N113 - High risk labor & delivery
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| Types of dysfunctional labor | Hypertonic, hypotonic, prolonged, precipitous
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| Hypertonic labor pattern | Usually occurs during early stage of labor, less 4cm dilated. Contractions are frequent and resting time between & intensity is decreased. Pain > effectiveness of contractions = lactic acid cycle.
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| Goal of hypertonic labor | Stop or slow down contractions, with the hope of establishing more effective uterine activity.
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| Hypertonic labor treatment | Bedrest & sedation, IV fluids, may use oxytocin &/or ROM if pattern continues
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| Hypotonic labor pattern | Infrequent contractions, occurs after 4 cm dilation, mild to moderate intensity, fetal descent & cervical dilation slows, less intense & less productive.
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| Hypotonic labor causes | Overstretched uterus, sedation, CPD - cephalopelvic disproportion
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| Hypertonic labor treatment | Pitocin, steadily increase dosage until contractions are 2-4 min apart lasting 40-60 seconds
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| Pitocin half-life | 2-3 minutes
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| Pitocin uses | To induce labor or regulate contractions
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| Pitocin side effects | Contractions closer than 2 minutes, intensity >90 mm Hg (Mercury), duration >90 seconds, resting tone >20 mm Hg, either felt by palpation or intrauterine catheter. Fetal tachycardia, bradycardia, late decels, altered variability
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| Prolonged labor | Lasting longer than 24 hrs, failure of cervix to dilate, need to prevent maternal & fetal complications
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| Prolonged labor causes | Cephalopelvic disproportion, fetal malposition
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| Prolonged labor complications | Maternal - uterine atony, exhaustion, risk for uterine rupture, infection, hemorrhage
Fetal - reduced fetal perfusion, fetal asphyxia
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| Prolonged labor treatment | Identify cause &/or complications, stimulate with oxytocin or ROM, birth by c-section if severe maternal/fetal distress
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| Precipitous labor & delivery | Rapid labor that lasts less than 3 hours
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| Precipitous labor causes | Rapid cervical dilation & fetal descent, exceptionally strong contractions, multiparity, large pelvis, small fetus in favorable position
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| Precipitous labor risks | Uterine rupture, postpartum hemorrhage, amniotic fluid embolism, cervical & perineal tears, rapid change in pressure on fetus can lead to cerebral trauma
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| Precipitous labor treatment | May use MgSO4 (magnesium sulfate) to slow contractions. Can occur with oxytocin overdose
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| Preterm labor | 20-37 weeks, documented uterine contractions 4 in 20 minutes &/or ruptured membranes, documented cervical change or effacement of 80%, dilation of 2 cm
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| Preterm labor contributing factors | Infection, placenta previa, abruptio, history of abortion, abdominal surgery, PIH, incomplete cervix, smoking, maternal age, multiple gestation
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| Preterm labor risks | Maternal - Psychological - concern for baby, Infection r/t PROM, risks r/t tocolytics & bedrest.
Fetal - Immaturity of organs, Intraventricular hemorrhage, high mortality
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| Preterm labor management | Early detection is key. Stop labor if - no cervical dilation, fetus is viable, no s/s of fetal distress, no medical or obstetrical disorders
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| Preterm labor - other managing factors | Bedrest, hydration - dehydration will cause uterus to constrict, medications
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| When preterm labor that shouldn't be stopped | Severe PIH, fetal anomalies that are incompatible with life, chorioamnionitis - infection in amnionic fluid, hemorrhage, fetal death, severe abruptio placenta, severe fetal growth restriction
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| When it might be okay to stop preterm labor | Dilation of 5 cm or more, mild chronic hypertension, stable placenta previa, uncontrolled DM, maternal cardiac disease, fetal distress, fetal anomaly
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| Ritodrine - Yutopar | Beta adrenergic tocolytic - not used very often due to severe and numerous side effects
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| Terbutaline sulfate - Brethine | Used more commonly, off label use if beta adrenergic drug - bronchodilator. Better tolerated, few side effects.
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| Terbutaline sulfate, Brethine dosage | Started subq then given PO or IV
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| Magnesium sulfate | Fewer side effects than beta adrenergics, given IV at lowest rate
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| Magnesium sulfate side effects | Loading dose can cause flushing, warmth, headache, nausea, dizziness, nystagmus. Must watch for decreased deep tendon reflexes - clonus
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| Magnesium sulfate contraindications | Respiration rate must be greater than 12/min, urine output must be at least 100ml/q4hr.
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| Calcium gluconate | Given to reverse side effects of magnesium sulfate.
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| Magnesium sulfate fetal effects | Hypotonia - sluggish, floppy baby
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| Betamethasone celestone | Steroid given to increase lung maturity. Given only if labor can be delayed 24-48 hours.
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| Betamethasone celestone contraindications | Inability to delay birth, maternal infection, DM, hypertension. May increase risk of pulmonary edema if used with tocolytics.
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| Prolapsed umbilical cord | Cord falls or is washed through cervix into vagina. Risk increased with breech birth, small fetus, long cord, hydraminos, multiple gestation
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| Prolapsed umbilical cord treatment | 1-Reposition-knee chest position or Trendelenburg, 2-give O2, 3-Gloved finger in vagina to lift fetal head off cord.
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| Post-term pregnancy, labor & birth | Extends beyond 42 weeks or 294 days
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| Post-term risks | Maternal-dysfunctional labor r/t macrosomia, lacerations, labor induction, forceps or vacuum assist, c-section.
Fetal-birth trauma, asphyxia r/t birth trauma, effects r/t aging placenta, cord compression r/t decreasing amniotic fluid volume
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