Child birth at risk 8


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Child birth at risk 8

  1. 1. <ul><li>Childbirth at Risk: Prelabor Complications </li></ul>
  2. 2. Learning Outcome <ul><li>Explain the possible causes, risk factors, and clinical therapy for premature rupture of the membranes or preterm labor in determining the hospital-based and community-based nursing care management of the woman and her fetus-newborn. </li></ul>
  3. 3. Premature Rupture of Membranes (PROM) is Spontaneous Rupture of the Membranes Before the Onset of Labor <ul><li>Preterm PROM (PPROM) is the rupture of membranes occurring before 37 weeks’ gestation </li></ul><ul><li>Although the exact cause is unknown, PPROM is associated with infection, previous history of PPROM, hydramnios, multiple pregnancy, and a variety of other pregnancies </li></ul>
  4. 4. Premature Rupture of Membranes (PROM) is Spontaneous Rupture of the Membranes Before the Onset of Labor <ul><li>PROM nursing care focuses on prevention of infection such as limiting vaginal exams and changing the bed pads frequently </li></ul><ul><li>The fetus is monitored carefully </li></ul>
  5. 5. Preterm Labor (PTL): Labor That Occurs Between 20 and 36 Completed Weeks of Pregnancy <ul><li>Women who are at risk for PTL are taught to recognize its symptoms to prevent it </li></ul>
  6. 6. Preterm Labor (PTL): Labor That Occurs Between 20 and 36 Completed Weeks of Pregnancy <ul><li>Nursing care: tocolysis, monitoring for progression of labor, maintaining good uterine blood flow, maintaining side-lying position, potential IV infusion, maternal laboratory studies including CBC, C-reactive protein, vaginal cultures, fetal fibronectin (fFN), urine culture and an ultrasound may be obtained to determine cervical shortening or funneling, as well as assess fetal well-being </li></ul>
  7. 7. Learning Outcome <ul><li>Compare and contrast abruptio placentae and placenta previa, including implications for the mother and fetus and nursing care. </li></ul>
  8. 8. Types of Abruptio Placentae <ul><li>Marginal </li></ul><ul><ul><li>Placenta separates at its edges </li></ul></ul><ul><ul><li>Blood passes between fetal membranes and uterine wall </li></ul></ul><ul><ul><li>Blood escapes vaginally </li></ul></ul>
  9. 9. Types of Abruptio Placentae <ul><li>Central </li></ul><ul><ul><li>Placenta separates centrally </li></ul></ul><ul><ul><li>Blood trapped between placenta and uterine wall </li></ul></ul><ul><ul><li>Concealed bleeding </li></ul></ul><ul><li>Complete </li></ul><ul><ul><li>Total separation </li></ul></ul><ul><ul><li>Massive vaginal bleeding </li></ul></ul>
  10. 10. Abruptio Placentae
  11. 11. Abruptio Placentae
  12. 12. Abruptio Placentae
  13. 13. Maternal Implications of Abruptio Placentae <ul><li>Intrapartum hemorrhage </li></ul><ul><li>DIC </li></ul><ul><li>Hypofibrinogenemia </li></ul><ul><li>Ruptured uterus from overdistention </li></ul><ul><li>Fatal hemorrhagic shock </li></ul>
  14. 14. Maternal Implications of Abruptio Placentae <ul><li>Postpartum complications </li></ul><ul><ul><li>Vascular spasm </li></ul></ul><ul><ul><li>Intravascular clotting </li></ul></ul><ul><ul><li>Hemorrhage </li></ul></ul><ul><ul><li>Renal failure </li></ul></ul><ul><ul><li>Fatal shock </li></ul></ul>
  15. 15. Differential Signs and Symptoms of Placenta Previa and Abruptio Placentae
  16. 16. Fetal-Neonatal Implications of Abruptio Placentae <ul><li>Sequelae of prematurity </li></ul><ul><li>Hypoxia </li></ul><ul><li>Anemia </li></ul><ul><li>Brain damage </li></ul><ul><li>Fetal demise </li></ul>
