1. Intrapartal Complications Complications of the: Powers Passageway Passenger Placenta

2. Complications of the Powers  Dystocia  Dysfunctional or uncoordinated uterine contractions that result in a prolongation of labor Normal labor curve Abnormal labor curve

3. Dysfunctional Labor HypertonicHypotonic Phase of LaborLatent (< 4 cm)Active (> 4 cm) Symptoms ↑freq & intensity of contractions, pain ↓effectiveness ↓ freq & intensity of contractions, No progress in labor RisksFetal Distress-early in labor process Infection, Exhaustion, Hemorrhage, Late fetal distress TreatmentRest UterusStimulate Uterus R/O CPD, Breech, etc. MedicationsMorphine, StadolPitocin

4. Nursing Care Careful monitoring of mother and fetus Offer warm shower Relaxation techniques Assist with AROM and careful monitoring of fetus Prepare to start Oxytocin infusion LOTS OF ENCOURAGEMENT Hypotonic Dystocia Hypertonic Dystocia Bedrest Sedation to promote relaxation and reduce pain Careful monitoring of mother and fetus Relaxation techniques Pain management LOTS OF ENCOURAGEMENT

5. Precipitous Labor  < 3 hours; Rapid Dilatation and Decent  Risks  Mom: genital tract lacerations, abruptio placentae, postpartum hemorrhage  Fetus:meconium-stained fluid, bruising, cerebral trauma  Treatment—safe passage of fetus through perineal support, calm atmosphere, careful assessment postpartum of both mom and baby  Treatment, if Hx of precipitous labor  Induce w/SROM  BE READY

6. Preterm Labor (PTL) = < 37 weeks  PTL is the #1 perinatal and neonatal problem in US.  A major goal of Healthy People 2020  Reduce PTL rate in US to 7.6 %  In 2011, 12.8 % of all babies were born preterm (all-time high  )  Rate is INCREASING, not decreasing

7. Maternal Causes  Race, SES, Age, < High School Education Unmarried  Smoking  Alcohol in excess  Illicit Drugs eg. Cocaine, heroine  Poor Nutrition  Exposure to Toxins  Low Wt. Gain in PG  Domestic Abuse  Infections  History of  AB’s  LBW/PTL  Metabolic Disease  UTI in 3 rd Trimester  DES Exposure  PIH  Anemia  Short interpregnancy interval  Hx of Heart Disease  Type 1 or 2 Diabetes

8. Other Factors  Fetal  Multiple gestation  Macrosomia  Polyhydramnios  Early Engagement  Fetal Distress  Placental  Previa  Abruption

9. Risks  Mother  If Placenta is cause  severe hemorrhage and Shock  Fetus  RDS and other complications of prematurity  Hypoxia if the problem is placental

10. Symptoms  Uterine Activity  Cx q 10” for 1 hour  w/ or w/o pain  Cervical changes  Dilatation of >2cm  Effacement of >80%  Vaginal Discharge  Thicker or thinner  Sudden spotting or blood, brown or colorless discharge  ↑ amt.; malodorous  SROM  Discomfort  Abdominal Cramping; w/ or w/o diarrhea  Dull, low back pain  Painful menstrual-like cramps  Suprapubic pain  Pelvic pressure  Urinary frequency

11. Treatment  Bedrest  Hydration  Antibiotics(if evidence of infection)  Analgesic  May be used in conjunction with tocolytics

12. Tocolytic drugs  Magnesium Sulfate—MgSO 4 (IV)  Bolus of 4-6 Gms over 15-30 min, then 1-4 gm/hour till contractions stop.  Maternal Mg serum level for effectiveness in tocolysis is 5.5-7.5mg/dL  Follow all nursing care r/t MgSO 4 discussed earlier  Nifedipine (Procardia; Ca++ channel blocker)  10-20 mg PO; 20 mg q6 hr x 24 hrs; 20mg q8 hrs  Because mechanism of action is different from beta- adrenergic agonists, it might be used in conjunction with terbutaline or ritodrine.

