HighRisk Births

1
High-Risk Births Obstetric Emergencies

• Chapter 36

2
INTRAPARTAL COMPLICATIONS

• Interference with normal processes patterns of
  labor/birth resulting in maternal or fetal
  jeopardy.
• Preterm labor dysfunctional labor patterns
  prolonged labor hemorrhage uterine
  ruputure/inversion amniotic-fluid embolus.

3
Dysfunctional Labor

• Possible Causes
• Catecholamines (response to anxiety/fear),
  increase physical/psychological stress, leads to
  myometrial dysfunction painful ineffective
  labor.
• Premature or excessive analgesia, particularly
  during latent phase.
• Maternal factors.
• Fetal factors.
• Placental factors.
• Physical restrictions (position in bed).

4
ASSESSMENT

• Antepartal history.
• Emotional status.
• Vital signs, FHR.
• Contraction pattern (frequency, duration,
  intensity).
• Vaginal discharge.
• GOAL to minimize physical
• / psychological stress during labor/birth.
  Emotional support.

5
Preterm Labor

• Occurs after 20 weeks gestation and before 38
  weeks.
• Causes may be from maternal, fetal, or placental
  factors.
• Prevention
• Primary close observation and eduction in SS of
  labor.
• Secondary prompt, effective Rx of associated
  disorders.
• Tertiary suppression of preterm labor.

6
Tertiary suppression of preterm labor

• Bedrest.
• Position side-lying to promote placental
  perfusion.
• Hydration.
• Pharmacological betaadrenergic agents to reduce
  sensitivity of uterine myometrium to oxytocic
  prostaglandin stimulation increase bld flow to
  uterus.
• Pt may be maintained at home with adequate
  follow-up health teaching.

7
CONTRAINDICATIONS for suppression of labor

• Placenta previa or abruptio placenta.
• Chorioamnionitis.
• Erythroblastosis fetalis.
• Severe preeclampsia.
• Severe diabetes (brittle).
• Increasing placental insufficiency.
• Cervical dilation of 4 cm or more.
• ROM (depends on cause if sepsis exists).

8
Nursing Assessment PTL

• Maternal VS. Response to medication
• Hypotension
• Tachycardia, arrhythmia
• Dyspnea, chest pain
• Nausea vomiting
• Signs of infection
• Increased temperature
• Tachycardia
• Diaphoresis
• Malaise

9

• Emotional status denial, guilt, anxiety,
  exhaustion.
• Signs of continuing progressing labor
• Effacement
• Dilation
• Station
• (vaginal exam ONLY if indicated by other signs of
  continuing labor progress)
• Status of membranes.
• FHR, activity (continuous monitoring).
• Ctx frequency, duration, strength.

10
Report PROMPTLY to MD

• Maternal pulse of 110 or more.
• Diastolic pressure of 60 mmHg or less.
• Increase in maternal temperature.
• Respirations of 24 or more crackles (rales).
• Complaint of dyspnes.
• Contractions increasing frequency, strength,
  duration, or cessation of ctx.

11

• Intermittent back and thigh pain.
• Rupture of membranes.
• Vaginal bleeding.
• Fetal distress.
• IF LABOR CONTINUES
• GOAL facilitate infant survival emotional
  support support comfort measures health
  teaching.

12
Dysfunctional Labor Pattern

• Hypertonic labor
• Hypotonic labor
• Precipitate labor level

Chapter 26
13
HYPERTONIC DYSFUNCTION

• Increased resting tone of uterine myometrium
  diminished refractory period prolonged latent
  phase.
• Nullipara more than 20 hours.
• Multipara more than 14 hours.
• Etiology unknown. Theory ectopic initiation
  of incoordiante uterine ctx.
• Assessment
• Onset (early labor)

14

• Contractions
• Continuous fundal tension, incomplete relaxation.
• Painful.
• Ineffectual no effacement or dilation.
• Signs of fetal distress
• Meconium-stained fluid.
• FHR irregularities.
• Maternal VS.
• Emotional status.
• Medical evaluation to rule out CPD.
• Vaginal examination, x-ray pelvimetry,
  ultrasonography.

15
Interventions with Hypertonic Dysfunction

• Short-acting barbiturates (to encourage rest,
  relaxation).
• IV fluids (to restore / maintain hydration
  fluid-electrolyte balance).
• If CPD c/s.
• Provide emotional support.
• Provide comfort measures.
• Prevent infection (strict aseptic technique).
• Prepare patient for c/s if needed.

