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1. Placenta Previa
The two most clinically significant causes of bleeding in the second half of pregnancy are: placenta previa and placentae In placenta previa, the placenta is implanted in the lower uterine segment rather than the upper portion of the uterus The placenta is implanted in the lower segment of the uterus or over the internal cervical os. Bleeding begins – may be either scanty or perfused Placenta previa is categorized as being: o Low lying – placenta is in the lower uterine segment but DOES NOT COVER THE OS o Partial – internal os is partially covered o Marginal – edge of placenta is covered o Complete – internal os is covered
CAUSE OF PLACENTA PREVIA IS
UNKNOWN
Women at higher risk are: Women of African descent Women who have undergone prior C- section Other risk factors : High gravidity High parity Advanced maternal age Previous miscarriage Previous induced abortion Cigarette smoking Male fetus
Fetal/Neonatal Implications
o Prognosis for fetus depends on the extent of placenta previa o Woman may be allowed to labor with : marginal and low-lying placenta previa o Fetus may have changes in: FHR and meconium staining of the aminotic fluid - FHR monitoring is imperative o Porfuse bleeding : fetus is compromised and suffers some hypoxia
o If nonreassuring fetal status occurs C-section is indicated
o Woman with complete or partial previa C-section because of
high risk for hemmoraging !!! o Postpartum: blood sampling to check for anemia in the newborn
Clinical Therapy Expectant Management
Goal of medical care is to identify the cause of bleeding and to (^) • Bed rest provide treatment^ that^ will^ ensure^ birth^ of^ a^ mature^ newborn^ • Bathroom privileges as long as woman is not bleeding
- Transabdominal ultrasound scan to localized placenta (^) • Performing no vaginal exams
- Until placenta previa is ruled out:^ VAGINAL^ • Monitoring blood loss, pain, and uterine contractility EXAMINATIONS ARE NEVER DONE WITH WOMAN WITH^ • Evaluating FHR with an external fetal monitor BLEEDING^ • Monitoring maternal v/s o Examiners fingers can perforate placenta if (^) • Labs: H&H, Rh factor and urinalysis cervical dilation^ has^ occurred^ • IV (LR solution) o Once^ r/o^ then^ examiner^ can^ perform^ vaginal^ • 2 units of cross-matched blood available for transfusion exam with speculum to determine cause of (^) • If frequent, recurrent or profuse bleeding persists or if fetal well- bleed (^) being appears threatened a C-section is needed
- Differential diagnosis of placental or cervical bleeding takes
careful consideration Clinical Signs
- Most accurate diagnostic sign of placenta previa: PAINLESS,
- Partial separation: painless bleeding
- True placenta previa: may not demonstrate overt bleeding BRIGHT-RED VAGINAL BLEEDING until labor begins •^ First^ bleeding^ episode^ is^ generally^ light,^ scanty
- If no vaginal examinations are performed it often subsides - Confusion between partial and true placental is an issue when diagnosis spontaneously, however each subsequent hemorrhage is more - Care of woman with painless late-gestational bleeding perfuse depends on:^ •^ Uterus^ remains^ soft
- If labor begins, the uterus relaxes during contractions
- week of gestation during which the 1 st^ bleeding episode maternal occurs •^ FHR^ remains^ stable^ unless^ profuse^ hemorrhage^ and
- The^ amount of bleeding shock^ occur
- (^) If pregnancy is less than 37 weeks’, expectant management •^ Fetal^ presenting^ part^ is^ often^ unengaged and transverse lie is is (^) used to delay birth until about 37 weeks’ to allow the common fetus time to mature
Nursing
Management
Prevent or treat complications
- Nurse should assess blood loss, pain and uterine contractility (subjective and objective)
- Maternal V/S and the result of blood loss and urine test - Monitor maternal vital signs every 15 min in the absence of hemorrhage and every 5 mins with active hemorrhage
- Evaluate the FHR w/continuous external fetal monitoring
- Observe and verify family’s ability to cope with the anxiety associated with an unknown outcome
- Record, I&O’s, V/S, prepare whole-blood setup to be ready for IV infusion, establish IV site,
- Fluid volume deficit due to excessive blood loss
- Impaired gas exchange of fetus r/t decreased blood volume and maternal hypotension
