Dystocia 2003 Comp

8/8/2019 Dystocia 2003 Comp

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PREPARED BY;

MARJORIE GALICIA ROMANO

Clinical Instructor


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PROBLEMS WITH THE PASSANGER

A. Fetal malposition: the ideal fetal position is flexed

with occiput in the right or left anterior quadrant of thematernal pelvis

1. Types of malpositions

a. Occiput posterior (OP) position

1) Right or left OP position occurs in about 25% ofall term pregnancies but usually rotates toocciput anterior (OA) as labor progresses

2) Failure to rotate is termed persistent occiputposterior

3) Maternal risk include prolonged labor, potential foroperative delivery, extension of the episiotomy, 3rd-

or 4th- degree of laceration of the perineum


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4) Maternal syptoms include intense back pain inlabor, dysfunctional labor pattern, prolonged

active phase, secondary arrest of dilation, and/orarrest of descent

Possible Problem

yProlonged active phaseyArrested descent

Risk Factors

yAndroid pelvis

yAntrhopid pelvis

yContracted pelvis


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b. Occiput tranverse (OT) position

1) Incomplete rotation of OP position to OA

results in the fetal head being in a horizontal ortranverse position (OT)

2) Persistent occiput tranverse position occurs as

a result of ineffective contractions or a flattenedbony pelvis

3) In the absence of abnormal pelvic structure,vaginal delivery can be accomplished bystimulating contractions with oxytocin (Pitocin)and application of forceps for delivery


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2. Nursing care

a. Encourage the mother to lie on her side opposite from thefetal back, which may help with rotation

b. Knee-chest position may facilitate rotation

c. Pelvic rocking may help with rotation

d. Apply sacral counter-pressure with heel of the hand to

relieve back paine. Continue support and ecouragement

1) Keep client and family informed of progress

2) Encourage relaxation with contractions

3) Praise clients efforts to maintain controlf. Anticipate forceps/manual rotation and forceps- assistedbirth


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MEDICAL MANAGEMENTa. Forceps: metal instruments applied to the fetal head to

facilitate delivery1) Provides traction or means of rotating the fetalhead

2) Risk are fetal ecchymosis or edema of the face,

transient facial paralysis, maternallacerations, or episiotomy extensions

b. Vacuum extraction: a suction cup applied to the fetal headto facilitate delivery

1) Provides traction to shorten the second stage oflabor

2) Risk are newborn cephalhematoma, retinalhemorrhage, and intracranial hemorrhage


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FETAL MALPRESENTATION

1. Vertex malpresentations are caused by failure of the fetus to

assume a flexed attitudea. Brow presentation

1) Fetal forehead is the presenting part

2) 50% convert to vertex or face presentation

b. Face presentation1) Increased risk of prolonged labor and operative

delivery

2) Anticipate vaginal delivery if pelvis is adequate

and the chin (mentum) is in the anterior

position

3) Anticipate cesarean delivery if mentum is

posterior or signs of fetal distress occur


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4) Fetal monitor electrode should not be placed

on the presenting part (infants face); requiresexternal fetal heart rate monitoring.

5) Edema and bruising of the face, eyes, and lips

are common occurrences clients should beprepared for this possibility before seeing the

infant for the first time


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Caput succedaneum


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A--Complete flexion. B-- Moderate flexion. C--Poor flexion. D--Hyperextension


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TYPES OF ATTITUDE


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y (a) Complete flexion. This is normal attitude in cephalicpresentation. With cephalic, there is complete flexion atthe head when the fetus "chin is on his chest." This

allows the smallest cephalic diameter to enter the pelvis,which gives the fewest mechanical problems withdescent and delivery.

y (b) Moderate flexion or military attitude. In cephalicpresentation, the fetus head is only partially flexed ornot flexed. It gives the appearance of a military person atattention. A larger diameter of the head would be

coming through the passageway.


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y (c) Poor flexion or marked extension. In reference to thefetus head, it is extended or bent backwards. This would

be called a brow presentation. It is difficult to deliverbecause the widest diameter of the head enters the pelvisfirst. This type of cephalic presentation may require aC/Section if the attitude cannot be changed.

y (d) Hyperextended. In reference to the cephalic position,the fetus head is extended all the way back. This allows aface or chin to present first in the pelvis. If there isadequate room in the pelvis, the fetus may be delivered

vaginally.


