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Intrapartal%20Complications

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Title: Intrapartal Complications Author: Eileen Fowles Last modified by: Hudgins, Rachael Created Date: 9/24/2006 2:29:37 PM Document presentation format – PowerPoint PPT presentation

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Title: Intrapartal%20Complications


1
Intrapartal Complications
  • Complications of the
  • Powers
  • Passageway
  • Passenger
  • Placenta

2
Complications of the Powers
  • Dystocia
  • Dysfunctional or uncoordinated uterine
    contractions that result in a prolongation of
    labor

Abnormal labor curve
Normal labor curve
3
Dysfunctional Labor
Hypertonic Hypotonic
Phase of Labor Latent (lt 4 cm) Active (gt 4 cm)
Symptoms ?freq intensity of contractions, pain ?effectiveness ? freq intensity of contractions, No progress in labor
Risks Fetal Distress-early in labor process Infection, Exhaustion, Hemorrhage, Late fetal distress
Treatment Rest Uterus Stimulate Uterus R/O CPD, Breech, etc.
Medications Morphine, Stadol Pitocin
4
Nursing Care
Hypertonic Dystocia
Hypotonic Dystocia
  • Bedrest
  • Sedation to promote relaxation and reduce pain
  • Careful monitoring of mother and fetus
  • Relaxation techniques
  • Pain management
  • LOTS OF ENCOURAGEMENT
  • Careful monitoring of mother and fetus
  • Offer warm shower
  • Relaxation techniques
  • Assist with AROM and careful monitoring of
    fetus
  • Prepare to start Oxytocin infusion
  • LOTS OF ENCOURAGEMENT

5
Precipitous Labor
  • lt 3 hours Rapid Dilatation and Decent
  • Risks
  • Mom genital tract lacerations, abruptio
    placentae, postpartum hemorrhage
  • Fetus meconium-stained fluid, bruising, cerebral
    trauma
  • Treatmentsafe passage of fetus through perineal
    support, calm atmosphere, careful assessment
    postpartum of both mom and baby
  • Treatment, if Hx of precipitous labor
  • Induce w/SROM
  • BE READY

6
Preterm Labor (PTL) lt 37 weeks
  • PTL is the 1 perinatal and neonatal problem in
    US.
  • A major goal of Healthy People 2020
  • Reduce PTL rate in US to 7.6
  • In 2011, 12.8 of all babies were born preterm
    (all-time high ? )
  • Rate is INCREASING, not decreasing

7
Maternal Causes
  • Race, SES, Age, lt High School Education
    Unmarried
  • Smoking
  • Alcohol in excess
  • Illicit Drugs eg. Cocaine, heroine
  • Poor Nutrition
  • Exposure to Toxins
  • Low Wt. Gain in PG
  • Domestic Abuse
  • Infections
  • History of
  • ABs
  • LBW/PTL
  • Metabolic Disease
  • UTI in 3rd Trimester
  • DES Exposure
  • PIH
  • Anemia
  • Short interpregnancy interval
  • Hx of Heart Disease
  • Type 1 or 2 Diabetes

8
Other Factors
  • Fetal
  • Multiple gestation
  • Macrosomia
  • Polyhydramnios
  • Early Engagement
  • Fetal Distress
  • Placental
  • Previa
  • Abruption

9
Risks
  • Mother
  • If Placenta is cause ? severe hemorrhage and
    Shock
  • Fetus
  • RDS and other complications of prematurity
  • Hypoxia if the problem is placental

10
Symptoms
  • Uterine Activity
  • Cx q 10 for 1 hour
  • w/ or w/o pain
  • Cervical changes
  • Dilatation of gt2cm
  • Effacement of gt80
  • Vaginal Discharge
  • Thicker or thinner
  • Sudden spotting or blood, brown or colorless
    discharge
  • ? amt. malodorous
  • SROM
  • Discomfort
  • Abdominal Cramping w/ or w/o diarrhea
  • Dull, low back pain
  • Painful menstrual-like cramps
  • Suprapubic pain
  • Pelvic pressure
  • Urinary frequency

11
Treatment
  • Bedrest
  • Hydration
  • Antibiotics(if evidence of infection)
  • Analgesic
  • May be used in conjunction with tocolytics

12
Tocolytic drugs
  • Magnesium SulfateMgSO4 (IV)
  • Bolus of 4-6 Gms over 15-30 min, then 1-4
    gm/hour till contractions stop.
  • Maternal Mg serum level for effectiveness in
    tocolysis is 5.5-7.5mg/dL
  • Follow all nursing care r/t MgSO4 discussed
    earlier
  • Nifedipine (Procardia Ca channel blocker)
  • 10-20 mg PO 20 mg q6 hr x 24 hrs 20mg q8 hrs
  • Because mechanism of action is different from
    beta-adrenergic agonists, it might be used in
    conjunction with terbutaline or ritodrine.

