Ob: Variations In Labor And Abnormal Labor Mgmt

Front 1

Labor Dystocia

Back 1

Long, difficult, abnormal labor
Problems in progress:
Dysfunctional labor
Alterations in the pelvic structure
Fetal causes
Maternal position
Psychological responses of the mother
Inadequate pain relief/coping

Front 2

Dysfunctional Labor

Back 2

Ineffective uterine contractions (Powers)
Factors that increase risk:
Body build (230 lbs or more over weight)
Uterine abnormalities
Malpresentations
Cephalopelvic disproproportion (CPD)
Overstimiulation with pitocin
Maternal fatigue, dehydration, fear
Inappropriate timing of analgesics

Front 3

Hypertonic Uterus

Back 3

Latent phase of labor
Contractions are uncoordinated
Manage with "therapeutic rest"

Front 4

Hypotonic Uterus

Back 4

Progress to active phase
Contractiosn become weak and insufficient
Augment labor

Front 5

Alterations in Passageway

Back 5

Pelvic Dystocia - contractures of the pelvic diameters
Soft tissue Dystocia - anatomic abnormality, full bladder or rectum, cervical edema

Front 6

Fetal Causes (Passenger)

Back 6

Fetal anomalies
Cephalopelvic Disproportion (CPD)
Malpresentation
Suboptimal fetal position

Front 7

Malpresentation

Back 7

More of a risk for cord prolapse
Face, shoulder, complete breech, Breech (most common @ 3-4%

Front 8

Frank Breech

Back 8

Lie: Longitudinal or vertical
Presentation: Breech (incomplete)
Presenting part (sacrum)
Attitude: Flexion, except for legs or knees

Front 9

Single footing Breech

Back 9

Lie: Longitudinal or vertical
Presentation: Breech (incomplete)
Presenting part: Sacrum
Attitude: Flexion, except for one leg extended or hop and knee

Front 10

Complete Breech

Back 10

Lie: Vertical
Presentation: Breech (sacrum and feet presenting)
Reference point: Sacrum (with feet)
Attitude: General Flexion

Front 11

External Cephalic Version (ECV)

Back 11

Risks - fetal distress, ROM, maternal/fetal hemorrhage placental eruption, preterm labor, fetal death
Alternative therapies - pelvic lifts, turn mom upside down, performed by external clinicians

Front 12

Psychological Response

Back 12

Fear affects stress hormones which affects cervical dilation
Anxiety - release hormones that slows down labor - affects uterine contractility - affects dilation
*Help mom refocus

Front 13

Friedman's Classification

Back 13

Progress monitored in terms of cervical dilation and fetal descent
Monitor for expected progress and cahgne based on phase of labor and parity
"Labor Curve"
Chart E/D
Curve based on phase of labor and parity of mother

Front 14

Labor Curve

Back 14

Station and dilations curves
x axis - hours of labor
y axis - cervical dilation

Front 15

Precipitous Labor

Back 15

Total labor process completed < 3 hours
Associated with significantly increased risk of maternal and fetal complications (hypoxia, intercranial hemorrhage)
Maternal complications (uterine rupture, lacerations, pph, and amniotic fluid, embolism PE)

Front 16

Abnomal Labor Management

Back 16

Trial of Labor
Induction of Labor
Augmentation of Labor

Front 17

Trial of Labor

Back 17

Allowance of "reasonable period" of spontaneous active labor to determine the safety
Indications
1) maternal pelvis is a questionable size/shape
2) Vaginal birth after cesarean (VBAC)
3) Abnormal Presentation

Front 18

Induction of Labor

Back 18

Initiate CTX before spontaneous onset (piton, amniotomy)
Success of IOL is greater if cervix is "favorable"
Less common methods: nipple stimulation, castor oil, herbal preparations, acupuncture

Front 19

Bishop Scoring

Back 19

Method of evaluating the favorability of a cervix (determine whether or not mom is inducable)
Nullip - greater than 9 (cervix is favorable)

Front 20

Cervical Ripening

Back 20

Chemical agents applied to "ripen" cervix
- prostaglandings (prepidil, cervidil)
- Misoprostaol (cytotec)
Results in - higher success of induction, lower doses of pitocin, shorter induction times

Front 21

Induction of Labor (IOL)

Back 21

Pitocin - intravenous tiration, concentration and starting dose per protocol, increases at intervals per protocol
Monitor FHR and contractions q15m

Front 22

Indications for IOL

Back 22

Suspected fetal jeopardy
PROM
Postterm
Chorioamnionitis
Maternal medical problems
PIH (pregnancy induced hypotension)
Fetal demise

Front 23

Risks of IOL

Back 23

Fetal Distress
Failed induction
Uterine Rupture
Water intoxication
Hyperstimulation

Front 24

Hyperstimulation with Pitocin

Back 24

Very frequent and intense ctx with non-reassuring FHR
- ctxs q2m x > 90 secs
- uterine resting tone > 20 mmhg
Nursing mgmt
1) turn pitocin off
2) increase IVF
3) o2 via face mask
4) notify provider
5) LLP

