Chapter 23: Nursing Care of a Family Experiencing Experienci ng a Complication of Labor or Birth Dystocia y y
a difficult labor cane arise from any of the 4 maincomponents of the labor process power passenger passageway psyche
Complications with the POWER Inertia sluggishness of contractions or dysfunctional labor 2 classifications: 1. Primary happens during onset of l abor 2. Secondary happens during later part of labor Ineffective Uterine Labor 1. Hypotonic contractions y Low (10-25 mmHg) or infrequent contractions (not more than 2-3 in a minute) y Occurs during active phase generally after administration of analgesia y Cervical opening of 3-4 inches y Bowel or kidney di stention prevents engagement y Occurs in overstretched overstretched (multiple gestation, large baby or hydramnios) or lax uterus (grand multiparity). y Characteristics: Not exceedingly painful Lacks intensity y Outcomes: Increase in length of labor Uterus does not e ffectively ffectively contract during post-partal post-partal period Increases chance of post-partal hemorrhage y To assess: Uterus and lochia to ensure postpartal contractions are not too hypotonic 2. Hypertonic contractions More frequent contractions but not y necessarily more intense (15 mmHg or more) y Occurs during latent phase Muscle fibers of myometrium do not r elax y after contractions More painful y y Makes breathing exercises less effective y Does not allow optimum uterine artery filling causing fetal anoxia y Does not achieve cervical dilation 3. Uncoordinated contractions y More than one pacemaker may be initiating contractions or receptor points in the myometrium may be acting independently of the pacemaker Dysfunctional Labor according to stage: Dysfunction at the first stage 1. Prolonged latent phase
than 20hours in a nullipara, and more than 14hours in a multipara y Brought about by Unripe cervix Excessive use of analgesia y What happens? Uterus in hypotonic state Inadequate relaxation between contractions Contractions are mild and inadequate y Nursing mngt. as Help uterus to rest (oxyticin as ordered) Provide adequate fluid Pain relief (morphine sulfate) Clean, dim, quiet enviro y Medical mngt. Amniotomy Oxytocin C/S Protracted Active Phase y Associated with CPD or fetal malposition y Cervix opens slower than the standard rate of 1.2 cm/hr. for nullipara or 1.5 cm/hr. for multipara y Hypotonic contractions y Medical mngt. No CPD oxytocin With CPD C/S Prolonged deceleration phase y Beyond 3 hour for nullipara and 1 hour for multipara y Usually due to abnormal fetal head position y Medical mngt. C/S y
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Dysfunction according to Second Stage 1. Prolonged descent y Fetus descends at a rate less than 1cm/hr. for a nullipara and 2cm/hr. for a multipara y Takes over 3 hours in multipara y Nursing mngt. Rest Increase fluid intake Position for more effective pushing: Semi-fowlers Squatting kneeling y Medical Mngt. Amnoitomy if membranes have not ruptured Oxytocin (IV) 2. Arrest of Descent > no descent y Medical mngt. No CPD oxytocin With CPD C/S Contraction Rings hard band that forms across uterus at the junction of upper and lower uterine segment which interferes with fetal descent Bandls Ring occurs early in labor due to uncoordinated contractions. contractions. Detected early through through ultrasound. y Medical mngt. IV morphine sulfate sulfate or inhalation inhalation of amyl nitrate for pain
C/S delivery Manual delivery of placenta if ring occurred after normal delivery of baby
Precipitate Labor strong, few, rapid contractions resulting in a speedy delivery of 3 hours or less y Occurs during grand multi parity, or after amniotomy or after admin of oxytocin y Danger: Mother lacerations and premature separation of placenta which could lead to hemorrhage Fetus subdural hemorrhage y Nursing Mngt. Educate multiparous to plan th early, be ready by the 28 week Prepare (labor/birthing room) Precipitate dilation 5 cm/hr. in primi 10 cm/hr. in multi Induction and Augmentation of labor y Induction of Labor labor is started artificially, usually done when fetus is in danger or normal labor can no longer continue (i.e. eclampsia, pre-eclampsia, severe HTN, DM, Rh sensitivity, Prolonged ROM, intrauterine growth restriction, post-maturity of fetus) Augmentation of Labor labor started y spontaneously but is not effective often due to hypotonic contractions y Risks: Uterine rupture Decrease in fetal blood supply y Caution in: Multi gestation Hydramnios Grand parity Woman age 40+ Uterine scars y Necessary conditions Longitudinal lie Ripe cervix Engaged No CPD Term Cervical Ripening change in cervical consistency from firm to soft (Bishop Score of 8+) How to ripen? 1. Stripping the membranes y Dangers Bleeding of undetected low lying placenta Infection Inadvert PRO M/amniotomy 2. Laminaria Technique or Hygroscopic suppositories (swelling seaweed) held in place by gauze sponges soaked in povidone i odine or antifungal cream 3. Prostaglandin gel (ex. Misoprostol) y Give every 6 hours in 2-3 doses y Side effects Vomiting Fever Diarrhea HTN
Avoid
if woman has: Cardiovascular dse Glaucoma Asthma Nursing mngt. Woman in bed, side lying Monitor FHR or 30min after application If oxytocin is to be give, be sure it at least 6-12 hours later to avoid uterine hyperstimulation
