child birth at risk 8
TRANSCRIPT
Copyright ©2011 by Pearson Education, Inc.All rights reserved.
Maternal & Child Nursing Care, Third EditionLondon • Ladewig • Ball • Bindler • Cowen
Childbirth at Risk: Prelabor Complications
Copyright ©2011 by Pearson Education, Inc.All rights reserved.
Maternal & Child Nursing Care, Third EditionLondon • Ladewig • Ball • Bindler • Cowen
Learning Outcome
Explain the possible causes, risk factors, and clinical therapy for premature rupture of the
membranes or preterm labor in determining the hospital-based and community-based nursing care
management of the woman and her fetus-newborn.
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Maternal & Child Nursing Care, Third EditionLondon • Ladewig • Ball • Bindler • Cowen
Premature Rupture of Membranes (PROM) is Spontaneous Rupture of the Membranes Before the
Onset of Labor
• Preterm PROM (PPROM) is the rupture of membranes occurring before 37 weeks’ gestation
• Although the exact cause is unknown, PPROM is associated with infection, previous history of PPROM, hydramnios, multiple pregnancy, and a variety of other pregnancies
Copyright ©2011 by Pearson Education, Inc.All rights reserved.
Maternal & Child Nursing Care, Third EditionLondon • Ladewig • Ball • Bindler • Cowen
Premature Rupture of Membranes (PROM) is Spontaneous Rupture of the Membranes Before the
Onset of Labor
• PROM nursing care focuses on prevention of infection such as limiting vaginal exams and changing the bed pads frequently
• The fetus is monitored carefully
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Maternal & Child Nursing Care, Third EditionLondon • Ladewig • Ball • Bindler • Cowen
Preterm Labor (PTL): Labor That Occurs Between 20 and 36 Completed Weeks of Pregnancy
• Women who are at risk for PTL are taught to recognize its symptoms to prevent it
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Maternal & Child Nursing Care, Third EditionLondon • Ladewig • Ball • Bindler • Cowen
Preterm Labor (PTL): Labor That Occurs Between 20 and 36 Completed Weeks of Pregnancy
• Nursing care: tocolysis, monitoring for progression of labor, maintaining good uterine blood flow, maintaining side-lying position, potential IV infusion, maternal laboratory studies including CBC, C-reactive protein, vaginal cultures, fetal fibronectin (fFN), urine culture and an ultrasound may be obtained to determine cervical shortening or funneling, as well as assess fetal well-being
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Maternal & Child Nursing Care, Third EditionLondon • Ladewig • Ball • Bindler • Cowen
Learning Outcome
Compare and contrast abruptio placentae and placenta previa, including implications for the mother and fetus and nursing care.
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Maternal & Child Nursing Care, Third EditionLondon • Ladewig • Ball • Bindler • Cowen
Types of Abruptio Placentae
• Marginal– Placenta separates at its edges– Blood passes between fetal membranes and
uterine wall– Blood escapes vaginally
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Maternal & Child Nursing Care, Third EditionLondon • Ladewig • Ball • Bindler • Cowen
Types of Abruptio Placentae
• Central– Placenta separates centrally– Blood trapped between placenta and uterine
wall– Concealed bleeding
• Complete– Total separation– Massive vaginal bleeding
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Maternal & Child Nursing Care, Third EditionLondon • Ladewig • Ball • Bindler • Cowen
Abruptio Placentae
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Maternal & Child Nursing Care, Third EditionLondon • Ladewig • Ball • Bindler • Cowen
Abruptio Placentae
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Maternal & Child Nursing Care, Third EditionLondon • Ladewig • Ball • Bindler • Cowen
Abruptio Placentae
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Maternal & Child Nursing Care, Third EditionLondon • Ladewig • Ball • Bindler • Cowen
Maternal Implications of Abruptio Placentae
• Intrapartum hemorrhage• DIC• Hypofibrinogenemia• Ruptured uterus from overdistention• Fatal hemorrhagic shock
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Maternal & Child Nursing Care, Third EditionLondon • Ladewig • Ball • Bindler • Cowen
Maternal Implications of Abruptio Placentae
• Postpartum complications– Vascular spasm– Intravascular clotting– Hemorrhage– Renal failure– Fatal shock
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Maternal & Child Nursing Care, Third EditionLondon • Ladewig • Ball • Bindler • Cowen
Differential Signs and Symptoms of Placenta Previa and Abruptio Placentae
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Maternal & Child Nursing Care, Third EditionLondon • Ladewig • Ball • Bindler • Cowen
Fetal-Neonatal Implications of Abruptio Placentae