13. Tocolytic drugs cont’d.  Indomethacin (Indocin)-  used for short-term management of PTL especially if Beta adrenergic agonists failed. Best to use for <5-7 days. As a prostaglandin inhibitor, it helps to stop contractions and prevent release of Oxytocin.  po or pr: 25-50 mg q6hr for 48hr. Discontinue if birth is imminent or likely to occur within 24hr.

14. Tocolytic drugs cont’d  17 Alpha-Hydroxyprogesterone Caproate  Used only with single gestation pregnancies  Acts to relax smooth muscle ie pregnant uterus  Administered to prevent PTL  Used for long-term management of PTL administered weekly  (17 P) IM injection given z-track slowly over 3- 5 min, to minimize discomfort best to ice the injection site prior to administration

15. Side Effects & Complications of Magnesium Sulfate  Magnesium Sulfate  SIDE EFFECTS~Mom: flushing, drowsiness, muscle weakness, blurred vision, N& V  COMPLICATIONS~Mom: pulmonary edema, respiratory depression or arrest, cardiac arrest, profound hypotension, hyporeflexia  COMPLICATIONS Neonate: hypermagnesemia

16. Side Effects & Complications of Calcium Channel Blockers  SIDE EFFECTS~ MOM: flushing, tachycardia  COMPLICATIONS~MOM: profound hypotension, possible decrease in uteroplacental perfusion

17. Side Effects & Complications of Prostaglandin Inhibitors~ Indomethacin  SIDE EFFECTS~ MOM: epigastric pain, nausea & vomiting  COMPLICATIONS~MOM: GI bleeding, renal failure  COMPLICATIONS Neonate: premature closure of the ductus arteriosus, necrotizing enterocolitis, intracranial hemorrhage

18. Tocolytics: Beta 2 Adrenergic Agonists  Terbutaline/Brethine  SQ .25 mg q 20-30” for 2 hrs .25 mg q 3-4 hrs  SQ Pump  0.03-.01 mg/hr  Max = 3 mg/24 hr  PO  2.5 – 5.0 mg Q 4-6 hrs

19. Tocolytics: Beta 2 Adrenergic Agonists Lots of SIDE EFFECTS  Maternal  SOB, tachypnea, pulmonary edema  Chest pain, ↓ B/P, Palpitations  Fluid retention, ↓ Urine  Tremors, Muscle cramps, H/A  Hyperglycemia, hypokalemia, hypocalcemia, metabolic acidosis  N/V  Fetal  Tachycardia  Hyperinsulinemia  Hyperglycemia (Fetus)  Hypoglycemia (Neonate)  Hyperbilirubinemia  Hypotension

20. Nursing Care w/Tocolytics  Monitor IV rates CAREFULLY  Continuous EFM—record q 15 minutes  If FHR> 180 bpm, STOP beta adrenergic agonists  Call MD  Maternal VS and Cxs;  record q 15” until stable then q 30”  Notify MD if P > 120,  STOP meds if:  P > 120, > 6 PVC’s/min, systolic > 180, diastolic < 40, c/o chest pain, SOB

21. Nursing Care w/Tocolytics  Strict I& O  Bedrest—Left Lateral  Lung sounds---Pulmonary edema  Daily Weights  Urine for Glucose  Serum Electrolytes  EMOTIONAL SUPPORT

22. PTL—Home Therapy  Timing of taking oral medications  Palpate contractions  No heavy lifting, nipple stimulation, intercourse  Quit work—take LOA  May have uterine home monitoring  Teach symptoms of PTL early in pregnancy

23. Premature Rupture of Membranes  Preterm PROM—rupture before 37 weeks gestation  Diagnosis  Nitrazine paper, pH strip- color change??  Fern test  Risks  Maternal: Chorioamnionitis/endometritis  Fetal: PTL/Prematurity  Stress of PROM may stimulate surfactant production and thus ↓ incidence of RDS

