Maternal-Neonatal Nursing

complications of labor & birth

16th & 17th Lectures

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Dystocia

Dystocia is “Difficult Labor” prolonged or abnormal labor/FAILURE TO PROGRESS IN LABOUR

It primarily results from one of four problems

Powers-abnormal uterine activity, ineffective contractions

Passageway- abnormal pelvic shape

Passenger-abnormal fetal size or presentation

Psyche-inadequate support, maternal stress & anxiety

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CEPHALOPELVIC DISPROPORTION (CPD)

A contracted or narrow diameter in birth passage especially if fetus is larger than the maternal pelvic diameters.

Implications: Maternal: prolonged labor, arrest of descent, uterine rupture, forceps-assisted birth with trauma

Implications: Fetal: cord prolapse, excessive molding of head, birth trauma to skull and CNS

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Nursing diagnoses r/t dysfunctional labor

Anxiety r/t slow progress of labor

Fatigue r/t the length of labor

Ineffective individual coping r/t inability to relax

Fluid volume deficit r/t lack of fluid intake

Risk for Infection r/t prolonged labor

Sleep pattern disturbance r/t maternal exhaustion and inability to relax

Knowledge deficit r/t potential fetal distress and fetal sepsis

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Management of Labor Dystocia

Augmentation of labor-use of drugs to enhance labor that has already begun

Amniotomy

Oxytocin Augmentation

Assisted and Operative Delivery

Vacuum - Assisted Delivery

Forceps Delivery

Cesarean Birth

Oxytocin induction & augmentation

Prior to administration of oxytocin a full assessment is preformed to determine cervical status, FHR, fetal presentation and station. The woman is placed on continous EFM

Oxytocin is administer IV through a controlled infusion pump and diluted in an intravenous solution

Vital signs are recorded frequently

Urinary out put is recorded as urine out put can decrease and water can be retained (maternal water intoxication)

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Side effects of oxytocin administration

Water intoxication- headache, nausea & vomiting, decreased urinary output, hypertension, tachycardia and cardiac arrhythmias

Hyperstimulation of the uterus

Uterine rupture

A rapid labor with potential uterine or cervical lacerations

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Nursing interventions when administering oxytocin

Observe for signs of water intoxication Changes in FHR-non reassuring FHR Contractions lasting longer than 90 seconds

with frequency of 1 minute Assess cervical dilation and progression of

labor If non reassuring FHR occurs or

hyperstimulation of the uterus occurs the infusion is stopped immediately and MD informed

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Contraindications for the induction of labor

Previous classic uterine incision

Cephalopelvic disproportion

Placentia previa

Active genital herpes

Preterm fetus

Fetal malposition-breech

Multiple gestations

Nonreassuring fetal status

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Case 1

You are working at the ED. A G9P2 patient presents to the department. Her water broke 1 hour ago, she is having frequent contractions and she feels the head coming out.

A delivery tray is available and the patient is in lithotomy position. She is pushing with each contraction and the baby’s head starts to come out.

However, with each push, the baby’s head comes out and then retracts back in towards the perineum. You quickly recognize this as the sign of shoulder dystocia. dr.Shaban 10

Shoulder Dystocia

be defined by a prolonged head-to-body delivery time (> 60 s) due to impaction of the fetal shoulders within the maternal pelvis

Risk factors: macrosomia, post-term, maternal obesity

Maternal morbidity: 4th degree perineal, cervical & vaginal lacerations, bladder injury, postpartum hemorrhage, endometritis

Fetal morbidity: brachial plexus injury, clavicular fracture, facial nerve paralysis, asphyxia, CNS injury, death

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ERB or brachial plexus

Shoulder Dystocia-Management

Obstetrical Maneuvers

Rotation and Delivery of Posterior Shoulder

Maternal Position Change

Issue of Fundal Pressure

Episiotomy dr.Shaban 13

Case 2

You are working in a small ED and a 35 week G4P3 presents with ROM and contractions. She is quite distressed and thinks the baby is coming out. You perform a pelvic examination and next to the head you feel a pulsate cord…

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Prolapse of the umbilical cord

When the umbilical cord precedes the fetal presenting part it is said to be prolapsed, this can interfere with fetal circulation

Factors that contribute to prolapsed cord are

Rupture of membranes before head is engaged

Small fetus

Breech presentations and transverse lie

Hydramnios

Unusually long cord

Multifetal pregnancy

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Nursing actions to relieve prolapsed cord

Place woman’s hips higher than her head- knee-chest position, trendelenburg’s position, or side lying with hips elevated on a pillow

With a sterile glove push fetal presenting part away from cord

Give oxygen at 8 to 10 L/Min

Monitor FHR

Prepare for rapid vaginal or caesarian birth

If cord protrudes apply sterile saline soaked towels to prevent drying of the cord and maintain blood flow until infant is delivered dr.Shaban 16

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FETAL DISTRESS

Common causes: cord compression, uteroplacental insufficiency, placental abnormalities, meconium-stained amniotic fluid

Correct maternal hypotension and enhance uteroplacental blood flow

Change position that improves FHR,

Increase rate of IV

O2 via face mask

Decrease uterine activity: adm tocolytic

Perform vaginal exam (prolapsed cord?) dr.Shaban 18

Indications for operative vaginal delivery

Fetal Distress An irregular fetal heart beat Bradycardia, under 100 beats per minute,

between uterine contractions A rapid fetal heart - more than 160 beats per

minute The passage of Meconium in cephalic

presentations Maternal Conditions

Maternal distress or exhaustion: This is shown by dehydration, pulse above 100 and temperature.

