Maternity & Newborn #7

Front 1

Preterm Labor: what is it?, btwn what weeks?, what % of neonatal deaths?, when do most of these deaths occur?, what are some causes?

Back 1

Defined as cervical changes and uterine contractions occurring between 20 and 37 weeks. Most serious of pregnancy complications. Account for 90% of neonatal deaths. More than 70% of these deaths occur before 32 weeks. Other conditions can cause IUGR (intrauterine growth restriction), especially uteroplacental insufficiency (not enough blood flow to placenta).

Front 2

Preterm Labor

Back 2

Differs from LBW (≤ 2500 g), which sometimes substitutes for preterm labor statistics

Front 3

See Olds, Table 20-2, for Risk Factors for Preterm Labor

Front 4

Nursing Interventions for PreTerm labor. Prevention strategies (Olds, Table 20-4) (5)

Back 4

1. Educate preterm labor symptoms: Uterine activity, Discomfort, Vaginal discharge
2. Fetal fibronectin (fFN) – assist with collection
3. Counsel on lifestyle modifications (reduce stress, hard physical work, sexual activity, encourage rest periods)
4. Bed rest may be prescribed. Counsel on adverse effects. Modify the home environment
5.Suppression of uterine activity with tocolytics.

Front 5

Suppression of uterine activity with tocolytics= medications that suppress uterine activity are (5) ? and when are they used?

Back 5

May be used before 34 weeks. Generally delay delivery for 48 hrs to several days.
Medications generally used:
1. Terbutaline- asthma pts., (beta-mimetics, epinephrine, relaxes smooth muscle).
2. Magnesium sulfate,(lowers calcium levels)
3. Indomethacin, (NSAID, prevents prostingladin production)
4. Nifedipine- late 20’s early 30’s, (calcium channel blocker)
5. Ritrodine

Front 6

How is Terbutaline given and when are tocolytics to be stoped?

Back 6

Terbutaline is given by SQ injection or pump, or oral. Discontinue tocolytics at least 4 hours before birth.

Front 7

Contraindications to tocolysis: (7)

Back 7

1. severe PIH (all meds increase blood pressure-vasocontrictors),
2. active bleeding,
3. uterine infection,
4. cardiac disease,
5. dilation > 6 cm,
6. acute fetal distress or death,
7. chronic IUGR (intrauterine growth restriction)

Front 8

Review Olds’ Drug Guide for nursing interventions (10) for women receiving magnesium sulfate therapy (Ch. 20)

Back 8

1. Monitor BP
2. Therapeutic range from 4-8 mg/dL (reflexes disappear at 9-13) (RR depression at level 14) (cardiac arrest at 30 mg or above)
3. Monitor respirations, no less than 12 bpm
4. Assess knee jerk- loss of reflex is the first sign of toxicity
5. Dertermine urinary output- no less than 30 ml/hour
6. if urine or RR is low, stop IV mag
7. Monitor fetal heart tones continuously with continuous IV
8. give mag 24 hours after birth to prevent seizures, if given for preclamspsia
9. watch for mag toxcity in newborn (if mag was given close to birth)
10. keep calcium gluconate at bedside (antagonist)

Front 9

Promotion of fetal lung maturity
What med is used? When does it take effect?

Back 9

Antenatal glucocorticoids (betamethasone, dexamethasone).
See Olds’ Drug Guide for Betamethasone (Ch. 20).
1. Must be administered timely, as they require 24 hours to take effect (nurse should be prepared)
2. they increase surfactant production

Front 10

PPROM

Back 10

Preterm Premature Rupture of Membranes

Front 11

PPROM,
definition?
what causes it?
what are the serious s/e?

Back 11

Defined as rupture of membranes before 37 weeks. Often proceeded by infection, but etiology is unknown. Infection is the serious side effect: (1.)=life threatening to mother and fetus. Most respond well to antibiotics, but sepsis can occur. Can lead to (2.)

Hint 11

1. Chorioamnionitis (intra-amniotic infection resulting from bacterial invasion and inflammation of the membranes before birth.)

2. cord prolapse/compression, oligohydramnios (too little amniotic fluid, baby not urinating properly)

Front 12

Nursing Interventions PPROM (6)

Back 12

1. Strict sterile technique for any vaginal exam.
2. Test for rupture of membranes (nitrazine paper-ph testing will be bright purple/BLUE or FERNING b/c amniotic fluid (pH 7.4-7.5) is more alkaline than vag secretions pH 4.5 to 5.5)
3. Emotional support.
4. Frequent biophysical profiles; teach mom how to do fetal kick counts.
5. Administer glucocorticoids, IF NO INFECTION.
6. Teach strict genital hygiene, pelvic rest, hydration and s& sx of infection to report

Front 13

Dysfunctional Labor Patterns: Hypertonic: what is it?, where are they?, in what phase?