24. Treatment of preterm PROM  If infection noted  Deliver  If w/o infection; conservative mgmt  VS q 4 especially noting elevated temp  CBC, vaginal culture on admission  Frequent BPP—assess amt of amniotic fluid  Assess for uterine tenderness, any vaginal leaking  Prophylactic antibiotics for 48 hrs often given  Modified bedrest (NO WORK)  NOTHING in Vagina; No Intercourse or tub bath

25. Treatments  Corticosteroids  stimulates surfactant production,  risk of NEC, & IVH in Fetus  Betamethasone (Celestone) = 12 mg IM x 2 doses 24 hours apart  Wait 1 week and repeat  Dexamethasone (Decadron) = 6 mg IM X 4 doses 12 hours apart  Fetal Kick Counts  Choose time of day to sit quietly  Count to 10  If < 10 movements in 12 hrs  Call MD  After meals, Count 4 movements  If < 4 movements in 2 hrs  Call MD

26. Complications of the Passageway  Cephalopelvic Disproportion (CPD)  Risks  Uterine Rupture  Assisted Delivery  cervical/vaginal lacerations  Trauma to fetal head,  Fracture, CNS damage  Treatment  Cesarean Section

27. Complications of the Passenger  Malpresentation  Tranverse Lie  Breech  Brow/Face  Multiple Gestation  IUFD  Fetal Distress  Shoulder Dystocia

28. Multiple Gestation (Twins +)  Increase risk of PTL, Malpresentation, PIH, Maternal Hemorrhage  ↑ incidence d/t fertility treatments  Most common is twins  1/85 births is a twin

29. Twins  Monozygotic—33% of all twins  1 egg + 1 sperm= “Identical”  Variations  2 amnions/2 chorions 30% (Dichorionic/diamniotic)  2 amnions & 1 chorion—68% (monochorionic/diamniotic)  1 amnion & 1 chorion –2% (monochorionic/monoamniotic)  MOST COMPLICATIONS  Twin-to-twin transfusion  Dizygotic — 67% of all twins  2 eggs = 2 sperm = “Fraternal”  2 ovums + 2 placentas = 2 babies

30. Risk for Multiple Gestation  Family HX  Increased maternal age  Increased parity  Conceiving within 1 month of stopping OC  Increased frequency of Coitus

31. Risks  Maternal  PTL  Cardiac stress  Anemia  PIH  Polyhydramnios  Placenta previa  Dysfunctional Labor  Abnormal Presentation  Fetal  Congenital anomalies  Monozygotic  twin-to-twin tranfusion  Polycythemic  Anemic  Umbilical Cords intertwined

32. Management  Antepartum  U/S early to confirm twins  > # of office visits  ↑ caloric needs—see dietician  ↑ rest  Assess for infection  Monitor fetal status  U/S, NST’s, BPP  Intrapartum  Monitor twins  1 tocotransducter  2 U/S transducers or 1 U/S transducer and 1 scalp electrode  Maternal VS, IV’s  Vag delivery with C/Sec back up  2 OB’s/Peds/RN’s  May have 1 baby vaginally and 1 baby by C/Section

33. Management  If Triplets or Quads or +++  C/Section is delivery method of choice  Postpartum  Assess CLOSELY for Uterine Atony  Emotional Support  Support with Breastfeeding  Referrals to social worker/PHN Morgan, Sam, & Ben

34. Shoulder Dystocia-an obstetrical emergency  An intrapartum event that occurs when the infant’s head has been delivered, but the shoulders remain wedged behind the mother’s pubic bone  Risk factors  Macrosomic babies are most at risk  GDM, Obesity, hx of previous LGA baby or previous shoulder dystocia  Shoulder dystocia may occur when the woman has no risk factors.