- Anxiety related to concern for own personal status and baby’s safety - osely, baby may require O2 and O
Clinical Therapy Mild Placental Separation
- DIC - there is abnormal coagulation and abnormal bleeding • Vaginal labor may be induced if baby is late preterm in o If induced labor or oxytocin don’t work C-section is required the skin, GI and respiratory system o The longer they delay birth the more risk for increased
- The^ DIC^ cascade^ leads^ to^ microclots^ that^ disrupt^ normal^ hemorrhage blood flow^ to^ major^ organs and^ can^ lead^ to^ organ^ failure^ Moderate to Severe placental Separation
- Coagulation^ test^ results^ are^ imperative!!!^ • Treat hypofibrinogemia 1 st^ by IV cryoprecipitate or fresh frozen
- fibrinogen^ levels^ and^ platelet^ counts^ are^ decreased^ plasma
- PT^ and^ PTT^ are^ prolonged (longer^ to^ clot)^ • Then after treatment of hypofibrinogemia then C- Section is done
- Maintain^ cardiovascular^ status^ of^ mother^ and^ baby^ • Vaginal birth is IMPOSSIBLE
- C-section is the safest option (^) Nursing Management
- Type and cross-match for blood transfusion (at least 3 units) (^) • Electronic monitoring of uterine contractions
- IV^ fluids^ • Resting tone btwn contractions
- Evaluate^ clotting^ mechanism^ • Evaluate uterine resting tone for increased tone (frequently
- CVP^ is^ monitored^ hourly^ to^ evaluate^ IV^ fluid^ replacement.^ increased tone with abruptio placentae)
- High^ CVP^ may^ indicate^ fluid^ overload^ and^ pulmonary^ edema^ • Abdominal girth measurement hourly (at level of umbilicus)
- Lab^ exams:^ H&H^ and^ coagulation^ status^ • Uterine size increases with bleeding
- HYPOVOLEMIA^ –^ with severe placentae abruptio is life^ • To measure uterine size from top of fundus to symphysis pubis threatening and is combated with whole blood^ • Over distension of uterus can lead to a ruptured uterus (life
- If^ fetus^ is^ under^ stress^ C-section^ is^ done!^ threatening)
- With still birth fetus, vaginal birth is preferred if bleeding has
been stabilized
3. Oxytocin (Pitocin)
Administering oxytocin is effective for initiating uterine (^) • Has effects on the cardiovascular system: contractions to induce labor and may also use to enhance o BP may decrease ineffective contractions (^) o Prolonged administration causes an increase above baseline (by
- It^ has^ a^ stimulatory effect^ on^ the^ smooth^ muscle^ of^ the^ 30%) uterus and blood vessels (^) o CO and SV increase
- Increases the strength of contractions and^ o 20 milliunits/min or more makes it a diuretic effect (decrease in propagations of contractions UO)
- Effects on uterus depends on the dosage used • Oxytocin is used to induce labor at term
- Has^ a^ half-life^ of^ 3-5^ mins^ • Oxytocin is also used to augment uterine contractions in the 1 st and 2 nd
- 40 mins to take effect in plasma stages of labor
- Oxytocin can also be given after birth to stimulate uterine contraction and thereby control uterine atony Route, Dosage and Frequency
- Start with primary IV tubing and piggyback secondary IV
- Oxytocin is infused in IV infusion pump
- Start with 0.5-1 milliunit/min and increase by 1-2 milliunit/min every 40-60 minutes until mom reaches adequate contraction pattern of contractions every 2-3 mins and lasting 40- seconds
- Provide continuous monitoring of fetus and uterine contractions
- Ensure that V/S: BP, heart rate and O saturation are good Administration of Oxytocin After Expulsion of Placenta
- 10 units of oxytocin are given IM or added to the IV fluids for continuous infusion
- Assess BP, pulse, and uterine resting tone before each increase in dose
- Record all patient activity and procedures
- **If bleeding is well controlled, the oxytocin is discontinued after the initial postpartum infusion Maternal Contraindications
- Severe preeclampsia/eclampsia**
- Predisposition to uterine rupture
- Cephalopelvic disproportion
- Malpresentation or malposition of fetus
- Cord prolapse
- More than one previous C-section birth
- Preterm infant
- Rigid, unripe cervix; total placenta previa
- Nonreassuring fetal status Maternal S/E
- Hyperstimulation can lead to too many contractions which can cause: o Abruptio placentae o Impaired uterine blood flow fetal hypoxia o Rapid labor and birth o Lacerations o Uterine atony o Uterine rupture o Water intoxication (n/v, hypotension, tachy) if too much is given 20mu/min o Hypotension with rapid IV bolus