16
HYPOTONIC DYSFUNCTION

• After normal labor at onset, ctx diminish in
  frequency, duration, strength.
• Lowered uterine resting tone cervical effacement
  dilation slow / cease.
• Etiology
• Premature or excessive analgesia / anesthesia
  (epidural, spinal block).
• CPD.
• Overdistention (hydramnios, fetal macrosomia,
  multifetal pregnancy).
• Fetal malposition / malpresentation.
• Maternal fear / anxiety.

17

• Assessment
• Onset (latent phase most common in active
  phase).
• Contractions - normal previously, will
  demonstrate
• Decreased frequency.
• Shorter duration.
• Diminished intensity (mild to moderate).
• Less uncomfortable.
• Cervical changes slow or cease.
• Signs of fetal distress rare.
• Usually late in labor d/t infection secondary to
  prolonged ROM.
• Tachycardia.

18

• Maternal VS (elevated temperature) may indicate
  infection.
• Medical diagnosis procedures vaginal
  examination, x-ray pelvimetry, ultrasonography.
  To rule out CPD (most common cause).
• Management
• Amniotomy (artificial ROM).
• Oxytocin augmentation of labor.
• If CPD, prepare for c/s.
• Emotional support, comfort measures, prevent
  infection.

19
Precipitate Labor

• Labor that progresses rapidly and ends with the
  delivery occurring less than 3 hours after the
  onset of uterine activity.
• Rapid labor and delivery.

20
Fetal Malpresentation and Malposition

• Breech presentation
• Shoulder presentation
• Face presentation
• Malpositions

Chapter 26
21
Breech Presentations

• Fetal descent in which the fetal buttocks, legs,
  feet, or combination of these parts is found
  first in the maternal pelvis.
• Labor tends to be longer and more difficult due
  to a softer presenting part, that does not fill
  the birth canal completely.
• Increase risks for fetal outcome.

22
Shoulder Presentation

• Fetal descent in which the shoulder precedes the
  fetal head in the maternal pelvis alone or along
  with the ftal arm and hand.
• Vaginally undeliverable.

23
Face Presentation

• Fetal descent in which hyperextension of the
  fetal head and neck allows the fetal face to
  descend into the maternal pelvis, as opposed to
  flexion that results in fetal vertex
  presentation.
• Brow presentation occurs when the area between
  the anterior fontanelle and the fetal eyes
  descends first.

24
Malpositions

• Persistent occipitoposterior position.
• Persistent occipitotransverse position.
• Result from fetal rotation as the fetus descends
  through the pelvis.
• Possible precipitating factors are macrosomia and
  pelvic abnormalities.
• Results in increased discomfort (particularly
  back labor), prolonged, abnormal labor, soft
  tissue injury, lacerations, or an extensive
  episiotomy incision.

25
Maternal and Fetal Structural Abnormalities

• Cephalopelvic disproportion (CPD)
• Macrosomia

Chapter 26
26
DYSTOCIA

• Difficult labor.
• Causes
• 3 Ps for mother Psych, Placenta, Position.
• 3Ps for fetus Power, Passageway, Passenger.
• POWER forces of labor (uterine contractions,
  use of abdominal muscles).
• Premature analgesia / anesthesia.
• Uterine overdistension (multifetal pregnancy,
  fetal macrosomia)
• Uterine myomas.

27

• PASSAGEWAY Resistance of cervix, pelvic
  structures.
• Rigid cervix.
• Distended bladder.
• Distended rectum.
• Dimensions of the bony pelvis oelvic
  contractures.
• PASSENGER accommodation of the presenting part
  to pelvic diameters.
• Fetal malposition / malpresentation.
• Fetal anomalies.
• Fetal size.

28
Hazards with Dystocia

• MATERNAL
• 1. Fatigue, exhaustion, dehydration.
• 2. Lowered pain threshold, loss of control.
• 3. Intrauterine infection.
• Uterine rupture.
• Cervical, vaginal, perineal lacerations.
• Postpartum hemorrhage.
• FETAL
• Hypoxia, anoxia, demise.
• Intracranial hemorrhage.

29
Placental Abnormalities

• Placenta previa
• Abruptio placentae
• Other placental abnormalities

Chapter 26
30
PLACENTA PREVIA

• Abnormal placement of placenta so that it
  partially covers the cervix dilatation results
  in bleeding, which can be of hemorrhagic
  proportions.
• The placenta is located over or very near the
  internal cervical os.
• Severe hemorrhage can result from digital
  palpation of the internal os.
• Previa is a serious but uncommon complication,
  occurring in .3-.5 of pregnancies.

