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<ul><li>Childbirth at Risk: Labor-Related Complications </li></ul>
Learning Outcome  <ul><li>Compare and contrast hypertonic and hypotonic labor patterns, including risk, clinical therapy, ...
Characteristics of Hypertonic Labor  <ul><li>Increased contraction frequency </li></ul><ul><li>Decreased contraction inten...
Implications of Hypertonic Labor  <ul><li>Increased discomfort due to uterine muscle cell anoxia </li></ul><ul><li>Stress ...
Implications of Hypertonic Labor  <ul><li>Reduced uteroplacental exchange resulting in nonreassuring fetal status </li></u...
Effects of Labor on the Fetal Head
Effects of Labor on the Fetal Head
Clinical Therapy for Hypertonic Labor <ul><li>Bed rest and relaxation measures </li></ul><ul><li>Pharmacologic sedation </...
Nursing Diagnoses for Hypertonic Labor <ul><li>Fatigue related to inability to relax and rest secondary to hypertonic labo...
Nursing Diagnoses for Hypertonic Labor <ul><li>Ineffective individual coping related to ineffectiveness of breathing techn...
Nursing Plan for Hypertonic Labor <ul><li>Provide support and encouragement </li></ul><ul><li>Facilitate rest </li></ul><u...
Nursing Plan for Hypertonic Labor <ul><li>Institute supportive measures </li></ul><ul><ul><li>Ambulation </li></ul></ul><u...
Nursing Plan for Hypertonic Labor <ul><li>Institute supportive measures </li></ul><ul><ul><li>Hydrotherapy (bath or shower...
Nursing Plan for Hypertonic Labor <ul><li>Provide information and encourage questions </li></ul><ul><ul><li>Cause, implica...
Outcomes for the Client with Hypertonic Labor <ul><li>Increased comfort </li></ul><ul><li>Decreased anxiety </li></ul><ul>...
Causes of Hypotonic Labor <ul><li>Fetal macrosomia </li></ul><ul><li>Multiple gestation </li></ul><ul><li>Hydramnios </li>...
Implications of Hypotonic Labor <ul><li>Stress on coping abilities </li></ul><ul><li>Prolonged labor resulting in: </li></...
Implications of Hypotonic Labor <ul><li>Postpartum hemorrhage due to uterine atony </li></ul><ul><li>Nonreassuring fetal s...
Clinical Therapy for Hypotonic Labor <ul><li>Oxytocin infusion </li></ul><ul><li>Nipple stimulation </li></ul><ul><li>Amni...
Active Management of Labor <ul><li>Purported benefits </li></ul><ul><ul><li>Decreased incidence of protracted labor </li><...
Nursing Diagnoses for Hypotonic Labor <ul><li>Acute pain related to uterine contractions secondary to dysfunctional labor ...
Nursing Plan for Hypotonic Labor <ul><li>Frequent monitoring of vital signs, FHR, and contractions </li></ul><ul><li>Asses...
Nursing Plan for Hypotonic Labor <ul><li>Assess bladder for distention and empty frequently </li></ul><ul><ul><li>Encourag...
Nursing Plan for Hypotonic Labor <ul><li>Assess for signs of infection </li></ul><ul><ul><li>Maternal fever </li></ul></ul...
Nursing Plan for Hypotonic Labor <ul><li>Institute supportive measures to decrease anxiety and discomfort </li></ul><ul><u...
Nursing Plan for Hypotonic Labor <ul><li>Institute supportive measures to decrease anxiety and discomfort </li></ul><ul><u...
Nursing Plan for Hypotonic Labor <ul><li>Provide information and encourage questions </li></ul><ul><ul><li>Dysfunctional l...
Outcomes for the Client with Hypotonic Labor <ul><li>Woman maintains comfort during labor </li></ul><ul><li>Woman understa...
Learning Outcome  <ul><li>Describe the risks and clinical therapy in determining the community-based and hospital-based nu...
Prolonged (Postterm) Pregnancy <ul><li>Prolonged pregnancy may result in an increased possibility of </li></ul><ul><ul><li...
Prolonged (Postterm) Pregnancy <ul><li>Prolonged pregnancy may result in an increased possibility of </li></ul><ul><ul><li...
Learning Outcome <ul><li>Relate the various types of fetal malposition and malpresentation, risks, and clinical therapy to...
Causes of Persistent OP Fetal Positioning <ul><li>Poor quality contractions </li></ul><ul><li>Abnormal flexion of head </l...
Occiput Presentation
Implications of Persistent OP Positioning <ul><li>Prolonged labor </li></ul><ul><li>Extensive perineal laceration at birth...
Implications of Persistent OP Positioning <ul><li>Increased fetal morbidity and mortality related to </li></ul><ul><ul><li...
Clinical Therapy for Persistent OP Positioning <ul><li>Close monitoring of maternal and fetal status </li></ul><ul><li>Car...
Implications of Brow Presentation <ul><li>Prolonged labor due to ineffective contractions </li></ul><ul><li>Arrested fetal...
