Exam 9: Special Situations in L&D
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| Amniotomy | rupture of the membranes (amniotic sac) by using a
disposable plastic hook (Amnihook).
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| Amniotomy: Indications | : usually performed in conjunction with induction and augmentation of labor
and to allow internal electronic fetal monitoring.
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| Amniotomy: Risks | Prolapse of umbilical Cord
Infection
Abrupto Placentae
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| Amniotomy: Nursing Considerations | MONITOR FHR for 1 MIN!!!
Record fluid
Take Mom's Temp
Peri-Care
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| Induction of Labor | Artificial initiation of labor
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| Augmentation of Labor | artificial stimulation of contractions that have begun
spontaneously but progress has slowed or stopped, even if contractions seem to be adequate.
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| Reasons to Induce Labor | Intrauterine hostile environment.
Hypertension.
PROM
Post-term Pregnancy
Chorioamnionitis
Abrupto Placenta
Maternal Medical Conditions
Fetal Death
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| Cervical ripening | procedures to ripen (soften) the cervix and make it more likely to
dilate with the forces of labor; usually done the day before the scheduled induction
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| Cervical ripening: Medical Methods | -prostaglandin E2: may be given as an intravaginal gel, an intracervical gel or a timed released vaginal insert.
I-V oxytocin (Pitocin)
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| Mechanical methods | laminaria tents
foley bulb
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| most common drug given for induction and augmentation of labor. | Pitocin (oxytocin)
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| Pitocin (oxytocin): Risks | Hypertonic uterine activity.
Uterine Rupture
Maternal Water Intoxication
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| Pitocin (oxytocin): Nursing Interventions | Steps to reduce uterine activity.
Reduce or stop infusion.
Keep woman off her back.
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| Pitocin (oxytocin): Nursing Considerations | Hypertonic Reactions can reduce placental bloodflow.
Baseline VS.
Monitor FHR q 15mins during 1st stage, q5 mins during 2nd stage.
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| External cephalic version (ECV) | changes fetal position from a breech, shoulder (transverse lie), or oblique
presentation; successful ECV may avoid need for a C section
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| Internal Version | malpresentation in twin gestations is usually managed by C section,
but internal version is sometimes used for vaginal birth of second twin. A fetal part (usually a leg or foot) is grasped through the cervix and used to turn and deliver the infant.
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| Version: Contraindications | Uterine Malformations.
Previous C section.
Fetal size ≥ 4000g
Disproportion between fetus and pelvis.
Placenta Previa.
Multifetal gestation.
Ruptured membranes or cord around body or neck.
Uteroplacental insufficiency.
Fetus head into pelvis.
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| Version: Risks | Fetus entangled in umbilical cord.
Abrupto Placentae.
Fetal and maternal blood mix.
C-section for fetal compromise.
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| Operative vaginal births | (forceps or vacuum extractor) may be used by physician to apply traction to
the head during birth, to aid expulsive efforts.
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| Forceps | curved, metal instruments with two curved blades that can be locked in the
center.
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| Piper forceps | special type used to deliver the fetal head during a breech
delivery.
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| Vacuum extractor | suction to grasp the fetal head while traction is applied
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| Episiotomy | the surgical enlargement of the vagina during birth
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| Lacerations | a tear in the perineum, vagina or cervix
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| Classifications: 1st and 2nd degree laceration | usually uncomplicated and heal quickly because they don’t affect the rectal sphincter.
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| Classifications: 3rd degree laceration | extend to the rectal sphincter
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| Classifications: 4th degree laceration | extend completely through the rectal sphincter
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| Operative cesarean birth: Indications | Dystocia
Cephalopelvic disproportion
Hypertension
Maternal disease, if labor unadvisable
Active genital herpes
Prior cesarean or prior ABD Sx
Persistent non reassuring fetal heart rate patterns
Prolapsed umbilical cord
Fetal malpresentation
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| Problems with Powers of Labor | may not be adequate to expel the fetus because of
ineffective contractions or ineffective maternal pushing efforts.
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| HYPOtonic Labor Dysfunction | contractions are coordinated but too weak to be effective. The women
start off with normal labor then the contractions diminish in the active phase.
(During active phase of labor 4cm)
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| HYPERtonic Labor Dysfunction | contractions are uncoordinated and erratic in their frequency, duration,
and intensity. They are painful but ineffective. Usually occurs during the latent phase of labor.
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| Problems with the Passenger | Fetal Size.
Abnormal Fetal Presentation or Position.
Multi-fetal Pregnancy
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| Macrosomia | a large fetus, generally weighing over 4000 gm (8 lb 13 oz) or more at
Birth; head may be so large it can’t mold to the pelvis.
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| Shoulder dystocia | Delayed or difficult birth of the shoulders may occur as they become impacted
above the symphysis pubis. As the head emerges it retracts (“turtle sign”).
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| Abnormal Fetal Presentation or Position | an unfavorable fetal presentation or position
may interfere with cervical dilation or fetal descent.
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| Rotation abnormalities | persistence of the fetus in the occiput posterior or occiput transverse position can contribute to dysfunctional labor.
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| Deflexion abnormalities | poorly flexed fetal head presents a larger diameter to the
pelvis than if flexed with chin on chest
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| Breech presentation | Cervical dilation and effacement slower because the buttocks or
feet do not form a smooth, round dilating wedge like the head
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| Trial of labor if... | a. Maternal pelvis is normal size and shape
b. Estimated fetal weight is 2000 to 3800 g (4.4 to 8.4 lb)
c. The fetal head is well flexed
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| Problems associated with a breech birth | a. Fetal injury
b. Prolapsed umbilical cord
c. Low birth weight due to preterm gestation, multifetal pregnancy, or
intrauterine growth restriction
d. Fetal anomalies
e. Complications secondary to placenta previa or cesarean birth
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| Problems with the Passage: Pelvis (Small) | A small or abnormally shaped pelvis may retard labor and obstruct fetal passage
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| Gynecoid | most common (50%) and most favorable for vaginal birth, pubic arch is wide.
