Which of the following are your nursing interventions in patient experiencing hypotonic contraction?

Presentation on theme: "Complications of Labor and Delivery by: Ann Hearn, MSN, RNC"— Presentation transcript:

1 Complications of Labor and Delivery by: Ann Hearn, MSN, RNC

2 The Powers Ineffective Contractions
Uterine Dystocia -defined as difficult labor. Hypotonic contractions – coordinated, infrequent, weak, brief, mildly painful. Hypertonic contractions – uncoordinated and erratic in frequency, duration and intensity; Painful.

3 Interventions for Uterine Dystocia
Hypotonic Uterus: results from overstretched uterine muscle leading to a prolonged active phase. Nursing Interventions: Position changes, ambulation Emptying bladder Amniotomy Pitocin administration Hydration Teaching/Support 1. What are the characteristics of hypotonic contractions? 2. What are the causes/ risk factors of hypotonic uterine contractions? 3. What interventions might the nurse use when caring for a woman experiencing hypotonic uterine contractions?

4 Interventions for Uterine Dystocia
Hypertonic Uterus: Contractions are painful but ineffective resulting in prolonged latent phase. Nursing Interventions: Bed rest Sedation or pain relief Position changes Support/educate Comfort measures: calm environment, music, therapeutic touch, back rub, warm shower, imagery 4. What are the characteristics of hypertonic uterine contractions? 5. What are the causes/risk factors of hypertonic uterine contractions? 6. What interventions would the nurse implement when caring for a woman experiencing hypertonic uterine contractions?  

5 Ineffective Pushing. If pushing is ineffective, correct the cause.
Incorrect techniques Fear of injury Minimal or no urge Maternal exhaustion Region block Psychological unreadiness There is no time limit for 2nd Stage 7. What intervention can the nurse use to assist a woman who is having difficulty pushing effectively?

6 The Passenger

7 Problems with the Passenger
Fetal Size Shoulder dystocia Presentation Fetal lie Position Assisted delivery Multi-fetal Fetal anomalies 8. Define macrosomia. 9. What methods may be used by the nurse to relieve impacted fetal shoulders? 10. How do each of the following relate to a complicated labor? 11. What nursing interventions are appropriate to assist with abnormal presentation or position?.

8 Three Malpresentations
Brow: forehead C/S delivery Face Vaginal delivery Breech Frank – buttocks Footling – foot/feet

9 The Passage Way Pelvis Bladder Size & shape
12. What are the signs of a small or abnormally shaped pelvis?. 13. How does a full bladder impede fetal descent?

10 The Psyche Pain Stress Fear Non-support
14. How does the body respond to stress? 15. What nursing interventions can be used to help a woman relax while in labor?

11 Failure to Progress Prolonged Labor Causes: Interventions:
Labor dystocia Malposition Malpresentation Macrosomia Interventions: R/O CPD Uterine rest Pitocin augmentation Prolonged Labor 16. What are the potential problems associated with a prolonged labor? 17. What nursing interventions should be employed for a prolonged labor?

12 Friedman’s Curve

13 Precipitous Labor Labor < 3 hours from onset Complications: Woman
loss of coping ability Lacerations of cervix, vagina, perineum Fetus Hypoxia Cerebral trauma Pnemothorax Precipitate Labor 18. What is precipitous labor? 19. What is the nursing care for a precipitous labor? 20. What is the nursing care for a precipitous delivery and potential complications?

14 Precipitous Labor Monica, a G1, 39.4wks is admitted to L&D with occasional uterine contractions that started soon after her BOW broke an hour ago. She pauses during conversation to breath during contractions and gives a pain rating of 5. Monica states she will probably want an epidural. While performing the admission history/assessment you notice that Monica’s contractions are occurring every 2 minutes and palpate strong. Monica is beginning to demonstrate difficulty with coping during contractions. Monica grunts during her last contraction. What nursing interventions will you provide?

15 Nursing Care in Dysfunctional Labor
intrauterine infection Identify s/s Reduce risk Assist with exhaustion Conserve energy Promote coping skills 21. What are the signs of maternal infection? 22. How can the nurse assist a woman who is experiencing exhaustion in labor?

16 Premature Rupture of Membranes - PROM
Spontaneous rupture of membranes prior to the onset of labor Associated conditions: Infection Previous history of PROM Hydramnios Multiple pregnancy UTI Trauma 23 a. What is premature rupture of membranes (PROM)?.

17 Premature Rupture of Membranes - PROM
Determine time of PROM Verification of PROM: Visualization Sterile speculum exam pH

18 Premature Rupture of Membranes - PROM
Nursing Assessment Vital signs (temp q 2hr) Fetal monitoring Nature of fluid WBC count PPROM: Preterm Celestone - betamethasone Antibiotics If leak seals, discharge instructions 27. Why are corticosteroids given to a woman in preterm labor? 28. How long should labor be delayed after administration of Betamethasone (Celestone) to realize the greatest benefit from this drug? 23 b. What assessments should the nurse make in the case of PROM? 23 c. What patient teaching is needed if a woman returns home after PROM?