Implications of Brow Presentation <ul><li>Increased fetal mortality from cerebral and nuchal compression </li></ul><ul><li...
Military and Brow Presentation
Clinical Therapy for Brow Presentation <ul><li>Monitor for conversion to face or occiput presentation </li></ul><ul><li>Mo...
Implications of Face Presentation <ul><li>Increased risk of CPD and prolonged labor </li></ul><ul><li>Cesarean birth if ch...
Criteria for Vaginal Birth with Face Presentation <ul><li>No evidence of CPD </li></ul><ul><li>Mentum anterior </li></ul><...
Face Presentation
Mechanism of Birth in Face Position
Mechanism of Birth in Face Position
Face Presentation
Clinical Therapy for Face Presentation <ul><li>Thorough assessment of fetal position/presentation </li></ul><ul><li>Carefu...
Types of Breech Presentation <ul><li>Frank </li></ul><ul><ul><li>Flexion at thighs, extension at knees </li></ul></ul><ul>...
Types of Breech Presentation <ul><li>Footling </li></ul><ul><ul><li>Single or double </li></ul></ul><ul><ul><li>Extension ...
Breech Position
Breech Position
Breech Position
Breech Position
Conditions Associated with Breech Presentation <ul><li>Preterm birth </li></ul><ul><li>Placenta previa </li></ul><ul><li>H...
Implications of Breech Presentation <ul><li>Likely cesarean birth </li></ul><ul><li>Increased perinatal morbidity and mort...
Implications of Breech Presentation <ul><li>Increased risk birth trauma (especially head) during any type of birth </li></...
Clinical Therapy for Breech Presentation <ul><li>External cephalic version (ECV) prior to labor between 36-38 weeks EGA </...
Conditions Associated with Transverse Lie <ul><li>Grand multiparity with lax musculature </li></ul><ul><li>Preterm fetus <...
Transverse Lie
Transverse Lie
Implications of Transverse Lie <ul><li>High risk of prolapsed cord </li></ul><ul><li>Cesarean birth </li></ul>
Clinical Therapy for Transverse Lie <ul><li>Expectant management if <37 weeks EGA </li></ul><ul><li>ECV at 37 weeks EGA </...
Learning Outcome  <ul><li>Explain the identification, risks, and clinical therapy in determining the nursing care manageme...
Fetal Macrosomia <ul><li>Newborn weighing more than 4500 g </li></ul><ul><li>Identification of fetal macrosomia is conduct...
Management of Fetal Macrosomia <ul><li>Cesarean birth performed if fetus is greater than 4500 g </li></ul><ul><li>Continuo...
Care of Newborn <ul><li>Care of newborn with macrosomia requires assessment of newborn for </li></ul><ul><ul><li>Cephalhem...
Care of Mother <ul><li>Care of mother after birth of newborn with macrosomia requires </li></ul><ul><ul><li>Fundal massage...
Learning Outcome  <ul><li>Relate the maternal implications, clinical therapy, prenatal history, and conditions that may be...
Nonreassuring Fetal Status Management
Intrauterine Resuscitation <ul><li>Corrective measures used to optimize oxygen exchange within maternal-fetal circulation ...
Intrauterine Resuscitation <ul><li>To position: </li></ul><ul><ul><li>Turn woman to left lateral position to treat hypoten...
Intrauterine Resuscitation <ul><li>To position: </li></ul><ul><ul><li>Discontinue Pitocin or administer a tocolytic agent ...
Learning Outcome <ul><li>Describe the nursing care for the mother and fetus with a prolapsed umbilical cord. </li></ul>
Nursing Care in Prolapsed Umbilical Cord <ul><li>Assess for nonreassuring fetal status </li></ul><ul><li>If a loop of cord...
Nursing Care in Prolapsed Umbilical Cord   <ul><li>Woman assumes knee-chest position or bed is adjusted to Trendelenburg p...
Nursing Care in Prolapsed Umbilical Cord
Learning Outcome  <ul><li>Summarize the identification, maternal and fetal-neonatal implications, clinical therapy, and nu...
Implications of Amniotic Fluid Embolism <ul><li>Sudden onset respiratory distress </li></ul><ul><li>Acute hemorrhage </li>...
Signs and Symptoms of Amniotic Fluid Embolism <ul><li>Dyspnea </li></ul><ul><li>Cyanosis </li></ul><ul><li>Frothy sputum <...
Nursing Plan for Amniotic Fluid Embolism <ul><li>Summon emergency team </li></ul><ul><li>Positive pressure oxygen delivery...
Learning Outcome  <ul><li>Explain the types, maternal and fetal-neonatal implications, and clinical therapy in determining...
Cephalopelvic Disproportion <ul><li>Occurs when fetus is larger than pelvic diameter  –  clinical and x-ray pelvimetry use...
Cephalopelvic Disproportion <ul><li>Labor usually prolonged in presence of CPD </li></ul><ul><li>Vaginal birth may be poss...
Cephalopelvic Disproportion <ul><li>Woman may increase pelvic diameter during labor by squatting, sitting, rolling from si...
