Childbirth at Risk

1
Childbirth at Risk

• Chapter 21

2
Dystocia

• Disruption of labor
• Emotional factors
• Contractions
• Fetus
• Pelvis
• Relation between pelvis and fetus

3
Contractions

• Hypertonic (latent) labor- irregular in strength
  and timing
• Do not change cervix. Tx- augmentation
• Hypotonic (active) labor-less than 2-3 ucs in 10
  minutes.
• Due to overdistention

4
Nursing Assessment

• Contractions
• FHT
• Coping
• Dehydration
• Fluid
• Infection

5
Post term Pregnancy

• Past 42 wks
• Associate with LGA, assisted delivery, oligo, mec
  aspiration, decrease perfusion
• After 40 weeks need NST, BPP X2 q week

6
Malposition

• OP common malposition -most rotate
• May visualize depression in maternal abdomen
  above symphysis
• Change positions- pelvic rocking, hand knees
• Assess for extreme back pain

7
Malpresentation

• Brow-widest diameter.
• Face
• Breech-ECV _at_ 36-38 wks
• Heart tones high
• Risk for prolapse
• T-lie- r/t multiparity, ECV
• Compound presentation

8
Macrosomia

• Greater than 4000 gms, risk for dystocia
• McRoberts, suprapubic pressure
• Greater than 4500 plan C/S
• Assess for Erbs, motor problem
• Maternal risk for PPH
• Falling off the labor curve

9
Multiple Gestation

• High risk, type of multiple gestation determines
  risk
• Associated with PIH, PTL, previa, malpresentation
• Need NST, BPP, serial UTZ
• Many need bed rest

10
Intrauterine Resuscitation

• Decreased uterine placental flow
• NSG- turn to L lat, IV fluids, give 02
• Correct maternal hypotension
• Turn off pit
• Explain to family

11
IUFD

• Perinatal death after 20 weeks
• Can cause DIC.
• Thromboplastin activates clotting system
• FIB., and factor V and VII are depleted
• DX confirmed by Spauldings sign, estriol levels,
  no heart tones

12
Parents of Stillborn

• Protest, refuse to believe.
• Disorganization
• Reorganization- time frame varies
• Use checklist
• Give mementos

13
Abruptio Placentae

• Cause may be decrease in blood flow.
• Marginal- at edges, may bleed vaginally
• Central-separates centrally, concealed
• Complete- massive bleed total separation
• S/S include rigid abdomen, constant pain

14
Abruption

• Retroplacental clotting can prompt release of
  thromboplastin, lead to DIC
• With severe abruption mortality 100
• Eval. fibrinogen and platelets
• Often uterine resting tone is elevated

15
Placenta Previa

• Located in lower uterine segment, may cover whole
  os, or portion. NO VE
• With dilatation and ucs villi are torn from
  uterus and leave sinus exposed
• Hemorrhage can cause fetal hypoxia
• Painless bright red blood
• Assess fetal response to blood loss

16
Prolapsed Cord

• Cord presents before fetus, vessels occluded
• Monitor FHT following SROM or with amniotomy X
  1min
• If feel cord push up head to relieve pressure
• Knee chest-Trendelenburg to OR
• Preventative- make sure head is engaged

17
Amniotic Fluid Emboli

• Break in chorion or amnion can allow amniotic
  fluid to enter maternal system
• Uterus forces emboli from circulation to lung
• S/S
• Give 02, CPR, ABO

18
Hydramnios

• Cause unknown, r/t with fetal anomalies.
• Rh sensitization, DM, multiple gestations
• Fetus swallows and urinates amniotic fluid
• Associated with SOB, edema
• Abruption if size of uterus reduced quickly
• Nursing- increase in fundal hgt, FHTs

19
Oligohydramnios

• Associated with IUGR, postmaturity, renal,
  kidney, uterine placental insufficiency
• Restricts fetal movement, effects lungs, cord
  compression.
• Increase fetal surveillance
• Amnioinfusion
• Reposition

20
CPD

• Head larger than pelvis
• Assess diagonal conjugate
• Bulging perineum and crowning indicate imminent
  delivery
• Fetus will not descend
• Fall off the labor curve
• Position change

21
Lacerations

• First degree- perineal skin, fourchette, vaginal
  mucous
• Second- skin underlying fascia, muscle
• Third-anal sphincter, ant. wall of rectum
• Fourth- through rectal mucousa to lumen