Maternal

Cards (90)

  • High-Risk factors related to intrapartum complications
    • Passenger (fetus, other related structures)
    • Passage way (pelvic bones and other pelvic structures)
    • Powers (uterine contractions)
    • Clients' psyche (psychological state)
  • Cord prolapse is descent of the umbilical cord into the vagina ahead of the fetal presenting part with resulting compression of the cord between the presenting part and the maternal pelvis
  • Cord prolapse is an emergency situation therefore, immediate delivery will be attempted to save the fetus
  • Cord prolapse occurs in 1 of 200 pregnancies
  • Etiology of cord prolapse
    • Occurs frequently in prematurity
    • Rupture of membranes with the fetal presenting part unengaged
    • Shoulder or footling breech presentations
    • May follow rupture of the amniotic membranes due to the fluid rush that may carry the cord along toward the birth canal
  • Pathophysiology of cord prolapse
    Compression of the cord results in the compromise or cessation of fetoplacental perfusion
  • Cord prolapse
    • Cord may be protruding from the vagina
    • Cord may be palpated in the vaginal canal or cervix
    • Fetal distress may occur as the cord is compressed between the presenting part and the bony prominence
  • Assessment findings for cord prolapse
    • FHR pattern may show variable decelerations with contractions or between contractions
    • Fetal bradycardia is present
    • If the cord is exposed to the cold air, there may be reflex constriction of the umbilical vessels (restricts O2 flow to fetus)
  • Management of cord prolapse

    Delivery of the fetus as soon as possible
  • Nursing management of cord prolapse
    1. Assess a laboring client often if the fetus is preterm or small for gestational age, if the fetal presenting part is not engaged, and if the membranes are ruptured
    2. Periodically evaluate FHR, especially right after rupture of membranes (spontaneous or surgical), and again in 5 to 10 minutes
    3. If prolapse cord is identified, notify the physician and prepare for emergency cesarean birth
    4. If the client is fully dilated, the most emergent delivery route may be vaginal. In this case, encourage the client to push and assist with the delivery as follows: Lower the head of the bed and elevate the client's hips on a pillow, or place the client in the knee-chest position to minimize pressure from the cord; Assess cord pulsations constantly; Gently wrap gauze soaked in sterile normal saline solution around the prolapsed cord
  • Fetal distress
    Fetal hypoxia that may result in fetal damage/death if not reversed or the fetus delivered immediately
  • Etiology of fetal distress - Maternal