4. Episiotomy
Surgical incision of the perineal body to enlarge the Factors that Predispose to Episiotomy outlet • PRIMIGRAVIDAS
- Minimize the risk of laceration of the perineum•^ Large Macrosomic fetus and the overstretching of perineal tissues • Occiput-posterior positions
- There is however an increased risk for 4rth • Forceps and vacuum degree perineal laceration^ • Shoulder dystocia
- Complications^ with^ episiotomy:^ Other causes: o Blood^ loss^ • Lithotomy position and recumbent position o Infection,^ pain^ • Sustained breath holding can cause stretching or perineal area and affects o Perineal^ discomfort^ blood flow to fetus and mom o Painful^ intercourse^ • Arbitrary time placed by MD/CNM on the length of the 2 nd^ stage of labor Preventative Measures
- Perineal massage during pregnancy in nulliparous mom
- Natural pushing in labor ( avoid lithotomy position or pulling back on legs )
- Side-lying to push
- Warm /hot compresses on perineum, firm counter pressure Procedure
- Midline and mediolateral cut
- Mediolateral is done in emergent situation such as in a prolapsed cord or breech birth
- When 3-4 com of fetal head is seen in contraction episiotomy is performed with scissors
- Performed with regional or local anesthesia
- May be done w/o anesthesia in emergencies
5. Presentations: ▪ Fetal attitude refers to the relation of the fetal parts to one another Normal attitude of the fetus: is one moderate flexion of the head, flexion of the arms onto the chest and flexion of the legs into the abdomen ▪ Fetal lie – refers to the relationship of the spinal column of the fetus to the spinal cord or the woman ▪ Fetal Presentation (to know do an ultrasound) is determined by fetal lie and by the body part of the fetus that enters the pelvic passage first. which can be cephalic, breech or shoulder o When cephalic presentation occurs labor and delivery are likely to proceed normally o Breech birth in which the butt or feet are first out, the sacrum is the landmark to be noted. Breech and shoulder are associated with more difficulties in labor (known as malpresentations) Butt firs - Butt first: feet can be flexed or extended upward Ultrasound is done to confirm Leopold's maneuver can be done too -Shoulder: External ECV, trying to move the baby, has its risks 6. Contractions : it is the primary force which causes complete effacement and dilation of the cervix, and causes baby to move down the birth canal (descend). ▪ The cervix dilates or opens from 0-10 cm during the 1st stage of labor in response to uterine contractions ▪ They are rhythmic but intermittent. There is a period of relaxation between them. This allows the muscles to rest and provides relief for the laboring mother. It also restores uteroplacental circulation, which is important to fetal oxygenation and adequate circulation in the uterine blood vessels. ▪ Each contraction has three phases: increment(build up, longest phase), acme(peak) and decrement (letting up) ▪ Frequency: time b/w the beginning of one contraction and the beginning of the next one. ▪ Duration: from the beginning of a contraction to the completion of the same one. ▪ Intensity: strength of contraction during acme. Determined by palpating the fundus or intrauterine catheter. ▪ If when palpating the uterus during the acme, it feels hard that means the contraction is strong ▪ If when palpating the uterus during the acme, it indents easily that means the contraction is mild ▪ Strong intensity exists when the uterine wall cannot be indented ▪ When measuring the intensity with the intrauterine catheter – the pressure increases as the woman pushes ▪ As labor progresses, the duration, frequency or intensity of contraction increases TRUE vs FALSE LABOR 1. True labor – produces effacement and dilation ❖ Discomfort starts in the back and radiates around the abdomen ❖ Contractions are REGULAR and increase in FREQUENCY, DURATION and INTENSITY ❖ pain is not relieved by ambulation ❖ Walking intensifies the pain 2. False labor –do not produce progressive cervical effacement or dilation ❖ IRREGULAR and do not increase in FREQ., DURA., AND INTENSITY ❖ Sometimes there is no discomfort ❖ If there is discomfort its more in the lower abdomen and groin ❖ Relived by ambulation , change in position, drinking large amount of water or warm shower 7. STAGES OF LABOR AND BIRTH First stage - begins with onset of true labor and ends when the cervix is completely dilated to 10 cm. Second stage – complete dilation and ends with the birth of the baby Third stage – begins with birth of the baby and ends with the expulsion of the placenta Fourth stage – last from 1-4 hrs after expulsion of the placenta, the uterus contracts to control bleeding at