Back 13

painful, frequent, ineffective contractions(ineffective dilation & effacing),
-usually in the mid-uterus rather than fundus, so not effective in pushing fetus down
-occurs during the latent phase

Front 14

Tx for hypertonic

Back 14

therapeutic rest (warm shower, analgesics) to allow 4-6 hours of rest; likely to awaken in normal labor

Front 15

Dysfunctional Labor Patterns: Hypotonic

Back 15

makes normal progress, then contractions weaken or stop. If vital signs, fetal heart rate/pattern, amniotic fluid are normal, tx is...? (next slide)

Front 16

Tx for hypotonic (5)

Back 16

1. ambulation,
2. hydrotherapy,
3. stripping membranes,
4. nipple stimulation or
5. oxytocin infusion

Front 17

CPD (cephalopelvic disproportion)

Back 17

Often related to macrosomia. Can be caused by too small pelvis, or one of abnormal shape

Front 18

Malposition

Back 18

Most common is persistent occiput posterior position.
“Back labor” (fetal head pressing against sacrum).
Physician may try maneuvers to rotate the fetus
(see Olds, Figures 26-3 and 26-4)

Front 19

Malpresentation: Breech
Interventions

Back 19

1. Usually will necessitate c-section.
2. Attempt at external cephalic version:
a. Done after 37 weeks, in L&D.
b. Constant gentle pressure on abdomen.
c. Nurse monitors. FHR/pattern (esp. bradycardia and variable decels), maternal vital signs and comfort level
d. After the version, continue to monitor vitals, FHR/pattern, uterine activity, assess for vaginal bleeding

Front 20

Precipitate labor

Back 20

Defined as labor lasting less than 3 hours from onset of contractions to time of birth

Front 21

Maternal complications of precipitate labor: (4)

Back 21

1.uterine rupture,
2. lacerations of birth canal,
3. amniotic fluid embolism,
4. postpartum hemorrhage.

**Listen to the mother when she says she feels need to push!

Front 22

Fetal complications from precipitate labor: (2)

Back 22

1. hypoxia (pressure of frequent contractions) and
2. intracranial hemorrhage from rapid birth

Front 23

Critical for nurse to maintain good nursing care (for medico-legal risks) (5)

Back 23

1. Clear documentation
2. Assess for informed consent
3. Provide full explanations of all procedures, meds
4. Medication safety
5. Follow the policies and procedures of your agency, and maintain maternal and fetal monitoring, even when decision made to go for c-section

Front 24

Labor induction (Olds, Chapter 27). Use of oxytocin to induce

Back 24

uterine contractions before their spontaneous onset

Front 25

Use of Bishop Score to evaluate for

Back 25

likely success of induction (a 13-point scale, with 9 or greater for primips and 5 or greater for multips); see Olds, Table 27-3

Front 26

Cervical ripening with chemical agents, like:

Back 26

(prostaglandin E2 gel – Cervidil) or
mechanical agents (laminaria) – administered by MD

Front 27

Amniotomy – AROM
what is it for?
often used with what meds?
done with?
assess for what?

Back 27

--Can induce labor when cervix is ripe or augment labor if progress slows.
--Often used with oxytocin induction (more effective than either method alone).
--Painless; done with Amnihook; amniotic fluid allowed to drain slowly.
--Assess FHR immediately before and after AROM (transient tachycardia is common, but bradycardia and variable decels are not)

Front 28

Forceps-assisted birth and conditions required for use?

Back 28

Used much less frequently than in the past.
Certain conditions required:
1. Cervix fully dilated
2. Bladder empty
3. Presenting part must be engaged (vertex is best)
4. Membranes ruptured
5. No CPD (cephalopelvic disproportion)
!!ASSESS FHR before and after application of the forceps!!

Front 29

After birth with use of forceps, assess mother for: (3)

Back 29

Vaginal and cervical lacerations (bleeding).
Urine retention.
Hematoma formation in pelvic soft tissues

Front 30

After use of forceps in delivery, assess infant for: (3)

Back 30

Bruising/abrasions at forceps site.
Facial palsy (pressure on CN VII).
Subdural hematoma

Front 31

Vacuum-assisted birth
requires what before use?
how does it work?

Back 31

Requires vertex presentation, ruptured membranes and no CPD.
Preferred over forceps.
Mother in lithotomy position, for best traction.
--Vacuum cup applied to fetal head (caput develops), and traction applied to facilitate descent of the head while mother pushes.
--Vacuum released and removed after birth of the head

Front 32

Nurse’s role is support and education in vacuum (3)

Back 32

1. Frequently assess FHR.
2. Observe newborn for trauma/infection at vacuum site; cerebral irritation (poor sucking or listlessness); cephalhematoma.
3. Reassure parents that caput will begin to disappear in a few hours.

