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COMPLICATIONS WITH THE PASSAGE
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CEPHALOPELVIC DISPROPORTION
- A narrowing, or contractions, of the birth canal, whichcan occur at the inlets, midpelvis, or outlet, causes adisproportion between the size of the fetal head andthe pelvic diameters, or cephalopelvic disproportion(CPD). CPD results in failure of labor to progress
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PRIMARY PROBLEMS
Malpositioning can occur because the fetuss
head isnt engaged in the pelvis.
Malpositioning can lead to further
complications. For example, if membranes
rupture, the risk for cord prolapse increases
significantly.
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Abnormal poritions of the fetus canal so cause
CPD.
Fetal anomalies such as hydrocephalus,
hydrops fetalis and tumors of the fetal head
can also result in CPD.
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DETECTION
A previous vaginal birth without any problemis substantial proof that the birth canal isconsidered adequate.
Pelvic measurement should be taken andrecorded before week24.
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MANAGEMENT
A trial labor may be allowed to continue of descent of thepresenting part and dilatationof the cervix are occurring.
The following nursing measures areimportant in trial labor:
Monitor fetal heart sounds anduterine contractions continuously.
Make sure that the womans urinarybladder is kept empty to allowthefetal head to use all space, makingdelivery possible.
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CEPHALOPELVIC DISPROPORTION
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PROBLEMS WITH POWERS
Hypotonic Uterus
- contraction is weak; dilatation and effacement doesnot progress.
-oxytocin stimulation will be beneficial.
-occur during the active phase of labor
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Induction or Stimulation of Labor
Elective Induction:
1. Pharmacologic means:
- Vaginal insertion of Prostaglandin E2, cervix softens andeffaces
- 8-12hrs after prostaglandin E2, oxytocin infusion
2. Mechanical means:
- amniotomy
-laminaria insertion
-nipple stimulation
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Augmentation of Labor:
-assisting client when labor process is notprogressing normally ( prolonged labor) by
pharmacologic or mechanical means
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Nursing Care of Clients During Induction of Labor:
Assessment
-Obstetric history- Maternal status:
- Uterine contractions
-Status of cervix, membranes
-ultrasound findings- Level of anxiety
- Fetal status:
- Gestational age- (-) CPD
- fetal monitor results
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Nursing Diagnoses:
1. Anxiety r/t uncertainty of labor and birth process
2. Risk for infection r/t ruptured membranes
3. Pain r/t use of oxytocics
4. Risk for trauma r/t possibility of sustainedcontractions from oxytocin or fetal cord prolapsefollowing amniotomy
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- D/C pitocindrip if:
sustained uterine contractions occur
fetal accelerations
decelerations persist urinary flow decreases to 30 ml/hr
signs of abruptio placenta appear
5. Monitor effect of prostaglandin6. Assist with amniotomy
maintain asepsis
monitor FHR immediately after rupture
Note time, color, amount of AF
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Hypertonic Uterus - contractions are painfully strong andfrequent but ineffective in producing effacement anddilatation.
-Reposition patient and administer analgesic.
-Tocolytic drugs (ritodrine) maybe effective.
-occur in the latent phase of labor.
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Pelvic Dystocia - abnormalities in any of the 3planes of the pelvis, inlet contraction, midplaneand outlet contraction.
-Contraction is low
-Cervical dilatation and effacement does notprogress
-Fetus fails to descent in the pelvic planes.