Learning Outcome  <ul><li>Identify common complications of the third and fourth stages of labor. </li></ul>
Retained Placenta <ul><li>Retention of placenta beyond 30 minutes after birth </li></ul><ul><li>Occurs in 1 in 100-1 in 20...
Lacerations <ul><li>Lacerations suspected when bright-red bleeding in presence of contracted uterus </li></ul><ul><li>Usua...
Placenta Accreta <ul><li>Chorionic villi attach directly to myometrium of uterus </li></ul><ul><li>May result in maternal ...
Learning Outcome  <ul><li>Explain the etiology, diagnosis, and phases of grief in determining the nursing care management ...
Perinatal Loss <ul><li>Results from three factors </li></ul><ul><ul><li>Fetal factors: Fetus has or develops disorder inco...
Perinatal Loss <ul><li>Results from three factors </li></ul><ul><ul><li>Placental or other factors: Certain conditions suc...
Diagnoses of Fetal Loss <ul><li>Diagnosis may be made when mother notices lack of movement in fetus or at regularly schedu...
Tests to Determine Cause of Fetal Loss
Nursing Care <ul><li>Nursing care involves supporting family through grief work </li></ul><ul><ul><li>Assist family throug...
Nursing Care <ul><li>Nursing care involves supporting family through grief work </li></ul><ul><ul><li>Prepare items for fa...
Nursing Care <ul><li>Nursing care involves supporting family through grief work </li></ul><ul><ul><li>Make referral to app...
Learning Outcome  <ul><li>Explain the psychologic factors that may contribute to complications during labor and birth in d...
Psychologic Disorders <ul><li>Depression </li></ul><ul><ul><li>Decreased ability to concentrate </li></ul></ul><ul><ul><li...
Psychologic Disorders <ul><li>Anxiety disorders </li></ul><ul><ul><li>Chest pain </li></ul></ul><ul><ul><li>Shortness of b...
Psychologic Disorders <ul><li>Labor is time of mixed emotions  –  laboring woman with psychologic disorder may have impair...
Nursing Implications <ul><li>Orient to new environment </li></ul><ul><li>Thoroughly assess background </li></ul><ul><li>En...
Nursing Implications <ul><li>Ongoing observation for objectives signs of disorder </li></ul><ul><li>Use therapeutic commun...
Nursing Implications <ul><li>Acknowledge woman’s fears, concerns, and symptoms  –  identify source of distress </li></ul><...
Nursing Implications <ul><li>Provide ongoing reassurance and information as needed </li></ul><ul><li>Give pharmacologic ag...
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Transcript of "Child birth at risk labor related complication -9"

  1. 1. <ul><li>Childbirth at Risk: Labor-Related Complications </li></ul>
  2. 2. Learning Outcome <ul><li>Compare and contrast hypertonic and hypotonic labor patterns, including risk, clinical therapy, and nursing care management. </li></ul>
  3. 3. Characteristics of Hypertonic Labor <ul><li>Increased contraction frequency </li></ul><ul><li>Decreased contraction intensity </li></ul><ul><li>Increased uterine resting tone </li></ul><ul><li>Prolonged latent phase </li></ul>
  4. 4. Implications of Hypertonic Labor <ul><li>Increased discomfort due to uterine muscle cell anoxia </li></ul><ul><li>Stress on coping abilities </li></ul><ul><li>Prolonged labor resulting in: </li></ul><ul><ul><li>Maternal exhaustion </li></ul></ul><ul><ul><li>Dehydration </li></ul></ul><ul><ul><li>Increased incidence of infection </li></ul></ul>
  5. 5. Implications of Hypertonic Labor <ul><li>Reduced uteroplacental exchange resulting in nonreassuring fetal status </li></ul><ul><li>Prolonged pressure on fetal head resulting in: </li></ul><ul><ul><li>Excessive molding </li></ul></ul><ul><ul><li>Caput succedaneum </li></ul></ul><ul><ul><li>Cephalhematoma </li></ul></ul>
  6. 6. Effects of Labor on the Fetal Head
  7. 7. Effects of Labor on the Fetal Head
  8. 8. Clinical Therapy for Hypertonic Labor <ul><li>Bed rest and relaxation measures </li></ul><ul><li>Pharmacologic sedation </li></ul><ul><li>Oxytocin </li></ul><ul><li>Amniotomy </li></ul>
  9. 9. Nursing Diagnoses for Hypertonic Labor <ul><li>Fatigue related to inability to relax and rest secondary to hypertonic labor pattern </li></ul><ul><li>Acute pain related to woman’s inability to relax secondary to hypertonic uterine contractions </li></ul>
  10. 10. Nursing Diagnoses for Hypertonic Labor <ul><li>Ineffective individual coping related to ineffectiveness of breathing techniques to relieve discomfort </li></ul><ul><li>Anxiety related to slow labor progress </li></ul>