13
Tocolytic drugs contd.
  • Indomethacin (Indocin)-
  • used for short-term management of PTL especially
    if Beta adrenergic agonists failed. Best to use
    for lt5-7 days. As a prostaglandin inhibitor, it
    helps to stop contractions and prevent release of
    Oxytocin.
  • po or pr 25-50 mg q6hr for 48hr. Discontinue if
    birth is imminent or likely to occur within 24hr.

14
Tocolytic drugs contd
  • 17 Alpha-Hydroxyprogesterone Caproate
  • Used only with single gestation pregnancies
  • Acts to relax smooth muscle ie pregnant uterus
  • Administered to prevent PTL
  • Used for long-term management of PTL administered
    weekly
  • (17 P) IM injection given z-track slowly over 3-5
    min, to minimize discomfort best to ice the
    injection site prior to administration

15
Side Effects Complications of Magnesium
Sulfate
  • Magnesium Sulfate
  • SIDE EFFECTSMom flushing, drowsiness, muscle
    weakness, blurred vision, N V
  • COMPLICATIONSMom pulmonary edema, respiratory
    depression or arrest, cardiac arrest, profound
    hypotension, hyporeflexia
  • COMPLICATIONS Neonate hypermagnesemia

16
Side Effects Complications of Calcium Channel
Blockers
  • SIDE EFFECTS MOM flushing, tachycardia
  • COMPLICATIONSMOM profound hypotension, possible
    decrease in uteroplacental perfusion

17
Side Effects Complications of Prostaglandin
Inhibitors Indomethacin
  • SIDE EFFECTS MOM epigastric pain, nausea
    vomiting
  • COMPLICATIONSMOM GI bleeding, renal failure
  • COMPLICATIONS Neonate premature closure of the
    ductus arteriosus, necrotizing enterocolitis,
    intracranial hemorrhage

18
Tocolytics Beta2 Adrenergic Agonists
  • Terbutaline/Brethine
  • SQ
  • .25 mg q 20-30 for 2 hrs
  • .25 mg q 3-4 hrs
  • SQ Pump
  • 0.03-.01 mg/hr
  • Max 3 mg/24 hr
  • PO
  • 2.5 5.0 mg Q 4-6 hrs

19
Tocolytics Beta2 Adrenergic Agonists Lots of
SIDE EFFECTS
  • Maternal
  • SOB, tachypnea, pulmonary edema
  • Chest pain, ? B/P, Palpitations
  • Fluid retention, ? Urine
  • Tremors, Muscle cramps, H/A
  • Hyperglycemia, hypokalemia, hypocalcemia,
    metabolic acidosis
  • N/V
  • Fetal
  • Tachycardia
  • Hyperinsulinemia
  • Hyperglycemia (Fetus)
  • Hypoglycemia (Neonate)
  • Hyperbilirubinemia
  • Hypotension

20
Nursing Care w/Tocolytics
  • Monitor IV rates CAREFULLY
  • Continuous EFMrecord q 15 minutes
  • If FHRgt 180 bpm, STOP beta adrenergic agonists
  • Call MD
  • Maternal VS and Cxs
  • record q 15 until stable then q 30
  • Notify MD if P gt 120,
  • STOP meds if
  • P gt 120, gt 6 PVCs/min, systolic gt 180, diastolic
    lt 40, c/o chest pain, SOB

21
Nursing Care w/Tocolytics
  • Strict I O
  • BedrestLeft Lateral
  • Lung sounds---Pulmonary edema
  • Daily Weights
  • Urine for Glucose
  • Serum Electrolytes
  • EMOTIONAL SUPPORT

22
PTLHome Therapy
  • Timing of taking oral medications
  • Palpate contractions
  • No heavy lifting, nipple stimulation, intercourse
  • Quit worktake LOA
  • May have uterine home monitoring
  • Teach symptoms of PTL early in pregnancy

23
Premature Rupture of Membranes
  • Preterm PROMrupture before 37 weeks gestation
  • Diagnosis
  • Nitrazine paper, pH strip- color change??
  • Fern test
  • Risks
  • Maternal Chorioamnionitis/endometritis
  • Fetal PTL/Prematurity
  • Stress of PROM may stimulate surfactant
    production and thus ? incidence of RDS

