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Nursing Management ofLabor and Birth at Risk
By: Faith Angeline C. Fernandez
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Dysfunctional labor
Problems with Power, Passenger, Passageand Psyche
Post-term with Labor and Birth
Women requiring Induction & AugmentationIntrauterine Fetal Demise
Obstetric Emergencies
Birth Related Procedures
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Difficult labor --Difficult labor --
DystociaDystocia
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DefinitionDefinition
Difficult labor orchildbirth
Abnormal slowprogress of labor
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IncidenceIncidence The most common
indication for
primary cesarean
section
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Evaluation indexEvaluation index Cervical dilation
Descent of the fetal
presentation
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Classification ofClassification of
DystociaDystocia Abnormalities of the Power
Abnormalities of the Passage
Abnormalities of the
Passenger
Abnormalities of the Psyche
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Characteristics of theCharacteristics of thepowerpower
Intensity is greater in the fundus Average 24mmHg
Well synchronized
Frequency Duration 60s
regular
Rhythm and force
Basal resting pressure 12-15mmHg
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Abnormalities in PowerAbnormalities in Power Inertia is a time honored term to
denote that sluggishness of acontractions, or the force of labor, hasoccurred.
More current term is dysfunctionallabor
Occurring at the onset in labor
Occurring later in labor
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Abnormalities in PowerAbnormalities in Power Prolonged labor appears to
result from several factors.
It is more likely to occur if thefetus is large
Hypotonic, hypertonic anduncoordinated contractions
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Fetal monitoringFetal monitoring
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Uterine dysfunctionUterine dysfunction Hypotonic
Hypertonic
Uncoordinated
Inadequate
expulsive
efforts
i
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HypotonicHypotonic
dysfunctiondysfunction
Insufficien
t
Irregular
Infrequent
Management:
Infusion of oxytocinMembranes may be
artificially ruptured
(amniotomy)
H i
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HypotonicHypotonic
dysfunctiondysfunction
Post Partal Period
Management:
In the 1st hour after birthoPalpate the uterus
oAssess lochia every 15 minutes
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Hypotonic dysfunctioHypotonic dysfunctionnetiologyetiology
Malfunction
Malpresentation
Extrinsic factor
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Hypertonic dysfunctionHypertonic dysfunction
Lack of
resting tone Frequent
intense
contraction
Management :
Morphine
Sulfate/Sedation
I and E monitoring
Darkening the room
lights
Decreasing noise
Cesarean section
iH t i
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HypertonicHypertonic
DysfunctionDysfunction
H iH t i
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HypertonicHypertonic
dysfunctiondysfunction etiologyetiology
Muscle fibers of the myometriumdo not repolarize.
U di dU di t d
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UncoordinatedUncoordinated
ContrationsContrations
Dyssynchronus
Frequent
Management:
I and E
monitoring
Oxytocin
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Comparison of Hypotonic andComparison of Hypotonic and
Hypertonic ContractionsHypertonic ContractionsCriteria Hypertonic Hypotonic
Phase oflabor
Latent Active
Symptoms Painful Painless
Medication
Oxytocin Unfavorable reaction FavorableReaction
Sedation Helpful Little value
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Abnormal patternsAbnormal patterns
Prolonged latent phase
Protraction disorders (activephase)
Arrest disorders (activephase)
Precipitate labor disorders
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Friedmans curveFriedmans curve
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Latent phase
Active phaseI II stage
Partogram
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Prolonged latentProlonged latent
phasephase
Nulliparas
Multiparas
Prolonged
>20 hr
> 14 hr
Normal average
6.4 hr
4.8 hr
P l d l t tP l d l t t
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Prolonged latentProlonged latent
phasephase
Management:
Administration of morphine mayrelax hypertonicity
Administering adequate fluid
AmniotomyOxytocin infusion
Cesarean Birth
P t ti A tiP t ti A ti
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Protraction ActiveProtraction Active
PhasePhase
Nulliparas
Multiparas
Descent
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Protraction ActiveProtraction Active
PhasePhaseManagement:
OxytocinCesarean Birth
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Arrest disorderArrest disorder
Nulliparas
Multiparas
Descent
>2h
>1h
Dilation
>2h
>1h
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Arrest disorderArrest disorder
Management:
Cesarean Birth
Oxytocin
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PartogramPartogram
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A prolonged latent phase
B prolonged active phase
C arrest active phase
Abnormal partogram
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PartogramPartogram
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Pathological retraction ringPathological retraction ring
Occurs at the junction of the upper and loweruterine segments
2nd stage of labor:
o Severe dysfunction labor is occurring.Formed by excessive retraction of theupper uterine segment; the myometrium is
much thicker above than below the ring
Early stage of labor:
o Caused by uncoordinated contractions.