  11. 11. Nursing Plan for Hypertonic Labor <ul><li>Provide support and encouragement </li></ul><ul><li>Facilitate rest </li></ul><ul><li>Administer pharmacologic agents as ordered </li></ul><ul><li>Monitor maternal fatigue </li></ul><ul><li>Monitor contractions and fetal status </li></ul>
  12. 12. Nursing Plan for Hypertonic Labor <ul><li>Institute supportive measures </li></ul><ul><ul><li>Ambulation </li></ul></ul><ul><ul><li>Position changes with pillow support </li></ul></ul><ul><ul><li>Quiet, soothing environment </li></ul></ul><ul><ul><li>Touch and massage techniques </li></ul></ul><ul><ul><li>Personal hygiene </li></ul></ul>
  13. 13. Nursing Plan for Hypertonic Labor <ul><li>Institute supportive measures </li></ul><ul><ul><li>Hydrotherapy (bath or shower) </li></ul></ul><ul><ul><li>Relaxation exercises </li></ul></ul><ul><ul><li>Visualization </li></ul></ul><ul><ul><li>Music </li></ul></ul>
  14. 14. Nursing Plan for Hypertonic Labor <ul><li>Provide information and encourage questions </li></ul><ul><ul><li>Cause, implications, and treatment of dysfunctional labor </li></ul></ul>
  15. 15. Outcomes for the Client with Hypertonic Labor <ul><li>Increased comfort </li></ul><ul><li>Decreased anxiety </li></ul><ul><li>Adequate coping </li></ul><ul><li>More effective labor pattern </li></ul>
  16. 16. Causes of Hypotonic Labor <ul><li>Fetal macrosomia </li></ul><ul><li>Multiple gestation </li></ul><ul><li>Hydramnios </li></ul><ul><li>Grand multiparity </li></ul>
  17. 17. Implications of Hypotonic Labor <ul><li>Stress on coping abilities </li></ul><ul><li>Prolonged labor resulting in: </li></ul><ul><ul><li>Maternal exhaustion </li></ul></ul><ul><ul><li>Dehydration </li></ul></ul><ul><ul><li>Increased incidence of infection </li></ul></ul>
  18. 18. Implications of Hypotonic Labor <ul><li>Postpartum hemorrhage due to uterine atony </li></ul><ul><li>Nonreassuring fetal status due to prolonged labor pattern </li></ul><ul><li>Fetal sepsis from pathogens ascending from birth canal </li></ul>
  19. 19. Clinical Therapy for Hypotonic Labor <ul><li>Oxytocin infusion </li></ul><ul><li>Nipple stimulation </li></ul><ul><li>Amniotomy </li></ul><ul><li>IV fluids </li></ul><ul><li>Surgical birth, if needed </li></ul>
  20. 20. Active Management of Labor <ul><li>Purported benefits </li></ul><ul><ul><li>Decreased incidence of protracted labor </li></ul></ul><ul><ul><li>Decreased cesarean birth rate </li></ul></ul><ul><li>Risks </li></ul><ul><ul><li>Increased risk of infection </li></ul></ul><ul><ul><li>Excessive intervention </li></ul></ul><ul><ul><li>Increased instrument-assisted birth </li></ul></ul>
  21. 21. Nursing Diagnoses for Hypotonic Labor <ul><li>Acute pain related to uterine contractions secondary to dysfunctional labor </li></ul><ul><li>Ineffective individual coping related to unanticipated discomfort and slow progress in labor </li></ul>
  22. 22. Nursing Plan for Hypotonic Labor <ul><li>Frequent monitoring of vital signs, FHR, and contractions </li></ul><ul><li>Assess amniotic fluid for meconium </li></ul><ul><li>Monitor maternal Input & Output </li></ul>
  23. 23. Nursing Plan for Hypotonic Labor <ul><li>Assess bladder for distention and empty frequently </li></ul><ul><ul><li>Encourage voiding at least q 2 hours </li></ul></ul><ul><ul><li>Catheterize as needed with regional block </li></ul></ul><ul><li>Minimize vaginal exams to decrease risk of infection </li></ul>
  24. 24. Nursing Plan for Hypotonic Labor <ul><li>Assess for signs of infection </li></ul><ul><ul><li>Maternal fever </li></ul></ul><ul><ul><li>Chills </li></ul></ul><ul><ul><li>Foul-smelling amniotic fluid </li></ul></ul><ul><ul><li>Fetal tachycardia </li></ul></ul><ul><li>Provide emotional support </li></ul><ul><li>Assist to cope with frustration of long labor </li></ul>
  25. 25. Nursing Plan for Hypotonic Labor <ul><li>Institute supportive measures to decrease anxiety and discomfort </li></ul><ul><ul><li>Ambulation </li></ul></ul><ul><ul><li>Position changes with pillow support </li></ul></ul><ul><ul><li>Quiet, soothing environment </li></ul></ul><ul><ul><li>Touch and massage techniques </li></ul></ul><ul><ul><li>Personal hygiene </li></ul></ul>
  26. 26. Nursing Plan for Hypotonic Labor <ul><li>Institute supportive measures to decrease anxiety and discomfort </li></ul><ul><ul><li>Hydrotherapy (bath or shower) </li></ul></ul><ul><ul><li>Relaxation exercises </li></ul></ul><ul><ul><li>Visualization </li></ul></ul><ul><ul><li>Music </li></ul></ul>