  17. 17. Nursing Plan for Abruptio Placentae <ul><li>Maintain two large-bore IV sites – fluids and blood products as ordered </li></ul><ul><li>Monitor fetus and uterine activity electronically </li></ul><ul><ul><li>Assess resting tone every 15 minutes </li></ul></ul><ul><ul><li>Assess fetal status every 15 minutes </li></ul></ul>
  18. 18. Nursing Plan for Abruptio Placentae <ul><li>Monitor for signs of DIC </li></ul><ul><li>Monitor Intake & Output and urine specific gravity </li></ul><ul><li>Measure abdominal girth hourly, as ordered </li></ul>
  19. 19. Nursing Plan for Abruptio Placentae <ul><li>Assess maternal cardiovascular status frequently </li></ul><ul><ul><li>Vital signs every 5-15 minutes </li></ul></ul><ul><ul><li>Skin color and pulse quality hourly </li></ul></ul><ul><ul><li>Measure CVP hourly, as ordered </li></ul></ul>
  20. 20. Nursing Plan for Abruptio Placentae <ul><li>Review and evaluate diagnostic tests </li></ul><ul><li>Prepare for cesarean, as needed </li></ul><ul><li>Neonatal resuscitation, as needed </li></ul><ul><li>Provide information and emotional support </li></ul>
  21. 21. Categories of Placenta Previa <ul><li>Total: The internal os completely covered </li></ul><ul><li>Partial: The internal os partially covered </li></ul><ul><li>Marginal: The edge of the os covered </li></ul><ul><li>Low-lying placenta: Implanted in lower segment in proximity to the os </li></ul>
  22. 22. Classification of Placenta Previa
  23. 23. Implications of Placenta Previa <ul><li>Maternal psychologic stress </li></ul><ul><li>Transverse lie common </li></ul><ul><li>Changes in FHR </li></ul><ul><li>Meconium staining </li></ul><ul><li>Fetal compromise (hypoxia) </li></ul><ul><li>Cesarean birth </li></ul><ul><li>Neonatal anemia </li></ul>
  24. 24. Nursing Plan for Placenta Previa <ul><li>No vaginal exams! </li></ul><ul><li>Objectively and subjectively assess blood loss, pain, uterine contractility </li></ul><ul><li>Continuous external monitoring of FHR and uterine activity – no internal monitoring </li></ul><ul><li>Monitor maternal vital signs and Intake & Output – every 5-15 minutes with active hemorrhage </li></ul>
  25. 25. Nursing Plan for Placenta Previa <ul><li>Obtain/evaluate labs </li></ul><ul><li>Maintain large – bore IV access-available whole blood setup </li></ul><ul><li>Verify family’s ability to cope with anxiety of unknown outcome </li></ul><ul><li>Provide information and emotional support </li></ul>
  26. 26. Nursing Plan for Placenta Previa <ul><li>Promote neonatal physiologic adaptation </li></ul><ul><ul><li>Resuscitation as needed </li></ul></ul><ul><ul><li>Evaluate hemoglobin, cell count, erythrocyte count </li></ul></ul><ul><ul><li>Administer oxygen and blood as needed </li></ul></ul>
  27. 27. Learning Outcome <ul><li>Explain the maternal and fetal-neonatal implications and the clinical therapy in determining the community-based and hospital-based nursing care management of the woman with multiple gestation. </li></ul>
  28. 28. Multiple Gestation <ul><li>Care of woman with more than one fetus includes: </li></ul><ul><ul><li>Frequent assessment of fetal heart tones of each fetus </li></ul></ul><ul><ul><li>Education of mother about signs and symptoms of preterm labor </li></ul></ul>
  29. 29. Multiple Gestation <ul><li>Care of woman with more than one fetus includes: </li></ul><ul><ul><li>Encouragement of mother to rest frequently prior to birth </li></ul></ul><ul><ul><li>Preparation of equipment needed to care for each individual newborn </li></ul></ul>
  30. 30. Presentations in Utero
  31. 31. Presentations in Utero
