Presentation on theme: "NURS 2410 UNIT 2 Nancy Pares, RN, MSN Metro Community College."— Presentation transcript:
NURS 2410 UNIT 2 Nancy Pares, RN, MSN Metro Community College
External Electronic Uterine Monitoring: Advantages Noninvasive Easy to place May be used before and following rupture of membranes Can be used intermittently Provides a permanent, continuous recording
External Electronic Uterine Monitoring: Disadvantages The nurse must compare subjective findings with monitor The belt may become uncomfortable The belt may require frequent readjustment The mother may feel inhibited to move
Internal Electronic Uterine Monitoring: Advantages Provides pressure measurements for contraction intensity and uterine resting tone Allows for very accurate timing of UCs Provides a permanent record of the uterine activity
Internal Electronic Uterine Monitoring: Disadvantages Membranes must be ruptured and adequate cervical dilation must be achieved Invasive Increases the risk of uterine infection or perforation Contraindicated in cases with active infections Use with a low-lying placenta can result in placenta puncture
Figure 23–3 INTRAN Plus intrauterine pressure catheter. There is a micropressure transducer (electronic sensor) located at the tip of the catheter and a port for amnioinfusion at the distal end of the catheter. SOURCE: Photographer: Elena Dorfman.
Auscultation: Advantages Uses minimum instrumentation Is portable Allows for maximum maternal movement Convenient and economical
Auscultation: Disadvantages Can only provide the baseline fetal heart rate, rhythms, and obvious increases and decreases Does not provide a permanent record
External Electronic Fetal Heart Monitoring: Advantages Produces a continuous graphic recording Can show the baseline, baseline variability, and changes in the FHR Noninvasive Does not require rupture of membranes
External Electronic Fetal Heart Monitoring: Disadvantages Is susceptible to interference from maternal and fetal movement May produce a weak signal Tracing may become sketchy and difficult to interpret
Internal Electronic Fetal Heart Monitoring: Advantages Clearer tracings Provides information about short term variability
Leopold’s Maneuvers Is the fetal lie longitudinal or transverse? What is in the fundus? Am I feeling buttocks or head? Where is the fetal back? Where are the small parts or extremities? What is in the inlet? Does it confirm what I found in the fundus? Is the presenting part engaged, floating, or dipping into the inlet?
Figure 23–7 Leopold’s maneuvers for determining fetal head position, presentation, and lie. NOTE: Many nurses do the fourth maneuver first to identify the part of the fetus in the pelvic inlet.
Figure 23–7 (continued) Leopold’s maneuvers for determining fetal head position, presentation, and lie. NOTE: Many nurses do the fourth maneuver first to identify the part of the fetus in the pelvic inlet.
Fetal Heart Rate (FHR) Baseline FHR – Mean FHR during 10 minute period – Must be observed for 2 minutes Changes in FHR – Episodic – not associated with uterine contractions – Periodic – associated with uterine contractions
Figure 23–10 Top, An FHR tracing obtained by internal monitoring. Normal FHR range is 110 to 160 bpm. This tracing indicates an FHR range of 140 to 155 bpm. Bottom, A uterine contraction tracing obtained by external monitoring. Each dark vertical line marks 1 minute, and each small rectangle represents 10 seconds. The contraction frequency is about every 3 minutes, and the duration of the contractions is 50 to 60 seconds.
Changes in FHR Baseline Fetal tachycardia – Baseline greater than 160 bpm for at least a 10- minute period Fetal bradycardia – Baseline less than 110 bpm for at least a 10- minute period
Figure 23–14 Types of accelerations. A, Episodic accelerations. B, Periodic accelerations.
Figure 23–14 (continued) Types of accelerations. A, Episodic accelerations. B, Periodic accelerations.
NICHD Classification: Baseline Variability (BV) Absent – amplitude undetected Minimal – amplitude range detectable but ≤ 5 bpm Moderate – amplitude range of 6-25 bpm Marked – amplitude greater than 25 bpm
Figure 23–12 A and B, Moderate variability. C, Minimal variability. D, Absent variability.
Figure 23–12 (continued) A and B, Moderate variability. C, Minimal variability. D, Absent variability.
NICHD Classifications: Decelerations Rate of descent Episodic Periodic – Early – Late – Variable
Figure 23–17 Early decelerations. Baseline FHR is 150 to 155 bpm. Nadir (lowest point) of decelerations is 130 to 145 bpm.
Figure 23–19 Late decelerations. Baseline FHR is 130 to 148 bpm. Nadir (lowest point) of decelerations is 110 to 120 bpm. Absent variability.
Figure 23–20 Variable decelerations with overshoot. The timing of the decelerations is variable, and most have a sharp decline. A rebound acceleration (overshoot) occurs after most of the decelerations. Baseline FHR is 115 to 130 bpm. Nadir of decelerations is 55 to 80 bpm. Variability is minimal.