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| Anthropoid | anteroposterior diameter is longer than the transverse diameter.
Narrow pubic arch
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| Android | heart or triangular-shaped inlet. Narrow pubic arch. Poor prognosis for
vaginal delivery (incidence 30%).
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| Platypelloid | flattened: wide, short, and oval. Transverse diameter wide but anteroposterior diameter short. Poor prognosis for vaginal delivery (incidence 3%).
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| Problems of the Psyche: excessive or prolonged stress interferes | ↑ glucose consumption, ↓ energy supply to contracting uterus.
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| Prolonged Labor | results from problems with any of the factors in the birth process
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| Average rate of cervical dilation in the active labor phase is: | 1.2 cm/hr in the nullipara, and 1.5 cm/hr in the parous woman.
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| Precipitate Labor | a labor that is completed in less than 3 hours
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| PROM (premature rupture of membranes) | rupture of the amniotic sac before onset of true labor.
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| PPROM (preterm, premature rupture of the membranes) | rupture of membranes earlier than the end of the 37th week of gestation, with or without contractions. Associated with preterm labor and birth.
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| Chorioamnionitis | Inflammation of the amniotic membranes caused by infection.
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| Complications with PROM | Chorioamnionitis
Oligohydramnios
Umbilical cord compression
Reduced lung volume and deformities
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| Oligohydramnios | deficiency in the amount of amniotic fluid.
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| Preterm Labor (PTL) | after 20 and before the end of the 37th week (38 weeks) gestation
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| Signs and symptoms of PTL | (a)Contractions that may or may not be painful.
(b)baby is “balling up” frequently.
(c)Menstrual-like cramps.
(d)Constant low backache.
(e)Pelvic pressure.
(f)change in vaginal discharge.
(g)ABD cramps.
(h)Pain, discomfort, or pressure.
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| Predicting Preterm Birth | Short cervical length.
Previous preterm birth.
Positive fetal fibronectin (fFN) screening result after 22 weeks.
Infection.
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| Accelerating fetal lung maturity: Meds | Corticosteroids (if before 34 weeks inevitable).
Dexamethasone and betamethasone (24 to 34 weeks of gestation)
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| Prolonged pregnancy | longer than 42 weeks
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| Prolonged pregnancy: Fetal | placenta ages it delivers oxygen and nutrients to the fetus less efficiently.
Growth Retardation.
Meconium.
Oligohydramnios.
If placenta is not functioning efficiently the fetus will not tolerate labor.
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| Prolonged pregnancy: Maternal | added fatigue diminishes resources for tolerating more stress and anxiety
about labor and birth as she feels as though the pregnancy will never end.
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| Prolapsed umbilical cord | the cord slips downward after the membranes rupture, subjecting it to
compression between the fetus and pelvis.
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| Prolapsed umbilical cord: Complete | the cord can be seen protruding from the vagina.
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| Prolapsed umbilical cord: In front of head | cord cannot be seen but it can be felt as a
pulsating mass during vaginal exam.
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| Prolapsed umbilical cord: occult (Hidden) | the cord is compressed between the fetal presenting part and pelvis
but cannot be seen or felt during vaginal exam.
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| Prolapsed umbilical cord: Management | Position:
Knee-chest.
Trendelenburg.
Hips elevate with pillows, with side-lying maintained.
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| Uterine rupture: | a tear in the uterine wall that occurs if the uterine muscle cannot withstand the
pressure against it. May precede labor’s onset.
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| Uterine rupture: Complete | a direct communication between the uterine and peritoneal cavities.
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| Uterine rupture: Incomplete | a rupture into the peritoneum covering the uterus or into the broad ligament but not the peritoneal cavity.
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| Uterine rupture: Dehiscence | a partial separation of an old uterine scar. Little or no bleeding may
occur. No signs or symptoms may exist and the rupture may be found incidentally during a subsequent C section or other abdominal surgery.
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| Uterine rupture: Causes | Previous uterine Sx.
high parity w/ a thin uterine wall.
Intense contractions may exceed uterine wall strength.
Blunt ABD trauma.
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| Uterine rupture: S/S | Asymptomatic
Hypovolemic shock
ABD pain and tenderness.
Chest pain (d/t blood below diaphragm).
Cessation of contractions.
Abnormal FHR.
Palpation of fetus outside of uterus.
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| uterine Inversion | Occurs when the uterus completely or partly turns inside out, usually during 3rd stage of labor.
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| Uterine Inversion: Causes | Fundal pressure during birth.
Pulling on the umbilical cord before the placenta detaches from the uterine wall.
Fundal pressure on an incompletely contracted uterus after birth.
Abnormally adherent placenta
Uterine weakness
Fundal placenta implantati
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| Uterine Inversion: S/S | Absent uterus from the abdomen or a depression in the fundal area
Protrusion of the interior of the uterus into the vagina or through cervix
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| Amniotic fluid embolism | occurs when amniotic fluid, with its particles such as vernix, fetal hair, and
sometimes meconium, is drawn into the maternal circulation and obstructs pulmonary vessels.
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| Trauma | due to accidents, assault, or suicide.
Battering is a significant cause of trauma during pregnancy.
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