Objective 10 The student will discuss methods of fetal surveillance during labor

Two basic approaches to fetal monitoring are taken: Low technology and High technology Low Technology: uses intermittent auscultation (IA) of the fetal heart rate (FHR) and palpation of uterine activity. Most often used in home births and birthing centers. Uses either a nonelectronic fetoscope or Doppler ultrasound fetoscope. Fingertips palpate uterine activity High Technology: Uses electronic fetal monitoring (EFM) to monitor FHR. 85% of live births use EFM. Supplies more data about the fetus than IA and archives a permanent record on paper, computer media, or both. Continuous EFM shows how the fetus responds before, during, and after each contraction rather than occasional contractions. a) Identify the purposes of intrapartal fetal assessment The purpose of intrapartal fetal assessment is to monitor and identify signs associated with well-being and with compromise. At a minimum, intrapartum fetal assessment includes evaluation of the FHR and the mother's uterine contractions. b) Explain types of equipment used EFM equipment consists of the bedside monitor unit and sensors for FHR and uterine activity. Sensors for each function may be internal or external. Bedside Monitor Unitrecieves information about FHR and uterine activity from the sensors. It processes the info and provides output in the form of a numeric display and a printed strip.

CPaper StripFHR and uterine activity are printed on a paper strip having horizontal grid for the FHR and
another for the uterine activity. FHR is recorded on the upper strip and the uterine activity on the lower grid as bell shaped curves. Data Entry Devices and Computer Softwareused to archive fetal monitoring information plus other info relating to the care of mother and fetus. May extend beyond the intrapartum stay and be used for documentation in the postpartum and newborn periods. Remote Surveillancedisplay units at the nursing station or other locations to allow surveillance when the nurse is not at the bedside. They have settings for alert such as upper and lower limits for the FHR, decelerations and end of paper. Devices for External Fetal MonitoringBoth FHR and uterine activity can be monitored by external sensors, or transducers secured on the mothers abdomen by elastic straps, a tube of wide stockinette, or an adhesive ring. Less accurate than internal ones but are non-invasive. c) Describe types of periodic patterns seen via electronic fetal monitoring Accelerations are abrupt, temporary increase in the FHR that peaks at least 15bpm above the baseline and lasts at least 15 seconds. Accelerations usually occur with fetal movement. Decelerations are classified into three types based on their shape and relationship to uterine contractions. Early decelerationsnot associated with fetal compromise and require no intervention. They occur during contractions as the fetal head is pressed against the woman's pelvis or soft tissue such as the cervix.

Late decelerationsresults from a deficient exchange of oxygen and waste products in the placenta. This nonreassuring pattern suggests that the fetus has reduced reserve to tolerate the recurrent reductions in oxygen supply that occur with contractions. Variable decelerationsresult from conditions that reduce flow through the umbilical cord. They do not have uniform appearance of early or late decelerations. They fall and rise abruptly with the onset and relief of cord compression. Their shape, duration and degree of fall below baseline vary. d) Explain differences between reassuring and non-reassuring fetal heart rate patterns Reassuring FHR patterns: Accelerations are usually a reassuring sign reflecting a responsive, non acidotic fetus. Nonreassuring FHR patterns suggest that the fetus has reduced reserve to tolerate the recurrent reductions in oxygen supply that occur with the contractions causing hypoxia or acidosis. Can be cause by maternal hypotension or chronic conditions that impair placental exchange such as hypertension, diabetes. e) Analyze appropriate nursing actions when non-reassuring fetal heart rate patterns occur.
INTERVENTIONS:

Identify the cause of the nonreassuring patterns: Check the mothers vital signs can indentify hypertension or hypotension and fever. Some sedatives can alter variability in the well-oxygenated fetus. A vaginal exam may identify a prolapsed cord or compression causing bradycardia and decelerations or both. Internal monitoring is chosen for greater accuracy.(fetal scalp electrode) Increase placental perfusion: The woman is placed in a nonsupine position to eliminate aortacaval compression, which can reduce placental blood flow. Increase infusion of IV fluids such as LR solution to increase the maternal blood volume to better perfuse the placental if hypotension in the problem. Hypotonic uterine activity may compromise fetal reserves therefore, oxytocin is discontinued or slowed so uterine activity is not stimulated. Increase maternal blood oxygen saturation: Administer 100% oxygen through snug face mask to 8-10L/min Reduce cord compression: reposition the woman side to side or elevate her hips to shift the fetal presenting part toward her diaphragm. A hand and knee position may reduce compression on the cord. Amnioinfusion increases the fluid around the fetus and cushions the cord. LR solution or NS is infused into the uterus through an IUPC.

