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Problems during labor and delivery 202

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Problems during labor and delivery 202

  1. 1. The woman who develops a complication during labor and birth
  2. 2. Hypotonic Uterine Contraction The number of contractions is usually low or infrequent May 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.
  3. 3. Management Start oxytocin infusion Amniotomy, to further speed labor In the first hour after birth palpate the uterus and assess lochia every 5 minutes.
  4. 4. 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.
  5. 5. 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
  6. 6. 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
  7. 7. 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
  9. 9. 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
  10. 10.  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.
  11. 11. FETAL DISTRESS General information  Cord compression  Placental abnormalities  Preexisting maternal disease Assessment findings  Decelerations in FHR  Meconium-stained amniotic fluid with a vertex presentation
  12. 12. 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
  13. 13. DYSTOCIA General 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.
  14. 14. – 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
  15. 15. 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
  16. 16. Shoulder dystocia Shoulder dystocia happens when after delivery of the head the anterior shoulder is trapped and arrested behind symphisis pubis. Fetal complications: 1. Erbs palsy 2. Fracture humerus and clavicle 3. Abnormal neurologic examinations
  17. 17. shoulder dystocia.flv
  18. 18. Management of shoulder dystocia
  19. 19. Mc Robert’s maneuver- flexing legs of the parturient sharply over the abdomen
  20. 20. Woodcorkscrew maneuver- rotating anterior shoulder 180 degrees to dislodge it
  21. 21.  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
  22. 22. 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
  23. 23. 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
  24. 24. 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
  25. 25. 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
  26. 26. 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
  27. 27. 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
  29. 29. Vaginal delivery of breech presentation
  33. 33. External Cephalic Version
  34. 34. 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 shock Bleeding Cyanosis Pulmonary edema
  35. 35. Nursing Intervention  Initiate emergency life support activities for mother.  administer oxygen  utilize 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
  36. 36. 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
  37. 37. Assessment findings Indication for use  Postmature pregnancy  Preeclampsia/eclampsia  Diabetes  Premature rupture of membranes Condition of fetus; mature, engaged vertex fetus , no distress Condition of mother; cervix “ripe” for induction, no CPD
  38. 38. 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
  39. 39.  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.
  40. 40. 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.
  41. 41. ASSESSMENT Risk factor: 1. Multiparity 2. Obstructive labor 3. Improper use of pitocin 4. Large fetus 5. Weakened, old cesarean section scar 6. External forces such as trauma Clinical manifestations:  Pain above the symphysis pubis  Sudden, acute abdominal pain during a contraction  Vaginal bleeding, shock; fetal distress
  42. 42. Uterine Rupture.flv Treatment: Surgical: laparotomy to remove fetus, followed by a hysterectomy. Medical management: 1. Blood transfusion 2. Prophylactic antibiotics
  43. 43. Nursing Intervention: Provide nursing management associated with hemorrhage. Assess for early diagnosis: Maternal mortality rate is high Prognosis for fetus is poor; fetus usually dies as a result of anoxia caused by placental separation.
  44. 44. 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.
  45. 45. 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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