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Sincipital presentation (Military Attitude)

1) Larger diameter of the fetal head is presented

2) Labor progress is slowed with slower descent of the fetalhead

Breech Presentation

There are three types of breech presentation1. Complete breech: sacrum is the presenting part, knees

flexed

2. Frank breech: sacrum is the presenting part, legs are

extended3. Incomplete: (footling) one or both feet are presenting,

increasing the risk of umbilical cord prolapse


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What causes a breech presentation?

The causes of breech presentations are not fullyknown. However, a breech birth is morecommon :

y In subsequent pregnancies

y In pregnancies of multiplesyWhen there is history of premature delivery

yWhen the uterus has too much or too little amnioticfluid

y In an abnormal shaped uterus or a uterus withabnormal growths, such as fibroids.

y For women with placenta previa


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Maternal Risk

1) Prolonged labor due to decreasepressure exerted by breech on thecervix

2) Cesarean or forceps delivery

3) Trauma to birth canal during deliveryfrom manipulation and forceps to free

fetal head4) Intra partum or postpartumhemorrhage


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Delivery of Breech Presentation by Forceps


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Vaginal delivery versus cesarean for breech

birth?

Most health care providers do not believe a vaginal deliveryis possible for a breech birth, although some will wait tomake that decision until a woman is in labor. However,

the following are often necessary in order for a vaginalbirth to be attempted:

y The baby is full-term and in the frank breechpresentation

y The baby does not show signs of distress while its heartrate is closely monitored

y The process of labor is smooth and steady; the cervix iswidening and the baby is moving down


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y The health care provider estimates that the baby is not

too big or the mother's pelvis too narrow for the babyto pass safely through the birth canal

y Anesthesia is available and a cesarean delivery can beperformed on short notice


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Piper forceps - applied to the after comingfetal head


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EXTERNAL CEPHALIC VERSIONManipulation of the fetus through the abdominal wall from

a breech or shoulder presentation to a vertexpresentation:

y May be done as early as 34 to 35 wks or usual time is 37 to38 wks

y

Client is placed on external fetal monitor and possiblyUTZ are recorded continuously

y IV fluids are started

y Terbutaline is administered via piggybacked IV line torelax the uterine muscle

y FHR is closely monitored during version attempt

yVersion is discontinued if undue maternal or fetal distressis noted


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VERSION

y

The breech and vertex of the fetus are graspedtransabdominally by the examiners hands onthe womans abdomen.

yGentle pressure is then exerted to rotate thefetus in a forward direction to a cephalic lie.

yThe use of external version can decrease thenumber of cesarean section from breech

presentation.


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Contraindication

y Multiple gestation

y Severe oligohydramnios

y Contraindications to vaginal births - The mother hasa condition (such as a heart problem) that prevents

her from receiving certain tocolytic medicines toprevent uterine contractions.

y Cord coil

y Unexplained third trimester bleeding (placenta

previa )


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y The bag of waters (amniotic sac) has ruptured.

yA cesarean delivery is needed, such as when theplacenta partially or completely covers the cervix(placenta previa) or has separated from the wall ofthe uterus (placenta abruptio).

y Fetal monitoring shows that the fetus may not be

doing well.y The fetus has a hyperextended head. This means

that the neck is straight, rather than bending thehead forward with the chin tucked into the chest.

y The fetus is known or suspected to have a birthdefect.

y The mother's uterus does not have a normal shape.


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External cephalic version has an average success rateof 58%. Version is most likely to succeed when:

y The mother has already had at least one pregnancyand childbirth.

y The fetus, or a foot or leg, has not dropped down intothe pelvis (has not engaged).

y The fetus is surrounded by a normal amount ofamniotic fluid.

y The procedure is performed near term (34 or more

completed weeks of pregnancy), before labor starts.


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Version is least likely to succeed when:

y The fetus is engaged down in the mother's pelvis.

y The doctor cannot grasp the fetal head.

y The uterus is hard or tense to the touch.

yAbout 4% of fetuses return to a breech position after asuccessful version.

Compared to the first attempt, repeat version attemptsare less likely to be successful.