Objective 11 The student will evaluate intrapartal pain management a) Describe unique pain factors during labor

Involves two components: Physiological component including reception by sensory nerves and transmission to the CNS. Psychological component which involves recognizing the sensation, interpreting it as painful and reacting to the interpretation. Pain is subjective and personal. Childbirth pain is different from other pain in several aspects: 1) It is part of a normal process 2) Preparation time exists 3) It is self-limiting 4) Labor pain is not constant but intermittent 5) Labor ends with the birth of a baby. b) Describe factors that influence responses to pain

Physiological reponses: Four sources of labor pain exists in most labor. Tissue eschemiablood supply to the uterus decreases during contractions leading to tissue hypoxia and anerobic metabolism causing ischemic uterine pain. Cervical dilationdilation and stretching of cervix and lower uterus are a major source of pain. Pressure and pulling on pelvic structuressuch as ligaments, fallopian tubes, ovaries, bladder and peritoneum. The pain is a visceral pain; referred to her back and legs. svchological responses: Poorly relieved pain can lessen the pleasure of this extrodinary life event for both partners. The womans support partner may feel inadequate during birth and feel helpless and frustrated when her pain is unrelieved. Physical influences to pain: Intensity of laborshort intense labors are more severe in pain. Rapid labor may limit her options for pharmacologic pain relief as well Cervical readinessIf cervical changes are incomplete, the cerivix does not open as easily...more contractions are needed to achieve dilation and effacement resulting in longer labor and more fatigue. Fetal positionlabor is more likely to be longer and more painful when the fetus is in an unfavorable position. Characteristics of the pelvissize and shape influence the course and length of labor. Fatigue and hungerReduces ability to tolerate pain and to use coping skills she has learned. Extremely fatigued women have exaggerated responses to contractions and may be unable to respond to the sensations of labor such as the urge to push. Psychosocial factors: Cultureinfluences how she perceives, interprets, and responds to pain during childbirth.

Anxiety and fearhigh anxiety and fear maginify sensitivity to pain and impair a woman's ability to tolerate it.

Previous experiences with painfear and withdrawal are a woman's natural reactions to pain during labor. Learning about the normal sensations of labor including pain, helps a woman suppress her natural reactions of fear and withdrawal. Preparation for childbirthA woman should be prepared realistically including reasonable expectations about analgesia and anesthesia. Support systemAnxiety in others can be contagious, increasing the woman's anxiety. She may assume that is others are worried than something must be wrong. c) Analyze factors that affect the use of pharmacologic and non-pharmacologic pain management techniques during childbirth. Non-pharmacologic pain management: Methods usually used to compliment pharmacologic pain management although some may use them as their only pain management technique. They do not slow labor and have no side effects or risk of allergy. Non pharmacologic methods may be the only option for a woman who enter the hospital in advanced rapid labor....drugs may not have enough time to take effect. As a sole method of pain relief, women do not always achieve their desired level of pain control. Pharmocologic pain management: includes systemic drugs, regional pain management techniques and general anesthesia. Effects on the fetus may be direct (decreased FHR)or indirect (maternal hypotension and decreased blood flow to the placenta) Fetal hypoxia and acidosis may result. Regional analgesia can slow progress during the second stage of labor by impairing the woman's ability to push. Complications during pregnancy may limit the choices of analgesia or anesthesia. Interactions with other substances may limit choices of analgesia and anesthesia as well. d) Discuss use of sedatives, analgesics, regional and general anesthetics, antiemetics and opiod antagonists Opioid analgesics: during labor and postop pain. Cesarean birth. Administered IM, IV, or PCA postop. Epidural Opioids: mixed with local anesthesia for pain relief during labor. Postoperatively given as long lasting non sedative allowing mother and infant to interact. Intrathecal Opioid Analgesics: first stage labor without maternal sedation. Not adequate for late labor or birth. Local Infiltration Anesthesia: Numbs the perineum for episiotomy at vaginal birth. No relief of labor pain. Pudendal Block: numbs the lower vagina and perineum for vaginal birth. No relief of labor pain; done just before birth. Adequate anesthesia for forcepts assisted birth. Epidural Block: insertion of catheter provides pain relief for labor, and vaginal birth or planned cesarean birth. If used during labor of C-section, then it can be extended upward to T-4-T6 level. Subarachnoid Block: can be established faster than epidural block in C-section. Rarely used in complicated vaginal birth. Does not provide pain relief in labor. General Anesthesia: Used in C-section birth if epidural or spinal block is not possible or if the woman refuses regional anesthesia. May be required for emergency procedures such as replacement of inverted uterus. Sedatives: barbiturates are not routinely given due to fetal depression, however, small amounts of short-acting /f -barbiturates can be given to promote rest if a woman is fatigued from false labor or a prolonged latent phase.