placenta site 1 st Stag e
LATENT PHASE
- Starts with the beginning of regular contractions which are mild at this time
ACTIVE PHASE
- Anxiety increases due to contractions and pain
- Decreased ability of coping and sense of helplessness
- In this phase the cervix dilates from 4cm to 7 cm
shaking chills
9. Fetal Descent
10. Cardinal Movements of labor For the fetus to pass though the birth canal, the fetal head and body must adjust to the passage by certain position changes: b.Descent: occurs because of four forces (1) pressure of the amniotic fluid, (2) direct pressure of the uterine fundus on the breech, (3) contraction of the abdominal muscles, and (4) extension and straightening of the fetal body. The head enters the inlet in the occiput transverse or oblique position because the pelvic inlet is widest from side to side. The sagittal suture is an equal distance from the maternal symphysis pubis and sacral promontory. c.Flexion: occurs as the fetal head descends and meets resistance from the soft tissues of the pelvis, the muscles of the pelvic floor and the cervix. As a result of the resistance, the fetal chin flexes downward onto the chest. d.Internal rotation: the fetal had must rotate to fit the diameter of the pelvic cavity, which is widest in the anteroposterior diameter. As the occiput of the fetal head meets resistance from the levator ani muscles and their fascia, the occiput rotates (usually from left to right_ and the sagittal suture aligns in the anteroposterior pelvic diameter. e.Extension: the resistance of the pelvic floor, and the mechanical movement of the vulva opening anteriorly and forward, assist with extension of the fetal head as it passes under the symphysis pubis. With this positional change, the occiput, then brow and face, emerge from vagina. f.Restitution: the shoulder of the fetus enter the pelvic inlet obliquely and remain oblique when the head rotates to the anteroposterior diameter through internal rotation. Because of this rotation, the neck becomes twisted. Once the head is born and is free of pelvic resistance, the neck untwists, turning the head to one side (restitution), and aligns the position of the back in the birth canal. g. External rotation: as the shoulder rotate to the anteroposterior position in the pelvis, the head turns farther to one side (external rotation). h.Expulsion: after the external rotation, and through the pushing efforts of the laboring woman, the anterior shoulder meets the undersurface of the symphysis pubis and slips under it. As lateral flexion of the shoulder and head occurs, the anterior shoulder is born before the posterior shoulder. The body follows quickly. 11. Electronic Monitoring ELECTRONIC MONITORING OF CONTRACTIONS - Provides continuous data - Electronic monitoring can be done eternally with a device placed on the maternal abdomen o Tocodyamometer – placed in the fundus, responds to pressure. When uterus contracts the change in pressure is amplified and transmitted to the monitor o It does not accurately record the intensity of contraction o It is difficult to obtain accurate FHR in women who are obese, abnormal amount of amniotic fluid, active fetus and premature cases of fetus - Electronic monitoring can be done internally with an intrauterine pressure catheter o Accurate measurement of contraction intensity (the strength of contraction and the pressure within the uterus Catheter is only placed with the membrane has ruptured
Variability Strip’s
Fetal • Baseline rate – normal FHR 110-
beats/min, during
- Baseline variability - interchange between
Heart
Rate
at 10 min duration, baseline should no less than 2 mins
- Variability – change in the FHR over a few seconds to a sympathetic and parasympathetic system over 10 mins. It reflects baseline fluctuations that are few mins
- Fetal tachycardia – sustained rate of 161 beats/min or irregular in frequency and amplitude.