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Risksy With frequent monitoring, the risks of external cephalic version

to the mother and fetus are low.

y Potential risks of version, for which the fetus and mother areclosely monitored, include:

y Twisting or squeezing of the umbilical cord, reducing blood flowand oxygen to the fetus.

y The beginning of labor, which can be caused by rupture of theamniotic sac around the fetus (premature rupture of themembranes, or PROM).

y Placenta abruptio, rupture of the uterus, or damage to theumbilical cord. The potential exists for such complications, but

they are very rare.On the rare occasion that labor begins or the fetus or mother

develops a serious problem during version, an emergencycesarean section (C-section) may be done to deliver the fetus.


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Shoulder PresentationTranverse lie acromium process is the presenting part

a. Vaginal delivery is not considered possible in terminfant

b. CS is preferred method of delivery

Causes

y Prematurity

y Placenta Previa

yAbnormal uterus

y Contracted pelvis or relaxed abdominal wally Polyhydramnios


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Shoulder presentation


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SHOULDER PRESENTATION WITH PROLAPSED ARM


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FETAL DISTRESS

- Insufficient oxygen supply to meet the demands of the

fetus

Causes

a. Compression of the umbilical cord

b. Uteroplacental insufficiency caused by placentalabnormalities or maternal condition

Signs and Sypmtoms

a. Meconium-stained amniotic fluid (excludingbreech presentation


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b. Changes in fetal heart rate baseline

1) Tachycardia (above 160): early sign of distress

2) Bradycardia (below 110): late sign of distressc. Decreased or absence of variability of heart rate

1) Heart rate varies less than 2 to 5 beats per

minute causing a f lattened appearance to theheart rate

2) Indicates depression of the autonomic

nervous system that controls heart rate

3) Fetal sleep, sedation, and hypoxia may affect

variability


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Late deceleration

1. Fetal heart rate slows following the peak of a contractionand slowly returns to baseline rate during the restingphase

2. Indicates fetal response to hypoxia from uteroplacentalinsufficiency

3. Considered an omnious pattern regardless of the depthof the deceleration of the FHR and requires immediateintervention


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Nursing management

(uteroplacental insufficiency)

yReposition the mother on her left side

yAdminister oxygen via face-mask at 8-10

lpmyIncrease IV fluids

yDiscontinue oxytocin infusion, if labor is

being inducedyNotify the doctor


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Severe variable deceleration

1. Fetal heart rate repeatedly deceleratesbelow 90 beats/min. for over 60 secs.before returning to baseline

2.Indicates interference of fetal blood flowfrom cord compression

3. Leads to fetal hypoxia and low APGAR

scores unless steps are taken to correct it


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Nursing management

(cord compression)yReposition the mother on her side

y If not corrected, reposition to opposite side

y

Administer oxygen by face-mask at 8-10 lpmyTrendelenburg or knee-chest position, if not

corrected

y

Perform vaginal examination and applyupward digital pressure on the presenting partto relieve pressure on the cord.


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AMNIOINFUSION

Amniotic fluid may be replacedwith warmed saline through anintrauterine catheter when signs

of cord compression are presentduring labor after PROM.

Infusion is continued until signsof cord compression disappear.


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SEVERE VARIABLE DECELERATION


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The two most common applications of transcervical

amnioinfusion are treatment of severe variable

decelerations and dilution of thick meconium fluidduring labor.

The greatest attractions of amnioinfusion have been

that it is easy to perform, inexpensive and safe.

After an initial bolus of 250 mL, normal saline is

infused at a rate of 10 to 20 mL per hour.


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AMNIOINFUSION PROCEDURE


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TECHNIQUE

y Amnioinfusion can per performed via a transcervical or

transabdominal route. The transcervical route is preferredbecause it is does not require ultrasound guidance and easily

allows for repeated fluid instillation.

y Transcervical approach A lactated Ringers or normal saline

(without dextrose) solution is infused into the amniotic cavitythrough an intrauterine pressure catheter. Normal saline

solution may cause derangement of neonatal electrolytes, thus

lactated ringers is preferable. Most protocols call for a bolus

infusion of 250 to 1,000 mL of fluid at a rate of 10 to 15mL/minute, followed by a continuous infusion of 100 to 200

mL/hour via pump infusion or gravity. Alternatively, repeat

boluses may be administered, as needed.