Pathological retractionPathological retraction
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Pathological retractionPathological retraction
ringringManagement:
Administration of morphine sulfate
Inhalation of amyl nitrite
Tocolytic
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ringring
retraction ringretraction ring
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retraction ringretraction ring
(bandls ring)(bandls ring)
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Precipitate laborPrecipitate labor
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Precipitate laborPrecipitate labor
disordersdisorders
Nulliparas
Multiparas
Descent
>5cm/hr
>10cm/hr
Dilation
>5cm/hr
>10cm/hr
Precipitate laborPrecipitate labor
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Precipitate laborPrecipitate labor
disordersdisorders
Management:
Tocolytic - to reduce the force andfrequency of the contraction
Ab liti f thAb liti f th
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Abnormalities of theAbnormalities of thePassagePassage
Bony pelvic (most
common)
Soft tissue obstruction
Abnormal placentalocation
Bony pelvicBony pelvic
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Bony pelvicBony pelvic
abnormalitiesabnormalities
Inlet Contraction
Generally contracted pelvis
Deformed pelvis
Three level of bonyThree level of bony
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Three level of bonyThree level of bony
pelvispelvis
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Inlet contractionInlet contraction
Contraction of pelvic inlet
AP
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Three anteroposterior diameters of
the pelvic inlet
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Diameter of the inlet and midpelvis
FetopelvicFetopelvic
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FetopelvicFetopelvic
disproportiondisproportion
10.9%
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funnel shaped pelvis
47.3% 5.8%
36.6%10.9%
gynecoid
android
Flat(platypelloid) anthropoid
transverselycontracted
Pelvis
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each pelvic
plane is 2 cmless than
normal
generally contracted pelvis
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osteomalacia oblique pelvis
kyphosis
Deformed
pelvis
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Soft tissue dystociaSoft tissue dystocia
Congenital anomalies
Scarring of birth canal
Pelvic masses
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Pelvic massPelvic mass
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Pelvic massPelvic mass
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Low lying placentaLow lying placenta
Abnormalities of theAbnormalities of the
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Abnormalities of theAbnormalities of thePassengerPassenger
Prolapse of the Umbilical
Cord
Fetal macrosomia
Malpresentation
Shoulder dystocia
Fetal malformation
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13.3
9.5
11.3
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Prolapse of theProlapse of the
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Prolapse of theProlapse of theumbilical cordumbilical cord
A loop cord slips down in front of thepresenting part.
Prolapse may occur at any time afterthe membranes rupture if thepresenting part is not fitted firmly
into the cervix.
Prolapse of theProlapse of the
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Prolapse of theProlapse of theumbilical cordumbilical cord
It tends to occur most often withthe ff. conditions:o
Premature rupture of themembrane
oPlacenta previa
o
A small fetusoHydramnious
oMultiple gestation
oCPD preventing firm engagement
Prolapse of theProlapse of the
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Prolapse of theProlapse of theumbilical cordumbilical cord
Management:
Administering Oxygen at 10 L/min byfacemask is also helpful to improve the
oxygenation of the fetus
Aimed toward relieving pressure on the cord
Placing a gloved hand in the vagina and
manually elevating the fetal head of the cordKnee chest position or trendelenburg positionwhich causes the fetal head fall back from thecord
Prolapse of theProlapse of the
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Prolapse of theProlapse of theumbilical cordumbilical cord
Do not attempt to push back anyexposed cord. This may add to thecompression by causing knotting or
kinking. Cover any exposed portion with
sterile saline compress to prevent
drying Deliver the infant quickly, possibly
with Forcep delivery to prevent fetalanoxia
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Fetal MacrosomiaFetal Macrosomia Size may become a problem in a fetus who weighs
more than 4,000 4,500g (9-10lbs.)