19 Preterm Labor Defined as: labor that occurs between 20 and 37 weeks gestation. Associated conditions Multiple gestation Hydraminos UTI Abdominal trauma Infection No prenatal care Low socio-economic status 24. What is Preterm labor? 25. What conditions are associated with preterm labor?

20 Preterm Labor Prevention of PTL Diagnosing PTL: Education
Fetal Fibronectin test (fFN) 99% accurate predictor of NO preterm birth within 7 days

21 Preterm Labor Tocolytics: Medications prescribed to stop preterm labor
Magnesium sulfate – CNS depressant Nifedipine – Calcium channel blocker Indomethacin – Prostaglandin synthesis inhibitor Terbutaline – B adrenergic receptor agonist

22 Tocolytic Drugs - Smooth Muscle Relaxants.
Magnesium Sulfate Contraindications: discontinue for resp. depression, magnesium level >8, administer ca+ gluconate Side Effects: flushing, headache, nausea, lethargy, dizziness, decreased DTR, decreased resp. rate, pulmonary edema Nifedipine Contraindications: kidney or liver disease (especially cirrhosis), coronary artery disease, congestive heart failure, or digestive problems Side Effects: flushing, headache, orthostatic hypotension, transient maternal/fetal tachycardia Terbutaline Contraindications: hold and notify HCP if mat. HR > 120bpm Side effects: increase heart rate, feeling of anxiety, headache, increased blood glucose Indomethacin Contraindications: given X48-72 hours Side effects: constriction of PDA, prolong bleeding, N/V, heartburn, rash 26. What are the actions, nursing implications, and side effects of the following medications used for treating preterm labor?

23 Nursing Management for the Woman in Preterm Labor
Nursing Implications Promote rest, hydration, circulation Monitor FHR and uterine activity Support Medical therapy Tocolytics Steriods Antibiotic Adherence to therapy 29. What nursing interventions are used to assist a woman in preterm labor?

24 Prolapsed Umbilical Cord
Occurs when the umbilical cord precedes the presenting part. Primary Risk Factor Fetal head is not engaged or at a high station Vessels carrying blood to & from the fetus are compressed, usually results in fetal distress or possible demise Nursing Interventions Knee chest position Administer O2 Manual lift of fetal head off the cord Prolapsed Umbilical Cord 30. Define prolapse of the umbilical cord. 31. What are specific nursing interventions for the woman with a prolapsed umbilical cord?

25 Variations of Prolapsed Umbilical Cord
Fig. 27-6a

26 Variations of Prolapsed Umbilical Cord (cont’d)
Fig. 27-6c

27

28 Ruptured Uterus Causes: Assessment Findings Obstetrical Treatment
Long difficult labor Injudicious use of Pitocin Previous C/S Assessment Findings Fetal bradycardia Maternal abdominal pain Obstetrical Treatment Emergency Cesarean Section delivery Uterine Rupture 31. What conditions are associated with rupture of the uterus? 32. What are the signs and symptoms of a uterine rupture?

29 Uterine Rupture

30 Anaphylactoid Syndrome: Amniotic Fluid Embolism
In the presence of a small tear in the amnion and chorion, a small amount of amniotic fluid may leak into the chorionic plate and enter the maternal blood system. Can also occurs at areas of placental separation, cervical tears or during trumultuous labor The more debris (meconium, vernix, lanugo) in the amnionic fluid, the greater the maternal problems caused by possible anaphylactic reaction to fetal antigens Anaphylactoid Syndrome (AFE) 33. What is the cause of an amniotic-fluid embolism?

31 Amniotic Fluid Embolism
Assessment Findings: Sudden onset Respiratory distress (dyspnia) Circulatory collapse (cyanosis) Tachycardia Hypotension Acute hemorrhage Cor Pulmonale Frothy sputum 34. What does the therapeutic management involve?

32 Amniotic Fluid Embolism
Obstetrical Emergency Interventions: Large bore IV line Positive pressure oxygen CPR Blood transfusion - DIC Emergency C/S if pregnant Prognosis – 50% of women die with the first hour of symptoms

33 Amniotomy/Artificial Rupture of Membranes (AROM)
Advantages: Increases frequency and intensity of uterine contractions Release of prostaglandins Facilitates decent of presenting part Allows for internal monitoring Ability to assess amniotic fluid Disadvantages: Increased risk for infection Possibility of prolapsed umbilical cord Amniotomy 1. Define the term amniotomy. 2. What are the risks associated with an amniotomy?

34 Artificial Rupture of Membranes
Fig. 20-1d

35 Amniotomy/Artificial Rupture of Membranes (AROM)
Nursing care Place disposable pads and towel under-buttock and change frequently Assess FHR before and after amniotomy Document: color, clarity, odor Contraindication: **Procedure should not be performed if head is not engaged** 3. What nursing care is required after this procedure? 4. When is this procedure contraindicated?