Front 33

Cesarean section delivery

Back 33

Review information in Week 4 lecture notes

Front 34

Post-term Pregnancy
defined as?

Back 34

Defined as one that extends beyond the end of 42 weeks gestation

Front 35

Post-term Pregnancy: Clinical manifestations: (4)

Back 35

1. Maternal weight loss.
2. Decreased uterine size (from decrease of amniotic fluid).
3. Meconium in the amniotic fluid.
4. Advanced bone maturation of the fetus (very hard skull)

Front 36

Post-term Pregnancy: Maternal risks

Back 36

Associated with macrosomia and increased dysfunctional labor; induction and assisted delivery procedures more likely

Front 37

Post-term Pregnancy: Fetal risks (5)

Back 37

1. Macrosomia: prolonged labor, shoulder dystocia, birth trauma, asphyxia (reduced amount of O2)
2. Compromised placenta from “aging”. Placenta gradually decreases function after 37 weeks.
3. Amniotic fluid volume decreases to 800 mL at 40 weeks, and 400 mL at 42 weeks: increased risk of cord compression.
4. Fetal distress in labor from placental insufficiency.
5. Neonatal problems (e.g., meconium aspiration, RDS, hypoglycemia, asphyxia)

Front 38

Why is Management is controversial

Back 38

1. Some experts recommend induction at 41-42 weeks to reduce c-section rates and stillbirth or neonatal death.
2. Others will allow individual approach to 43 weeks, provided fetal well-being is normal

Front 39

Nursing interventions: Postterm (4)

Back 39

1. Antepartum assessments once or twice weekly, daily fetal movement monitoring.
2. Monitoring in labor.
3. Careful assessment of FHR and pattern, pH for acidosis.
4. May need amnioinfusion

Front 40

OBSTETRIC EMERGENCIES: Shoulder Dystocia

Back 40

The head is born but the shoulder cannot pass under the pubic arch

Front 41

Sx of shoulder dystocia (4)

Back 41

Symptoms may include:
1. labor progress that slows markedly,
2. a caput forming that is increasing in size;
3. as head emerges it retracts against the perineum or
4. external rotation does not occur

Front 42

Potential injuries to fetus include (3)

Back 42

asphyxia, brachial plexus damage and fracture (humerus or clavicle)

Front 43

Mother’s risk of shoulder dystocia is (1)

Back 43

excessive blood loss from uterine atony or rupture, and lacerations.

Front 44

Nursing interventions for shoulder dystocia (4)

Back 44

1. Assist to position woman on hands and knees, or lateral recumbent, to help reposition the fetus.
2. AVOID FUNDAL PRESSURE!!
3. May be called to assist in applying suprapubic pressure – be certain to document appropriately.
3. Assess newborn for fracture of clavicle or humerus, as well as brachial plexus injuries or asphyxia.
4. Assess woman for risk of uterine rupture (excessive bleeding, hemorrhagic shock with firm uterus).

Front 45

OBSTETRIC EMERGENCIES: Uterine rupture

Back 45

May be small, and managed with laparotomy, repair of laceration and blood transfusions as needed.
If severe, hysterectomy and blood replacement needed

Front 46

Nursing interventions uterine rupture (4)

Back 46

1. IV fluids; administer blood products as needed
2. Oxygen
3. Prep for immediate surgery
4. Provide support and encouragement to family

**Fetal mortality 50-75%; maternal mortality may be high if not treated immediately**

Front 47

Prolapsed Umbilical Cord (3 s/s)

Back 47

1. Fetal bradycardia with variable decels
2. Woman may report feeling the cord after ROM
3. Cord is seen or felt in or protruding from vagina

Front 48

Nursing Interventions Prolapsed Umbilical Cord (3)

Back 48

1. CALL FOR ASSISTANCE!!
2. Glove the examining hand quickly, and insert two fingers into the vagina to the cervix– with fingers on either side of the cord or both to one side, exert upward pressure against presenting part, to keep pressure off the cord.
3. Put woman into EXTREME TRENDELENBURG or knee-chest

Front 49

If cord is protruding from vagina

Back 49

wrap in sterile towel saturated with warm sterile normal saline

Front 50

Nursing Interventions Prolapsed Umbilical Cord protuding from vagina (5)

Back 50

1. Administer oxygen at 8-10 L/min until birth accomplished.
2. Start IV fluids
3. Continue to monitor FHR and pattern, if possible by scalp electrode
4. Provide explanations to woman and partner
5. Prepare for immediate vaginal birth (if fully dilated) or for c-section.

can be scary and exciting....variable decels is the key!!

