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dr.Shaban 2
Dystocia
Dystocia is “Difficult Labor” prolonged or abnormal labor/FAILURE TO PROGRESS IN LABOUR
It primarily results from one of four problems
Powers-abnormal uterine activity, ineffective contractions
Passageway- abnormal pelvic shape
Passenger-abnormal fetal size or presentation
Psyche-inadequate support, maternal stress & anxiety
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CEPHALOPELVIC DISPROPORTION (CPD)
A contracted or narrow diameter in birth passage especially if fetus is larger than the maternal pelvic diameters.
Implications: Maternal: prolonged labor, arrest of descent, uterine rupture, forceps-assisted birth with trauma
Implications: Fetal: cord prolapse, excessive molding of head, birth trauma to skull and CNS
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Nursing diagnoses r/t dysfunctional labor
Anxiety r/t slow progress of labor
Fatigue r/t the length of labor
Ineffective individual coping r/t inability to relax
Fluid volume deficit r/t lack of fluid intake
Risk for Infection r/t prolonged labor
Sleep pattern disturbance r/t maternal exhaustion and inability to relax
Knowledge deficit r/t potential fetal distress and fetal sepsis
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Management of Labor Dystocia
Augmentation of labor-use of drugs to enhance labor that has already begun
Amniotomy
Oxytocin Augmentation
Assisted and Operative Delivery
Vacuum - Assisted Delivery
Forceps Delivery
Cesarean Birth
Oxytocin induction & augmentation
Prior to administration of oxytocin a full assessment is preformed to determine cervical status, FHR, fetal presentation and station. The woman is placed on continous EFM
Oxytocin is administer IV through a controlled infusion pump and diluted in an intravenous solution
Vital signs are recorded frequently
Urinary out put is recorded as urine out put can decrease and water can be retained (maternal water intoxication)
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Side effects of oxytocin administration
Water intoxication- headache, nausea & vomiting, decreased urinary output, hypertension, tachycardia and cardiac arrhythmias
Hyperstimulation of the uterus
Uterine rupture
A rapid labor with potential uterine or cervical lacerations
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Nursing interventions when administering oxytocin
Observe for signs of water intoxication Changes in FHR-non reassuring FHR Contractions lasting longer than 90 seconds
with frequency of 1 minute Assess cervical dilation and progression of
labor If non reassuring FHR occurs or
hyperstimulation of the uterus occurs the infusion is stopped immediately and MD informed
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Contraindications for the induction of labor
Previous classic uterine incision
Cephalopelvic disproportion
Placentia previa
Active genital herpes
Preterm fetus
Fetal malposition-breech
Multiple gestations
Nonreassuring fetal status
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Case 1
You are working at the ED. A G9P2 patient presents to the department. Her water broke 1 hour ago, she is having frequent contractions and she feels the head coming out.
A delivery tray is available and the patient is in lithotomy position. She is pushing with each contraction and the baby’s head starts to come out.
However, with each push, the baby’s head comes out and then retracts back in towards the perineum. You quickly recognize this as the sign of shoulder dystocia. dr.Shaban 10
Shoulder Dystocia
be defined by a prolonged head-to-body delivery time (> 60 s) due to impaction of the fetal shoulders within the maternal pelvis
Risk factors: macrosomia, post-term, maternal obesity
Maternal morbidity: 4th degree perineal, cervical & vaginal lacerations, bladder injury, postpartum hemorrhage, endometritis
Fetal morbidity: brachial plexus injury, clavicular fracture, facial nerve paralysis, asphyxia, CNS injury, death
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Shoulder Dystocia-Management
Obstetrical Maneuvers
Rotation and Delivery of Posterior Shoulder
Maternal Position Change
Issue of Fundal Pressure
Episiotomy dr.Shaban 13
Case 2
You are working in a small ED and a 35 week G4P3 presents with ROM and contractions. She is quite distressed and thinks the baby is coming out. You perform a pelvic examination and next to the head you feel a pulsate cord…
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Prolapse of the umbilical cord
When the umbilical cord precedes the fetal presenting part it is said to be prolapsed, this can interfere with fetal circulation
Factors that contribute to prolapsed cord are
Rupture of membranes before head is engaged
Small fetus
Breech presentations and transverse lie
Hydramnios
Unusually long cord
Multifetal pregnancy
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Nursing actions to relieve prolapsed cord
Place woman’s hips higher than her head- knee-chest position, trendelenburg’s position, or side lying with hips elevated on a pillow
With a sterile glove push fetal presenting part away from cord
Give oxygen at 8 to 10 L/Min
Monitor FHR
Prepare for rapid vaginal or caesarian birth
If cord protrudes apply sterile saline soaked towels to prevent drying of the cord and maintain blood flow until infant is delivered dr.Shaban 16
FETAL DISTRESS
Common causes: cord compression, uteroplacental insufficiency, placental abnormalities, meconium-stained amniotic fluid
Correct maternal hypotension and enhance uteroplacental blood flow
Change position that improves FHR,
Increase rate of IV
O2 via face mask
Decrease uterine activity: adm tocolytic
Perform vaginal exam (prolapsed cord?) dr.Shaban 18
Indications for operative vaginal delivery
Fetal Distress An irregular fetal heart beat Bradycardia, under 100 beats per minute,
between uterine contractions A rapid fetal heart - more than 160 beats per
minute The passage of Meconium in cephalic
presentations Maternal Conditions
Maternal distress or exhaustion: This is shown by dehydration, pulse above 100 and temperature.