31

• Advanced maternal age and multiparity increase
  the risk.
• Painless hemorrhage is symptomatic of previa,
  often around the end of the 2nd trimester.
• Clinical diagnosis is reached through ultrasound
  examination in which the placenta is localized in
  relationship to the cervix.
• Manual examination is contraindicated!
• Management of pregnancy depends on gestational
  age.

32
PLACENTAL ABRUPTION

• Premature separation of the placenta from the
  uterine wall usually results in maternal
  hemorrhage and fetal compromise.
• Classified as partial or total.
• Total Abruption fetal death is inevitable.
• Partial Abruption the fetus has a chance of
  survival.
• Separation of gt50 is incompatible with fetal
  survival.

33

• Grading of Placental Abruptions
• Grade I Slight vag.bleeding some uterine
  irritability. Maternal BP is unaffected there
  are normal fibrinogen levels. FHR has a normal
  pattern.
• Grade II External bleeding is mild to
  moderate. The uterus is irritable. Tetanic ctx
  may be present. Maternal BP is maintained. FHR
  shows signs of distress. Maternal fibrinogen
  level is decreased.

34

• Grade III The bleeding may be severe may be
  concealed in some instances. Uterine ctx are
  tetanic and painful. Maternal hypotension may be
  present. The fibrinogen level is greatly
  decreased there are coagulation problems.
• Diagnosis may be made by ultrasound, but
  frequently the diagnosis is made and confirmed at
  delivery, by inspection of the placenta.

35
Umbilical Cord Abnormalities

• Velamentous insertion of the cord
• Umbilical cord compression
• Umbilical cord prolapse

Chapter 26
36
Velamentous Insertion of the Cord

• Condition where the umbilical cord joins the
  placenta at the edge, rather than the typical
  insertion in the center.
• Can result in chronic altered fetal perfusion.
  Can lead to trauma and compression during LD,
  resulting in rupture and hemorrhage.

37

• PROLAPSED UMBILICAL CORD
• Cord descent in advance of presenting part
  compression interrupts blood flow, exchange of
  fetal / maternal gases. Leads to fetal hypoxia,
  anoxia, death (if unrelieved).
• Etiology
• SROM or AROM.
• Excessive force of escaping fluid (hydramnios).
• Malposition (breech, compound presentation,
  transverse lie).
• Preterm or SGA fetus allows space for cord
  descent.

38

• Assessment
• Visualization of cord outside (or inside) vagina.
• Palpation of pulsating mass on vaginal exam.
• Fetal distress variable deceleration and
  persistent bradycardia.
• Nursing interventions
• Reduce pressure on cord.
• Increase maternal / fetal oxygenation (O2 per
  mask _at_ 8-10 liters).
• Protect exposed cord (continuous pressure on
  presenting part to keep pressure off cord).

39

• Identify fetal response to these measures, reduce
  threat to fetal survival moniotr FHR
  continuously.
• Expedite termination of threat to fetus (prepare
  for immediate vaginal or c/s).
• Support mother and significant other (try to
  explain things while mobilizing delivery team).

40
Amniotic Fluid Abnormalities

• Polyhydramnios
• Oligohydramnios
• Amniotic fluid embolism

Chapter 26
41
Summary of Danger Signs During Labor

• Contractions strong, every 2 min. or less,
  lasting 90 sec. or more poor relaxation between
  ctx.
• Sudden sharp abdominal pain followed by boardlike
  abdomen and shock (abruptio placenta or uterine
  rupture).
• Marked vaginal bleeding.
• FHR periodic pattern decelerations late
  variable absent.

42

• Baseline FHR
• Bradycardia (lt100 bpm)
• Tachycardia (gt160 bpm)
• Amniotic fluid
• Amount excessive diminished.
• Odor
• Color meconium stained or particulate
  port-wine yellow.
• 24 hr or more since ROM.
• Maternal hypotension.

43
POSTPARTUM COMPLICATIONS

• Chapter 37

44
Postpartum Hemorrhage

• Definition
• More than 500cc of blood loss after vaginal
  birth.
• More than 1000cc of blood loss after C/S.
• Blood loss is often underestimated by up to 50
  (ACOG, 1998). Subjective.
• 1 cause of PP Hemorrhage Uterine Atony.