e) Explain pharmacologic pain management methods in regard to body area affected, advantages, disadvantages, maternal effects, fetal effects, residual effects on the newborn, methods to overcome adverse effects Advantages: Provide pain relief without loss of consciousness. May be used for intrapartum analgesia, surgical anesthesia or both. Greatest relief of pain from labor and birth. Disadvantages: Any drug a woman takes is likely to affect the fetus. Drugs may have effects in pregnancy that they do not have in non pregnant persons. Pregnancy complications may limit the choice of pharmacologic pain management methods. Women who require other therapeutic drugs or preparations or practice substance abuse have fewer safe choices for pain relief. Maternal effects: Affects the cardiovascular system, respiratory system, Gl system, and nervous system. Drugs can affect the length and course of labor. Adverse affects from epidurals are maternal hypotension, bladder distention, prolonged second stage labor, catheter migration, cesearan births, maternal fevers. Adverse affects of epidural opioids are N/V, pruritis, delayed respiratory depression. Fetal effects: Cross the placenta to the fetus either directly or indirectly. Causes decrease in FHR. If the drug causes maternal hypotension then the blood flow to the placenta is decreased causing hypoxia and acidosis in the fetus. Residual effects on the newborn: General anesthesia can cause the baby to be slow to breathe at birth. Methods used to overcome adverse effects: Restricting fluids or maintaining NPO can reduce the risk for aspiration during anesthesia. Administering drugs to reduce the acidic secretions in the stomach can reduce nausea and vomiting. Neonatal respiratory depression can be prevented by reducing the time from induction of anesthesia to clamping of the umbilical cord. Keeping use of sedating drugs and anesthetics to a minimum until the cord is clamped. IV fluids are increased to reduce the effect of hypotension caused by eipidural and spinal blocks. Narcan can be given to the infant at birth to reverse the effects of general anesthesia. f) Develop nursing care to promote pain management

Focus on reducing factors that hinder pain control and enhance those that benefit it. Non-pharmacologic Relaxationprovide environmental comfort and general comfort. Reduce anxiety and fear and implement specific relaxation techniques. Cutaneous Stimulationencourage self massage or massage by others. Apply counterpressure and touch. Many woman like warmth applied to the back, abdomen, and perineum during labor. Hydro therapytub bath, whirlpool is relaxing and provides thermal stimulation. Mental Stimulationpractice imagery technique. Focal point technique Breathing Techniquesfirst stage breathing (cleansing breath, slow-paced breathing, modified paced breathing, patterned-paced breathing, breathing to prevent pushing). Second stage breathing (prolonged breath holding while breathing)

Pharmacologic Vital signs and FHR are taken at the usual intervals for the woman's stage of labor. Treat N/V, hypotension, and ensure safety and avoidance of injury.