- If an fetus has absent or minimal variability they are above
- Marked tachycardia is 180 bpm or above
- Causes of tachy : fetal hypoxia, maternal fever, maternal dehydration, sympathetic drugs, intrauterine at high risk of acidosis and subsequent hypoxia
- Causes of reduced variability: hypoxia and acidosis, drugs that depress the CNS, fetal sleep cycle
- Causes of marked variability: early mild hypoxia, infections, maternal hyperthyroidism, and fetal anemia
- Fetal bradycardia – rate less than 110 bpm during a 10 min period or longer
- Causes of brady : late fetal hypoxia, maternal fetal stimulation, fetal breathing movements, stimulant meds - Absent variability that does not appear to be associated with a fetal sleep cycle or meds is a hypotension (less blood to fetus), umbilical cord compression, fetal arrhythmia, abruptio placentae, warning sign! - External fetal monitoring is not adequate way to uterine rupture, vagal stimulation, heart block and assess variability, internal monitor is more accurate maternal hypothermia Accelerations – the transient increases in the FHR (normally caused by fetal movement)
- When fetus move heart rate increases
- Accelerations may accompany uterine contractions (due to fetal movements)
- Accelerations during contractions are a sign of fetal well- being Decelerations – decreases in FHR from normal baseline
- • • • • • When the fetal head is compressed, cerebral blood flow is decreased, which leads to central vagal stimulation and results in early deceleration Types of decelerations
- Early – occurs before the onset of uterine contractions (considered benign and doesn’t require intervention)
- Late – caused by uteroplacental insufficiency resulting from decreased blood flow and O2. Late deceleration occurs after the onset of contraction. Late decelerations are considered a nonreassuring sign. If late decelerations continue and birth is not forthcoming, a C- section may be needed ☹
- Variable – occurs when the umbilical cord is compressed, thus reduces blood flow between the placenta and the fetus. The resulting increase in peripheral resistance in the fetal circulation causes fetal HTN. The fetal HTN stimulates the
- baroreceptors which lowers the FHR
Nursing Management
- It is crucial that nurses balance technology with holistic nursing practice
- Before the nurse uses the electronic fetal monitoring, explain the reason for its use and the information it can provide
- Record basic information on the strip
- As the monitor strip runs should note down occurrences during labor such as: dilation, effacement, station, position, color and amount of amniotic fluid and odor, maternal vital signs, maternal position, O administration, emesis, cough, hiccups, pushing and administration of anesthesia blocks
- If monitor doesn’t automatically add the time on the strip at specific intervals, include the time on the strip **- If more than one nurse is adding info on the strip, make sure to initial each note on the strip
- Fetal monitor strip should be reviewed regularly** (at least every 30 mins in the first stage and every 15 min in the 2 nd^ stage of labor) - Evaluating the electronic monitor tracing by looking at the uterine contraction patterns: o The nurse should determine the uterine resting tone and should assess the contractions frequency, duration and intensity - Share information with mother to reassure that everything is ok 11. Demerol
- Aka Meperidine
- CNS analgesic
- Narcotic antagonist Common s/e: - Sedation - Dizziness, Pruritus - Nausea and Constipation 12. Epidural Block - Involves injection of an anesthethic agent into the epidural space to provide pain relief throughout labor Administration - Given in the active phase of the first
o Decreased anxiety o Earlier mobilization o Retained cough reflux o Decreased risk for DVT o Decreased myocardial oxygen demand o Ease of adminsitration o If RR decreased below 14, Narcan may be given
- N/V —give antiemetic or decrease infusion rate
- Pruritus (itching and rash)—appears first in the face, neck, or torso; give benadryl Hypotension —may occur from hypovolemia or from
• PATIENT STILL NEEDS TO BE CONTINOUSLY
MONITORED
