Complicated Obsterics 2
Complications during labor and delivery
Dystocia
Definition
painful, difficult, prolonged labor and birth resulting in failure to efface, and/or descend within an expected time frame
fetal dystocia
pelvic dystocia
uterine dystocia
hypotonic dysfunction
hypertonic dysfunction
CPD - cephalopelvic disproportion
Data collection
monitor uterine contraction frequency, intensity, duration
observe effacement , dilitation and descent
observe uterine resting tone for hypertonus
monitor fetal heart rate for non-reassuring pattern
observe fetal presenting part for molding , asyncliticism
monitor maternal coping skills
monitor amniotic fluid
Management
establish cause for dystocia
powers
passage
passenger
maternal position
psychologic responses
treat cause of dystocia for vaginal delivery
prepare for cesarean birth if approrpriate
Nursing interventions
evaluate fetal status for size, position and reassuring heart rate
evaluate pelvic parameters for adequacy, empty bladder
evaluate uterine activity for frequency, intensity and duration
provide sedation and rest if appropriate in latent phase, ambulation in active phase, maternal repositioning to turn fetal head position, and hydration
prepare for pitocin augmentation if in active phase
provide adequate physical and emotional support for pain
provide pain relief if appropriate
prepare for cesarean birth if appropriate
prepare for shoulder dystocia if macrosomic
prepare for neonatal resuscitation if necessary
Evaluation
progress toward birth is made hourly
maternal and fetal status reflect well-being
monitor maternal and fetal status closely post delivery
Emergency birth
Definitions
birth of the newborn in the absence of expected health care provider (health care provider and/or midwife)
precipitous labor
precipitous birth
Data collection
assess contractions for excessively strong (tetanic-like) frequency (tachysystole), or excessively long contractions
review history for previous precipitous labor
assess for lax maternal soft tissue or large pelvis
assess for SGA or preterm fetus
primigravida cervical dilatation > 5 cm/hr
multigravida cervical dilatation > 10 cm/hr
rapid fetal descent
increased bloody show , initiation of and strong expulsive efforts
Management
safe conduct of birth with minimal maternal soft tissue trauma
safe conduct of birth with minimal fetal trauma
preparation for neonatal resuscitation and stabilization
anticipation of postpartum hemorrhage
Nursing interventions
constant nursing attendance at bedside and monitor mother and fetal heart rate (FHR)
notification of appropriate health care provider
preparation for emergency delivery (supplies and personnel)
emotional and physical support of client
discontinue oxytocin if being administered
neonatal resuscitation prepared
support of perineum and allow gradual extension, restitution and shoulder delivery, be prepared for cord around the neck
delivery of newborn by most qualified personnel
medication available for postpartum hemorrhage
support parental-newborn attachment
prepare for and assist placental delivery if separating
Evaluation
maternal condition supported
maternal trauma to soft tissue minimized
newborn stabilized
minimal newborn trauma
adequate post-delivery care for mother and newborn
Prolapsed cord
Definitions
displacement of the umbilical cord in front of presenting part
classifications:
funic
occult
first degree - into vagina
second degree - through introitus
historical data predisposes to prolapse
Data collection
note characteristic, color and nature of amniotic fluid when membranes rupture
vaginal examination for location of presenting part
observe for fetal non-reassuring heart rate: severe variables or bradycardia
palpate or observe for umbilical cord if bradycardia occurs
monitor for moderate to variable decelerations of fetal heart rate
Management
maintain placental perfusion
maintain cord circulation
provide for expeditious delivery
assemble and prepare for newborn resuscitation
Nursing intervention
vaginal examination and dislodge presenting part to relieve cord pressure
trendelenberg or elevation of hips on pillows to maintain fetal position
tocolysis therapy may be given
initiate intrauterine resuscitation:
oxygen therapy
fluid bolus
side-lying position
iv. placental perfusion maintained
do not manipulate or replace cord related to vasospasms
immediate notification of health care provider
prepare for newborn resuscitation
prepare for most expeditious birth - vaginal or cesarean
provide for physical and emotional needs of parents in a calm environment
Evaluation
provide care to avoid prolapse of cord
respose to prolapse is efficient and effective
fetal well-being is maintained
newborn resuscitation is prepared