Objective 12 The student will analyze labor induction/augmentation a) Discuss indications for induction or augmentation

Performed when a continued pregnancy may jeopardize the health of the woman or fetus and labor and vaginal birth are considered safe. Induction is not done if the fetus must be delivered more quickly than the process permits, in which case a cesarean birth is performed. Augmentation of labor with Oxytocin is considered when labor has begun spontaneously but progress is slowed or stopped. Induction is indicated in the following conditions: Intrauterine environment is hostile to fetal well-being. Spontaneous rupture of the membranes at or near term without onset of labor Postterm pregnancy Chorioamnionitis (inflammation of the amniotic sac) Hypertension associated with pregnancy or chronic Htn Abruptio plancentae (separation of a normally implanted placenta) Maternal medical conditions that worsen with continuation of the pregnancy (ie. diabetes, renal disease heart disease, pulmonary disease) Fetal death b) Discuss contraindications for induction or augmentation Any contraindication to labor and vaginal birth is a contraindication to induction or augmentation of labor. Induction is contraindicated in the following conditions: Placenta previa (abnormal implantation of the placenta in the lower uterus, presents first before the fetus). Results in hemorrhage during labor Vasa previa (fetal umbilical cord vessels branch over the amniotic sac rather than inserting into the Placenta) Results in fetal hemorrhage. Umbilical cord prolapsed (cord compression) Abnormal fetal presentation for which vaginal birth is often hazardous Fetal presenting part above the pelvic inlet Previous surgery in the upper uterus (previous cesarean incision or uterine fibroids) One or more low-transverse cesarean deliveries Breech presentation of the fetus Conditions in which the uterus is overdistended such as multi-fetal pregnancy Severe maternal conditions such as heart disease and severe HTN. Fetal presenting part above the pelvic inlet, Nonreassuring FHR patterns (added stress of stimulated contractions will reduce placental perfusion) c) Describe methods and medications used to induce or augment labor

Amniotomy is the method of surgical induction and augmentation because rupturing membranes stimulates uterine contractions and occasionally may be adequate in itself if the cervix is very favorable. A disposable plastic hook (AmniHook) is used to perforated the amniotic sac. Mechanical methods for cervical ripening involve placing hydrophilic inserts into the cervical canal where they absorb water and swell, gradually dilating the cervix, (ie. Dilapen, Lamicel, Laminaria)

Medical methods for induction and augmentation use drugs such as prostaglandis, IVoxytocin (Pitocin) or both to stimulate contractions. Prostaglandisused to ripen the cervix via intravaginal gel, intracervical gel, time-released vaginal inserts IVOxytocin (Pitocin)Started slowly and increased gradually through a primary line. Uterine activity and FHR patterns are monitored when given. Oxytocin is reduced when the woman is in the active phase of labor and 5-6 cm of cervical dilation. d) Develop nursing care for the patient who is undergoing labor induction or augmentation

Observe the woman and fetus for complications and take corrective actions if abnormalities are noted. Before induction and augmentation, the nurse determines whether the FHR and fetal heart patterns are reassuring. Observe the mothers response and uterine activity for hypertonus that may reduce fetal oxygenation and contribute to uterine rupture. Blood pressure and pulse are taken QSOmin. Temp is checked every 2-4 hours. Record intake and outtake to indentify fluid retention which may precede water intoxication. After birth the mother is observed for postpartum hemorrhage caused by uterine relaxation. Hypovolemic shock may occur with hemorrhage.