Maternal disease: When the mother has cardiac disease, toxemia, forceps & vacuum can be used to shorten the second stage. dr.Shaban 19

Assisted and Operative Delivery- Vacuum

Mechanism: Suction and Traction used to assist delivery of presenting part.

Indication: Most commonly related to prolonged 2nd Stage of Labor.

Contraindications: Cephalopelvic Disproportion (CPD); Most malpresentations and malpositions; extreme prematurity.

Nursing Responsibility: FHR checks q 5 minutes; Hand held suction pump. Pressure release between UC’s; Assess neonatal head for Cephalohematoma after delivery.

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Assisted and Operative Delivery- Forceps Delivery

Mechanism: Traction and rotation of fetal presenting part with curved metal tongs.

Indication: Prolonged 2nd stage (> 3 hrs); maternal exhaustion;

Contraindications: Cephalopelvic Disproportion (CPD); Most malpresentations and malpositions.

Disadvantages: Maternal and fetal trauma (Caphalohematoma;Transient facial paralysis)

Nursing Responsibility: FHR checks q 5 minutes; obtain forceps; assess neonate and mother for trauma.

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Cesarean Birth Definition

a surgical incision made into the abdomen and uterus to deliver the fetus after 32 WK gestational age. It is called hysterotomy, if removal is done before 32 weeks of pregnancy

Types of Cesarean (Uterine) Incisions -Lower Uterine Segment (Low Transverse) -Classical (Vertical Midline)

Only L. Uterine Segment Cesareans allow a trial of labor with the next pregnancy.

Classical is used for emergency Cesareans or for some mal presentations.

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Uterine Incisions

Kerr Incision vs Sellheim Incision vs Classical

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Skin Incision

Transverse (Pfannenstiel)-lower uterine segment

Adv: below pubic hair line, less bleeding, better healing,cosmatic

Disadv: difficult to extend if needed, requires more time, if adipose fold difficult to keep clean and dry

Vertical-between naval and symphysis

Adv: quicker, more room

Disadv: scar obvious, longer dr.Shaban 27

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INDICATIONS FOR ELECTIVE CS

Known CPD

Fetal macrosomia > 4500 gm

Placenta previa

HIV

Active herpes

Repeat CS

Previous uterine surgery eg. Hystrotomy, myomectomy

Severe IUGR

Breech

Multiple pregnancy

Transverse lie

Ca of the Cx/ obstructing the birth canal

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INDICATIONS FOR EMERGRENCY CS

Severe PET,

Abruptio placntae, APH

Fetal distress

Failure to progress in the first stage of labour

Cord prolapse

Obstructed labour

Failed induction; failed vacuum or forcepes

Malpresentation brow, face, shoulder & compound presentations, breech

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COMPLICATIONS- Mother

INTRAOPERATIVE

Bleeding & the need for bld transfusion

Hysterectomy, Fetal injury

Complications of anesthesia

Damage to the bladder, ureter, colon , retained placental

POSTOPERATIVE

Gaseous distension, Paralytic ileus

Wound dehiscence & infection

Infections UTI, pulmonary

DVT & pulmonary embolism, Death

Longer hospital stay

Risk for maternal/infant attachment dr.Shaban 31

COMPLICATIONS-the baby

Premature birth. If the due date was not accurately calculated, the baby could be delivered too early.

Breathing problems. Babies born by cesarean are more likely to develop breathing problems such as transient tachypnea (abnormally fast breathing during the first few days after birth).

Low Apgar scores. dr.Shaban 32

Nursing care in the preoperative period

NP0

IV fluids

Insertion of urinary catheter

Medication may be given IV to prevent stomach irritation or aspiration

Consent is obtained

Pubic shave now not needed

Patient teaching and explanations of events

Assessment of FHR, maternal vital signs dr.Shaban 33

Nursing care intra-operative period

Skin preparations

Draping

COUNTS

Sterile field maintenance

Step 14: Uterus is closed in 2 layers

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Postoperative care

Monitor vital signs every 15 minutes for first hour, then every 30 mins in second hour then hourly until transferred to postpartum unit

Administer oxygen as ordered Assess fundus for firmness, height, location, massage

fundus if boggy Assess vaginal bleeding for color amount and

consistency Assess abdominal dressing for bleeding Assess urine output Change woman’s position Allow the mother to breast feed as soon as she wishes

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Postoperative care-Cont.

Women should be offered Pethidine (100mg im). Avoid over

sedation as this will limit mobility

If the woman is receiving IV fluids, they should be continued until she is taking liquids well. A liquid diet if bowel sounds are heard

Removal of the urinary bladder catheter should be carried out once a woman is mobile

Ambulation enhances circulation, encourages deep breathing and stimulates return of normal gastrointestinal function. Encourage foot and leg exercises and mobilize as soon as possible, usually within 24 hours

If the dressing comes loose, reinforce with more tape rather than removing the dressing. This will help maintain the sterility of the dressing and reduce the risk of wound infection .1st dressing changed by doctors .

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