An oversized infant may cause uterine dysfunctionduring labor or at birth because of over stretching
of the fibers of the myometrium. A large infant born vaginally has a higher than
normal risk of:
o Cervical nerve palsy
o Diaphragmatic nerve injury
o Fractured clavicle because of shoulder dystocia
o Hemorrhage
F l i
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Fetal macrosomiaFetal macrosomialarge for gestational age(LGA)
4000g
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Fetal macrosomiaFetal macrosomia
Management:
Pelvimetry or Sonography can be
used to compare the size of the fetuswith the womans pelvic capacity
Cesarean section
M l t tiM l t ti
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MalpresentationMalpresentation
In approximately 1/10
th
of all labors, thefetal position is posterior rather thananterior.
Posterior position tend to occur in women
with android, anthropoid or contractedpelvis.
A posterior position is suggested by adysfunctional labor pattern such as aprolonged active phase, arrested descentor fetal heart sounds best heard at thelateral sides of the abdomen.
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MalpresentationMalpresentation Breech presentation
Face presentation
Brow presentationTransverse Lie
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Cepholic position and the diameter through pelvis
occiput
presentation
parietal
presentation
brow
presentation
face
presentation
M l t tiM l t ti
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MalpresentationMalpresentation
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Breech presentation
Sh ld d t iSh ld d t i
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Shoulder dystociaShoulder dystocia
Is a birth problem that is increasing inincidence along with the increasingaverage of new born.
The problem occurs at the second stage oflabor, when the fetal head is born but theshoulders are too broad to enter and bornthrough the pelvic inlet.
The force of birth can result in a fracturedclavicle or a brachial plexus in jury for thefetus.
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Shoulder dystociaShoulder dystocia
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presentationpresentation
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presentationpresentation
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Brachial Plexus InjuryBrachial Plexus Injury
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Fetal malformationFetal malformation
P hP h
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PsychePsyche
The fourth P refers to the psychologicalfeelings that a woman brings into labor.
For many women, this feeling ofapprehension or fright.
Women who manage best in labor
typically are those who have a strongsense of self-esteem and a meaningfulsupport person with them.
P hPsyche
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PsychePsyche Women without adequate support can
have an experience so frightening andstressful they can develop a posttraumatic stress syndrome.
P hPsyche
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PsychePsyche
Management:Encouraging women to ask questions atprenatal visits and to attend preparation forchildbirth classes helps prepare them forlabor.
Encouraging them to share their experience
after labor serves as debriefing time andhelps them integrate the experience intotheir total life
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Induction andInduction and
Augmentation of LaborAugmentation of Labor
LaborLabor
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LaborLabor Induction of Labor means that labor is started
artificially
Augmentation refers to assisting labor that hasstarted spontaneously to be more effective.
Induction may be necessary to initiate labor beforethe time when it would have occurredspontaneously because the fetus is in danger or
labor does not occur spontaneously and the fetusappears to be at term.
I di ti f i d ti f l bIndication for induction of labor
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Indication for induction of laborIndication for induction of labor Primary reason for induction of labor
include the presence of:o Preeclampsia/Eclampsia
oDiabetes mellitus
o Prolonged rupture of the membraneso Postterm pregnancy
oRh incompatibility
o
Intrauterine fetal demise (iufd)o Intrauterine growth retardation
Indication for augmentationIndication for augmentation
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Indication for augmentationIndication for augmentation
Or assistance to make uterine contractions
stronger may be necessary if the contractionsare hypotonic or too weak or infrequent to beeffective.
Prolonged labor Dysfunctional labor
Poor progress of cervical dilatation
o Fetus is estimated to be mature by date demonstrated by a
lecithin sphingomyelin or sonogram to rule out preterm
Induction and Augmentation ofInduction and Augmentation of
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Induction and Augmentation ofInduction and Augmentation of
LaborLabor Before induction of labor is begun, the ff.
conditions should be present:
o Fetus is in longitudinal lie
oCervix is ripe, or ready for birtho Presenting part is engaged
oNo CPD
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Learning OutcomeLearning OutcomeCompare the methods for inducing labor,
explaining their advantages and disadvantages in
determining the nursing management for womenduring labor induction.