  27. 27. Nursing Plan for Hypotonic Labor <ul><li>Provide information and encourage questions </li></ul><ul><ul><li>Dysfunctional labor process </li></ul></ul><ul><ul><li>Implications for mom and baby </li></ul></ul><ul><ul><li>Treatments, their disadvantages and alternatives </li></ul></ul>
  28. 28. Outcomes for the Client with Hypotonic Labor <ul><li>Woman maintains comfort during labor </li></ul><ul><li>Woman understands the type of labor pattern and the treatment plan </li></ul>
  29. 29. Learning Outcome <ul><li>Describe the risks and clinical therapy in determining the community-based and hospital-based nursing care management of postterm pregnancy on the childbearing family. </li></ul>
  30. 30. Prolonged (Postterm) Pregnancy <ul><li>Prolonged pregnancy may result in an increased possibility of </li></ul><ul><ul><li>Probable labor induction </li></ul></ul><ul><ul><li>Forceps or vacuum-assisted or cesarean birth </li></ul></ul><ul><ul><li>Decreased perfusion to the placenta </li></ul></ul><ul><ul><li>Decreased amount of amniotic fluid and possible cord compression </li></ul></ul>
  31. 31. Prolonged (Postterm) Pregnancy <ul><li>Prolonged pregnancy may result in an increased possibility of </li></ul><ul><ul><li>Meconium aspiration </li></ul></ul><ul><ul><li>Macrosomia or a loss of fat and muscle mass resulting in small-for-gestational age (SGA) newborn </li></ul></ul>
  32. 32. Learning Outcome <ul><li>Relate the various types of fetal malposition and malpresentation, risks, and clinical therapy to the nursing management for each. </li></ul>
  33. 33. Causes of Persistent OP Fetal Positioning <ul><li>Poor quality contractions </li></ul><ul><li>Abnormal flexion of head </li></ul><ul><li>Inadequate maternal pushing efforts – usually due to regional anesthesia </li></ul><ul><li>Large fetus </li></ul>
  34. 34. Occiput Presentation
  35. 35. Implications of Persistent OP Positioning <ul><li>Prolonged labor </li></ul><ul><li>Extensive perineal laceration at birth (3 rd or 4 th degree) </li></ul><ul><li>Vaginal trauma </li></ul><ul><li>Extension of midline episiotomy </li></ul>
  36. 36. Implications of Persistent OP Positioning <ul><li>Increased fetal morbidity and mortality related to </li></ul><ul><ul><li>Prolonged labor </li></ul></ul><ul><ul><li>Instrumental or cesarean birth </li></ul></ul>
  37. 37. Clinical Therapy for Persistent OP Positioning <ul><li>Close monitoring of maternal and fetal status </li></ul><ul><li>Careful assessment of labor progress </li></ul><ul><li>Instrument-assisted birth as needed </li></ul><ul><li>Instrument-assisted rotation to OA </li></ul><ul><li>Cesarean if lack of labor progress or fetal descent indicates CPD </li></ul>
  38. 38. Implications of Brow Presentation <ul><li>Prolonged labor due to ineffective contractions </li></ul><ul><li>Arrested fetal descent </li></ul><ul><li>Cesarean birth for persistent brow presentation </li></ul><ul><li>Increased risk episiotomy and extension if vaginal birth attempted </li></ul>
  39. 39. Implications of Brow Presentation <ul><li>Increased fetal mortality from cerebral and nuchal compression </li></ul><ul><li>Trauma to trachea or larynx </li></ul><ul><li>Facial bruising and edema </li></ul><ul><li>Exaggerated fetal head molding </li></ul>
  40. 40. Military and Brow Presentation
  41. 41. Clinical Therapy for Brow Presentation <ul><li>Monitor for conversion to face or occiput presentation </li></ul><ul><li>Monitor for CPD with persistent brow presentation </li></ul><ul><li>Cesarean indicated in most cases </li></ul><ul><li>Monitor for facial edema and nonreassuring fetal status </li></ul>
  42. 42. Implications of Face Presentation <ul><li>Increased risk of CPD and prolonged labor </li></ul><ul><li>Cesarean birth if chin is posterior </li></ul><ul><li>Increased risk of infection (with prolonged labor) </li></ul><ul><li>Pronounced molding of fetal head </li></ul><ul><li>Facial cephalhematoma </li></ul><ul><li>Edema of baby’s face and throat if chin is anterior </li></ul>
  43. 43. Criteria for Vaginal Birth with Face Presentation <ul><li>No evidence of CPD </li></ul><ul><li>Mentum anterior </li></ul><ul><li>Effective labor pattern </li></ul><ul><li>Reassuring FHR </li></ul>
  44. 44. Face Presentation
  45. 45. Mechanism of Birth in Face Position
  46. 46. Mechanism of Birth in Face Position
  47. 47. Face Presentation
  48. 48. Clinical Therapy for Face Presentation <ul><li>Thorough assessment of fetal position/presentation </li></ul><ul><li>Careful monitoring for labor progress </li></ul><ul><li>Cesarean birth if mentum posterior </li></ul>
