Childbirth at Risk Chapter 21

Dystocia Disruption of labor Emotional factors Contractions Fetus Pelvis Relation between pelvis and fetus

Contractions Hypertonic (latent) labor- irregular in strength and timing Do not change cervix. Tx- augmentation Hypotonic (active) labor-less than 2-3 ucs in 10 minutes. Due to overdistention

Nursing Assessment Contractions FHT Coping Dehydration Fluid Infection

Post term Pregnancy Past 42 wks Associate with LGA, assisted delivery, oligo, mec aspiration, decrease perfusion After 40 weeks need NST, BPP X2 q week

Malposition OP common malposition -most rotate May visualize depression in maternal abdomen above symphysis Change positions- pelvic rocking, hand knees Assess for extreme back pain

Malpresentation Brow-widest diameter. Face wks Heart tones high Risk for prolapse T-lie- r/t multiparity, ECV Compound presentation

Macrosomia Greater than 4000 gms, risk for dystocia McRoberts, suprapubic pressure Greater than 4500 plan C/S Assess for Erb’s, motor problem Maternal risk for PPH “Falling off” the labor curve

Multiple Gestation High risk, type of multiple gestation determines risk Associated with PIH, PTL, previa, malpresentation Need NST, BPP, serial UTZ Many need bed rest

Intrauterine Resuscitation Decreased uterine placental flow NSG- turn to L lat, IV fluids, give 02 Correct maternal hypotension Turn off pit Explain to family

IUFD Perinatal death after 20 weeks Can cause DIC. Thromboplastin activates clotting system FIB., and factor V and VII are depleted DX confirmed by Spaulding’s sign, estriol levels, no heart tones

Parents of Stillborn Protest, refuse to believe. Disorganization Reorganization- time frame varies Use checklist Give mementos

Abruptio Placentae Cause may be decrease in blood flow. Marginal- at edges, may bleed vaginally Central-separates centrally, concealed Complete- massive bleed total separation S/S include rigid abdomen, constant pain

Abruption Retroplacental clotting can prompt release of thromboplastin, lead to DIC With severe abruption mortality 100% Eval. fibrinogen and platelets Often uterine resting tone is elevated

Placenta Previa Located in lower uterine segment, may cover whole os, or portion. NO VE With dilatation and ucs villi are torn from uterus and leave sinus exposed Hemorrhage can cause fetal hypoxia Painless bright red blood Assess fetal response to blood loss

Prolapsed Cord Cord presents before fetus, vessels occluded Monitor FHT following SROM or with amniotomy X 1min If feel cord push up head to relieve pressure Knee chest-Trendelenburg to OR Preventative- make sure head is engaged

Amniotic Fluid Emboli Break in chorion or amnion can allow amniotic fluid to enter maternal system Uterus forces emboli from circulation to lung S/S Give 02, CPR, ABO

Hydramnios Cause unknown, r/t with fetal anomalies. Rh sensitization, DM, multiple gestations Fetus swallows and urinates amniotic fluid Associated with SOB, edema Abruption if size of uterus reduced quickly Nursing- increase in fundal hgt, FHTs

Oligohydramnios Associated with IUGR, postmaturity, renal, kidney, uterine placental insufficiency Restricts fetal movement, effects lungs, cord compression. Increase fetal surveillance Amnioinfusion Reposition

CPD Head larger than pelvis Assess diagonal conjugate Bulging perineum and crowning indicate imminent delivery Fetus will not descend Fall off the labor curve Position change

Lacerations First degree- perineal skin, fourchette, vaginal mucous Second- skin underlying fascia, muscle Third-anal sphincter, ant. wall of rectum Fourth- through rectal mucousa to lumen