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Child birth at risk labor related complication -9

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

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