Chapter 21: Obstetrical Emergencies

Obstetrical Emergencies Shoulder Dystocia Obstruction of fetal decent and birth after delivery of head due to fetal shoulders Nurse will push an public bone push legs backRisks: macrosomia, excessive weight gain, history of shoulder dystocia WARNING: turtle signs head will come out and go back in Maternal Outcomes: PP hemorrhage and laceraation Fetal outcomes: brachial plexus injury and clavicle fracture + - Cgestational Risk of : Tsarisk Diabetes ↳ nerves disturbed feeling luse hemorrhage of baby can lose arm . Umbilical Cord Prolapse Cord precedes the fetus causing occlusion of blood flow Rapid fetal deterioration variable decelerations Risk: malpresentation, high station, preterm labor, low birth weight, multiple gestations, hydramnios to much Fluid Need to relieve compression Prompt recognition Push up on presenting part to releive pressure - - > - ~ on cord = #1 Nursing Intervention Uterine Rupture Tearing of the uterus into the abdominal cavity Sudden fetal bradycardia Risks: uterine scar, prior rupture, trauma, hypertonic contractions Urgent cesarean delivery ( fibroids is mom can when Baby a risk hemorrhage rupture - no perfusion /02 to baby in abdomen mom has signs of I loss of fetal station Irregular rigid Painful abdomen bleeding shock (d BP , HR Amniotic Fluid Embolism S Amniotic fluid containing hair, skin, vernix, or meconium enters maternal circulation and obstructs pulmonary vessels Rapid maternal deterioration and poor prognosis hypoxemia , He Risks: placental abruption, uterine over distention, fetal demise, uterine trauma, amnioinfusion, amniocentesis, ROM Symptoms: severe respiratory distress, sudden hypotension, hypoxia, seizures, and coagulation failure-disseminated intravascular coagulation (DIC) causing hemorrhage , fluid gets to maternal circulation Activates clotting factors uses all of them go Amniotic - then to DIC start It sense of bleeding impending doom , SOB , 202 , DIC-Bleed anywher Maa m Chapter 21 Dystocia of Labor “Failure to Progress” slow progression Lack of progressive dilation and/or descent Apparent during the active phase of labor Risk Need an adequate trial of labor to declare Factos #1 reason for for cesarean delivery Complications: postpartum hemorrhage, infection, perineal lacerations Causes 5 P's Passageway- pelvis/birth canal Passanger Position (5th P) occiput posterior Presentation- face, brow, breech Fetal development- multiple babies, macrosomia, structural abnormalities Powers- contractions Hypertonic- never fully relaxes to many Hypotonic- to relaxed to little Psychologic response Psychological distress- fear, anxiety can I strength contractions Dystocia of Labors: Powers Hypertonic Uterine Dysfunction Hypotonic Uterine Dysfunction Risk: primigravida Risk: overstretching of the uterus Prolonged latent phase; stay 2-3 cm Occurs during active phase Assessment: minimal relaxation, Assessments: mild and infrequent ctx compromised placental perfusion Treatment: stimulation use oxytocin Terbutaline uterus of Treatment: relaxation - - - , uncoordinated and too close together , late decelerations Dystocia of Labor Education is key Management Assessment: provide physical and emotional support Review risk factors Promote comfort for relaxation and normal labor progress Assess signs of stress and support Prepare family for cesarean delivery if labor does not Evaluate uterine contractions and FHR progress Assess fetal position Perform Vaginal exams Precipitate Labor very fast Labor is completed in < 3 hours from start of contractions to birth less than 3 hours Common Causes- Hypertonic labor, use of oxytocin, multiparty, drug use Maternal risks: uterine rupture, lacerations, amniotic fluid embolism, postpartum hemorrhage Fetal risks: hypoxia, intracranial hemorrhage, nerve damage Trauma ! Preterm Labor Regular uterine contractions with cervical effacement and dilation before the end of 37 weeks Risk Factors: African American, smoking, cocaine, multiples, infections, cervical insufficiency Infant Risk: respiratory distress syndrome, infections, thermoregulation, feeding difficulties, hypoglycemia Preterm Labor Tocolytics want corticosteriods 2 doses 24hrs apart if able Indomethacin- inhibits prostaglandins and uterine contraction, Given PO, contraindicated in >32 weeks, risk for neonatal side effects Blocks calcium movement into the muscle cells, inhibits need NifedipineMonitor Uterine uterine given PO, contraindicated with cardiovascular disease time aMagnesiumcontractions, contractions Sulfate- reduces the muscles ability to contract, given IV Terbutaline- betamimetic, prevents and slows uterine contractions, given Sub Q, do not given beyond 48-72 hours Preterm Labor Assessment Indistinct signs Contraction pattern: 4 contractions