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yThere is no evidence that the fluid needs to bewarmed above ambient room temperature

prior to administration. A blood warmer

should be used if warming to body

temperature is desired. In cases of prolongedamnioinfusion, sonographic assessment of the

amniotic fluid volume is suggested to avoid

iatrogenic polyhydramnios.


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INTRAUTERINE RESUCITATION

Administration of terbutaline(tocolytics), to stop uterinecontractions and provide an

opportunity for uteroplacentalcirculation to improve when

fetal distress is present duringthe first stage of labor.


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PREVENTION OF MECONIUM ASPIRATION

1. If meconium is present during labor (green-tinged amniotic fluid), steps to prevent

aspiration at the time of delivery should be

taken

2. The nasopharynx of the infant is suctioned prior

to delivery of the chest and abdomen

3. Visualization of the larynx and vocal cords with

deep suction is performed immediately after

delivery and before the first breath is taken


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PROLAPSED UMBILICAL CORD

yCause: fetus is not firmly engaged, allowing room

for the cord to move beyond (overt prolased) oralongside the presenting part (occult prolapse)

yContributing factors

a. rupture of membranes before engagement of thepresenting part

b. small fetus

c. Breech presentation

d. multifetal pregnancy

e. Tranverse lie


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Overt prolapse, which is the most common, refers to

protrusion of the cord in advance of the fetal

presenting part, often through the cervical os and intoor beyond the vagina. The fetal membranes are

invariably ruptured in these cases and the cord is

visible or palpable on examination.

Occult prolapse occurs when the cord descendsalongside, but not past, the presenting part. It can

occur with intact or ruptured membranes. The

diagnosis should be considered in the setting of a

sudden, prolonged fetal heart rate deceleration. Anoccult prolapse often cannot be diagnosed with

certainty, but is suggested by clinical features (eg, fetal

bradycardia) and findings at cesarean delivery.


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Managing UCP


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Managing UCP

Goal of care: actions to relieve pressure on the cord and

restore fetal oxygenation

a. Place the mothers hip higher than her head

y Knee-chest position

yTrendelenburg position

b. Perform sterile vaginal exam pushing fetal

presenting part upward with fingers to relieve

pressure on the cord

c. Administer oxygen by face mask at 8-10 lpm

d. Maintain continuous electronic fetal monitoring


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Managing UCP

e. Prepare for rapid delivery eithervaginally or cesarean section

f. If cord protrudes through the vagina,

determine that pulsation is present and

apply sterile saline soaked dressing toprevent drying


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Abnormal size or shape of pelvisContracted pelvic inlet: anterior-posterior diameter less than

11 cm; transverse dm less than 12 cm.1. Caused by rickets in early life or inherited small pelvis

2. Makes engagement difficult

3. Influences fetal position and presentation

4. Risk of UCP

Contracted mid-pelvic plane: interspinous dm less than 9.5 cm

1. Hampers internal rotation of the fetal head

2. Secondary arrest of dilation or arrest of fetal head occursContracted pelvic outlet: interschial tuberous diameter

less than 11 cm

TRIAL OF LABOR


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TRIAL OF LABOR

y The physician may allow labor to continue or

even stimulate labor with oxytocin when pelvicmeasurements are borderline to see if the fetal

head will descend making vaginal delivery

possible; if progressive changes in dilation andstation do not occur, a cesarean delivery is

performed

yUrge woman to void every 2 hours

yAssess UCP after membranes ruptured

yEmphasize advantage of vaginal delivery


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Cephalopelvic disproportion (CPD)

1. Fetal head is too large to pass through thebony pelvis

2. Signs & symptoms: fetal head does not

descend even though there are strongcontractions

3. Maternal risks include prolonged labor,

exhaustion, hemorrhage, and infection4. Fetal risks include hypoxia and birth trauma

5. Cesarean birth is necessary


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Fetal macrosomia

yNeonatal Risk (Vaginal delivery)

1. Cervical nerve palsy

2. Diaphragmatic nerve injury

3. Fracture clavicle

h ld


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Shoulder Dystocia

y An obstetric emergency resulting from

difficulty or inability to deliver the shoulders.