C i l Ri iC i l Ri i
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Cervical RipeningCervical Ripening
Consists of effacement and softening of the cervix
May be used at or near term to enhance success ofand reduce time needed for labor induction whencontinuing pregnancy is undesirable
May hasten beginning of labor or shorten course oflabor
C i l Ri iC i l Ri i
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Cervical RipeningCervical Ripening
May cause hyperstimulation of uterus
Pharmacologic agents includeCytotec and prostaglandin agents
can cause uterine stimulation afterinsertion
iscoring
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scoringscoringScoringfactor
0 1 2 3
Dilatation(cm)
0 1-2 3-4 3-4
Effacement(%) 0-30 40-50 60-70 80
Station -3 -2 -1-0 +1-+2
Consistency Firm Medium Soft
Position Posterior Mid-position
Anterior
St i i f th M bSt i i f th M b
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Stripping of the MembranesStripping of the Membranes
Mechanical method: Gloved fingerinserted into internal os and rotated360 degrees twice separating
amniotic membranes lying againstlower uterine segment
St i i f th M bSt i i f th M b
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Stripping of the MembranesStripping of the Membranes
Disadvantages:
Does not require monitoring or other
assessments often done asoutpatient service
May not induce labor if labor is
initiated, it typically begins within 48hours
May cause bleeding
Oxytocin inductionOxytocin induction
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Oxytocin inductionOxytocin induction
Administration of oxytocin initiatescontraction in a uterus at pregnancyterm.
Oxytocin is always administeredintravenously, so, hyperstimulationshould occur. It can be quicklydiscontinued.
Pit i I f iPitocin Infusion
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Pitocin InfusionPitocin Infusion
Usually effective at producingcontractions may causehyperstimulation of the uterus
Requires small, precise dosage 10 IU in1,000 mL of Ringers Lactate.
An alternative dilution method is to add
15 IU of oxytocin to 250 mL of an IVsolutio; this yields of concentration of 60mU/1mL.
Pitocin InfusionPitocin Infusion
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Maximum rate and dosing interval based
on facility protocol, clinician order,individual situation, and maternal-fetalresponse
Infusion are usually begun at a rate of 0.5to 1 mU/min until contraction begin.
Do not increase the rate to more than 20
mU/min without checking furtherinstructions, due to an administration rategreater than this is likely to cause tetaniccontractions.
Pitocin InfusionPitocin Infusion
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Pitocin InfusionPitocin Infusion
Management:
Take the womans pulse and BP every 15minutes
Monitor uterine contractions conscientiously
Contractions should occur no more oftenthan every 2 minutes, should not bestronger than 50 mmHg preassure andshould not lst longer than 70 seconds.
Pitocin InfusionPitocin Infusion
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Pitocin InfusionPitocin Infusion B-adrenergic receptor drug such as terbutaline
sulfate (Brethine)or Magnesium Sulfate mayprescribed to decrease myometrial activity.
Anti diuretic effect:o Decreased urine flow
o
Headache and vomitingo Keep accurate record of I and O
oTest and record urine specific gravity
o Limit the amount of fluid (150mL/hr) by ensuring that the main IV fluidline is infusing at a rate not greater than 2.5 mL/min.
Augmentation by oxytocinAugmentation by oxytocin
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Augmentation by oxytocinAugmentation by oxytocin
Is required if labor contractions begins
spontaneously but then become so weak,irregular, or ineffective (hypotonic) thatassistance is needed to strengthen them.
Precautions regarding oxytocinaugmentation are the same as for primaryinduction of labor.
Be certain that the drug is increased in
small increments only and that fetal heartsounds are well monitored duringprocedure.
LaborLabor
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It include the aggressiveadministration of oxytocin to shortenlabor to 12 hours, which presumablyreduces the incidence of CS birth and
post partal infection.
The Maximum dosage may be as
high as 36 40 mU/min.
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Birth-Related Procedures
External VersionExternal Version
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External VersionExternal Version
May be done 37 to 38 weeks gestation tochange breech presentation to cephalicpresentation before birth
Physician applies external manipulation to
maternal abdomen. gentle pressure is then exerted to rotate
the fetus in a forward direction to cephalic
lie Fetal part must not be engaged.
