticoagulantsAntiarrhythmicsAnti-infectivesDrugs for heart failureCardiac Disease: Intrapartum Management300 to 500 mL of blood is shifted from the uterus and placenta into the central circulation with every contraction.Extra fluid causes a sharp rise in cardiac workload. Vaginal delivery is recommended for a woman with heart disease unless there are specific indications for cesarean birth. Minimize maternal pushing and use of the valsalva maneuver. Limit prolonged labor.Cardiac Disease: Postpartum ManagementEven with no evidence of distress during pregnancy, labor, and childbirth, women may have cardiac decompensation during the postpartum period. Women require close observation for signs of infection, hemorrhage, and thromboembolism.Conditions can act together to precipitate postpartum heart failure in women with underlying heart disease.Signs and symptoms of congestive heart failure include:Cough (frequent, productive, hemoptysis)Progressive dyspnea with exertionOrthopneaPitting edema of legs and feet or generalized edema of face, hands, or sacral areaHeart palpitationsProgressive fatigue or syncope with exertionMoist rales in lower lobes, indicating pulmonary edemaAltered level of consciousnessApplication of the Nursing Process: Pregnant Woman with Heart DiseaseAssessmentVital signs

9FatigueSigns of congestive heart failureWeightMother’s knowledge baseIdentification of patient problemsPlanningInterventionsTeaching about increased cardiac workloadExcessive weight gain and anemiaExertionExposureEmotional stressHelping the family accept restrictions on activityProviding postpartum careEvaluationObesityPublic health epidemic in the United StatesRiskAntenatal careIntrapartum carePostpartum careNursing considerationsAnemiasIron-deficiency anemiaFolic acid deficiency anemia (megaloblastic)Sickle cell diseaseThalassemiaMedical ConditionsImmune-complex diseasesSystemic lupus erythematosusAntiphospholipid syndromeHashimoto’s thyroiditisRheumatoid arthritisNeurologic disordersSeizure disordersBell’s palsyInfections During Pregnancy: ViralCytomegalovirusRubellaVaricella-zosterHerpes simplexParvovirus B19Hepatitis BHuman immunodeficiency virus (HIV)Infections During Pregnancy: NonviralToxoplasmosisGroup B streptococcusTuberculosis