Shoulder is too broad to enter and be born

through the pelvic outlet.

yFetal macrosomia increases the risk ofshoulder dystocia. Occurs at the second stage

of labor.

yMaternal Risk:1. Lacerations and tears of birth canal (vaginal

& cervical tears)

2. Postpartum hemorrhage


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Shoulder Entrapment


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y Neonatal Risks

1. Hypoxia

2. Fractures of clavicle or brachial plexus3. Injury to neck and head

y Risk Factors

1. Obesity

2. Increased fundal height

3. History of macrosomia

4. Maternal diabetes or gestational diabetes

5. Prolonged second-stage labor/descent arrest6. Post date pregnancy

7. Multiparity


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McRoberts Maneuver


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Rescue Maneuvers

y It is very rare that the baby cannot be delivered

by the maneuvers discussed so far. If theshoulder dystocia persists, however, other rescue

maneuvers include:

y Zavanelli Maneuve

r

.The baby's head and body are

pushed back into the uterus and cesarean

delivery is performed. Although there are some

risks to the mother and baby with this

procedure, there are many reports of itsuccessfully relieving severe shoulder dystocia.

This maneuver would be considered heroic and is

not practiced routinely.y .


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Proctoepisiotomy.y

In this maneuver, the normal midlineepisiotomy is extended intentionally intothe rectum. Though this requires a

complex repair that can lead to futurerectal dysfunction, it can also serve towiden the birth canal posteriorly and

allow for disimpaction of the anteriorshoulder.


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y Corkscrew. The shoulders of the baby are twisted

around and pushed out of the anterior-posterior (frontto back) plane. This may allow the front shoulder tocome out from behind the pubic bone and bedelivered.

y Delive

r

y of the fur

ther

ar

m. The obstetricianreaches back into the birth canal alongside the baby tograsp the baby's further hand or forearm and pull itout by sweeping it across the baby's chest. Once thearm is out, the rest of the baby's body is usually

delivered easily. The upper bone of the baby's arm,called the humerus, may be broken during thismaneuver, but it heals up quite easily.


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Problems with Powers


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Problems with Powers

A. Induction of labor: pharmacologic

and nonpharmacologic measures toinitiate contractions and cervicalchange

y Labor is started artificially

1. Methods of induction

a. Cervical Ripening1)Prostaglandins (PGE2) gel

2)Laminaria (hydrophilic agent)

D U d f I d ti f L b


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Drugs Used for Induction of Labor

Drug Route/Action Side Effects & Potential

Complications

Prostaglandins(Cervidil;

Prepidil)

Intravaginally close tocervix;Causes softening &effacement or cervicalripening

Abdominal cramping, nausea,vomiting, diarrhea

Misoprostol(Cytotec)

Synthetic prostaglandinadministered orally orintravaginally to produce

contractions

Sudden onset of hypertoniccontractions & elevated restingtone of the uterus w/c may lead

to fetal distressOxytocin(Pitocin)

Synthetic oxytocinadministered IV in smallamts. & titrated toproduce contraction that

mimic normal labor

Uterine tetany & fetal distressare major concerns; can lead to

water intoxication,hyponatremia &

hypochloremia

Amniotomy


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Amniotomyy Artificial rupture of membranes (AROM)

1) Auscultate FHR prior to and immediately afterAROM to detect prolapse of the umbilical cord or fetaldistress

2) Take maternal temperature q 1 to 2 hrs followingAROM to detect signs of infection

y Misoprostol (Cytotec) administration

1) administered orally/vaginally at doses of 25 to 50

mg2) Continuous monitoring of the FHR, uterineactivity, & maternal v/s is essential

y Oxytocin administration


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y Oxytocin administration

1) Bishop score may be used to asses maternal

readiness for induction2) Prior to induction, begin external fetal monitoring

3) Assess & record maternal v/s, I&O, & contractionfrequency & intensity

4) Begin primary intravenous infusion

5) Mix oxytocin in 500 to 1000cc of IV balanced-saline fluids such as lactated Ringers & piggyback