External VersionExternal Version
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External VersionExternal Version
Management before theprocedure:
NST performed to establish fetal well-being
Tocolytic given during procedure to
relax the uterus
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Transverse fetal lieTransverse fetal lie
Internal VersionInternal Version
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Internal VersionInternal Version
Podalic version used to turn second twinduring vaginal birth
Used only if second fetus does not
descend readily and heartbeat is notassuring
Physician reaches into uterus and grabsfeet of fetus and pulls them down through
cervix
Internal VersionInternal Version
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Internal VersionInternal Version
Management before theprocedure:
Tocolytic given during procedure torelax the uterus
Purpose of AmniotomyPurpose of Amniotomy
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Purpose of AmniotomyPurpose of Amniotomy
Stimulate or induce labor Apply internal fetal or contraction monitors
Obtain fetal scalp blood sample for pH
monitoring Assess color and composition of amniotic
fluid
Episiotomy TypesEpisiotomy Types
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Episiotomy TypesEpisiotomy Types
Surgical incision of perineal body toenlarge outlet commonly used toavoid spontaneous laceration
Episiotomy TypesEpisiotomy Types
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Episiotomy TypesEpisiotomy Types
Two typesoMidline: Incision begins at bottom
center of perineal body and extends
straight down midline to fibers
oMediolateral: Incision begins in
midline of posterior fourchette andextends at 45 degree angle downwardto right or left
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Episiotomy TypesEpisiotomy Types Episiotomy usually performed with
regional or local anesthesia
Types of EpisiotomyTypes of Episiotomy
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Types of EpisiotomyTypes of Episiotomy
Nursing CareNursing Care
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Nursing CareNursing Care
During procedure, provide mother withsupport and comfort
Use distraction if needed if procedure is
uncomfortable, act as advocate for mother Document type of episiotomy in records
and report to subsequent caregivers
After procedure, provide comfort and
apply ice pack
Nursing CareNursing Care
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Nursing CareNursing Care
Assess perineal area frequently inspect every 15minutes during first hour after birth for redness,edema, tenderness, ecchymosis, and hematomas
Apply ice pack immediately in fourth stage
Instruct mother in perineal hygiene and comfortmeasures
Inadequate expulsiveInadequate expulsiveff tff t
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effortsefforts
Second stage
Assisted delivery might be needed
Analgesic / anesthetic agents wear
off
Operative deliveryOperative delivery
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Operative deliveryOperative delivery
1)forceps
operations
IndicationsIndications
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IndicationsIndications
Maternal heart disease Maternal pulmonary edema
Maternal infection
Maternal exhaustion
Fetal stress
IndicationsIndications
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IndicationsIndications
Premature placental separation Need for shorter second stage of
labor
Heavy regional block with ineffectivepushing
Applications of ForcepsApplications of Forceps
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Applications of ForcepsApplications of Forceps
Applications of ForcepsApplications of Forceps
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Applications of ForcepsApplications of Forceps
Applications of ForcepsApplications of Forceps
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Applications of ForcepsApplications of Forceps
RisksRisks
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RisksRisks
Newborn may experienceoBruising
oEdema
oFacial lacerations
oCephalhematoma
o
Transient facial paralysisoCerebral hemorrhage
RisksRisks
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RisksRisks
Woman may experienceoVaginal or perineal lacerations
o Infection secondary to lacerations
o Increased bleeding
oBruising
o
Perineal edema
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Learning OutcomeLearning OutcomeDescribe the use of and risk of vacuum extraction
use to assist birth.
Operative deliveryVacuum
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Vacuum ExtractorVacuum Extractor
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Vacuum ExtractorVacuum Extractor
Assists birth by applying suction to fetalhead
Should be progressive descent with firsttwo pulls, procedure should be limited toprevent cephalhematoma risk increasesif birth not within six minutes
Increases risk for jaundice due to
reabsorption of bruising at cup attachmentsite
Vacuum ExtractorVacuum Extractor
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Vacuum ExtractorVacuum Extractor
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Learning OutcomeLearning OutcomeExplain the indications for cesarean birth, impact onthe family unit, preparation and teaching needs, and
associated nursing care.