  32. 32. Presentations in Utero
  33. 33. Learning Outcome <ul><li>Compare the identification, maternal and fetal-neonatal implications, clinical therapy, and nursing care management of women with hydramnios and oligohydramnios. </li></ul>
  34. 34. Implications of Hydramnios <ul><li>Maternal </li></ul><ul><ul><li>Shortness of breath </li></ul></ul><ul><ul><li>Edema </li></ul></ul><ul><ul><li>Greatly increased cesarean rate </li></ul></ul><ul><ul><li>Uterine dysfunction </li></ul></ul><ul><ul><li>Abruptio placentae </li></ul></ul><ul><ul><li>Postpartum hemorrhage </li></ul></ul>
  35. 35. Implications of Hydramnios <ul><li>Fetal-Neonatal </li></ul><ul><ul><li>Malformations </li></ul></ul><ul><ul><li>Preterm birth </li></ul></ul><ul><ul><li>Increased mortality rate </li></ul></ul><ul><ul><li>Prolapsed cord </li></ul></ul><ul><ul><li>Malpresentation </li></ul></ul>
  36. 36. Conditions Associated with Hydramnios <ul><li>Diabetes </li></ul><ul><li>Rh sensitization </li></ul><ul><li>Hydrops fetalis </li></ul><ul><li>Malformations of fetal swallowing </li></ul><ul><li>Neural tube defects with exposed meninges </li></ul>
  37. 37. Conditions Associated with Hydramnios <ul><li>Anencephaly </li></ul><ul><li>Cardiac anomalies </li></ul><ul><li>Esophageal or duodenal atresia </li></ul><ul><li>Monozygotic, monochorionic twins </li></ul><ul><li>Large placenta </li></ul>
  38. 38. Assessment Findings Suspicious for Hydramnios <ul><li>Fundal height disproportionately large for dates </li></ul><ul><li>Difficulty palpating fetus and auscultating FHR </li></ul><ul><li>Tense, tight abdomen on inspection </li></ul><ul><li>Large spaces between fetus and uterine wall on ultrasound </li></ul>
  39. 39. Nursing Plan with Hydramnios <ul><li>Provide information and emotional support </li></ul><ul><li>Maintain absolute sterility during amniocentesis </li></ul><ul><li>Collaborate with social services if fetal defect identified </li></ul>
  40. 40. Conditions Associated with Oligohydramnios <ul><li>Postmaturity </li></ul><ul><li>IUGR secondary to placental insufficiency </li></ul><ul><li>Major renal malformations </li></ul><ul><ul><li>Renal agenesis </li></ul></ul><ul><ul><li>Dysplastic kidneys </li></ul></ul><ul><ul><li>Lower urinary tract obstructive lesions </li></ul></ul>
  41. 41. Implications of Oligohydramnios <ul><li>Dysfunctional labor with slow progress </li></ul><ul><li>Fetal deformation defects </li></ul><ul><ul><li>Adhesions </li></ul></ul><ul><ul><li>Skin and skeletal abnormalities </li></ul></ul><ul><ul><li>Pulmonary hypoplasia </li></ul></ul><ul><ul><li>Dysmorphic facies </li></ul></ul><ul><ul><li>Short umbilical cord </li></ul></ul>
  42. 42. Implications of Oligohydramnios <ul><li>Umbilical cord compression </li></ul><ul><li>Head compression </li></ul>
  43. 43. Assessment Findings Suspicious for Oligohydramnios <ul><li>Fundal height small for dates </li></ul><ul><li>Fetus easily palpated and outlined </li></ul><ul><li>Fetus not ballottable </li></ul><ul><li>Variable decelerations </li></ul><ul><li>Reduced AFI on ultrasound </li></ul>
  44. 44. Nursing Plan for Oligohydramnios <ul><li>Provide information and encourage questions </li></ul><ul><li>Evaluate EFM tracing for variable decels or nonreassuring fetal status </li></ul><ul><li>Reposition mother to relieve cord compression </li></ul><ul><li>Notify clinician of signs of cord compression </li></ul>
  45. 45. Nursing Plan for Oligohydramnios <ul><li>Evaluate newborn </li></ul><ul><ul><li>Anomalies </li></ul></ul><ul><ul><li>Pulmonary hypoplasia </li></ul></ul><ul><ul><li>Postmaturity </li></ul></ul>