into primary IV at a site as close to the client aspossible

6) Control & titrate the oxytocin solution using IVpump


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Precipitate labor & birth


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Precipitate labor & birth

y Rapid labor ( 3 hours) resulting in precipitous birth

y Maternal Risk

a. Cervical, vaginal, or rectal lacerations

b. Hemorrhage due to rapid passage through the birth

canalc. Injury at birth

y Interventionsa. Tocolytics

b. Do not leave the client; send someone or call for help

c. Don sterile gloves, if time allows

d. Instruct the client to pant or blow to decrease urge to push

d S t th i / t il t l i


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d. Support the perineum w/ sterile towel as crowningoccurs

e. Apply gentle pressure on the fetal head to preventrapid delivery

1) lacerations of perineum can occur

2) Subdural or dural tears may occur w/ sudden

expulsion of the infants head

f. After delivery of the head, suction the infantsmouth then nose with bulb syringe

g. Check around the infants neck for possible tightumbilical cord; if present, cord must be clamped &cut before delivery

h Place hands on each side of the infants head &


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h. Place hands on each side of the infant s head &instruct client to push

i. Gentle down ward pressure facilitates birth of theanterior shoulder

j. Gentle upward traction facilitates birth of theanterior shoulder

k. Support the infants body w/ a towel as it is expelledfrom the birth canal

l. suction & dry the infant

m. Place infant on mothers abdomen asapn. Clamp & cut U.C

o. Observe for placental separation

G tl ll th d hil i


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p. Gently pull the cord while massagingthe fundus to deliver the placenta

q. Continue to massage the fundus toprevent hemorrhage or put the infant tobreast

r. Inspect the perineum for lacerations ortears

Uterine prolapse


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Uterine prolapsey 1. Vigorous massage of the fundus and pulling on the

umbilical cord to speed placental separation may causeprolapse of the cervix and lower uterine segment through theintroitus.

y 2.Uterine inversion: turning inside out of the uterusy a. Complete inversion.

y 1.) Inverted uterus is visible outside the introitus.

y 2.) Life-threatening because of severe hemorrhage and

shock .y 3.) Uterus must be immediately replaced manually to

stop blood loss.

b. Partial inversion

) bl b b l d


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1.) Is not visible but can be palpated.

2.)Uterine fundus is partially inverted hampering contraction

and control of hemerrhage.Nursing Management:

-Maintain IV line-optimal flow to restore fluid vol.

-Anticipate blood transfusion

-O2 by facemask

-Asses v/s and hypovolemic shock

-Anticipate CPR

-Woman will be placed on gen. anesthesia, tocolytics given to relaxuterus

-Oxytocin is administered after manual replacement for uterus tocontract and remain in place

-Future pregnancy will be delivered via CS

-Antibiotic therapy endometrium was exposed

3.) Corrected by the physician using a bimanual technique

Uterine rupture: tearing open or


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Uterine rupture: tearing open or

separation of uterine wall

1.Rare but serious complication, occuring in 1 in 1,500 to2,000 births.

2.Most common causes

a. Separation of scar from previous classical cesarean

b. Uterine trauma

c. Intense uterine contractions

d. Overstimulation of labor with oxytocin

e. Difficult forceps-assisted birth

f. External cephalic or internal version

g. Prolonged labor

k f f


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3. Risk factors for uterine rupture

a. Multiparity

b. Overdistension of the uterus (multifetal pregnancy)c. Malpresentation

d. Previous uterine surgery

4. Types

a. Complete extends through the uterine wall into theperitoneal cavity

b. Incomplete extends into the peritoneum but not into theperitoneal cavity

1.) Partial separation of cesarean scar2.) May go unnoticed until repeat cesarean is performed

y Medical management depends on t pe of rupture


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y 5. Medical management depends on type of rupture

y a. Complete rupture requires management of shock,

replacement of blood, and hysterectomyy b. Incomplete rupture may require laparotomy, repair, and

blood transfusion

y 6. Nursing assessment: signs and symptoms may be silent

or dramatic.y a. Sudden, sharp, lower abdominal pain

y b. Tearing sensation

y c. Signs of shock

y

d. Cessation of contractionsy e. FHR ceases

y f. Blood loss is often concealed

y g. Fetal parts may be easily palpated through abdominal

wall

7 Priority nursing diagnosis; Risk for injury; Impaired gas


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7. Priority nursing diagnosis; Risk for injury; Impaired gasexchange; Deficient fluid volume