Intrapartal high-risk factors
Frequency of maternal-fetal assessment
Contraction and labor progress
Frequency of auscultation
Electronic fetal monitoring
Management of Deceleration
Evaluation of Fetal Monitoring: Uterine Contractions Determine the uterine resting tone Assess the contractions – What is the frequency? – What is the duration? – What is the intensity (if internal monitoring)?
Evaluation of Fetal Monitoring: FHR Determine the baseline Determine FHR variability Determine whether a sinusoidal pattern is present Determine whether there are periodic changes
Nonreassuring Patterns Variable decelerations Late decelerations of any magnitude Absence of variability Prolonged deceleration Severe (marked) bradycardia
Nursing Interventions for Nonreassuring Patterns Notify MD/Midwife and document Change position Increase IV fluids Provide oxygen Tocolytics Prepare for cesarean or vacuum birth
Scalp Stimulation Direct stimulation to fetal scalp to elicit an acceleration Uncompromised fetuses will elicit acceleration of at least 15 bpm for 15 seconds
Figure 26–1 Comparison of labor patterns. A, Normal uterine contraction pattern. Note that the contraction frequency is every 3 minutes; duration is 60 seconds. The baseline resting tone is below 10 mm Hg. B, Hypotonic uterine contraction pattern. Note in this example that the contraction frequency is every 7 minutes with some uterine activity between contractions, duration is 50 seconds, and intensity increases approximately 25 mm Hg during contractions.
Impact of Post-term Pregnancy: Maternal Perineal damage Hemorrhage Increased risk of cesarean birth Anxiety Emotional fatigue Persistence of normal discomforts
Impact of Post-term Pregnancy: Fetal Decreased perfusion Oligohydramnios Small-for-gestational-age (SGA) Macrosomia Increased risk for meconium staining
Malposition/Malpresentation Persistent occiput-posterior (OP) position Brow presentation Face presentation
Figure 26–7 Face presentation. Mechanism of birth in mentoanterior position. A, The submentobregmatic diameter at the outlet. B, The fetal head is born by movement of flexion.
Figure 26–7 (continued) Face presentation. Mechanism of birth in mentoanterior position. A, The submentobregmatic diameter at the outlet. B, The fetal head is born by movement of flexion.
Breech Presentation: Types Frank Single or double footling (incomplete) Complete
Figure 26–10 Breech presentation. A, Frank breech. B, Incomplete (footling) breech. C, Complete breech in left sacral anterior (LSA) position. D, On vaginal examination, the nurse may feel the anal sphincter. The tissue of the fetal buttocks feels soft.
Figure 26–10 (continued) Breech presentation. A, Frank breech. B, Incomplete (footling) breech. C, Complete breech in left sacral anterior (LSA) position. D, On vaginal examination, the nurse may feel the anal sphincter. The tissue of the fetal buttocks feels soft.
Breech Presentation: Risks Head trauma Increased risk for infant mortality Neonatal complications Cord prolapse
Third and Fourth Stage Complications Retained placenta Lacerations Placental adherence – Accreta – Increta – Percreta
Impact of Procedures on Childbearing Woman Disappointment Guilt Conflict between expectation and need for intervention
Contraindications to Induction
Prelabor Status Evaluation
Version External Cephalic Version (ECV) Podalic Version (Internal)
Figure 27–1 External (or cephalic) version of the fetus. A new technique involves applying pressure to the fetal head and buttocks so that the fetus completes a “backward flip” or “forward roll.”
Figure 27–2 Use of podalic version and extraction of the fetus to assist in the vaginal birth of the second twin. A, The physician reaches into the uterus and grasps a foot. Although a vertex birth is always preferred in a singleton birth, in this instance of assisting in the birth of a second twin it is not possible to grasp any other fetal part. The fetal head would be too large to grasp and pull downward, and grasping the fetal arm would result in a transverse lie and make vaginal birth impossible. B, While applying pressure on the outside of the abdomen to push the baby’s head up toward the top of the uterus with one hand, the physician pulls the baby’s foot down toward the cervix. C, Both feet have been pulled through the cervix and vagina. D, The physician now grasps the baby’s trunk and continues to pull downward on the baby to assist the birth.
Figure 27–2 (continued) Use of podalic version and extraction of the fetus to assist in the vaginal birth of the second twin. A, The physician reaches into the uterus and grasps a foot. Although a vertex birth is always preferred in a singleton birth, in this instance of assisting in the birth of a second twin it is not possible to grasp any other fetal part. The fetal head would be too large to grasp and pull downward, and grasping the fetal arm would result in a transverse lie and make vaginal birth impossible. B, While applying pressure on the outside of the abdomen to push the baby’s head up toward the top of the uterus with one hand, the physician pulls the baby’s foot down toward the cervix. C, Both feet have been pulled through the cervix and vagina. D, The physician now grasps the baby’s trunk and continues to pull downward on the baby to assist the birth.