36 Indications for Induction (ACOG, 1999)
Medical Conditions Diabetes mellitus Renal disease Chronic HTN Preeclampsia Premature rupture of membranes Chorioamnionitis Postterm gestation Mild abruptio placenta IUFD IUGR Induction and Augmentation of Labor 5. What are some reasons that labor may be induced?

37 Induction/Augmentation of Labor
Artificial methods to stimulate uterine contractions. Induction: Initiation of labor Medical Elective Augmentation: Improve quality of contractions

38 Bishop Score Pre-labor status evaluation scoring system
A predictor for the potential success of induction of labor A high score indicates the cervix is favorable and vaginal delivery will likely occur How does the Bishop's Score determine readiness for labor?

39 Induction of Labor Bishop Score
1 2 3 Dilation <1cm 1-2cm 2-4cm >4cm Effacement 0-30% 40-50% 60-70% 80% Fetal Station -3 -2 -1, 0 +1, +2 Cervical Consistency Firm Intermediate Soft Cervical Position Posterior Anterior

40 Cervical Ripening Prostaglandin E2 preparations Prepidil 2.5mg – gel
Cervidil 10mg – insert on string Cytotec 25mcg - pill 10. What is cervical ripening? Softens the cervix and makes it more likely to dilate with the forces of labor. Usually precedes induction of labor. 11. What medications are used in this process?

41 Pitocin (Oxytocin) Administration
Uses of Pitocin: Induction – initiates uterine contractions Augmentation – enhances ineffective contraction pattern Goal: A labor pattern with uterine contractions occurring every 2-3 minutes, lasting seconds and a return to baseline between contractions Goal: accomplish birth 6. When is augmentation of labor employed? When spontaneous labor has begun but progress is slow or stopped because of poor quality of contractions. 8. What are the techniques used to induce or augment labor? Amniotomy, medication and mechanical inserts 12. What precautions should be taken when administering Oxytocin? 13. What observations of the fetal response to Oxytocin should be made? 14. What observations of the maternal response to Oxytocin should be made?

42 Pitocin (Oxytocin) Administration
Nursing interventions when titrating Pitocin: Maternal V/S FHR pattern Baseline Variability Periodic changes Uterine contraction pattern Frequency Duration Interval 7. What are the risks associated with the induction and augmentation of labor?

43 External Version Version 15. What is an external version?
16. What is an internal version? 17. What are the nursing considerations for a woman undergoing an external version? Fig. 20-3

44 Internal & External Rotation (version)
A procedure performed to change the fetal presentation Internal Changing the position of the 2nd twin after delivery of the 1st via vaginal manipulation External Manual rotation of the fetus from breech to cephalic presentation via external manipulation of the maternal abdomen

45 External Version: Nursing Management
Pre Procedure: Admission process Consent for procedure & delivery V/S & EFM IV access Tocolytic Ultrasound Post Procedure: V/S & EFM Presences of contraction - Labor Rhogam if Rh – S/S abruptio placentae Rupture of membranes

46 Obstetric Forceps Operative Vaginal Birth
18. What are the indications for the use of forceps or vacuum extractor? 19. What are the risks of using these devices? 20. What are the nursing considerations? Fig Middle row

47 Obstetric Forceps (cont’d)
Fig Last row

48 Birth Assisted with a Vacuum Extractor
Fig. 20-5

49 Episiotomy Incision of the perineum just before birth. Indications:
Shoulder dystocia Assisted delivery (forceps/vacuum) OP position Midline or Mediolateral * Laboring down, perineal massage, pushing in the upright position reduce the incidence of episiotomy. Episiotomy 21. What is an episiotomy? 22. What are nursing considerations in reducing the need for an episiotomy?

50 Cesarean Birth Indications Risks Pre-operative care & prep Maternal
Infant Pre-operative care & prep IV hydration/prophylactic antibiotics Anesthesia: epidural/spinal FHR Foley/shave & skin prep Time-out

51 Skin Incisions for Cesarean Birth
Fig. 20-8

52 Uterine Incisions for Cesarean Birth
Fig. 20-9

53 Cesarean Birth: Recovery Care
V/S, respirations, O2 sats, ECG LOC Abdominal dressing Fundus/Lochia Urinary output/ IV fluids Sensation/movement lower extremities Pain scale Bonding with infant

54 Vaginal Delivery After Cesarean Section - VBAC
Indications: Previous low transverse uterine incision No more than 2 previous C/S Obtain informed consent Nursing Implications Large bore IV access Continuous EFM ** Increased risk for uterine rupture 24. What is a VBAC? 25. What risk is associated with an attempted VBAC?

What do you do for hypotonic contractions?

How do you manage hypertonic uterine contractions?

What are hypotonic and hypertonic uterine contractions?

What is hypertonic uterine contraction?