8. Planning and implementationa. Prevention is best

1.) Identify clients at risk

2.) Avoid hyperstimulation of the uterus during induction

Amniotic Fluid Embolism

- amniotic fluid is forced into an open maternal uterineblood sinus due to membrane defects or after partial

premature separation of the placenta- anaphylactoid response

- lung embolism previously thought

Risk factors:


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Risk factors:

-oxytocin administration

-abruptio placentae-hydramnios

S/Sx- in strong contraction of labor the woman sudden sits

up and grasps her chest because of sharp pain andinability to breath

- becomes pale then cyanotic

- admin oxygen by mask

- anticipate CPR death may occur


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Problems with the Psyche


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Problems with the Psyche

A. Factors influencing the psyche of the client inlabor

1. Fear and anxiety

2. Perception of the problem

3. Self-image4. Preparation for childbirth

5. Support systems

6. Coping ability

B. The effect of fear and anxiety on laborprogress


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1. Epinephrine secretion in response to stress

2. Vascular changes divert blood from the uterus to skeletal

muscles3. Decrease in oxygen and glucose supply with accumulationof lactic acid in uterine muscle

4. Higher perception of pain

5. Decrease in available energy supply to support effectivecontractions

6. Labor progress is slowed

C. Nursing assessment

1. Determine clients past experience with, preparation for, andexpectations of labor and birth

2. Determine clients current coping behaviors and theireffectiveness with the current situation


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E. Planning and implementation

1. Establish a trusting relationship with the client and

family2. Reamain at the bedside with the client and familyduring labor

3. Encourage relaxation

4. Keep the client and family informed about progressand procedures

5. Encourage positive coping behaviors and discouragenegative behaviors

6. Promote self-image by praising efforts


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Cesarean Section


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Cesarean SectionA. Delivery of the infant by an abdominal incision:

purpose is to facilitate delivery to preserve the health of themother and fetus

1. Number of cesarean births has increased dramaticallybeginning in the late 1970s and 1980s

2. National goal of Healthy People 2010 is to reduce theincidence from the current rate of 25% to 30% to 15% of alldeliveries

B. Major indications for cesarean delivery

1. Dystocia or CPD2. Fetal distress

3. Breech presentation

4. Previous cesarean birth


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E Surgical techniques


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E. Surgical techniques

1. Skin incisions

a. Verticalb. Pfannenstiels (transverse lower abdominal incision)

2. Uterine incisions

a. Classical: through the upper uterine segment

b. Low cervical transverse: lower uterine segmentc. Lower uterine segment vertical

F. Nursing assessment

1. Determine the reason for the cesarean delivery

2. Determine the clients understanding of the indication,procedure, and implications for recovery from abdominaldelivery

H. Planning and implementation

1 Discuss cesarean birth in childbirth preparation classes


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1. Discuss cesarean birth in childbirth preparation classes

a. Clients and families cope better if they have time to learn aboutcesarean birth

b. Emergency cesarean birth increases anxiety and alters the couplesexpectations about childbirth

2. Preoperative care

a. Assess NPO status (mother should have nothing by mouth, if possibleto prevent aspiration)

b. Explain procedure so that client and family will know what to expect

c. Obtain client signature on consent form

d. Perform abdominal prep

e. Insert Folley catheter to prevent bladder trauma during surgery

f. Start intravenous fluids using a large bore catheterg. Administer an antacid either IV or PO to decrease risk of lung damage

from aspirating acidic gastric contents during surgery

h. Administer antibiotics, as ordered

i. Assist with positioning and administration of regional anesthesia, if

used

3. Intraoperative carea Provide heated crib and supplies to receive the newborn


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a. Provide heated crib and supplies to receive the newborn

b. Provide immediate care to the newborn or assist nursery personnel asneeded

c. Provide assistance to surgical team and immediate care for the mother

4. Postoperative carea. Begin postanesthesia (recovery room) monitoring of vital signs, pulse

oximetry, and cardiac monitoring; monitor vital signs q 15 mins. for

first hour and until stableb. Assess fundus for firmness and location (if boggy, massage until

firm)

c. Assess vaginal bleeding

d. Assess abdominal dressinge. Assess catheter and urine output

f. Turn, cough, and deep breathe hourly

g Administer medications for pain as needed

Dystocia 2003 Comp

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