- Potential problems: breakthrough pain, sedation, N/V, pruritus and hypotension o If breakthrough pain occurs, check the pump itself and notify the analgesia provider epidural o Give crystalloid fluids, give O2, notify analgsia provider o Woman may be placed in Trendelenburg position Combined Spinal-Epidural Block Local Infiltration Anesthesia
- Can be used for labor analgesia and for cesarean birth
- Administered in the subarachnoid space - Has a faster onset of pain relief than epidural anesthesia
- Use in the second stage of labor
- Spinal analgesia may be given early in labor; epidural is activated when active labor begins
- Woman can abulate after CSE is placed
- Usually used for cesarean births
- Duramorph protocol
- Used at the time of birth, both in preperation for an episiotomy if needed
- Practically free of complications
- A disadvatange is the large amounts used to infuse tissues
- No affect on VS or FHR 13. Betamethasone Maternal-Fetal action: Maternal SE Is capable of inducing pulmonary maturation and decreasing the incidence Some infection of RDS in preterm infants. It stimulates enzyme activity Hyperglycemia Shouldn’t be used frequently Fetus/newborn Contraindication: Low cortisol levels, Inability to delay birth rebound occurs by 2 Adequate L/S ratio hours of age Presence of a condition that necessitates immediate birth Hypoglycemia Presence of maternal infection, DM, Increased risk of neonatal Gestational age greater than 34 completed weeks sepsis
NI
Assess for contraindications Provide education about SE Administer deep into gluteal muscle Monitor BP, HR, weight, and edema Assess lab for electrolytes and BG Monitor for pulmonary edema.
14. Premature ROM
Some complications can occur before the onset of labor that significantly impact the outcome of pregnancy
- Premature rupture of membranes is a spontaneous rupture of the membranes before the onset of labor
- Occurring before 37 weeks gestation
- The exact cause is unknown but thought to be due to infection, trauma, amniocentesis, placenta issues, incompetent cervix, bleeding and multiple pregnancy etc.
- Fetal/neonatal: risk for respiratory distress syndrome, fetal sepsis , malpresentations, prolapse of umbilical cord, nonreassuring FHR, compression of the umbilical cord, premature birth
- The greater the gestational age, the greater the chances of infant complications
Clinical Therapy •^ After^ birth,^ newborn^ is^ assessed^ for^ sepsis^ and
placed on
- Sterile^ speculum examination is done to detect the presence of antibiotics amniotic fluid in the vagina •^ Continues^ electronic^ fetal^ monitoring - Nitrazine^ paper – other test done, turns deep blue when •^ Regular^ NST^ or^ BPP amniotic fluid is present. •^ Maternal^ BP,^ HR,^ temp,^ and^ FHR^ every^ 4hr o (^) Bacterial pathogens may cause a positive Nitrazine •^ If^ woman^ has^ a^ preterm^ PROM,^ she is assessed and exams such test as: CBC, NST, BPP are done - Ferning test – microscopic test done to determine rupture of - (^) Vaginal exams are avoided to decrease chance of infections - Maternal corticosteroid administration promotes fetal lung membranes (^) maturity and prevent respiratory distress syndrome - (^) Digital examination increases the risk for infection (not (^) o BETAMETHASONE recommended) - If maternal s/s of infection are evident, antibiotic
with prolapsed cord if the cervix is Give mommy O2 via face mask pelvic measurements are adequate Force^ of^ gravity^ to
- Risk for infection related to premature rupture of membranes
- Impaired gas exchange in fetus related to compression of umbilical cord - Mother and father need to understand that although the membranes have rupture, amniotic fluid Is still done
15. Brethine
Brethine is used to attempt labor (preterm labor)
- It suppresses uterine contractions and allow pregnancy to continue
- Can cause maternal side effect of PULMONARY EDEMA
- Was once used to stop labor but are now being replaced by other meds
- Long term use of Brethine is no longer considered standard of care – because of risk of maternal morbidity r/t pulmonary edema
16. Prolonged Labor
Posterm pregnancy is one that extends more than 294 days or 42 weeks past the first day of the LMP