Objective 13 The student will discuss operative obstetrical procedures a) Describe operative obstetrical procedures Operative obstetrical procedures are referred to as operative vaginal births (forceps, or vacumm extraction) Cesarean births, and episiotomies. Cesarean birthregional anesthesia such as an epidural is commonly used. Premeds are used to control gastric and respiratory secretions. The fetus is monitored for 20 to 30 minutes after admission for a scheduled C-section. A wedge under one hip and a tilted operating table avoid aortocaval compression and promote placental blood flow, A single dose of prophylactic antibiotics are given. Two incisions are made, one in the abdominal wall the other in the uterine wall. The bladder is then separated from the uterine wall and held downward with a retractor; the uterus is incised. The physician lifts the fetal presenting part through the uterine incision. The infants face is wiped and nose is suctioned. Cord is clamped and cut. The physician then removes the placenta and oxytocin is given to contract the uterus firmly. Then the incisions are closed and wash with a topical antibiotic solution. Forceps birthcurved metal instruments shaped to grasp the fetal head. The are used to assist the descent and rotation of the fetal head from an occiput posterior or occiput transverse position to the occiput anterior position. Vacuum assisted birthuses suction to grasp the fetal head while traction is applied. It is not used to deliver the fetus in a nonvertex presentation such as breech or face; otherwise it's use is similar to that of forceps. Used to assist the descent and rotation of the fetal head to the occiput anterior position. Episiotomyincision made in the perineal area one when the fetal presenting part is crowned to a diameter of about 3-4 cm. Two types have different advantages and disadvantages: median (midline) and mediolateral (see figure pg 378 16-8) Amniotomybreaking of the amniotic sac. A disposable plastic hook is commonly used to perforate the amniotic sac. The hook is passed through the cervical opening, snagging the membranes. The opening is enlarged with the finger, allowing fluid to drain. Internal versionused to change fetal position. Used in malpresentation in twin gestation and is usually managed by cesarean birth but internal version is sometimes used for vaginal birth of the second twin. It is an unexpected, urgent procedure. The physician reaches into the uterus with one hand and with the other hand on the maternal abdomen, moves the fetus into a longitudinal lie to allow delivery. External Cephalic versionUsed to change fetal position from breech, shoulder or oblique presentation. Preformed at a location that allows for a possible c-section. The woman is given a tocolytic drug to relas the uterus while the version is performed. Epidural block or other analgesics may be given to reduce discomfort during the procedure. Labor induction is done immediately after successful ECV or the woman may await spontaneous labor or later induction. b) Describe indications for cesarean birth, forceps and vacumm assisted births, episiotomy, amniotomy, and internal and external version c) Describe precautions and contraindications for mother and fetus Cesarean birth Indications:performed when awaiting vaginal birth would compromise the mother, fetus or both. They include but are not limited to the following: Dystocia (difficult or prolonged labor) Cephalopelvic (fetopelvic) disproportion

HTN Maternal disease such as diabetes, heart disease, or cervical cancer if labor is not advisable Active genital herpes Some previous uterine surgical procedures such as a classic cesarean incision Persistent nonreassuring FHR patterns Prolapsed umbilical cord (cord compression) Fetal malpresentation such as breech, or transverse lie Hemorrhagic conditions such as abruption placentae or placenta previa
Contraindicationsfew exist. Conditions include fetal death, a fetus that is too immature to survive and maternal coagulation defects. Risks/Precautionsmore potential risk than vaginal birth but the safest major surgical procedure. Mother: Infection Hemorrhage UTI Thrombophlebitis, thromboembolism Paralytic ileus Atelectasis Anesthesia complications Infant: Inadvertent preterm birth Transient tachypnea of the newborn caused by delayed absorption of lung fluid Persistent pulmonary HTN of the newborn Injury such as laceration, bruising, and other trauma

Forceps and vacumm assisted births Indicationsconsidered if the second stage should be shortened for the well-being of the woman, fetus or both and if vaginal birth can be accomplished quickly without undue trauma. They may include the following: Maternal indications may include exhaustion, inability to push effectively. Cardiac and pulmonary disease. Fetal indications my include nonoreassuring FHR patterns, failure of the fetal presenting part to fully rotate and descend into the pelvis Paritial separation of the placenta or non reassuring FHR near the time of birth. Contraindicationsc-section is preferable if the maternal and fetal condition mandate a more rapid birth than can be accomplished with forceps or vacuum extraction and if the procedure would be too traumatic. Severe fetal compromise Acute maternal conditions such as congestive heart failure Pulmonary edema High fetal stations Disproportion between size of fetus and maternal pelvis Risks/Precautionsmain risk is trauma to fetal and maternal tissues. Mother Lacerations and hematoma of the vagina Infant Ecchymoses Facial and scalp lacerations and abrasions Facial nerve injury, Cephalhematoma Subgaleal hemorrhage and intracranial hemorrhage Vacuum extractor can cause scalp edema (chignon) at the application area The attempt at an instrumental birth usually is abandoned if the fetal head does not descend easily and a csection is preferred.

Episiotomy Indicationsconsidered to reduce pressure on the head when a small, preterm infant is born. Maternal benefits are unclear. Contraindicationsroutine prefomance of an episiotomy remains controversial Risks/PrecautionsInfection is the main risk of episiotomy; perineal pain impairs resumption of sexual intercourse and makes it uncomfortable for the woman.