Nursing Management Maternal/fetal assessments NST Lab studies Psychological support Education Monitor VS
Uses of Amniotomy Labor induction Labor augmentation Allow access to fetus and uterus to – Apply an internal fetal heart monitoring scalp electrode – Insert an intrauterine pressure catheter – Obtain a fetal scalp blood sample
Cervical Ripening: Prostaglandin E2 Advantages – Cervical ripening – Shorter labor – Lower requirements for oxytocin during labor induction – Vaginal birth is achieved within 24 hours for most women – Incidence of cesarean birth is reduced
Labor Induction: Stripping Membranes Advantages – Labor usually occurs in hours Disadvantages – Can be painful – Uterine contractions – Bloody discharge
Labor Induction: Oxytocin Risks – Hyperstimulation of the uterus – Uterine rupture – Water intoxication – Nonreassuring fetal heart rate patterns
Labor Induction: Natural Methods Sexual intercourse/lovemaking Self or partner stimulation of the woman’s nipples and breasts Use of herbs – Blue/black cohosh – Evening primrose oil – Red raspberry leaves
Labor Induction: Natural Methods (continued) Use of homeopathic solutions – Caulophyllum or pulsatilla – Castor oil, enemas – Acupressure/acupuncture Mechanical dilatation with balloon catheter
Amnioinfusion Prevent the possibility of variable decelerations Treat nonperiodic decelerations Meconium dilution
Episiotomy Types – Midline – Mediolateral
Figure 27–3 The two most common types of episiotomies are midline and mediolateral. A, Right mediolateral. B, Midline.
Nursing Management Support Assist with communication of woman’s needs Pain relief measures Assessment Education
Forceps-Assisted Birth: Maternal Indications Heart disease Acute pulmonary edema or pulmonary compromise Certain neurological conditions Intrapartal infection Prolonged second stage Exhaustion
Figure 27–5 Application of forceps in occiput-anterior (OA) position. A, The left blade is inserted along the left side wall of the pelvis over the parietal bone. B, The right blade is inserted along the right side wall of the pelvis over the parietal bone. C, With correct placement of the blades, the handles lock easily. During uterine contractions, traction is applied to the forceps in a downward and outward direction to follow the birth canal.
Figure 27–5 (continued) Application of forceps in occiput-anterior (OA) position. A, The left blade is inserted along the left side wall of the pelvis over the parietal bone. B, The right blade is inserted along the right side wall of the pelvis over the parietal bone. C, With correct placement of the blades, the handles lock easily. During uterine contractions, traction is applied to the forceps in a downward and outward direction to follow the birth canal.
Types of Forceps Outlet forceps Midforceps Breech forceps
Figure 27–4 Forceps are composed of a blade, shank, and handle and may have a cephalic and pelvic curve. (Note labels on Piper and Tucker- McLean forceps.) The blades may be fenestrated (open) or solid. The front and lateral views of these forceps illustrate differences in blades, open and closed shanks, and cephalic and pelvic curves. Elliot, Simpson, and Tucker-McLean forceps are used as outlet forceps. Kielland and Barton forceps are used for midforceps rotations. Piper forceps are used to provide traction and flexion of the aftercoming head (the head comes after the body) of a fetus in breech presentation.
Fetal Risks Ecchymosis, edema, or both along the sides of the face Caput succedaneum or cephalhematoma Transient facial paralysis Low Apgar scores Retinal hemorrhage Corneal abrasions
Maternal Risks Lacerations of the birth canal Periurethral lacerations Extension of a median episiotomy into the anus More likely to have a third- or fourth-degree laceration Report more perineal pain and sexual problems in the postpartum period Postpartum infections
Nursing Management Explains procedure to woman Monitors contractions Informs physician/CNM of contraction Encourages woman to avoid pushing during contraction Assessment of mother and her newborn Reassurance
Indications for Vacuum Extraction Prolonged second stage of labor Nonreassuring heart rate pattern Used to relieve the woman of pushing effort When analgesia or fatigue interfere with ability to push effectively Borderline CPD
Vacuum Extraction Procedure Procedure – Suction cup placed on fetal occiput – Pump is used to create suction – Traction is applied – Fetal head should descend with each contraction
Figure 27–6 Vacuum extractor traction. A, The cup is placed on the fetal occiput, creating suction. Traction is applied in a downward and outward direction. B, Traction continues in a downward direction as the fetal head begins to emerge from the vagina. C, Traction is maintained to lift the fetal head out of the vagina.