IndicationsIndications
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IndicationsIndications
Most common indications forcesarean birtho Fetal distress
oActive genital herpes
oMultiple gestation (three or morefetuses)
oUmbilical cord prolapseoTumors that obstruct birth canal
o Lack of labor progression
IndicationsIndications
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IndicationsIndications
Most common indications forcesarean birtho Maternal infection
o
Pelvic size disproportiono Placenta previa
o Abruptio Placenta
o Previous cesarean section
o Eclampsia
TeachingTeaching
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TeachingTeaching
Teaching needs includeoWhat to expect before, during, and
after delivery
oWhy it is being doneoWhat sensations the woman will
experience
oRole of significant others
o Interaction with newborn
Cesarean Section
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Performed when
mom or fetus in
danger
If in moms history,ask why section
done. May give you
clues as to pastdelivery
complications
Cesarean Section
PreparationPreparation
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PreparationPreparation
Preparation for cesarean birthrequiresoEstablishing IV lines
oPlacing indwelling catheter
oPerforming abdominal prep
Cesarean SectionCesarean Section
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er ne nc s ons orer ne nc s ons orCesarean BirthCesarean Birth
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Cesarean BirthCesarean Birth
er ne nc s ons orer ne nc s ons orCesarean BirthCesarean Birth
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Cesarean BirthCesarean Birth
er ne nc s ons orer ne nc s ons orCesarean BirthCesarean Birth
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Cesarean BirthCesarean Birth
Nursing CareNursing Care
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Nursing Careg
Routine postpartal care including:o Fundal checks
oCare of incision
oMonitoring Intake & Output andmaintaining IV access
oAdminister and teach about post-op
medicationsoAssessment of respiratory system
oAssessment of bowel sounds
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Learning OutcomeLearning OutcomeExamine the risks, guidelines, and
nursing care of the woman undergoing
vaginal birth following cesarean birth.
Vaginal Birth After Cesarean BirthVaginal Birth After Cesarean Birth
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Vaginal Birth After Cesarean Birthag a t te Cesa ea t
Can occur after trial of labor in cases ofnonrecurring indications for cesareanbirth
Most common risks areoHemorrhage
o Surgical injuries
o
Uterine ruptureo Infant death or neurological
complications
Vaginal DeliveryVaginal DeliveryWhen crowning apply gentle pressure to infants head
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When crowning, apply gentle pressure to infant s head
Vaginal DeliveryVaginal Delivery
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Examine neck for looped umbilical cord
Vaginal DeliveryVaginal Delivery
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Support infants head as it rotates for shoulder
presentation
Nursing CareNursing Care
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gg
Continuous EFM Internal Monitoring
IV fluids
Avoid Pitocin if at all possible Classic or T uterine incision is
contraindication to VBAC
Nursing CareNursing Care
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gg
Important for nurse to supportcouple, explore their feelings, andprovide information throughout labor
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Obstetric Emergencies
Nuchal Cord
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Occurs inroughly 25% of
all deliveries Cord wrapped
around neck Can lead to
decreased
blood flow of
infant
Preeclampsia
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p
Unknown cause Often healthy, normotensive
primigravida
After twentieth week, oftennear term
Diagnosis of preeclampsia Hypertension
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HypertensionBlood pressure >140/90 mm Hg
Acute rise of 20 mm Hg in systolic pressure or 10mm Hg rise in diastolic pressure over pre-pregnancy levels
Proteinuria
Excessive weight gain with edema
Management
Treat hypertension, prevent seizures
Eclampsia
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Same signs and symptoms plus seizures orcoma
Tonic-clonic activity
Often begins as oral twitching
Often apnea during seizure
Can initiate labor
p
Management
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Left lateral recumbent position
Minimize stimulation
Oxygen and ventilation assistance
If seizures:
Monitor vital signs Safety of the patient
Gestational Diabetes Mellitus
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Mother cant metabolize carbohydrates
Excess glucose goes to fetus Stored as fat
Management Glucose monitoring
Diet Exercise Insulin
Vaginal Bleeding
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Abortion (miscarriage)
Ectopic pregnancy
Abruptio placenta
Placenta previa
Uterine rupture