Amniotomy Indicationsperformed in conjunction with induction and augmentation of labor and to allow for fetal monitoring and inducing uterine contractions. Contraindicationsnone noted however not used as the sole means to induce and augment labor. Risks/Precautionsthree risks associated with rupture of membranes which may lead to emergency procedures Prolapse of umbilical cord (cord compression) Infection (chorioamnionitis) Abruption placentae Internal and External version Indicationsused when the fetus is not in the proper position for birth (breech, transverse lie or oblique presentation);may allow for the avoidance of a c-section. Internal version is usually done for vaginal birth of the second twin. Contraindicationsif the woman is likely to deliver vaginally, which is the goal of the procedure. Mother Uterine malformation that limit the room available to perform the version Previous cesarean birth with a vertical uterine incision Disproportion between fetal size and maternal pelvic size. Infant Placenta previa Multifetal gestation which reduces the room available in which to turn the fetus or fetuses Oligohydramnios, ruptured membranes and a cord around the fetal neck or body Uteroplacental insufficiency Engagement of the fetal head into the pelvis

d) Analyze nurses role in operative obstetrical procedures Assess the woman and the fetus and help reduce anxiety. Explain the indications and the risks to the woman before she signs an informed consent and verify their understanding of the purposes, risks and limitations of the procedure and related treatments. Observe appropriate site for edema and hematoma (episiotomy) and apply cold packs if needed. Provide emotional support with postoperative care. Observe fetal responses. In addition to temp, monitor vital signs, respiratory character and oxygenation Return of motion and sensation if a regional block was given. LOG particularly if general anesthesia and sedatives were given Abdominal dressing Uterine firmness and position Lochia (color, quantity, other characteristics) IV infusion (rate, fluid, condition of the IV site) Pain relief medication

The nurse is responsible for administering uterine stimulants to a pregnant woman. She must decide when to start, change and stop an oxytocin infusion using the facility's protocol and medical orders. This responsibility requires additional education and refinement of the nurses critical thinking skills. e) Develope nursing care for the patient who has an operative obstetrical procedure. Care plan on pg. 384-385 of text

Objective 14 The student will explain postpartum complications a) Indentify risk factors Two most common risk factors in the postpartum period are hemorrhage, and infection Hemorrhage: Grand multiparity (5 or more) Overdistention of the uterus or uterine atony (large baby, twins hydramnios) Precipitous labor (less than 3 hours) Prolonged labor Retained placenta Subinvolution of the uterua (delayed return of the uterus to prepregnancy size and consistency) Placenta previa or abruption placentae Induction and augmentation of labor Administering of tocolytics to stop uterine contractions Operative procedures (vacuum extraction, forceps, cesarean birth) Trauma to the birth canal (vaginal, cervical or perineal lacerations and hematomas Infection: Operative procedures (vacuum extraction, forceps, cesarean birth) Multiple cervical examinations Prolonged labor (more than 24 hrs) Prolonged rupture of membranes Manual extraction of placenta Diabetes Catheterization Anemia (Hgb <10.5 mg/dl) b) Describe multidisciplinary actions that can prevent postpartum complications To prevent hemorrhage: Frequent assessments; Q15min during the first hour after birth, QSOmin for the next 2 hours, and Q1hr for the next 4 hours. Monitor for S/S of hemorrhage and infection, and perform actions to minimize postpartum hemorrhage and prevent hypovolemic shock. To prevent infection: Aseptic technique for all invasive procedures and meticulous handwashing. Prevent urinary stasis; adequate intake of fluids, encourage the woman to empty her bladder every 2-3 hours during the day, Teach breast feeding technique to empty the breast at each feeding to reduce the risk of nipple trauma Teach S/S of infection: fever, chills, dysuria, redness and tenderness of the wound c) Describe signs and symptoms of early and late postpartum hemorrhage, uterine subinvolution, hypovolemic shock, thromboembolic disorders, puerperal infection and affective disorders S/S of postpartum hemorrhage: Uncontracted uterus, large gush or slow steady trickle or ooze of blood from the vagina. Saturation of more than one peripad per hour. Severe unrelieved perineal or rectal pain. Tachycardia. S/S of uterine subinvolution: Prolonged discharge of lochia, irregular or excessive uterine bleeding, and 'sometimes profuse hemorrhage. Pelvic pain, pelvic heaviness, backache, fatigue and persisten malaise.