Figure 27–6 (continued) Vacuum extractor traction. A, The cup is placed on the fetal occiput, creating suction. Traction is applied in a downward and outward direction. B, Traction continues in a downward direction as the fetal head begins to emerge from the vagina. C, Traction is maintained to lift the fetal head out of the vagina.
Nursing Management Inform woman about procedure Pumps the vacuum Supports the woman Assesses the mother and neonate for complications
Neonatal Risks with Vacuum Extraction Scalp lacerations and bruising Shoulder dystocia Subgaleal hematomas Cephalhematomas Intracranial hemorrhages Subconjunctival hemorrhages
Neonatal Risks with Vacuum Extraction (continued) Neonatal jaundice Fractured clavicle Erb’s palsy Damage to the sixth and seventh cranial nerves Retinal hemorrhage Fetal death
Maternal Risks with Vacuum Extraction Perineal trauma Edema Third- and fourth-degree lacerations Postpartum pain Infection More sexual difficulties in the postpartum period
Indications for Cesarean Birth Complete placenta previa CPD Placental abruption Active genital herpes Umbilical cord prolapse Failure to progress in labor
Indications for Cesarean Birth (continued) Proven nonreassuring fetal status Benign and malignant tumors that obstruct the birth canal Breech presentation Previous cesarean birth Major congenital anomalies Cervical cerclage
Indications for Cesarean Birth (continued) Severe Rh isoimmunization Maternal preference for cesarean birth
Impact on the Family Stress and anxiety Sense of loss of vaginal birth experience Fear Relief
Preparation for Cesarean Birth Preoperative teaching – Coughing and deep breathing – Splinting – What to expect
Nursing Management Before Cesarean Birth Assisting with the epidural Monitoring maternal vital signs and fetal heart rate Inserting an indwelling urinary catheter Preparing the abdomen and perineum Making sure that all necessary personnel and equipment are present Positioning the woman on the operating table
Nursing Management Before Cesarean Birth (continued) Supporting the couple Instrument count
Nursing Management After Cesarean Birth Normal newborn post-delivery care Monitoring vital signs Checking the surgical dressing Palpating the fundus and checking lochia Monitoring intake and output Administration of oxytocin and pain management
Vaginal Birth After Cesarean (VBAC): Criteria One previous cesarean birth and a low transverse uterine incision An adequate pelvis No other uterine scars or previous uterine rupture An available physician who is able to do a cesarean In-house anesthesia personnel
Hypertonic can evolve into normal pattern If ineffective continues: c/delivery RN responsible for reporting and documenting data in time current Outcome evaluation
Characterized by contractions that are inadequate in frequency, duration, intensity Risks – Maternal exhaustion from long labor – Infection – Maternal/fetal injury Management – Rest, hydration, sedation – Labor augmentation (oxytocin, AROM) Contributing factors – Large fetus,malpresentation,early or repeated maternal sedation Dysfunctional Labor Patterns: Hypotonic Labor
The same in all aspects of process to hypertonic Nursing Process
Labor that progresses rapidly (< 3hrs after onset of uterine activity) Contributing factors – Grand multip, small fetus, relaxed pelvic muscles, hx of same Risks – Uncontrolled delivery – ACOG allows for induction with contributing factors Precipitate delivery
Assessment – Thorough hx, EFM, fetal position changes, (U/S), client responses, fetal tolerance – Be alert for amniotic fluid emboli, uterine atony Nursing dx – Risk for soft tissue injury – Risk for infection – Anxiety Nursing process- precip del
CPD – Contributing factors Irregular shaped pelvis Fetal macrosomia Hx of crushed or fx pelvix Macrosomia – Passenger too big – Can lead to shoulder dystocia – Maternal diabetes – Excessive mat wt gain – Adv. Mat age – Erb’s palsy
Interventions for shoulder dystocia Mc Roberts maneuver Suprapubic pressure Woods corkscrew – Push ant chest wall of fetus and turn 180 degrees Rubin maneuver push against scapula of ant. Shoulder to rotate forward 180
Prolapsed Cord Occult (hidden, cannot be seen or felt) Complete (cannot be seen, but may be felt) Visible (can be seen protruding from vagina)
Cord abnormalities Velamentous insertion – Developmental abnormality which may cause decreased fetal perfusion Vasa previa – Cord vessels over os Cord compression – During descent – Cord wrapping Cord prolapse – Cord precedes fetus – Check EFM
Evaluate for shared amnion and chorion Higher incidence of PTL Cojoining abnormalities 1:1 ratio of nurse to baby in delivery Perinatal abnormalities 5 x greater Maternal complications increase Financial concerns Multiples
Fetuses can assume a variety of positions in utero Twin Gestation