24
Treatment of preterm PROM
  • If infection noted ? Deliver
  • If w/o infection conservative mgmt
  • VS q 4 especially noting elevated temp
  • CBC, vaginal culture on admission
  • Frequent BPPassess amt of amniotic fluid
  • Assess for uterine tenderness, any vaginal
    leaking
  • Prophylactic antibiotics for 48 hrs often given
  • Modified bedrest (NO WORK)
  • NOTHING in Vagina No Intercourse or tub bath

25
Treatments
  • Corticosteroids? stimulates surfactant
    production, ? risk of NEC, IVH in Fetus
  • Betamethasone (Celestone) 12 mg IM x 2 doses
    24 hours apart
  • Wait 1 week and repeat
  • Dexamethasone (Decadron) 6 mg IM X 4 doses 12
    hours apart
  • Fetal Kick Counts
  • Choose time of day to sit quietly
  • Count to 10
  • If lt 10 movements in 12 hrs? Call MD
  • After meals, Count 4 movements
  • If lt 4 movements in 2 hrs ? Call MD

26
Complications of the Passageway
  • Cephalopelvic Disproportion (CPD)
  • Risks
  • Uterine Rupture
  • Assisted Delivery ?cervical/vaginal lacerations
  • Trauma to fetal head,
  • Fracture, CNS damage
  • Treatment ? Cesarean Section

27
Complications of the Passenger
  • Malpresentation
  • Tranverse Lie
  • Breech
  • Brow/Face
  • Multiple Gestation
  • IUFD
  • Fetal Distress
  • Shoulder Dystocia

28
Multiple Gestation (Twins )
  • Increase risk of PTL, Malpresentation, PIH,
    Maternal Hemorrhage
  • ? incidence d/t fertility treatments
  • Most common is twins
  • 1/85 births is a twin

29
Twins
  • Monozygotic33 of all twins
  • 1 egg 1 sperm Identical
  • Variations
  • 2 amnions/2 chorions 30
  • (Dichorionic/diamniotic)
  • 2 amnions 1 chorion68
  • (monochorionic/diamniotic)
  • 1 amnion 1 chorion 2
  • (monochorionic/monoamniotic)
  • MOST COMPLICATIONS
  • Twin-to-twin transfusion
  • Dizygotic 67 of all twins
  • 2 eggs 2 sperm Fraternal
  • 2 ovums 2 placentas 2 babies

30
Risk for Multiple Gestation
  • Family HX
  • Increased maternal age
  • Increased parity
  • Conceiving within 1 month of stopping OC
  • Increased frequency of Coitus

31
Risks
  • Maternal
  • PTL
  • Cardiac stress
  • Anemia
  • PIH
  • Polyhydramnios
  • Placenta previa
  • Dysfunctional Labor
  • Abnormal Presentation
  • Fetal
  • Congenital anomalies
  • Monozygotic
  • twin-to-twin tranfusion
  • Polycythemic
  • Anemic
  • Umbilical Cords intertwined

32
Management
  • Antepartum
  • U/S early to confirm twins
  • gt of office visits
  • ? caloric needssee dietician
  • ? rest
  • Assess for infection
  • Monitor fetal status
  • U/S, NSTs, BPP
  • Intrapartum
  • Monitor twins
  • 1 tocotransducter
  • 2 U/S transducers or 1 U/S transducer and 1 scalp
    electrode
  • Maternal VS, IVs
  • Vag delivery with C/Sec back up
  • 2 OBs/Peds/RNs
  • May have 1 baby vaginally and 1 baby by C/Section

33
Management
  • Postpartum
  • Assess CLOSELY for Uterine Atony
  • Emotional Support
  • Support with Breastfeeding
  • Referrals to social worker/PHN
  • If Triplets or Quads or
  • C/Section is delivery method of choice

Morgan, Sam, Ben
34
Shoulder Dystocia-an obstetrical emergency
  • An intrapartum event that occurs when the
    infants head has been delivered, but the
    shoulders remain wedged behind the mothers pubic
    bone
  • Risk factors
  • Macrosomic babies are most at risk
  • GDM, Obesity, hx of previous LGA baby or
    previous shoulder dystocia
  • Shoulder dystocia may occur when the woman has no
    risk factors.