Maternal disease: When the mother has cardiac disease, toxemia, forceps & vacuum can be used to shorten the second stage. dr.Shaban 19
Assisted and Operative Delivery- Vacuum
Mechanism: Suction and Traction used to assist delivery of presenting part.
Indication: Most commonly related to prolonged 2nd Stage of Labor.
Contraindications: Cephalopelvic Disproportion (CPD); Most malpresentations and malpositions; extreme prematurity.
Nursing Responsibility: FHR checks q 5 minutes; Hand held suction pump. Pressure release between UC’s; Assess neonatal head for Cephalohematoma after delivery.
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Assisted and Operative Delivery- Forceps Delivery
Mechanism: Traction and rotation of fetal presenting part with curved metal tongs.
Indication: Prolonged 2nd stage (> 3 hrs); maternal exhaustion;
Contraindications: Cephalopelvic Disproportion (CPD); Most malpresentations and malpositions.
Disadvantages: Maternal and fetal trauma (Caphalohematoma;Transient facial paralysis)
Nursing Responsibility: FHR checks q 5 minutes; obtain forceps; assess neonate and mother for trauma.
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Cesarean Birth Definition
a surgical incision made into the abdomen and uterus to deliver the fetus after 32 WK gestational age. It is called hysterotomy, if removal is done before 32 weeks of pregnancy
Types of Cesarean (Uterine) Incisions -Lower Uterine Segment (Low Transverse) -Classical (Vertical Midline)
Only L. Uterine Segment Cesareans allow a trial of labor with the next pregnancy.
Classical is used for emergency Cesareans or for some mal presentations.
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Skin Incision
Transverse (Pfannenstiel)-lower uterine segment
Adv: below pubic hair line, less bleeding, better healing,cosmatic
Disadv: difficult to extend if needed, requires more time, if adipose fold difficult to keep clean and dry
Vertical-between naval and symphysis
Adv: quicker, more room
Disadv: scar obvious, longer dr.Shaban 27
INDICATIONS FOR ELECTIVE CS
Known CPD
Fetal macrosomia > 4500 gm
Placenta previa
HIV
Active herpes
Repeat CS
Previous uterine surgery eg. Hystrotomy, myomectomy
Severe IUGR
Breech
Multiple pregnancy
Transverse lie
Ca of the Cx/ obstructing the birth canal
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INDICATIONS FOR EMERGRENCY CS
Severe PET,
Abruptio placntae, APH
Fetal distress
Failure to progress in the first stage of labour
Cord prolapse
Obstructed labour
Failed induction; failed vacuum or forcepes
Malpresentation brow, face, shoulder & compound presentations, breech
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COMPLICATIONS- Mother
INTRAOPERATIVE
Bleeding & the need for bld transfusion
Hysterectomy, Fetal injury
Complications of anesthesia
Damage to the bladder, ureter, colon , retained placental
POSTOPERATIVE
Gaseous distension, Paralytic ileus
Wound dehiscence & infection
Infections UTI, pulmonary
DVT & pulmonary embolism, Death
Longer hospital stay
Risk for maternal/infant attachment dr.Shaban 31
COMPLICATIONS-the baby
Premature birth. If the due date was not accurately calculated, the baby could be delivered too early.
Breathing problems. Babies born by cesarean are more likely to develop breathing problems such as transient tachypnea (abnormally fast breathing during the first few days after birth).
Low Apgar scores. dr.Shaban 32
Nursing care in the preoperative period
NP0
IV fluids
Insertion of urinary catheter
Medication may be given IV to prevent stomach irritation or aspiration
Consent is obtained
Pubic shave now not needed
Patient teaching and explanations of events
Assessment of FHR, maternal vital signs dr.Shaban 33
Nursing care intra-operative period
Skin preparations
Draping
COUNTS
Sterile field maintenance
Step 14: Uterus is closed in 2 layers
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Postoperative care
Monitor vital signs every 15 minutes for first hour, then every 30 mins in second hour then hourly until transferred to postpartum unit
Administer oxygen as ordered Assess fundus for firmness, height, location, massage
fundus if boggy Assess vaginal bleeding for color amount and
consistency Assess abdominal dressing for bleeding Assess urine output Change woman’s position Allow the mother to breast feed as soon as she wishes
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Postoperative care-Cont.
Women should be offered Pethidine (100mg im). Avoid over
sedation as this will limit mobility
If the woman is receiving IV fluids, they should be continued until she is taking liquids well. A liquid diet if bowel sounds are heard
Removal of the urinary bladder catheter should be carried out once a woman is mobile
Ambulation enhances circulation, encourages deep breathing and stimulates return of normal gastrointestinal function. Encourage foot and leg exercises and mobilize as soon as possible, usually within 24 hours
If the dressing comes loose, reinforce with more tape rather than removing the dressing. This will help maintain the sterility of the dressing and reduce the risk of wound infection .1st dressing changed by doctors .
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