45
Risk Factors for PP Hemorrhage

• Uterine Atony Marked hypotonia of the uterus
• Overdistended uterus
• Anesthesia and analgesia
• Previous history of uterine atony
• High parity
• Prolonged labor, oxytocin-induced labor
• Trauma during labor and birth

46
Risk Factors for PP Hemorrhage

• Lacerations of the birth canal
• Retained placental fragments
• Ruptured uterus
• Inversion of the uterus
• Placenta accreta
• Coagulation disorders
• Placental abruption

47
Risk Factors for PP Hemorrhage

• Placenta previa
• Manual removal of a retained placenta
• Magnesium sulfate administration during labor or
  postpartum period
• Endometritis
• Uterine subinvolution

48
Lacerations

• Cervix, vagina, perineum.
• Suspected when bleeding continues despite a firm,
  contracted uterine fundus.
• Characteristics bleeding can be a slow trickle,
  an oozing, or frank hemorrhage.
• Influencing factors structural, maternal, fetal
• Lacerations the most common cause of injuries
  in the lower portion of the genital tract.

49
Retained Placenta

• Causes
• Partial separation of normal placenta
• Entrapment of the partially or completely
  separated placenta by uterine constriction ring
• Mismanagement of the 3rd stage of labor
• Abnormal adherence of the entire placenta or a
  portion of placenta to the uterine wall
• Types
• Nonadherent retained placenta
• Adherent retained placenta

50
Inversion of the Uterus

• Rare, but life threatening. (1 in 2000-2500
  births). May recur with additional births.
• Contributing factors
• Fundal implantation of placenta
• Vigorous fundal pressure
• Excessive traction applied to cord
• Uterine atony
• Leiomyomas
• Abnormally adherent placental tissue

51
Uterine Subinvolution

• Causes
• Retained placental fragments
• Pelvic infection
• Signs and symptoms
• Prolonged lochial discharge
• Irregular or excessive bleeding
• Hemorrhage
• Pelvic exam reveals a uterus that is larger than
  normal and may be boggy

52
Assessing Cardiac Output PPH

• NURSING ASSESSMENTS
• Palpation of pulses (rate,quality, equality)
• Auscultation
• Inspection
• Observation

53
Meds used to Rx PP Hemorrhage

• Oxytocin (Pitocin)
• Methylergonovine (Methergine Ergotrate)
• Prostaglandin F2 (Prostin / 15M Hemabate)

54
Emergency Hemorrhagic Shock

• Assessments
• Respirations rapid and shallow
• Pulse rapid, weak, irregular
• BP decreasing (late sign)
• Skin cool, pale, clammy
• Urinary Output decreasing
• Level of Consciousness lethargy to coma
• Mental status anxiety to coma
• Central venous pressure decreased

55
Emergency Hemorrhagic Shock

• Intervention
• Summon assistance and equipment
• Start IV per standing orders (large bore
  preferable)
• Ensure patent airway administer oxygen
• Continue to monitor status

56
Coagulopathies

• Idiopathic Thrombocytopenic Purpura (ITP)
• von Willebrand Disease a type of hemophilia,
  factor VIII deficiency, most common congenital
  clotting defect of women in childbearing years.
• Disseminated Intravascular Coagulation (DIC) a
  pathologic form of clotting, diffuse. Includes
  platelets, fibrinogen, prothrombin, and factors V
  and VII.
• Thromboembolic Disease formation of clot(s) in
  blood vessels caused by inflammation or partial
  obstruction of the vessel.

57
Postpartum Infection

• Antepartal factors
• Hx of previous venous trhombosis, UTI, mastitis,
  pneumonia
• Diabetes mellitus
• Alcoholism
• Drug abuse
• Immunosuppression
• Anemia
• Malnutrition

58
Intrapartal Factors

• Cesarean birth
• PROM
• Chorioamnionitis
• Prolonged labor
• Bladder catheterization
• Internal fetal or uterine pressure monitor
• Multiple vaginal exams after ROM

59
Intrapartal Factors (continued)

• Epidural anesthesia
• Retained placental fragments
• PP hemorrhage
• Episiotomy or lacerations
• Hematomas

60
Types of PP Infection

• Endometritis (most common usually begins as a
  localized infection at the placental site, but
  can involve entire endometrium)
• Wound infections (c/s incision, episiotomy,
  repaired laceration site)
• UTIs (2-4 of PP women)
• Mastitis (1 of BF moms, usually 1st)

61
Sequelae of Childbirth Trauma

• Uterine Displacement prolapse
• Cystocele and Rectocele
• Urinary Incontinence
• Genital Fistulas

62
PP Psychologic Complications

• Mood Disorders with or without psychotic
  features, if the onset occurs within 4 weeks of
  childbirth.
• Baby Blues occurs in up to 70 of PP moms
• Postpartum Depression
• Postpartum Psychosis