Postpartum hemorrhage
Abortion
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Termination of pregnancy from any cause
before 20th week of gestationLater is known aspreterm birth
Common classifications of abortion
Determine:Onset of pain and bleedingAmount of blood lossIf any tissue passed with blood
Management
Third-Trimester Bleeding
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3% of pregnancies
Never normal
Most often due to: Abruptio placentae Placenta previa Uterine rupture
Abruptio Placenta
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Partial or complete detachment of normallyimplanted placenta at more than 20 weeksgestation
Predisposing factors Trauma Maternal hypertension Preeclampsia
Multiparity Previous abruption
Placenta Previa
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Sudden vaginal bleeding in 3rd trimester
PainAbdomen may be tender or rigid
May be minimal bleeding with shockMost of hemorrhage may be hidden
Contractions may be present
If fetal heart tones absent, fetal death islikely
Pl t l i l t ti i l t i
Placenta Previa
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Placental implantation in lower uterine
segment, encroaching on or coveringcervical os
1 in 300 deliveries
More common in preterm birth
Painless, bright red bleedingIncreases if labor beginsFetal compromise
Placenta Previa
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More common with:
Increased maternal age
Multiparity
Previous cesarean section
Previous placenta previa
Uterine Rupture
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p
Spontaneous or traumatic rupture ofuterine wall
Causes Previous scar opens Trauma Prolonged or obstructed labor
Rare but accounts for 5%-15% maternal
deaths
50% of fetal deaths
Uterine Rupture
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Sudden abdominal painTearing
Active labor
Early signs of shock
Vaginal bleedingMay be hidden
Management of 3rd Trimester Bleeding
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Management of 3 Trimester Bleeding
Prevent shock
Do not examine patient vaginally
May increase bleeding and startlabor
Emergency careABCsLeft lateral recumbent positionCheck fundal height
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Post-termPost-termPregnancyPregnancy
www.freelivedoctor.com
DefinitionDefinition
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DefinitionDefinition A pregnancy that persists for 42 weeks or
more from the onset of the last menstrualperiod. Sometimes called postmaturity orpostdate.
Incidence:
5-10%. It is more common in
primigravidae.
EtiologyEtiology
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EtiologyEtiology
Unknown, but hereditary, hormonaland non-engagement of the
presenting part are suspected factors.
Risk of Post-termRisk of Post-term
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Risk of Post termRisk of Post termA. Placental insufficiency: which may lead to
fetal hypoxia or even death.
B. Oligohydramnios: with its sequelparticularly cord compression during labor.
C. Obstructed labor: due to;
* oversized baby,
* no molding of the skull due to more
calcification.
D. Increased incidence of operative delivery.
DiagnosisDiagnosis Antenatal
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> History: calculation of gestational age.
> Examination: larger baby size.
> X-ray: large ossification center in the upper endof the tibia.
> Ultrasonography: can detect, Biparietal diameter more than 9.6 cm.
Increased foetal weight.
Oligohydramnios. Increased placental calcification.
>Tests for placental function.
DiagnosisDiagnosis
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Postnatala. Baby length: more than 54 cm.
b. Baby weight: more than 4.5 kg.
c. Skull: well ossified with smallerfontanels.
d. Finger nails: project beyond finger
tips.
ManagementManagement
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ManagementManagement
Induction of labor if the condition isfavorable for vaginal delivery using:
> amniotomy oxytocin, or
> prostaglandins oxytocin.
Caesarean section: if conditions are not
favorable for vaginal delivery, or ifinduction of labor failed.
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Intrauterine Fetal Demise
Intrauterine Fetal DemiseIntrauterine Fetal Demise
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A stillbirth occurs when a fetus has died in theuterus. The Australian definition specifies thatfetal death is termed a stillbirth after 20weeks gestation or the fetus weighs more than
400 grams (14 oz).
Once the fetus has died the mother still hascontractions and remains undelivered.
The term is often used in distinction to live birthor miscarriage. Most stillbirths occur in full termpregnancies.
Intrauterine FetalIntrauterine FetalDemiseDemise
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Demisee se
Risk factors:Alcohol abuse, drug use and smoking
due to inadequate prenatal care
unmanaged diabetes or high blood pressureWomen over 35 are more likely toexperience stillborn births
Maternal Obesity; Obesity raises stillbirthrisks