• Sequelae of prematurity• Hypoxia• Anemia• Brain damage• Fetal demise
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Maternal & Child Nursing Care, Third EditionLondon • Ladewig • Ball • Bindler • Cowen
Nursing Plan for Abruptio Placentae
• Maintain two large-bore IV sites – fluids and blood products as ordered
• Monitor fetus and uterine activity electronically– Assess resting tone every 15 minutes– Assess fetal status every 15 minutes
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Maternal & Child Nursing Care, Third EditionLondon • Ladewig • Ball • Bindler • Cowen
Nursing Plan for Abruptio Placentae
• Monitor for signs of DIC• Monitor Intake & Output and urine specific
gravity• Measure abdominal girth hourly, as
ordered
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Maternal & Child Nursing Care, Third EditionLondon • Ladewig • Ball • Bindler • Cowen
Nursing Plan for Abruptio Placentae
• Assess maternal cardiovascular status frequently– Vital signs every 5-15 minutes– Skin color and pulse quality hourly– Measure CVP hourly, as ordered
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Maternal & Child Nursing Care, Third EditionLondon • Ladewig • Ball • Bindler • Cowen
Nursing Plan for Abruptio Placentae
• Review and evaluate diagnostic tests• Prepare for cesarean, as needed• Neonatal resuscitation, as needed• Provide information and emotional support
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Maternal & Child Nursing Care, Third EditionLondon • Ladewig • Ball • Bindler • Cowen
Categories of Placenta Previa
• Total: The internal os completely covered• Partial: The internal os partially covered• Marginal: The edge of the os covered• Low-lying placenta: Implanted in lower
segment in proximity to the os
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Maternal & Child Nursing Care, Third EditionLondon • Ladewig • Ball • Bindler • Cowen
Classification of Placenta Previa
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Maternal & Child Nursing Care, Third EditionLondon • Ladewig • Ball • Bindler • Cowen
Implications of Placenta Previa
• Maternal psychologic stress• Transverse lie common• Changes in FHR• Meconium staining• Fetal compromise (hypoxia)• Cesarean birth• Neonatal anemia
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Maternal & Child Nursing Care, Third EditionLondon • Ladewig • Ball • Bindler • Cowen
Nursing Plan for Placenta Previa
• No vaginal exams!• Objectively and subjectively assess blood
loss, pain, uterine contractility• Continuous external monitoring of FHR
and uterine activity – no internal monitoring
• Monitor maternal vital signs and Intake & Output – every 5-15 minutes with active hemorrhage
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Maternal & Child Nursing Care, Third EditionLondon • Ladewig • Ball • Bindler • Cowen
Nursing Plan for Placenta Previa
• Obtain/evaluate labs• Maintain large – bore IV access-available
whole blood setup• Verify family’s ability to cope with anxiety
of unknown outcome• Provide information and emotional support
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Maternal & Child Nursing Care, Third EditionLondon • Ladewig • Ball • Bindler • Cowen
Nursing Plan for Placenta Previa
• Promote neonatal physiologic adaptation– Resuscitation as needed– Evaluate hemoglobin, cell count, erythrocyte
count– Administer oxygen and blood as needed
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Maternal & Child Nursing Care, Third EditionLondon • Ladewig • Ball • Bindler • Cowen
Learning Outcome
Explain the maternal and fetal-neonatal implications and the clinical therapy in determining the community-based and
hospital-based nursing care management of the woman with multiple gestation.
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Maternal & Child Nursing Care, Third EditionLondon • Ladewig • Ball • Bindler • Cowen
Multiple Gestation
• Care of woman with more than one fetus includes:– Frequent assessment of fetal heart tones of
each fetus– Education of mother about signs and
symptoms of preterm labor
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Maternal & Child Nursing Care, Third EditionLondon • Ladewig • Ball • Bindler • Cowen
Multiple Gestation
• Care of woman with more than one fetus includes:– Encouragement of mother to rest frequently
prior to birth– Preparation of equipment needed to care for
each individual newborn
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Maternal & Child Nursing Care, Third EditionLondon • Ladewig • Ball • Bindler • Cowen
Presentations in Utero
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Maternal & Child Nursing Care, Third EditionLondon • Ladewig • Ball • Bindler • Cowen
Presentations in Utero
Copyright ©2011 by Pearson Education, Inc.All rights reserved.