Front 51

Amniotic Fluid Embolism

Back 51

Occurs when amniotic fluid containing debris (e.g., vernix, hair, skin cells or meconium) enters maternal circulation, causing pulmonary obstruction, leading to respiratory distress and circulatory collapse

Front 52

Amniotic Fluid Embolism can occur when?

Back 52

Can occur whenever the amniotic sac is open, and enough pressure exists to force fluid into maternal veins (especially if uterine laceration or rupture)

Front 53

amnoiotic fluid embolism risk for fatality increase with?

Back 53

Although uncommon, it causes about 10% of maternal deaths in U.S. – fetal mortality rate as high as 50%

Front 54

Amniotic Fluid Embolism can lead to what conditions?

Back 54

Can lead to DIC (Disseminated intravascular coagulation) and other coagulation problems; pulmonary HTN and left ventricular failure

Front 55

Risk factors for AFE include

Back 55

1. multiparity,
2. rapid labor,
3. abruption,
4. oxytocin induction;

fetal factors include:
1. macrosomia,
2. death,
3. meconium passage

Front 56

Nursing interventions AFE (5)

Back 56

1. Observe for respiratory distress, circulatory collapse and hemorrhage
2. Oxygenate with face mask or resuscitation bag delivering 100% oxygen and prepare for intubation
3. Assist with CPR (tilt pregnant woman 30 degrees to the side to displace the uterus)
4. Maintain cardiac output with IV fluids; administer blood; insert Foley catheter and monitor urinary output
5. Monitor maternal and fetal status; prepare for emergency birth

**If she survives, will be moved to critical care for monitoring and blood replacement, coagulopathy treatment**

Front 57

What is the leading cause of maternal morbidity and mortality?

Back 57

Postpartum Hemorrhage, when is it classifed?

Hint 57

Classified as early (in first 24 hours) or late (between 24 hours and 6 weeks)

Front 58

Risk factors for postaprtum hemorrhage (11)

Back 58

1. Uterine atony (overdistended uterus, anesthesia, previous history of uterine atony, prolonged labor, trauma during assisted delivery procedures)
2. Lacerations of birth canal
3. Retained placental fragments
4. Ruptured uterus or inversion of uterus
5. Placenta accreta (deep attachement of the placenta)
6. Coagulation disorders
7. Placenta previa or abruptio
8. Manual removal of placenta
9. Magnesium sulfate in labor or postpartum
10. Endometritis
11. Uterine subinvolution

Front 59

Nursing Interventions for postpartum hemorrage (6)

Back 59

1. Assess vital signs and maternal condition, especially inspect the perineum
2. Assess uterine fundus, which should be firm and at level of umbilicus
3. Assess for bladder distention, which can prevent proper uterine contraction
4. If uterus is hypotonic, provide firm massage to fundus, expel clots from the uterus, and administer oxytocin infusions as ordered
**See Olds, Table 38-1, for uterine stimulant drugs used to manage postpartum hemorrhage and the appropriate nursing interventions (Table 37-1 in 7th ed.)
5. Assist with laceration repair, or possible surgical interventions as needed
6. Provide calm explanations to woman and her family about the interventions and the need to act quickly **See Olds, Nursing Care Management text section for Postpartum Hemorrhage.

Front 60

Postpartum Infection

Back 60

Defined as any clinical infection of the genital tract which occurs within 28 days of childbirth, miscarriage or induced abortion

Front 61

Postpartum Infection signs

Back 61

Presence of fever of 38°C or more on 2 consecutive days in first 10 postpartum days after first 24 hours

Front 62

Postpartum Infection rate

Back 62

The major cause of worldwide maternal morbidity and mortality; in U.S. accounts for about 6%. More common after c-section births

Front 63

Common postpartum infections: (5)

Back 63

1. Endometritis
2. Wound infection
3. Mastitis
4. UTI’s
5. Respiratory tract infections.

Front 64

Most effective and least expensive treatment for postpartum infection is:

Back 64

prevention

Front 65

ways to prevent infection (3)

Back 65

1. Good maternal nutrition status
2. Perineal hygiene and good handwashing
3. Strict adherence to aseptic technique during childbirth and postpartum.

Front 66

Management of endometritis (3)

Back 66

1. IV broad-spectrum antibiotics.
2. Supportive care (rest, hydration, pain relief)
3. Continue assessment of lochia, vital signs and changes in condition

Front 67

Discharge teaching for infection (4)

Back 67

1. Hygiene
2. Signs and symptoms of infection
3. Wound care
4. Follow-up by home care nurses can be beneficial for woman at high risk.