63
High-Risk Newborn Family

• Chapter 26

64
Infants With Special Needs

• Priorities
• Initiation maintenance of respirations
• Establishment of extrauterine circulation
• Control of body temperature
• Intake of adequate nourishment
• Establishment of waste elimination
• Establishment of an infant-parent relationship
• Prevention of infection
• Provision of developmental care for mental
  social development

65
High-Risk Infants

• May need resuscitation at birth.
• Most institutions require AHA Certification in
  Neonatal Resuscitation of all personnel at
  deliveries
• Requirements may include
• Warmth
• Oxygen
• Intubation
• Suctioning

66
Small for Gestational Age (SGA)

• Definition birth weight is below the 10th
  percentile on an intrauterine growth curve for
  that age infant.
• Infant could be preterm, term, or postterm.
• Have difficulty maintaining body warmth d/t low
  fat stores may develop hypoglycemia from low
  glucose stores.

67
Large for Gestational Age (LGA)

• Definition birthweight is above the 90th
  percentile on an intrauterine growth chart for
  that gestational age.
• Infant could be preterm, term, or postterm.
• Often are IDM (infants of diabetic mothers), and
  particularly prone to hypoglycemia or birth
  trauma.

68
Preterm Infants

• Definition born before 37 weeks of gestation.
• Particular problems respiratory function,
  anemia, jaundice, persistent patent ductus
  arteriosus, intracranial hemorrhage.
• Low-birthweight infants those weighting
  1500-2500 grams.

69

• Very-low-birthweight infants those weighing
  1000-1500 grams.
• Extremely-very-low-birthweight infants those
  weighing between 500-1000 grams.
• All such infants need intensive care from the
  moment of birth.
• Risks neurologic after-effects caused by being
  so critically close to the age of viability.

70
Postterm Infants

• Definition born after 42 weeks gestation.
• Particular problems establishing respirations,
  meconium aspiration, hypoglycemia, temperature
  regulation, and polycythemia.

71
Respiratory Distress Syndrome

• Commonly occurs in preterm infants from a
  deficiency or lack of surfactant in the alveoli.
• Without surfactant the alveoli collapse on
  expiration require extreme force for
  reinflation.
• Primary Rx synthetic surfactant replacement at
  birth by ET tube insufflation, followed by oxygen
  and ventilatory support.

72
Transient Tachypnea

• A temporary condition caused by slow absorption
  of lung fluid at birth.
• Close observation of the infant is necessary
  until the fluid is absorbed and respirations slow
  to a normal rate.

73
Meconium Aspiration Syndrome

• Occurs when infant inhales meconium-stained
  amniotic fluid during birth.
• Results in irritation to the airway (from
  meconium) may lead to both airway spasm and
  pneumonia.
• Infant needs oxygen, ventilatory support,
  possibly antibiotic until the effects of the
  airway subside.

74
Apnea

• Definition a pause in respirations longer than
  20 seconds, with accompanying bradycardia.
• Occurs in preterm infants who have secondary
  stresses such as infection, hyperbilirubinemia,
  hypoglycemia, or hypothermia.

75
Sudden Infant Death Syndrome

• Definition the sudden, unexplained death of an
  infant.
• Associated with infants sleeping on their
  stomachs (prone) and infants who were born
  premature.
• Nursing prevention advising parents to position
  their infant on the back for sleeping.

76
Hyperbilirubinemia

• Results from destruction of RBCs, due either to
  a normal physiologic response or an abnormal
  destruction of the RBCs.
• Hemolytic disease of the newborn is destruction
  of RBCs from Rh or ABO incompatibility.
• Phototherapy or exchange transfusion is used to
  prevent kernicterus.

77
Neonatal Hemorrhagic Disease

• Definition a lack of clotting ability resulting
  from a deficiency of vitamin K at birth.
• Prevention is by injection of vitamin K to all
  infants at birth.

78
Retinopathy of Prematurity

• Definition destruction of the retina due to
  exposure of immature retinal capillaries to
  oxygen.
• Monitoring oxygen saturation via arterial blood
  gases is an important prevention measure.

79
Infections of the Newborn

• Streptococcal Group B pneumonia from maternal
  GBBS.
• Hepatitis B infection
• Ophthalmia neonatorum from gonococcal and
  chlamydial conjunctivitis.
• Herpes Virus infection.

80
Other Neonatal Risks

• Infants of diabetic mothers (IDM)
• Infants of drug abusing women
• NOTE respiratory distress, hypoglycemia,
  hypo/hyperthermia are common SS of neonatal
  infection.