  49. 49. Types of Breech Presentation <ul><li>Frank </li></ul><ul><ul><li>Flexion at thighs, extension at knees </li></ul></ul><ul><ul><li>Feet up by head </li></ul></ul><ul><ul><li>Buttocks present </li></ul></ul><ul><li>Complete </li></ul><ul><ul><li>Flexion at thighs and knees </li></ul></ul><ul><ul><li>Feet and buttocks present </li></ul></ul>
  50. 50. Types of Breech Presentation <ul><li>Footling </li></ul><ul><ul><li>Single or double </li></ul></ul><ul><ul><li>Extension at thighs and knees </li></ul></ul><ul><ul><li>Foot or feet present </li></ul></ul><ul><li>Kneeling </li></ul><ul><ul><li>Extension at thighs, flexion at knees </li></ul></ul><ul><ul><li>Knees present </li></ul></ul>
  51. 51. Breech Position
  52. 52. Breech Position
  53. 53. Breech Position
  54. 54. Breech Position
  55. 55. Conditions Associated with Breech Presentation <ul><li>Preterm birth </li></ul><ul><li>Placenta previa </li></ul><ul><li>Hydramnios </li></ul><ul><li>Multiple gestation </li></ul><ul><li>Uterine anomalies – e.g. bicornuate uterus </li></ul><ul><li>Fetal anomalies </li></ul><ul><ul><li>Anencephaly </li></ul></ul><ul><ul><li>Hydrocephaly </li></ul></ul>
  56. 56. Implications of Breech Presentation <ul><li>Likely cesarean birth </li></ul><ul><li>Increased perinatal morbidity and mortality rates </li></ul><ul><li>Increased risk of prolapsed cord </li></ul><ul><li>Increased risk of cervical spinal cord injuries due to hyperextension of fetal head during vaginal birth </li></ul>
  57. 57. Implications of Breech Presentation <ul><li>Increased risk birth trauma (especially head) during any type of birth </li></ul><ul><li>Increased risk of asphyxia and nonreassuring fetal status </li></ul>
  58. 58. Clinical Therapy for Breech Presentation <ul><li>External cephalic version (ECV) prior to labor between 36-38 weeks EGA </li></ul><ul><li>Probable cesarean if version unsuccessful </li></ul><ul><li>Consider alternative methods of version </li></ul>
  59. 59. Conditions Associated with Transverse Lie <ul><li>Grand multiparity with lax musculature </li></ul><ul><li>Preterm fetus </li></ul><ul><li>Abnormal uterus </li></ul><ul><li>Excessive amniotic fluid </li></ul><ul><li>Placenta previa </li></ul><ul><li>Contracted pelvis </li></ul>
  60. 60. Transverse Lie
  61. 61. Transverse Lie
  62. 62. Implications of Transverse Lie <ul><li>High risk of prolapsed cord </li></ul><ul><li>Cesarean birth </li></ul>
  63. 63. Clinical Therapy for Transverse Lie <ul><li>Expectant management if <37 weeks EGA </li></ul><ul><li>ECV at 37 weeks EGA </li></ul><ul><li>Labor induction following successful version </li></ul><ul><li>May attempt ECV in early labor </li></ul><ul><li>Cesarean birth if version unsuccessful </li></ul>
  64. 64. Learning Outcome <ul><li>Explain the identification, risks, and clinical therapy in determining the nursing care management of the woman and fetus at risk for macrosomia. </li></ul>
  65. 65. Fetal Macrosomia <ul><li>Newborn weighing more than 4500 g </li></ul><ul><li>Identification of fetal macrosomia is conducted through </li></ul><ul><ul><li>Palpation of fetus in utero </li></ul></ul><ul><ul><li>Ultrasound of fetus </li></ul></ul><ul><ul><li>X-ray pelvimetry </li></ul></ul>
  66. 66. Management of Fetal Macrosomia <ul><li>Cesarean birth performed if fetus is greater than 4500 g </li></ul><ul><li>Continuous fetal monitoring if labor is allowed to progress </li></ul><ul><li>Requires notification of physician for early decelerations, labor dysfunction, or nonreassuring fetal status </li></ul>
  67. 67. Care of Newborn <ul><li>Care of newborn with macrosomia requires assessment of newborn for </li></ul><ul><ul><li>Cephalhematoma </li></ul></ul><ul><ul><li>Erb’s palsy </li></ul></ul><ul><ul><li>Fractured clavicles </li></ul></ul>
  68. 68. Care of Mother <ul><li>Care of mother after birth of newborn with macrosomia requires </li></ul><ul><ul><li>Fundal massage to prevent maternal hemorrhage from overstretched uterus </li></ul></ul><ul><ul><li>Close monitoring of vital signs </li></ul></ul>
  69. 69. Learning Outcome <ul><li>Relate the maternal implications, clinical therapy, prenatal history, and conditions that may be associated with nonreassuring fetal status to the nursing care of the mother and fetus. </li></ul>
  70. 70. Nonreassuring Fetal Status Management
  71. 71. Intrauterine Resuscitation <ul><li>Corrective measures used to optimize oxygen exchange within maternal-fetal circulation </li></ul>