    • Poor placental perfusion
    • Hypovolemia
    • Hypotension
    • Myometrial hypertonus
    • Prolonged labor
    • Excess oxytocin
  • Etiology of fetal distress - Fetal
    • Cord compression
    • Oligohydramnios
    • Entanglement
    • Prolapse
    • Pre-existing hypoxia or growth retardation
    • Infection
    • Cardiac problems
  • Signs and symptoms of fetal distress
    • Increased/decreased fetal heart rate (tachycardia and bradycardia), especially during and after a contraction, decreased variability in the fetal heart rate
    • Abnormal fetal heart rate (< 120 or > 160 bpm)
    • Amniotic fluid is contaminated by meconium
    • Decreased fetal movement felt by the mother
  • Management of fetal distress
    1. Let the mother assume left side lying position
    2. Administer oxygen by mask
    3. Perform vaginal examination to check for prolapsed cord
    4. Administer oxygen by mask
    5. Carry out doctor's orders for pre operative routines
    6. Monitor fetal heart tones (continuous fetal monitoring)
    7. Vaginal examination to check for prolapsed cord
    8. Rule out imminent vaginal delivery
    9. Initiate preoperative routines
  • Cephalopelvic disproportion
    • Implies disproportion between the head of the baby (cephalous) and the mother's pelvis
    • Complications can occur if the fetal head is too large to pass through the mother's pelvis or birth canal
    • Common cause of different complications in labor
    • Frequently diagnosed indication of cesarian sections
  • Diagnosis of cephalopelvic disproportion
    1. Radiologic pelvimetry x-rays or CT scans are taken of the pelvis in different angles and views and the pelvic diameter measured
    2. Ultrasound estimation of the baby's size can be made by ultrasonogram
  • Nursing interventions for cephalopelvic disproportion
    1. Monitor heart sounds and uterine contractions continuously, if possible, during trial labor
    2. Urge the woman to void every 2 hours
    3. Assess FHR carefully
    4. Establish a therapeutic relationship, conveying empathy and unconditional positive regard
    5. Instruct in methods to conserve energy
    6. Massage bony prominences gently and change position on bed in a regular schedule
    7. Convey confidence in clients ability to cope with current situation
  • Dystocia / dysfunctional labor
    Dysfunctional labor is difficult, painful, prolonged labor due to mechanical factors
  • Etiology of dystocia / dysfunctional labor
    Uterine contractions are ineffective secondary to muscle fatigue or overstretching
  • Assessment findings for dystocia / dysfunctional labor
    • Clinical manifestations include irregular uterine contractions and ineffective uterine contractions in terms of contractile strength and duration
  • Nursing management of dystocia / dysfunctional labor
    1. Optimize uterine activity: Monitor uterine contractions for dysfunctional patterns; use palpation and an electronic monitor
    2. Prevent unnecessary fatigue: Check the client's level of fatigue and ability to cope with pain
    3. Prevent complications of labor for the client and infant: Assess urinary bladder; catheterize as needed; Assess maternal vital signs, including temperature, pulse, respiratory rates, and blood pressure; Check maternal urine for acetone (an indication of dehydration and exhaustion); Assess condition of fetus by monitoring FHR, fetal activity, and color of amniotic fluid
    4. Provide physical and emotional support: Promote relaxation through bathing and keeping the client and bed clean, back rubs, frequent position changes (side-lying position), walking (if indicated), and by keeping the environment quiet; Coach the client in breathing and relaxation techniques
    5. Provide client and family education
  • Shoulder dystocia
    In shoulder dystonia, the anterior shoulder of the baby is unable to pass under the maternal pubic arch
  • Pathophysiology of shoulder dystocia
    The plane of the fetal shoulders aligns perpendicular to the pubis instead of at an angle. This causes the shoulder to become wedged under the pubic arch
  • Assessment findings for shoulder dystocia
    • The birth process may seem unnecessarily prolonged
    • The fetal head retracts against the mother's perineum as soon as the head is delivered. This is known as the "turtle sign"
    • External rotation does not occur
  • Nursing management of shoulder dystocia
    1. Place the client in the McRobert's Maneuver (ie, thighs pulled up against the abdomen with hips abducted)
    2. Apply suprapubic pressure by an assistant pushes the fetal anterior shoulder downward to displace it from above the mother's symphysis pubis. Fundal pressure should not be used, because it will push the anterior shoulder more firmly against the mother's symphysis
  • Uterine rupture
    • Spontaneous or traumatic rupture of the uterus
    • Classified into 2 types: complete and incomplete rupture
  • Etiology of uterine rupture
    • May be caused by injury from obstetric instruments such as uterine sound or curette used in abortion
    • May result from obstetric intervention, such as excessive fundal pressure, forceps delivery, violent bearing-down, tumultuous labor and fetal shoulder dystocia
    • Spontaneous uterine rupture is most likely to occur after previous uterine surgery, grand multiparity combined with the use of oxytocic agents, cephalopelvic disproportion, malpresentation, or hydrocephalus
  • Assessment findings for uterine rupture
    • Rupture of the scar from a previous cesarean delivery or hysterectomy
    • Prolonged or obstructed labor (shoulder dystocia)
    • Forceps delivery of fetus with abnormalities (hydrocephalus)
    • Application of forceps and extraction before cervical os has completely dilated
    • Injudicious use of oxytocin
    • Excessive manual pressure applied to the fundus during delivery
    • Violent, bearing down
  • Assessment findings for complete uterine rupture
    • Sudden sharp abdominal pain during contractions
    • Abdominal tenderness
    • Cessation of contractions
    • Bleeding into the abdominal cavity and sometimes into the vagina
    • Fetus easily palpated; FHT cease
    • Signs of shock: rapid, weak pulse; cold, clammy skin; pallor; flaring of nostrils
  • Uterine rupture can occur due to disproportion, malpresentation, or hydrocephalus
  • Causes of uterine rupture
    • Rupture of the scar from a previous cesarean delivery or hysterectomy
    • Prolonged or obstructed labor (shoulder dystocia)
    • Forceps delivery of fetus with abnormalities (hydrocephalus)
    • Application of forceps and extraction before cervical os has completely dilated
    • Injudicious use of oxytocin
    • Excessive manual pressure applied to the fundus during delivery
    • Violent, bearing down
  • Clinical manifestations of uterine rupture
    • Vary from mild to severe, depending on the site and extent of the rupture, degree of extrusion of the uterine contents, and intraperitoneal evidence or absence of spilled amniotic fluid and blood
  • Signs and symptoms of uterine rupture
    • Sudden sharp abdominal pain during contractions
    • Abdominal tenderness
    • Cessation of contractions
    • Bleeding into the abdominal cavity and sometimes into the vagina
    • Fetus easily palpated; FHT cease
    • Signs of shock (rapid, weak pulse; cold, clammy skin; pallor; flaring of nostrils due to air hunger)
  • Signs of incomplete uterine rupture
    • Abdominal pain during contractions, Contractions continue, but cervix fail to dilate, Vaginal bleeding may be present, Rising pulse rate and skin pallor, Loss of fetal heart tones
  • Incomplete uterine rupture develops over a period of a few hours
  • Nursing management of uterine rupture
    1. Monitor for the possibility of uterine rupture
    2. Assist with rapid intervention
    3. Implement the following preparations for surgery
    4. Prevent and manage complications
    5. Provide physical and emotional support
  • Uterine inversion occurs immediately following delivery of the placenta or in the immediate postpartum period
  • Forced uterine inversion
    Caused by excessive pulling of the cord or vigorous manual expression of the placenta or clots from an atonic uterus
  • Spontaneous uterine inversion
    Due to increased abdominal pressure from bearing down, coughing, or sudden abdominal muscle contraction