Maternal & Child Nursing Care, Third EditionLondon • Ladewig • Ball • Bindler • Cowen
Presentations in Utero
Copyright ©2011 by Pearson Education, Inc.All rights reserved.
Maternal & Child Nursing Care, Third EditionLondon • Ladewig • Ball • Bindler • Cowen
Learning Outcome
Compare the identification, maternal and fetal-neonatal implications, clinical therapy, and nursing care management of women
with hydramnios and oligohydramnios.
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Maternal & Child Nursing Care, Third EditionLondon • Ladewig • Ball • Bindler • Cowen
Implications of Hydramnios
• Maternal– Shortness of breath– Edema– Greatly increased cesarean rate– Uterine dysfunction– Abruptio placentae– Postpartum hemorrhage
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Maternal & Child Nursing Care, Third EditionLondon • Ladewig • Ball • Bindler • Cowen
Implications of Hydramnios
• Fetal-Neonatal– Malformations– Preterm birth– Increased mortality rate– Prolapsed cord– Malpresentation
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Maternal & Child Nursing Care, Third EditionLondon • Ladewig • Ball • Bindler • Cowen
Conditions Associated with Hydramnios
• Diabetes• Rh sensitization• Hydrops fetalis• Malformations of fetal swallowing• Neural tube defects with exposed
meninges
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Maternal & Child Nursing Care, Third EditionLondon • Ladewig • Ball • Bindler • Cowen
Conditions Associated with Hydramnios
• Anencephaly• Cardiac anomalies• Esophageal or duodenal atresia• Monozygotic, monochorionic twins• Large placenta
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Maternal & Child Nursing Care, Third EditionLondon • Ladewig • Ball • Bindler • Cowen
Assessment Findings Suspicious for Hydramnios
• Fundal height disproportionately large for dates
• Difficulty palpating fetus and auscultating FHR
• Tense, tight abdomen on inspection• Large spaces between fetus and uterine
wall on ultrasound
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Maternal & Child Nursing Care, Third EditionLondon • Ladewig • Ball • Bindler • Cowen
Nursing Plan with Hydramnios
• Provide information and emotional support• Maintain absolute sterility during
amniocentesis• Collaborate with social services if fetal
defect identified
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Maternal & Child Nursing Care, Third EditionLondon • Ladewig • Ball • Bindler • Cowen
Conditions Associated with Oligohydramnios
• Postmaturity• IUGR secondary to placental insufficiency• Major renal malformations
– Renal agenesis– Dysplastic kidneys– Lower urinary tract obstructive lesions
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Maternal & Child Nursing Care, Third EditionLondon • Ladewig • Ball • Bindler • Cowen
Implications of Oligohydramnios
• Dysfunctional labor with slow progress• Fetal deformation defects
– Adhesions– Skin and skeletal abnormalities– Pulmonary hypoplasia– Dysmorphic facies– Short umbilical cord
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Maternal & Child Nursing Care, Third EditionLondon • Ladewig • Ball • Bindler • Cowen
Implications of Oligohydramnios
• Umbilical cord compression• Head compression
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Maternal & Child Nursing Care, Third EditionLondon • Ladewig • Ball • Bindler • Cowen
Assessment Findings Suspicious for Oligohydramnios
• Fundal height small for dates• Fetus easily palpated and outlined• Fetus not ballottable• Variable decelerations• Reduced AFI on ultrasound
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Maternal & Child Nursing Care, Third EditionLondon • Ladewig • Ball • Bindler • Cowen
Nursing Plan for Oligohydramnios
• Provide information and encourage questions
• Evaluate EFM tracing for variable decels or nonreassuring fetal status
• Reposition mother to relieve cord compression
• Notify clinician of signs of cord compression
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Maternal & Child Nursing Care, Third EditionLondon • Ladewig • Ball • Bindler • Cowen
Nursing Plan for Oligohydramnios
• Evaluate newborn– Anomalies– Pulmonary hypoplasia– Postmaturity