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ABNORMAL PROGRESS IN LABOR
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Labor Curves
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PATHOLOGIC RETRACTION RING
PROLONGED LABOR
PELVIC DYSTOCIA
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PATHOLOGIC RETRACTION RING
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CESAREAN DELIVERY
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CS delivery Indications:
1.CPD2.malposition
3.Malpresentation
4previous CS
5.complete or partial placenta previa
6.abruptio placenta
7.prolapsed umbilical cord8.fetal distress
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Obstetric Intervention
Types:
1. Low Segment
incision done on lower uterine segment
blood loss is minimal
possibility of later uterine rupture is lessened
2.Classic
incision is made on the wall of the body of the uterus
done for anterior placenta previa done for transverse lie
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PFANNENSTIEL ( BIKINI) INCISION
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PFANNENSTIEL
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VERTICAL ABDOMINAL INCISION
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Indications of Cesarean Section
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Obstetric Interventions:
Nursing Care:a. monitor vital signs closely
b. check dressing site
c. inspect perineal padd. check uterine fundus for firmness
e. breathing exercises
f. out of bed 1stpost-op day
g. have the woman hold the baby ASAP
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Other Complications:
A. PREMATURE LABOR & BIRTH ContributingFactors:
a. multiple gestation
b. Polyhydramnios
c. PROM
d. incompetent cervix
E .placenta previa / abruptio placenta
f. previous preterm laborg. infection
Management :
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Management :
1. Prevention of Premature Delivery
- if woman is currently in preterm labor, she is admitted to the hospital
Bedrest monitoring of contractions
IE
Tocolytic drugs ( Ritodrine, Terbutaline SO4)
Patient Teaching:
- teach woman symptoms of preterm labor
uterine contractions irregular pattern for more than 1 hour while at rest
intermittent or constant uterine cramps
low, dull backache & abdominal cramping
rupture of membrane
f l h b h l
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Nursing Care of Clients with Preterm Labor with TocolyticTherapy:
A. Assessment
1. Number of weeks of gestation2. Presence of live and viable fetus
3. Presence of labor:
2 contractions lasting 30 seconds in a 15 minute period
cervical dilatation less than 4 cms
effacement of 50% or less
4. No signs of hemorrhage or infection
5. Presence of severe PIH
6. Prolonged rupture of membranes7. Emotional impact on mother
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Analysis/Nursing Diagnoses:
1. Anxiety r/t uncertainty of labor and birth process
2. Ineffective family coping r/t need for specialized care andcontinued hospitalization of the newborn
3. Fear r/t acute status of baby and potential for death
4. Knowledge deficit r/t cause and treatment for preterm labor
5. Altered parenting r/t the physical condition of the baby
6. Situational low self -esteem r/t failure to carry pregnancy to fullterm
7. Risk of trauma r/t use of medications
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Interventions:
1. Monitor VS, FHR, contractions and progression of labor
2. Maintain bed rest
3. Inform client about the medication; obtain consent
4. Provide emotional support; reduce anxiety and prepare for possibleloss of baby
5. Provide special care related to the administration of tocolytic drugs
6. Prepare for use of glucocorticoid therapy for the fetus
7. Prepare for premature birth if labor continues
8. Provide home instructions for halting preterm labor
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Evaluation/Outcome:
1. Labor ceases
2. FHT satisfactory
3. No adverse effects from tocolytic drugs
4. Anxiety decreases
5.Client and partner able to state recurring signs
of preterm labor
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Other Complications:
PRECIPITATE DELIVERY - characterized by very strong contractions &delivery that occurs less than 3 hours of labor
Predisposing Factors:
multiparity
history of rapid labor premature or small fetus
large bony pelvis Risks:
perineal lacerations
hemorrhage
cerebral trauma
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Management:
fetal monitoring- fht..
analgesia - nubain (nalbuphine); demerol
assess for birth injury
assess for cervical, vaginal & perineallacerations
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Nursing Care of Clients During Precipitate Labor:
A. Assessment
1. Rapid cervical dilatation
2. Accelerated fetal descent
3. History of rapid labor
4. Frequent uterine contractions with decreased relaxation
B. Analysis/Nursing Diagnoses
1. Risk for maternal injury r/t rapid expulsion of fetus resultingin lacerations and hemorrhage
2. Risk for fetal trauma r/t cranial battering during rapid birth
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Planning/Implementation:
1. Remain with mother and monitor closely
2. Keep emergency birth pack at bedside
3. Keep mother and partner informed throughout process oflabor and birth
Evaluation/Outcomes:
1. Mother is safe throughout labor and birth*babys are nose breathers
2.Neonate remains injury free during birth
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UTERINE INVERSION
*baby out. Placenta next.. Delivered w/in 30mins.
Check for placental separation
*gushing of blood
*involution of uterus
*rising of fundus*lenghtening of the cord
*BRANTANDREWS MANUEVER-movement: up-down, right-left placenta
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UTERINE INVERSION CORRECTION
UTERINE PROLAPSE/inversion
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UTERINE PROLAPSE/inversion
- can happen to old women; multigravida.. ; who didnt give birth
& h-mole
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UTERINE RUPTURE
*prolonged labor due to cephalopelvic
disproportion
*previous CS
*primigravida with prolonged cpd
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PLACENTAL PROBLEMS
PLACENTA PREVIA
ABRUPTIO PLACENTA
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Abnormally Adherent Placenta:
Accreta - attachment of the placental villi to themyometrium.
Increta - invasion of the placental villi into themyometrium.
