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Complicated Obsterics 2

Complications during labor and delivery

  1. Dystocia
    1. Definition
      1. painful, difficult, prolonged labor and birth resulting in failure to efface, and/or descend within an expected time frame
      2. fetal dystocia
      3. pelvic dystocia
      4. uterine dystocia
      5. hypotonicdysfunction
      6. hypertonic dysfunction
      7. CPD - cephalopelvic disproportion
    2. Data collection
      1. monitor uterine contraction frequency, intensity, duration
      2. observe effacement, dilitationand descent
      3. observe uterine resting tone for hypertonus
      4. monitor fetal heart rate for non-reassuring pattern
      5. observe fetal presenting part for molding, asyncliticism
      6. monitor maternal coping skills
      7. monitor amniotic fluid
    1. Management
      1. establish cause for dystocia
        1. powers
        2. passage
        3. passenger
        4. maternal position
        5. psychologic responses
      2. treat cause of dystocia for vaginal delivery
      3. prepare for cesarean birth if approrpriate
    2. Nursing interventions
      1. evaluate fetal status for size, position and reassuring heart rate
      2. evaluate pelvic parameters for adequacy, empty bladder
      3. evaluate uterine activity for frequency, intensity and duration
      4. provide sedation and rest if appropriate in latent phase, ambulation in active phase, maternal repositioning to turn fetal head position, and hydration
      5. prepare for pitocinaugmentation if in active phase
      6. provide adequate physical and emotional support for pain
      7. provide pain relief if appropriate
      8. prepare for cesarean birth if appropriate
      9. prepare for shoulder dystocia if macrosomic
      10. prepare for neonatal resuscitation if necessary
    3. Evaluation
      1. progress toward birth is made hourly
      2. maternal and fetal status reflect well-being
      3. monitor maternal and fetal status closely post delivery
  2. Emergency birth
    1. Definitions
      1. birth of the newborn in the absence of expected health care provider (health care provider and/or midwife)
      2. precipitouslabor
      3. precipitous birth
    2. Data collection
      1. assess contractions for excessively strong (tetanic-like) frequency (tachysystole), or excessively long contractions
      2. review history for previous precipitous labor
      3. assess for lax maternal soft tissue or large pelvis
      4. assess for SGA or preterm fetus
      5. primigravidacervical dilatation > 5 cm/hr
      6. multigravidacervical dilatation > 10 cm/hr
      7. rapid fetal descent
      8. increased bloody show, initiation of and strong expulsive efforts
    1. Management
      1. safe conduct of birth with minimal maternal soft tissue trauma
      2. safe conduct of birth with minimal fetal trauma
      3. preparation for neonatal resuscitation and stabilization
      4. anticipation of postpartum hemorrhage
    2. Nursing interventions
      1. constant nursing attendance at bedside and monitor mother and fetal heart rate (FHR)
      2. notification of appropriate health care provider
      3. preparation for emergency delivery (supplies and personnel)
      4. emotional and physical support of client
      5. discontinue oxytocin if being administered
      6. neonatal resuscitation prepared
      7. support of perineum and allow gradual extension, restitution and shoulder delivery, be prepared for cord around the neck
      8. delivery of newborn by most qualified personnel
      9. medication available for postpartum hemorrhage
      10. support parental-newborn attachment
      11. prepare for and assist placental delivery if separating
    3. Evaluation
      1. maternal condition supported
      2. maternal trauma to soft tissue minimized
      3. newborn stabilized
      4. minimal newborn trauma
      5. adequate post-delivery care for mother and newborn
  3. Prolapsed cord
    1. Definitions
      1. displacement of the umbilical cord in front of presenting part
      2. classifications:
        1. funic
        2. occult
        3. first degree - into vagina
        4. second degree - through introitus
      3. historical data predisposes to prolapse
    2. Data collection
      1. note characteristic, color and nature of amniotic fluid when membranes rupture
      2. vaginal examination for location of presenting part
      3. observe for fetal non-reassuring heart rate: severe variables or bradycardia
      4. palpate or observe for umbilical cord if bradycardia occurs
      5. monitor for moderate to variable decelerations of fetal heart rate
    1. Management
      1. maintain placental perfusion
      2. maintain cord circulation
      3. provide for expeditious delivery
      4. assemble and prepare for newborn resuscitation
    2. Nursing intervention
      1. vaginal examination and dislodge presenting part to relieve cord pressure
      2. trendelenberg or elevation of hips on pillows to maintain fetal position
      3. tocolysistherapy may be given
      4. initiate intrauterine resuscitation:
        1. oxygen therapy
        2. fluid bolus
        3. side-lying position

                                                                                                    iv.            placental perfusion maintained

        1. do not manipulate or replace cord related to vasospasms
        2. immediate notification of health care provider
        3. prepare for newborn resuscitation
        4. prepare for most expeditious birth - vaginal or cesarean
        5. provide for physical and emotional needs of parents in a calm environment
      1. Evaluation
        1. provide care to avoid prolapse of cord
        2. respose to prolapse is efficient and effective
        3. fetal well-being is maintained
        4. newborn resuscitation is prepared