Front 25

Augmentation of Labor

Back 25

Labor has begun spontaneously
Ctx stop or abnormal labor diagnosied
Pitocin augmentation
Amniontomy

Front 26

Symptoms of Preterm Labor (PTL)

Back 26

Pelvic Pressure
Low, dull backache
Menstrual-like cramps
Change or increase in vaginal discharge
Intestinal cramping with or without diarrhea
CTX occuring less than or equal to 10 min

Front 27

Causes of PTL

Back 27

Unknown and assumed to be multifactorial
Infection is a majore culprit (bacterial vaginosis, chlamhydia, gonorrhea, UTI, pylenophritis)

Front 28

Risk Factors

Back 28

Infection, long distance traveling, on feet > 50%, stress acute or chronic, poor nutrition, begin underweight, later or no prenatal care, lower ses or education, eton, tobacco, illicit drug use, pre-existing or pregnancy complications

Front 29

Diagnosing PTL

Back 29

Documented uterine contractions using tachometer
Documented cervical change - effacement of 80%, dilation > 1cm

Front 30

Predictors of PTL/PTB

Back 30

Diagnostic testing used to "predict PTB in woman/fetus at risk
Biochemical markers
Transvaginal Ultrasound
Home uterine activity monitoring (HUAM)

Front 31

Biochemical Markers

Back 31

Best Identify who will not experience PTL
Salivary estriol (98% sure not going into preterm labor)
Fetal fibronectin

Front 32

Clinical Mgmt of PTL

Back 32

Tocolytic therapy - suppression of uterine activity
Administrations of glucocorticoids (promote fetal lung maturity)

Front 33

Tocolytic Agents

Back 33

Ritodrine - Betamimetic - relaxes smooth muscle
Terbutaline - Betamimetic - relaxes smooth muscle
Magnesium sulfate - cns depressant
Indomethacin - prostagalindin inhibition
Nifedipine - calcium channel blocker

Front 34

Possible SE of Terbutaline

Back 34

Tachycardia, dysrhythmias, tremors/muscle weakness, headache, n/v, hypoglycemai, hypokalemia, pulmonary edema, myocardial ischemia, hypotension, jitteriness and apprehension

Front 35

Possible SE of MgSO4

Back 35

Decreased RR
Absent or decrease in deep tendon reflexes
Muscle Weakness
Decreased urine output (oliguria)
7-8 toxic
Antidote - calcium glucomate

Front 36

Nursing Care of Tocolytic Tx

Back 36

LLP, assess VS regularly, notify provider if maternal HR greater than 120, assess sxs of pulmonary edema, assess urinary output q1hr, monitor for ketonuria, limit fluid intake to 2500-3000 ml/day, provide psychosocial support

Front 37

Antenatal Glucocorticoids

Back 37

Accelerate fetal lung maturity
May be repeated in 7 days if birth has not occurred
Agents
-betamethasone
-dexamethasone

Front 38

Contraindications

Back 38

Severe preeclampsia or eclampsia, active vaginal bleeding, intrauterine infection (choriomnionitis), cardiac disease, acute fetal distress, chronic IUGR)

Front 39

Mgmt considerations

Back 39

Birth inevitable - dilation over 4cm
Continuation of pregnancy impractical - fetal demise, lethal fetal anamaly, ega >37 weeks, efw greater than 2500 gm

Front 40

PROM

Back 40

Premature repture of membanes
At least one hour before onset of labor at any gestational age

Front 41

PPROM

Back 41

Preterm PROM - rupture of membranes before 37 weeks of gestation -occurs in 25% of all cases of preterm albor

Front 42

Management of PPROM

Back 42

Preventing preterm birth and maternal-fetal complications is goal
Expectant management
Self care at home
Biweekly testing (NST, BPP), amniotic fluid measurements

Front 43

BPP - Biophysical profile

Back 43

U/S, non strest testing, HR, muscle tone, movement breathing, amniotic

Front 44

Criteria for Home Care

Back 44

Documented PPROM >72 hr
Cervical dilation <3 cm
No sxs of infection
Client willingness to comply
No breech or transverse prevention

Front 45

Home/Self Care: Self assessment

Back 45

1) temp q4h
2) Monitor sxs infection
3) Assess for uterine contractions
4) Daily fetal movement counting (FMC) q 6hr
-foul smelling discharge - call provider immediately

Front 46

Home/self care: Activity modifications

Back 46

1) Modified bed rest
2) Nothing in the vagina (NPV)
3) proper hygeine
4) no tub baths
5) take antibiotics if prescribed

Front 47

Complications of PPROM and PTL

Back 47

Infection, preterm birth, cord prolapse

Front 48

Choriamnionitis

Back 48

Intraamniotic infection with risks for mother and fetus
SXS:
1) fetal tachycardia
2) elevated maternal temp
3) uterine tenderness (infection)
4) decreased ctxs

Front 49

Premature newborn

Back 49

1) maintain body temp
2) function of all organ systems is at risk
3) respiratory: increase risk for respiratory distress syndrome (RDS)
4) L/S ratio to check for maturity

Front 50

L/S ratio

Back 50

used to assess fetal living maturity
diabetic women < 3 risk of RDS
non dm woemn < 2 risk for RDS