Download - Problems during labor and delivery 202
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The woman who develops a complication during labor
and birth
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Hypotonic Uterine ContractionThe number of contractions is usually low or infrequentMay occur after the administration of analgesia especially if the cervix is not dilated to 3 or 4 cm or if bowel and bladder distension prevents descent or from engagement.
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Management Start oxytocin infusion
Amniotomy, to further speed labor
In the first hour after birth palpate the uterus and assess lochia every 5 minutes.
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Hypertonic Contractions Are marked by an increased in resting tone.
Management:
Rest and pain relief with a drug such as morphine sulfate. Darkening room lights. Decrease noise and stimulation Cesarean birth maybe necessary.
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POSTMATURE PREGNANCY
General information Defined as those pregnancies lasting
beyond the end of the 42nd week. Fetus at risk due to placental
degeneration and loss of amniotic fluid Decreased amounts of vernix also allow
the drying of the fetal skin, resulting in a dry, parchment like skin condition
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Medical management Directed toward ascertaining precise
fetal gestational age and condition, and determining fetal ability to tolerate labor
Induction of labor and possibility cesarean birth
Nursing Interventions Perform continual monitoring of
maternal/fetal vital signs Support mother through all testing and
labor
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PROLAPSED UMBILICAL CORD
General information Displacement of cord in a downward direction,
near or ahead of the presenting part, or into the vagina
May occur when membranes rupture. Associated with breech presentation,
unengaged presentations and premature labor Obstetric emergency if compression of the
cord occurs, fetal hypoxia may result in CNS damage or death.
Assessment findings Vaginal examination identifies cord prolapsed
into vagina
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PROLAPSED UMBILICAL CORD
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Nursing Interventions Check FHT immediately when
membranes rupture, and again after next contraction, or within 5 minutes; report decelerations
If fetal bradycardia, perform vaginal examination and check for prolapsed cord
If cord prolapsed into vagina, exert upward pressure against presenting part to lift part off cord, reducing pressure on cord
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Get help to move the mother into a position where gravity assist in getting presenting part off cord (knee chest position or severe trendelenburg’s)
Administer oxygen for immediate cesarean birth
If cord protrudes outside vagina, cover it with sterile gauze moistened with sterile saline while carrying out above tasks. Do not attempt to replace cord.
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FETAL DISTRESS
General information Cord compression Placental abnormalities Preexisting maternal diseaseAssessment findings Decelerations in FHR Meconium-stained amniotic fluid
with a vertex presentation
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Nursing interventions: Check FHR on appropriate basis Conduct vaginal exam for presentation
and position Place mother on left side, administer
oxygen, check for prolapsed cord, notify physician
Support mother and family Prepare for emergency birth if indicated
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DYSTOCIAGeneral information Any labor/delivery that is prolonged or difficult Usually results from a change in the
interrelationships among the 4 P’s that is the factors in labor and delivery
Frequently seen causes include: disproportion between fetal presentation (usually the head) and the maternal pelvis (CPD) if disproportion is minimal, vaginal birth may be attempted if fetal injuries can be minimized or eliminated.
cesarean birth needed if disproportion is great.
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– problems with presentation» any presentation unfavorable
for delivery (e.g. breech, shoulder, face, transverse lie)
» posterior presentation that does not rotate, or cannot be rotated with ease.
» cesarean birth is the usual intervention
– problems with maternal soft tissue
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Nursing Interventions Individualized as to cause Provide comfort measures for
client Provide clear, supportive
descriptions of all actions taken Administer analgesia if ordered Prepare oxytocin infusion for
induction of labor as ordered. Monitor mother/fetus continuously Prepare for cesarean birth if
needed
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Shoulder dystociaShoulder dystocia
happens when after delivery of the head the anterior shoulder is trapped and arrested behind symphisis pubis.
Fetal complications:1. Erbs palsy2. Fracture humerus and
clavicle3. Abnormal neurologic
examinations
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shoulder dystocia.flv
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Management of shoulder dystocia
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Mc Robert’s maneuver- flexing legs of the parturient sharply over the abdomen
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Woodcorkscrew maneuver- rotating anterior shoulder 180 degrees to dislodge it
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Cleidotomy- cutting the clavicles
Rubins maneuver- rocking the shoulders from side by side by applying force over the abdomen
Suprapubic pressure Strong fundal pressure• Rotate posterior arm to
anterior position• Extraction of posterior arm• All procedures should not
take more than five minutes
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PRECIPITOUS LABOR AND DELIVERY
General Information• Labor less than 3 hours• Emergency delivery without clients
physician or midwife Assessment findings• As a labor is progressing quickly,
assessment may need to be done rapidly.