Percreta -penetration of the placental villi through themyometrium to the serosa
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PLACENTA ACCRETA
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1.First Trimester
- ambivalence; focuses more on self
- fear
-possible decrease in sex drive
TASK:
Accepting the pregnancy, I am pregnant
2.Second Trimester
- increased awareness and interest in fetus
-acceptance of reality of pregnancy
- feeling of well-being
-preoccupation with self
TASK:Accepting the baby, A baby is growing inside
me
3. Third Trimester
f l b d d l
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- anticipation of labor and delivery
- fears ( impending labor ) and fantasies
( motherhood) about pregnancy
- heightened introversion- view infant as reality vs fantasy
- spurt of energy during the last month
TASK:
Preparing for parenthood, I am a mother COUVADE SYNDROME - group of physiological & behavioral
manifestation experienced by the husban-
- are often the results of stress, anxiety & empathy for the pregnantwomen
Onset:3-5 days after birth
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Onset:3 5 days after birth
Symptoms: sadness, fears
Incidence:75% of all births
Etiology :probable hormonal changes, life
changesTherapy :support, empathy
Nursing Role: offer compassion&understanding
*taking in centered on mothers feelings
*taking hold -return demo
*letting go: holding the baby
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Onset: 1-6 months after birth
Symptoms: anxiety , feeling of loss,
sadness
Incidence: 10% of all births
Etiology : history of poor parental
relationship ,hormonal response
Therapy : counseling
Nursing Role: refer for counseling
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Onset: within 1st month after birth
Symptoms: delusions, hallucinations
Incidence: 2% of all birth
Etiology : possible activation
of previous mental illness, hormonal
changes
Therapy : psychotherapy , drug
therapy
Nursing Role: refer for
counseling, safeguard mother
from injury to self or newborn
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HIGH RISK POSTPARTAL CLIENTS:
BLEEDING
INFECTION
THROMBOEMBOLISM
PSYCHIATRIC DISORDERS
Postpartum Complications : Subinvolution
Description
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Description
- Incomplete involution or failure of uterus to return to its norma lsize andcondition
Assessment : Pelvic pain or heaviness
Backache
Uterus is larger and softer than expected
Prolonged lochial discharge
Irregular or excessive uterine bleeding
Interventions:
Monitor fundal height and lochia
Prepare to administer methylergonovine maleate (Methergine) asprescribed
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Postpartum
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Postpartum
Complications:Hemorrhage
Description - Blood loss exceeding 500 ml. after vaginal childbirth or1000 ml. after cesarean birth
Assessment :
Early
Occurs during 24 hours after delivery Caused by uterine atony or laceration or inversion of uterus
Late
Occurs after the 24 hours following delivery
Caused by retained fragments of placenta
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Signs of Uterine Atony :
Uterine fundus is difficult to locate
Soft or boggy fundus
Uterus becomes firm when massaged but loses tone when massage
is stopped Uterine fundus located above expected level
Excessive lochia, especially if it is bright red
Expulsion of excessive number of clots
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Interventions:
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Interventions:
Notify health-care provider if hemorrhage occurs
Assess client for uterine atony If uterus is not firmly contracted, massage fundus until it is firm
and to express clots that may have accumulated in the uterus (butdo not push on uterus)
Monitor client's vital signs and fundus every 5 to 15 minutes
Prepare to administer intravenous fluids, blood transfusions, andmedications such as oxytocin (Pitocin) to maintain firm contractionof uterus
If bleeding is due to a laceration, prepare client for repairof laceration
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Postpartum Complications: Infection
Description - Any infection of the reproductive organsthat occurs within 28 days of delivery or abortion
Assessment :
Chills and fever
Anorexia
Pelvic discomfort or pain
Vaginal discharge Increased white blood cell count
Interventions:
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Interventions:
Check client's vital signs and temperature every 2 to 4
hours Make mother as comfortable as possible; position her for
comfort and to promote vaginal drainage
Keep mother warmed if chilled
Isolate newborn from the mother only if mother isinfectious
Provide a high-calorie, high-protein diet and encouragefluids to 3000 to4000 ml/day if not contraindicated
Encourage frequent voiding and monitor client's intake and
output Monitor results of cultures if they were prescribed
Administer antibiotics according to organism, as prescribed
Postpartum
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Postpartum
Complications:Endometritis
Description : Infection of uterine lining after delivery; caused by bacteria
that invade uterus at site of attachment of placenta
Infection may spread, involving entire endometrium andcausing peritonitis, paralytic ileus, or pelvic abscess
Assessment :
Chills and fever
Uterine tenderness and enlargement
Foul odor or purulent lochia; may increase or decrease involume
Malaise, fatigue, tachycardia
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I nterventions:
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Monitor client's vital signs
Obtain cultures of blood and lochia Assist client into Fowler's position to facilitate
drainage of lochia
Administer antibiotics and pain medication as
prescribed Instruct client in proper handwashing techniques
Initiate wound(contact) precautions as necessary
Breastfeeding may be restricted during infectiousperiod; if woman is breastfeeding, she may needto pump her breasts to establish and maintainlactation
Postpartum Complications:
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Postpartum Complications:
Thrombophlebitis
Description: A condition in which a clot forms in a vessel wall as a
result of inflammation of the wall
Partial obstruction of vessel may occur
Increased levels of clotting factors in postpartumperiod place client at risk
Assessment :
Heat, tenderness, and pain in affected leg Swelling of affected leg
Homans' sign
Chills and fever
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Swelling/Homans sign
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- pain is felt when the foot is dorsiflexed on the affected area.
Do not massage