  72. 72. Intrauterine Resuscitation <ul><li>To position: </li></ul><ul><ul><li>Turn woman to left lateral position to treat hypotension </li></ul></ul><ul><ul><li>Begin or increase IV flow rate </li></ul></ul><ul><ul><li>Perform vaginal exam to check for cord prolapse </li></ul></ul><ul><ul><li>Have woman assume knee-chest position if cord prolapse is suspected </li></ul></ul>
  73. 73. Intrauterine Resuscitation <ul><li>To position: </li></ul><ul><ul><li>Discontinue Pitocin or administer a tocolytic agent to decrease contraction frequency and intensity </li></ul></ul><ul><ul><li>Administer oxygen </li></ul></ul><ul><ul><li>Notify physician </li></ul></ul><ul><ul><li>Obtain additional information about fetus by fetal scalp blood sampling, fetal scalp stimulation or fetal acoustical stimulation </li></ul></ul>
  74. 74. Learning Outcome <ul><li>Describe the nursing care for the mother and fetus with a prolapsed umbilical cord. </li></ul>
  75. 75. Nursing Care in Prolapsed Umbilical Cord <ul><li>Assess for nonreassuring fetal status </li></ul><ul><li>If a loop of cord is discovered, the examiner’s gloved fingers must remain in vagina to provide firm pressure on fetal head until physician or CNM arrives </li></ul><ul><li>Oxygen via face mask </li></ul><ul><li>Monitor FHR to determine whether cord compression is adequately relieved </li></ul>
  76. 76. Nursing Care in Prolapsed Umbilical Cord <ul><li>Woman assumes knee-chest position or bed is adjusted to Trendelenburg position </li></ul><ul><li>Transport to the delivery or operating room in this position </li></ul>
  77. 77. Nursing Care in Prolapsed Umbilical Cord
  78. 78. Learning Outcome <ul><li>Summarize the identification, maternal and fetal-neonatal implications, clinical therapy, and nursing care management of women with amniotic fluid embolus. </li></ul>
  79. 79. Implications of Amniotic Fluid Embolism <ul><li>Sudden onset respiratory distress </li></ul><ul><li>Acute hemorrhage </li></ul><ul><li>Circulatory collapse </li></ul><ul><li>Cor pulmonale </li></ul><ul><li>Hemorrhagic shock </li></ul><ul><li>Coma and maternal death </li></ul><ul><li>Fetal death if birth not immediate </li></ul>
  80. 80. Signs and Symptoms of Amniotic Fluid Embolism <ul><li>Dyspnea </li></ul><ul><li>Cyanosis </li></ul><ul><li>Frothy sputum </li></ul><ul><li>Chest pain </li></ul><ul><li>Tachycardia </li></ul><ul><li>Hypotension </li></ul><ul><li>Mental confusion </li></ul><ul><li>Massive hemorrhage </li></ul>
  81. 81. Nursing Plan for Amniotic Fluid Embolism <ul><li>Summon emergency team </li></ul><ul><li>Positive pressure oxygen delivery </li></ul><ul><li>Large-bore IV </li></ul><ul><li>CPR as needed </li></ul><ul><li>Prepare for cesarean if birth has not occurred </li></ul><ul><li>Prepare for CVP line insertion </li></ul><ul><li>Administer blood </li></ul>
  82. 82. Learning Outcome <ul><li>Explain the types, maternal and fetal-neonatal implications, and clinical therapy in determining the nursing care management of the woman with cephalopelvic disproportion. </li></ul>
  83. 83. Cephalopelvic Disproportion <ul><li>Occurs when fetus is larger than pelvic diameter – clinical and x-ray pelvimetry used to determine smallest diameter through which fetal head must pass </li></ul><ul><ul><li>Shortest AP diameter <10 cm </li></ul></ul><ul><ul><li>Diagonal conjugate <11.5 cm </li></ul></ul><ul><ul><li>Greatest transverse diameter <12 cm </li></ul></ul>
  84. 84. Cephalopelvic Disproportion <ul><li>Labor usually prolonged in presence of CPD </li></ul><ul><li>Vaginal birth may be possible depending upon type of CPD </li></ul>
  85. 85. Cephalopelvic Disproportion <ul><li>Woman may increase pelvic diameter during labor by squatting, sitting, rolling from side to side, maintaining knee-chest position, use of a labor ball – </li></ul><ul><li>CPD may make cesarean only available method of birth </li></ul>
  86. 86. Learning Outcome <ul><li>Identify common complications of the third and fourth stages of labor. </li></ul>
  87. 87. Retained Placenta <ul><li>Retention of placenta beyond 30 minutes after birth </li></ul><ul><li>Occurs in 1 in 100-1 in 200 vaginal births </li></ul><ul><li>If not expelled, placenta must be manually removed from uterus – if woman does not have an epidural anesthesia in place, conscious sedation may be required </li></ul>
  88. 88. Lacerations <ul><li>Lacerations suspected when bright-red bleeding in presence of contracted uterus </li></ul><ul><li>Usually repaired immediately after birth of child </li></ul><ul><li>Vaginal and perineal lacerations are categorized in terms of degrees </li></ul>