every 20 minutes or 8 contractions in 1 hour Cervical exam: dilation and effacement Lab and diagnostic testing: CBC, urinalysis (U/A), amniotic fluid analysis, fetal fibronectin, cervical length ↳ present preterm lapor Teaching guidelines 21.1 for preventing preterm labor * In book - & = as TocOly Preterm Labor Fetal Fibronectin Fetal Fibronectin: found at the junction of fetal membranes and uterus -Acts as the glue attaching fetal membranes to the uterine lining -Usually not detected between 24-34 weeks unless there has been a disruption -Nothing is the vagina 24 hours prior to test L should not be present if it ise increases risk - No Cervical Exam , No sex etc ... , ↓ preterm 2 labor weeks in the of next Preterm Labor Cervical Length Measurement of the closed portion of the cervix by transvaginal ultrasound Single most reliable parameter for preterm labor in high risk women Best obtained 16-24 weeks Unlikely to deliver in the next 2 weeks if cervical Sem less-concerned length is 3 cm or more for preterm labor Post Term Labor Pregnancy continuing past 42 weeks Maternal Risks- cesarean birth, dystocia of labor, shoulder dystocia, birth trauma, postpartum . N M B A Assessment hemorrhage, infection Fetal Risk- macrosomia, brachial plexus injuries, hypoxemia see meconium bic of hypoxemia ↓ Amniotic fluid low APGARS, post maturity syndrome ( loss of SubQ fat and muscle and meconium staining) ↑ risk cord compression variable Labor Induction and Augmentation . 2 or . . T . A . . , , decel , Induction Must have a clear medical induction 39 weeks more Indications: posterm pregnancy, prolonged premature rupture of membranes, gestational hypertension, cardiac disease, chrioamnionitis, intrauterine fetal demise, diabetes, IUGR Contraindication: complete previa, placenta abruption, malpresentation, classical uterine incision, active vertical incision genital herpes, abnormal FHR Risk: infection, cesarean birth, prolonged labor, instrumented delivery, epidural analgesia Bishop Scoring System or ↳ score 6 need cervical blf score Induction: Cervical Ripening sping wit Breast - oxytocin Uhrs after cytotec : cooks catheter balloon blow up : - more start. successful only need oxytocin - stimulation Sex oxytocin vaginal delivery and memrammar nods >8 ripening to mechanically up to 4cm dilate Induction and Augmentation Assessment Management Review indications and contraindications -Explanations; informed consent Gestational Age determination -Medication administration with continued Fetal status have to assess bif any interventions monitoring of maternal and fetal status Cervical readiness, Bishop Score Above -Pain relief and support Amnioinfusion fluid Indications some -Severe variable decelerations due to cord compression -Oligohydramnios (Not enough fluid) -Rupture of membranes -Thick meconium fluid thin out flush out meconium Nursing management: teaching, maternal and fetal assessment, preparation for possible cesarean be careful of uterine distention Forceps or Vacuum Assisted Birth Application of traction to fetal head Risk- tissue trauma > may need episiotomy -Maternal: lacerations, hematoma, hemorrhage, infection -Newborn: lacerations, facial nerve injury, cephalohematoma, caput succedaneum can have head trauma Criteria: membranes ruptured, complete dilation, vertex position and engaged, adequate pelvis size - ↳ Forceps have to use on head Ikiwi) Indications of Assisted Birth vacuum a cancause m Cesarean Birth Classic or low transverse incision Indications: Adv Maternal Age -Maternal: AMA, obesity, previous c-section (classical incision), active genital herpes, dystocia of labor ## reason) -Fetal: distress, presentation (breech), congenital anomalies, macrosomia -Placenta: Previa, abruption > increased risk of infection Transversa classical Major surgical procedure with increased risks compared to vaginal delivery Incision Cesarean Birth Assessment History and physical exam for maternal and fetal indications last time pt ate Management -H/H WBC pIt Preoperative care: client teaching, blood type and crossmatch, CBC, surgical site prep, Foley bif Incision catheter, IV antibiotics, SCDs, epidural/spinal IV Antibiotics Postoperative care: assess vitals, lochia, fundus, abdominal dressing, pain; osculate bowel sounds, ↓ DV T early ambulation, encourage use of incentive spirometer classical myomectomy Vaginal Birth after Cesarean (VBAC) only after transverse Never after Risk: uterine rupture and hemorrhage Contraindications: classic incision, myomectomy, ripening agents Special considerations: consent, documentation, surveillance, readiness for emergency Nurses advocate for client: expertise in fetal monitoring to identify non reassuring pattern and institute measures for emergency delivery ~ . . , , 30 mins - or ,