- Gone beyond EDB
- Cause of postdate pregnancy is unknown
- Occurs more frequently in Primigravidas and women with hx of prolonged pregnancy
- Women who have a previous posterm pregnancy are at risk for posterm pregnancy in subsequent pregnancies - Maternal Risks: o Probable labor induction o Increased risk for large-for-gestational age (LGA) infant and resultant perineal trauma o Increased incidence for forceps-assisted, vacuum assisted or C-section birth and risk for infection - Fetal risks: o Decreased perfusion from the placenta o Oligohydramnios – decreased amount of amniotic fluid (increases risk for cord compression) o Meconium aspiration (more likely if Oligohydramnios and thick meconium are present) o Low 5 minute Apgar score - Some fetus grow beyond 42 weeks and can be excessively large at birth (Macrosomia) - Intrauterine environment becomes unfavorable for growth, uteroplacental insufficiency occurs and at birth the infant has lost muscle mass and fat known as dysmaturity syndrome - Macrosomic fetus is at risk for birth trauma Concerns of posterm pregnancy
- Increase in fetal mortality rate after 40 weeks
- Mortality rate doubles by 42 weeks
- Post 40 weeks and GD increases morbidity
- Post 38 weeks the placenta begins to deteriorate
- Meconium staining increases with prolonged pregnancies
- Anxiety Clinical Therapy
- Some HCP prefer induction at 41 weekOther HCP do NST and BPP (especially the amniotic fluid volume portion of the BPP) 2 to 3 times a week to see fetal well-being
- If fetus has problems interventions are begun to accomplish birth Nursing Management
- Reassuring FHR and evaluate nonreassuring patterns (such as nonperiodic variable decelerations – which indicate cord compression or Oligohydramnios )
- When amniotic membranes rupture assess fluid for meconium
- Teach mother about assessing fetal movement every day in the community
- If Oligohydramnios exists, obtain continuous FHR tracing
- Variable decelerations are often associated with oligohydramnios because the decreased amount of fluid may allow compression of the umbilical cord
- If fetus is Macrosomic, carefully assess labor progress o contraction characteristics o progressive cervical dilation o fetal descent
- Emotional support 17. Prolapsed Umbilical Cord
- The umbilical cord falls in front of, lies beside, or hangs below the fetal presenting part
- Related to a long umbilical cord
- Malpresentation - Contributing factors - Transverse lie and breech presentations - Prolapsed umbilical cord results when the umbilical cord precedes the fetal presenting part - Pressure is placed in the umbilical cord as it is trapped between the presenting part and the maternal pelvis the vessels carrying blood to and from fetus are compressed
Risks of Prolapsed Cord
- Maternal Risks: o Does not directly precipitate physical alterations in women o Enormous stress on mother due to concern of fetus o C section may be needed o Sometimes death of baby can occur - Fetal Risks: o Decreased blood flow o Leading to nonreassuring fetal status o Cord compression is further in each contraction o Fetus can die if pressure on cord isn’t relived - Risk factors o Preterm labor o fetal abnormalities,Polyhydramnious
o pROM, placenta previa, pelvic tumors, ECV
- Vaginal birth is possible completely dilated and Clinical Therapy for Prolapsed Cord Preventing prolapse of the cord is the preferred medical approach - In bed, until fetal head is well engaged to prevent risks of prolapse of cord - Relieving pressure on the prolapse cord is critical for fetus - Medical team work together to facilitate birth - Bed rest – for women with Hx of ROM, until engagement with no cord prolapse has been documented - Auscultate FHR for at least a min full (at beginning and end of contractions) - If fetal bradycardia perform vaginal examination to r/o cord prolapse - Cord prolapse Monitoring findings: o severe, moderate or prolonged variable decelerations with baseline bradycardia - examiners gloved fingers must remain in vagina to provide firm pressure on fetal head (to relieve compression) o LIFE SAVING MEASURE - - ion of cord