35
Management
  • Position in McRoberts position
  • Legs and thighs flexed up to her abdomen with the
    head of the bed lowered
  • Apply suprapubic pressure
  • Apply pressure directly over they symphysis pubis
    to aid in dislodging the fetal shoulder

36
Complications of Shoulder Dystocia
  • Permanent injury to baby
  • Brachial plexus injury (caused by excessive
    traction on fetal head)
  • Fractured clavicles
  • Asphyxia
  • Neurologic damage
  • Maternal Complications
  • Heavy bleeding after delivery
  • Tearing of the uterus, vagina, cervix or rectum
  • Bruising of the bladder

37
Other Fetal Complications
  • IUFDIntrauterine Fetal Demise
  • Often detected by absent fetal movement
  • Nursing Dx Grieving, Altered family processes,
    Ineffective individual coping
  • Goal a supportive, pain-free delivery with
    resources available to make this a special memory
    for the family

38
  • Cause is often unknown or there is some
    physiological maladaptation such as placenta
    previa/abruptio, maternal diabetes, or severe
    renal disease, profound congenital anomalies.
  • Risks to mother -- prolonged retention of dead
    fetus can lead to DIC
  • Diagnosis is based on absence of fetal heart
    tones and/or ultrasound
  • Usually labor will begin on its own, if not,
    labor will be induced within 2 weeks of
    documented demise
  • During labor, the woman is often sedated and an
    epidural is initiated soon after the onset of
    contractions so that labor is made as painless as
    possible.

39
  • The couple may or may not wish to see the baby at
    that time, some may want to hold their baby.
    Treat them with respect. If the parents do not
    wish to see the baby, the baby should be baptized
    (if parents are Catholic), pictures taken,
    identification bands made out, foot prints taken,
    a lock of hair cut, and a weight and length
    recorded. This information is given to the family
    in a sealed envelope for them to open whenever
    they wish. If parents wish to hold the baby, give
    them some privacy and be near to answer any
    questions.
  • Post-partally, offer the parents to be
    transferred off the maternity unit, and allow the
    father to stay as much as possible. Call pastor,
    priest, or rabbi for support. Refer to support
    groups, such as Resolve, Share, or Compassionate
    Friends.
  • Studies have shown that parental grief after a
    stillbirth is aided if the parents name the baby,
    see the baby, hold the baby, and bury the baby.
  • BE COMPASSIONATE, IT IS OKAY TO CRY WITH THE
    FAMILY. TRY TO FORGET YOUR OWN DISCOMFORT IN
    ORDER FOR THE FAMILY TO EXPRESS THEIRS.

40
Complications of the Placenta
  • Placenta Previa
  • Placenta Abruptio
  • Placenta Accreta
  • Umbilical Cord Prolapse

41
Placenta Previa
  • Types
  • Low Implantation
  • Partial Previa
  • Complete Previa
  • PAINLESS VAGINAL BLEEDING in the 2nd-3rd
    Trimester
  • Dx
  • Ultrasound
  • Management
  • Hospitalized, Bedrest
  • Tocolysis, if contracting
  • C/Sec
  • NO VAGINAL EXAMS

42
Placenta Abruptio
  • DX
  • Fetal Distress
  • U/S or CAT Scan
  • Treatment
  • Emergency C/Sec
  • Types
  • Covert/Concealed
  • Overt/Partial
  • Overt/Complete
  • Symptoms
  • Knife-like pain w/concealed
  • Shock
  • Varying amt. of bleeding

43
Placenta Accreta
  • Placenta adheres to uterine myometrium
  • It attaches itself too deeply into the lining of
    the uterus
  • Maternal hemorrhage is often severe
  • Does not respond to treatment for P/P hemorrhage
  • Often results in hysterectomy

44
Umbilical Cord Prolapse
  • Extremely critical obstetrical situation
  • Cord protudes from cervix into vagina
  • Seen in breech and when presenting part is
    unengaged
  • Position Mom
  • Knee-chest, Trendelenburg, elevate hips
  • Sterile gloved handhold presenting part off cord
  • EMERGENCY C/SECTION, O2, ?IV flow rate

45
Other Complication Amniotic Fluid Embolism
  • Symptoms
  • Restlessness
  • Chills
  • Pallor
  • ? B/P, ?Pulse, ? Resp.
  • Dyspnea
  • Chest Pain
  • Pathophysiology
  • Amniotic fluid enters maternal circulation?
    pulmonary capillaries
  • Tiny emboli form ? pulmonary vasospasm ?Hypoxemia
    and Acute Right-sided Heart Failure
  • Vernix and Lanugo
  • DIC may develop

46
Amniotic Fluid Embolism
  • Medical Management
  • Drugs
  • Morphine
  • Aminophyllie
  • Digoxin
  • Cortisone
  • Nursing
  • Follow orders
  • Semi-fowlers position
  • Oxygen
  • Medication
  • Blood Products
  • I O
  • If undelivered? C/Sec
  • STAY WITH MOTHER if suspect AFE

47
  • Nurses must be alert to symptoms of what can go
    wrong and take initial steps to enhance the
    health of the mother and the baby.
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