• Client have history of previous precipitous labor and delivery
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Nursing Intervention: If you have to deliver the
baby yourself: Asses the client’s affect and ability
to understand directions, as well as other resources available
Stay with the client at all times Do not prevent birth of the baby Maintain sterile environment if
possible
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Rupture membranes if necessary
Support baby’s head as it emerges, preventing too-rapid delivery with gentle pressure
Use gentle aspiration with bulb syringe to remove blood and mucus from nose and mouth
Deliver shoulders after external rotation, asking mother to push gently
Provide support for baby’s body as it delivered
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Hold baby in a head down position to facilitate drainage of secretions
Promote cry by gently rubbing over back and soles of feet
Dry to prevent heat loss Place baby on mother’s abdomen Check for signs of placental
separation Check mother for excess
bleeding, massage uterus prn
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Hold placenta as it delivers Cut cord when pulsation
cease, if cord clamped available, if no clamps keep it intact.
Wrap baby in dry blanket, give to mother, put to breast if possible
Check mother for fundal firmness and bleeding
Record all pertinent data Comfort mother and family as
needed
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SPONTANEOUS DELIVERY• The encirclement of the largest head
diameter by the vulvar ring is known as crowning.
• RITGEN MANEUVER * gloved hand is used to exert pressure on
the chin of the fetus through the perineum just in front of the coccyx
* allows controlled delivery of the fetal head
* favors extension of the fetal head
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RITGEN MANEUVER
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Vaginal delivery of breech presentation
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PINARD MANEUVER
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MAURICEU MANEUVER
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PRAGUE MANEUVER
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External Cephalic Version
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AMNIOTIC FLUID EMBOLISM
General information Escape of amniotic fluid into the maternal
circulation, usually in conjunction with a pattern of hypertonic, intense uterine contractions, either naturally or oxytocin induced.
Obstetric emergency; may be fAtal to the mother or to the fetus.
Assessment findings Sudden onset of respiratory distress,
hypotension, chest pain, signs of shockBleedingCyanosisPulmonary edema
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Nursing Intervention Initiate emergency life support
activities for mother.administer oxygenutilize CPR in case of cardiac
arrest establish IV line for blood
transfusion administer medication to control
bleeding as ordered prepare for emergency birth of
baby keep client/family informed as
possible
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INDUCTION OF LABOR
General Information -Deliberate stimulation of uterine
contractions before the normal occurrence of labor.
Medical management Amniotomy (the deliberate rupture
of the membrane) Oxytocins, usually Pitocin Prostaglandin in gel/suppository
form to improve cervical readiness
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Assessment findings Indication for use
Postmature pregnancyPreeclampsia/eclampsiaDiabetesPremature rupture of
membranes Condition of fetus; mature,
engaged vertex fetus , no distress
Condition of mother; cervix “ripe” for induction, no CPD
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Nursing Interventions Explain the procedure to client Prepare appropriate equipment
and medications. Amniotomy; a small tear made
in amniotic membrane as part of sterile vaginal exam
Oxytocin (Pitocin); IV administration “piggybacked” to main IV
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Know the continuous monitoring and accurate assessment are essential.
Discontinue oxytocin infusion when fetal distress, hypertonic contractions occur, signs of obstetric complications appear. (hemorrhage/shock, abruption placenta, amniotic fluid embolism)
Notify physician of any untoward reactions.
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RUPTURED UTERUS
A ruptured uterus is characterized by a tearing or splitting of the uterine wall during labor; it is usually a result of a thinned or a weakened area that cannot withstand the strain and force of uterine contraction.
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ASSESSMENT Risk factor:1. Multiparity2. Obstructive labor3. Improper use of pitocin4. Large fetus5. Weakened, old cesarean
section scar6. External forces such as traumaClinical manifestations: Pain above the symphysis
pubis Sudden, acute abdominal pain
during a contraction Vaginal bleeding, shock; fetal
distress
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Uterine Rupture.flv
Treatment: Surgical: laparotomy to
remove fetus, followed by a hysterectomy.
Medical management:1. Blood transfusion2. Prophylactic
antibiotics
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Nursing Intervention:Provide nursing management
associated with hemorrhage.Assess for early diagnosis:
Maternal mortality rate is highPrognosis for fetus is poor; fetus usually dies as a result of anoxia caused by placental separation.
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INTRAUTERINE FETAL DEATH
Intrauterine fetal death is also called fetal demise.
ASSESSMENT: Absence of FHR and fetal
movement. Negative pregnancy test result Ultrasound examination
determines absence of FHR and occurrence of fetal skull collapse.
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Nursing Intervention:Goal: To support the couple through
the grieving process.• Encourage expression of feelings;
do not minimize the situation or event.
• Provide opportunity for the couple to spend time with still born, if they so desire.
• Monitor for complication.
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