Induction of Labor by Oxytocin Augmentation of Labor by Oxytocin
Uterine Rupture y Accounts for 5% of all maternal deaths y Occurs when uterus undergoes more stress than it can sustain y Occurs in: Women with previous vertical C/S scar Long labor Abnormal presentation Multiple gestation Obstructed labor Unwise use of oxytocin Traumatic use of forceps or traction y 2 Types: 1. Incomplete peritoneum left intact Less evident signs compared to complete rupture Lack of contractions Changes in v/s Localized tenderness in lower uterine segment 2. Complete goes thru all layers of the uterus Contractions stop immediately Two swellings visible on abdomen (fetus and uterus) Blood floods into abdominal cavity and vagina Shock begins Air hunger (nasal flaring) FHR fades then becomes absent y Medical management Oxytocin to contract uterus Laparoscopy C/S hysterectomy Uterine Inversion uterus turns inside out y Nursing management Never handle uterus Never remove attached placenta Increase IVF Administer oxygen Assess v/s Prepare for CPR y Medical management General anesthesia Manual replacement of fundus Antibiotics C/S for future birth
Problems with the PASSENGER D. Prolapse of the umbilical cord loop of umbilical cord slips over presenting part y Occurs most often in: PROM Noncephalic presentation Placental previa Intrauterine tumors Small fetus CPD Hydramnios Multiple gestation y To assess U/S FHR (deceleration) y Nursing management Manually elevate fetal head off cord Position mother knee in chest or trendelenburg Admin oxygen Cover exposed cord with compress soaked in saline solution
E.
Amnioninfusion
addition of sterile fluid into uterus to supplement amniotic fluid y Mother in lateral recumbent position y Strict aseptic method Monitor FHR y y Monitor temp for infection y Change wet bed frequently y Watch out for hydramnios Multiple Gestation y y
Assess
hematocrit in case of PIH or anemia Monitor each FHR
Problems with fetal position, presentation and size: Face Brow Transverse Lie Breech y Causes y Less than 40 weeks y Abnormality in fetus y Hydramnios y Space occupying mass y Pendulous abdomen y Multiple gestation y Unknown factors Macrosomia Problems with PASSAGE A.
B. C.
Inlet contraction narrowing of anteropostertior diameter to less than 11cm and transverse diameter to less than 12cm y Caused by: Inherited small inlet Rickets early in life y Primigravidas should have pelvic measurement th taken before 24 week Outlet contraction narrowing of transverse diameter to less than 11cm. Trial labor determines whether labor can progress normally; 6-12 hours y Monitor FHR and contractions y Have woman void every 2 hours
Educate and explain External cephalic version turning of fetus from breech to cephalic position before birth (34-35 weeks or 37-38 weeks) y Assess: u/s FHR y Give tocolytics to relax uterus y Contraindicated to: Multiple gestation Severe oligohydramios Those contraindicated to vaginal birth Cord wrapped around fetal neck rd Unexplained 3 trimester bleeding Possible placenta previa y Give women who are Rh-, RhIg Forceps Birth y Dangers to the woman: Dyspareunia Anal incontinence Urinary stress incontinence y Necessary if: Woman unable to push with contractions nd Cessation of contractions at 2 stage of labor Fetal distress (cord compression) y Above +2 station low forceps birth y Below +2 station mid forceps birth y Before forceps birth, ensure: Membranes are rupture No CPD Fully dilated cervix Empty bladder Take FHR (and again after application of forceps) Record time and amount of last voiding y After procedure: Assess newborn for facial palsy or subdural hematoma (transient erythematous mark gone in 2 days) Vacuum Extraction disc shaped cup placed against fetal scalp over posterior fontanel to suction and extract baby from birth canal. y Advantages over FB: Less anesthesia Fewer lacerations y Disadvantages: Causes marked caput on newborns head w/c lasts for 7 days Tentorial tears y Not for: Fetus that had a fetal scalp sampling Preterms soft scalp y
F.
Anomalies
of PLACENTA and CORD th
Placenta normally 500g (1/6 the wt., of fetus), 15-20 cm. in diameter, 1.5 to 3 cm. thick y Syphilis or erythroblastosis = heavier placenta y Uterine scars or septum = wider placenta 1. Placenta succenturiata has one or more accessory lobes connected to the main placenta by blood vessels.
delivery, ensure no lobes are retained Placenta circumvallata fetal side of placenta covered to some extent by chorion Placenta Marginata chorion fold reaches to e dge of placenta Battledore placenta cord is i nserted marginally rather than centrally Velamentous insertion of cord i nstead of entering placenta directly, the cord separates into small vessels that reach placenta by spread across a fold of amnion. y Often in multiple gestation y Examine newborn carefully for anomalies Vasa previa umbilical vessels cross cervical os and is delivered before fetus y Danger: Vessels may tear with cervical dilation Insertion of instruments y Medical Management C/S y
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Cord 1. 2.
After
2 vessel cord associated with heart and heart anomalies Unusual cord length y Short - Causes premature separation of placenta or abnormal fetal lie y Long although cord tends to twist ant knot, pulsations keep blood flow adequate
