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N113 Risky Labor

N113 - High risk labor & delivery

Types of dysfunctional labor Hypertonic, hypotonic, prolonged, precipitous
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.
Goal of hypertonic labor Stop or slow down contractions, with the hope of establishing more effective uterine activity.
Hypertonic labor treatment Bedrest & sedation, IV fluids, may use oxytocin &/or ROM if pattern continues
Hypotonic labor pattern Infrequent contractions, occurs after 4 cm dilation, mild to moderate intensity, fetal descent & cervical dilation slows, less intense & less productive.
Hypotonic labor causes Overstretched uterus, sedation, CPD - cephalopelvic disproportion
Hypertonic labor treatment Pitocin, steadily increase dosage until contractions are 2-4 min apart lasting 40-60 seconds
Pitocin half-life 2-3 minutes
Pitocin uses To induce labor or regulate contractions
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
Prolonged labor Lasting longer than 24 hrs, failure of cervix to dilate, need to prevent maternal & fetal complications
Prolonged labor causes Cephalopelvic disproportion, fetal malposition
Prolonged labor complications Maternal - uterine atony, exhaustion, risk for uterine rupture, infection, hemorrhage Fetal - reduced fetal perfusion, fetal asphyxia
Prolonged labor treatment Identify cause &/or complications, stimulate with oxytocin or ROM, birth by c-section if severe maternal/fetal distress
Precipitous labor & delivery Rapid labor that lasts less than 3 hours
Precipitous labor causes Rapid cervical dilation & fetal descent, exceptionally strong contractions, multiparity, large pelvis, small fetus in favorable position
Precipitous labor risks Uterine rupture, postpartum hemorrhage, amniotic fluid embolism, cervical & perineal tears, rapid change in pressure on fetus can lead to cerebral trauma
Precipitous labor treatment May use MgSO4 (magnesium sulfate) to slow contractions. Can occur with oxytocin overdose
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
Preterm labor contributing factors Infection, placenta previa, abruptio, history of abortion, abdominal surgery, PIH, incomplete cervix, smoking, maternal age, multiple gestation
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
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
Preterm labor - other managing factors Bedrest, hydration - dehydration will cause uterus to constrict, medications
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
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
Ritodrine - Yutopar Beta adrenergic tocolytic - not used very often due to severe and numerous side effects
Terbutaline sulfate - Brethine Used more commonly, off label use if beta adrenergic drug - bronchodilator. Better tolerated, few side effects.
Terbutaline sulfate, Brethine dosage Started subq then given PO or IV
Magnesium sulfate Fewer side effects than beta adrenergics, given IV at lowest rate
Magnesium sulfate side effects Loading dose can cause flushing, warmth, headache, nausea, dizziness, nystagmus. Must watch for decreased deep tendon reflexes - clonus
Magnesium sulfate contraindications Respiration rate must be greater than 12/min, urine output must be at least 100ml/q4hr.
Calcium gluconate Given to reverse side effects of magnesium sulfate.
Magnesium sulfate fetal effects Hypotonia - sluggish, floppy baby
Betamethasone celestone Steroid given to increase lung maturity. Given only if labor can be delayed 24-48 hours.
Betamethasone celestone contraindications Inability to delay birth, maternal infection, DM, hypertension. May increase risk of pulmonary edema if used with tocolytics.
Prolapsed umbilical cord Cord falls or is washed through cervix into vagina. Risk increased with breech birth, small fetus, long cord, hydraminos, multiple gestation
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.
Post-term pregnancy, labor & birth Extends beyond 42 weeks or 294 days
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
Created by: jrb265