35. Management  Position in McRobert’s positionMcRobert’s position  Legs and thighs flexed up to her abdomen with the head of the bed lowered  Apply suprapubic pressure  Apply pressure directly over they symphysis pubis to aid in dislodging the fetal shoulder

36. Complications of Shoulder Dystocia  Permanent injury to baby  Brachial plexus injury (caused by excessive traction on fetal head)  Fractured clavicles  Asphyxia  Neurologic damage  Maternal Complications  Heavy bleeding after delivery  Tearing of the uterus, vagina, cervix or rectum  Bruising of the bladder

37. Other Fetal Complications  IUFD—Intrauterine Fetal Demise  Often detected by absent fetal movement  Nursing Dx: Grieving, Altered family processes, Ineffective individual coping  Goal: a supportive, pain-free delivery with resources available to make this a special memory for the family

38.  Cause is often unknown or there is some physiological maladaptation such as placenta previa/abruptio, maternal diabetes, or severe renal disease, profound congenital anomalies.  Risks to mother -- prolonged retention of dead fetus can lead to DIC  Diagnosis is based on absence of fetal heart tones and/or ultrasound  Usually labor will begin on its own, if not, labor will be induced within 2 weeks of documented demise  During labor, the woman is often sedated and an epidural is initiated soon after the onset of contractions so that labor is made as painless as possible.

39.  The couple may or may not wish to see the baby at that time, some may want to hold their baby. Treat them with respect. If the parents do not wish to see the baby, the baby should be baptized (if parents are Catholic), pictures taken, identification bands made out, foot prints taken, a lock of hair cut, and a weight and length recorded. This information is given to the family in a sealed envelope for them to open whenever they wish. If parents wish to hold the baby, give them some privacy and be near to answer any questions.  Post-partally, offer the parents to be transferred off the maternity unit, and allow the father to stay as much as possible. Call pastor, priest, or rabbi for support. Refer to support groups, such as Resolve, Share, or Compassionate Friends.  Studies have shown that parental grief after a stillbirth is aided if the parents name the baby, see the baby, hold the baby, and bury the baby.  BE COMPASSIONATE, IT IS OKAY TO CRY WITH THE FAMILY. TRY TO FORGET YOUR OWN DISCOMFORT IN ORDER FOR THE FAMILY TO EXPRESS THEIRS.

40. Complications of the Placenta  Placenta Previa  Placenta Abruptio  Placenta Accreta  Umbilical Cord Prolapse

41. Placenta Previa  Types  Low Implantation  Partial Previa  Complete Previa  PAINLESS VAGINAL BLEEDING in the 2 nd - 3 rd Trimester  Dx  Ultrasound  Management  Hospitalized, Bedrest  Tocolysis, if contracting  C/Sec  NO VAGINAL EXAMS

42. Placenta Abruptio  Types  Covert/Concealed  Overt/Partial  Overt/Complete  Symptoms  Knife-like pain w/concealed  Shock  Varying amt. of bleeding  DX  Fetal Distress  U/S or CAT Scan  Treatment  Emergency C/Sec

43. Placenta Accreta  Placenta adheres to uterine myometrium  It attaches itself too deeply into the lining of the uterus  Maternal hemorrhage is often severe  Does not respond to treatment for P/P hemorrhage  Often results in hysterectomy

44. Umbilical Cord Prolapse  Extremely critical obstetrical situation  Cord protudes from cervix into vagina  Seen in breech and when presenting part is unengaged  Position Mom  Knee-chest, Trendelenburg, elevate hips  Sterile gloved hand—hold presenting part off cord  EMERGENCY C/SECTION, O 2, ↑ IV flow rate

45. Other Complication Amniotic Fluid Embolism  Pathophysiology  Amniotic fluid enters maternal circulation → pulmonary capillaries  Tiny emboli form → pulmonary vasospasm → Hypoxemia and Acute Right-sided Heart Failure  Vernix and Lanugo  DIC may develop  Symptoms  Restlessness  Chills  Pallor  ↓ B/P, ↑ Pulse, ↑ Resp.  Dyspnea  Chest Pain

46. Amniotic Fluid Embolism  Medical Management  Drugs  Morphine  Aminophyllie  Digoxin  Cortisone  Nursing  Follow orders  Semi-fowler’s position  Oxygen  Medication  Blood Products  I & O  If undelivered  C/Sec  STAY WITH MOTHER if suspect AFE

47.  Nurses must be alert to symptoms of what can go wrong and take initial steps to enhance the health of the mother and the baby.