  89. 89. Placenta Accreta <ul><li>Chorionic villi attach directly to myometrium of uterus </li></ul><ul><li>May result in maternal hemorrhage and failure of placenta to separate from uterus </li></ul><ul><li>May result in need for hysterectomy at time of birth </li></ul><ul><li>Incidence of placenta accreta is 1 in 533 births </li></ul>
  90. 90. Learning Outcome <ul><li>Explain the etiology, diagnosis, and phases of grief in determining the nursing care management of the family experiencing perinatal loss. </li></ul>
  91. 91. Perinatal Loss <ul><li>Results from three factors </li></ul><ul><ul><li>Fetal factors: Fetus has or develops disorder incompatible with life </li></ul></ul><ul><ul><li>Maternal factors: Mother has disorder such as diabetes, preeclampsia, advanced maternal age, Rh disease, uterine rupture or ascending maternal infection that creates hostile environment for fetus </li></ul></ul>
  92. 92. Perinatal Loss <ul><li>Results from three factors </li></ul><ul><ul><li>Placental or other factors: Certain conditions such as abruptio placentae, placenta previa or cord accident cut off blood supply to fetus, leading to death </li></ul></ul>
  93. 93. Diagnoses of Fetal Loss <ul><li>Diagnosis may be made when mother notices lack of movement in fetus or at regularly scheduled physician’s visit when fetal heart tone cannot be found </li></ul>
  94. 94. Tests to Determine Cause of Fetal Loss
  95. 95. Nursing Care <ul><li>Nursing care involves supporting family through grief work </li></ul><ul><ul><li>Assist family through labor and birth </li></ul></ul><ul><ul><li>Provide for woman’s physical needs after birth </li></ul></ul><ul><ul><li>Encourage family members to express and share their thoughts and feelings about loss </li></ul></ul><ul><ul><li>Give family an opportunity to view, hold, name infant </li></ul></ul>
  96. 96. Nursing Care <ul><li>Nursing care involves supporting family through grief work </li></ul><ul><ul><li>Prepare items for family to keep to remember infant </li></ul></ul><ul><ul><li>Provide opportunities for religious or spiritual counseling and cultural practices </li></ul></ul><ul><ul><li>Visit or phone family after discharge to assist in closure </li></ul></ul>
  97. 97. Nursing Care <ul><li>Nursing care involves supporting family through grief work </li></ul><ul><ul><li>Make referral to appropriate perinatal loss counseling services if indicated </li></ul></ul>
  98. 98. Learning Outcome <ul><li>Explain the psychologic factors that may contribute to complications during labor and birth in determining the nursing care management. </li></ul>
  99. 99. Psychologic Disorders <ul><li>Depression </li></ul><ul><ul><li>Decreased ability to concentrate </li></ul></ul><ul><ul><li>Decreased ability to process information </li></ul></ul><ul><ul><li>Feeling overwhelmed </li></ul></ul><ul><ul><li>Hopelessness about outcome of labor </li></ul></ul><ul><li>Bipolar disorder </li></ul><ul><ul><li>Symptoms of depression </li></ul></ul><ul><ul><li>Hyperexcitability if in manic phase </li></ul></ul>
  100. 100. Psychologic Disorders <ul><li>Anxiety disorders </li></ul><ul><ul><li>Chest pain </li></ul></ul><ul><ul><li>Shortness of breath </li></ul></ul><ul><ul><li>Faintness </li></ul></ul><ul><ul><li>Fear or terror </li></ul></ul>
  101. 101. Psychologic Disorders <ul><li>Labor is time of mixed emotions – laboring woman with psychologic disorder may have impaired coping mechanisms and face additional emotional challenges during labor </li></ul>
  102. 102. Nursing Implications <ul><li>Orient to new environment </li></ul><ul><li>Thoroughly assess background </li></ul><ul><li>Encourage appropriate coping strategies </li></ul><ul><li>Maintain a safe environment </li></ul><ul><li>Decrease stimulation, as needed </li></ul>
  103. 103. Nursing Implications <ul><li>Ongoing observation for objectives signs of disorder </li></ul><ul><li>Use therapeutic communication and information sharing to establish rapport </li></ul>
  104. 104. Nursing Implications <ul><li>Acknowledge woman’s fears, concerns, and symptoms – identify source of distress </li></ul><ul><li>Use comfort measures, touch, and therapeutic communication as appropriate </li></ul><ul><li>Assist in maintaining and regaining orientation to person/place/time </li></ul>
  105. 105. Nursing Implications <ul><li>Provide ongoing reassurance and information as needed </li></ul><ul><li>Give pharmacologic agents as ordered for severe distress </li></ul>
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