S/S of hypovolemic shock: Tachycardia, gradual increase in the pulse rate. A decrease in blood pressure and narrowing of the pulse pressure. Respiratory rate increase. Vasoconstriction in the vessels cause the skin to become pale and cool to the touch. As hemorrhage worsens, the skin changes to pallor and becomes cold and clammy. S/S of thromboembolic disorders: DVT's: Swelling of the involved extremity as well as redness, tenderness, and warmth. An enlarged, hardened, cordlike vein may be palpated. Pain when walking. Sometimes there are no sign at all. Pulmonary embolism: Dyspnea, sudden, sharp chest pain, tachycardia, syncope, tachypnea, pulmonary rales, cough and hemoptysis. Pulse ox. shows low saturation. S/S of puerperal infection: Endometritis: Fever, chills, malaise, lethargy, anorexia, abdominal pain and cramping, uterine tenderness, and purulent, foul-smelling lochia. Additional signs include tachycardia and subinvolution. Wound Infection: Edema, warmth, redness, tenderness and pain. Edges of the wound may pull apart and seropurulent drainage may be present. Mastitis: Mother may think she has the flu because of fatigue and aching muscles. Symptoms progress to fever, chills, malaise, and headache. Localized are of pain, redness and inflammation. A hard tender area may be palpated. S/S of urinary tract infection: Dysuria, urgent and frequent urination and suprapubic pain, low grade fever. Upper DTI can cause, fever, chills, costovertebral angle tenderness, flank pain and N/V. S/S of septic pelvic thrombophlebitis: Pain in the groin, abdomen, or flank. May present with fever, tachycardia, Gl distress and decreased bowel sounds, a spiking fever that does not respond to antibiotics. d) Identify appropriate medications used to treat the various postpartum complication

Methergine: Used to treat and prevent postpartum or postabortion hemorrhage caused by uterine atony or jf,~ subinvolution. Hemabate, Prostin 15M: used for the treatment of postpartum hemorrhage cuased by uterine atony. Clindamycin, ampicillin, cephalosporins, metronidazole: Used to treat endometritis and UTI Heparin (IV) therapy: used to treat septic pelvic thrombophlebitis. Oxytocin, methylergonovine, and prostaglandis: used to treat postpartum hemorrhage. e) Discuss multi-disciplinary management of post partum complications Massage the fundus of the uterus until it is firm and express clots that may have accumulated in the uterus to manage uterine atony. Hemorrhage caused by trauma may require the woman to return to the surgical area to view the lacerations. She is place in a lithotomy position and carefully draped while repairs are made. Oxytocin is administered for postpartum hemorrhage. If bleeding continues, dilation and curettage may be necessary to remove placental fragments. To manage hypovolemic shock, treatment is focused on controlling bleeding. Second IV line is inserted to accommodate whole blood. Sufficient fluid volume in infused to produce urinary output of 30ml/hr. To manage subinvolution, Methergine is given for 24 to 48 hours to sustain uterine contractions. o manage thromoembolic disorders, analgesics, rest and elastic support (TED hose) are used. Elevation of the affected extremity improves venous return. As soon as able, the woman should ambulate frequently. If

unable to ambulate then ROM exercises should be done. SCO's can be used for mothers with varicose viens, a history of DVT or thrombosis or cesarean birth. f) Develop nursing care for the patient who has a postpartum complication Care plan on pg 752.

Objective 15 The student will analyze labor variations

a) Describe types of dysfunctional labor patterns Normal labor is characterized by progress. Dysfunctional labor is one that does not result in normal progress of cervical effacement, dilation, and fetal descent mainly due to ineffective contractions: Two types of dysfunctional contractions. Hypotonic dysfunction: Contractions too weak to be effective; infrequent and brief. Usually occurs during the active phase of labor when progress normally quickens. Easily indented at peak. Minimal discomfort because the contractions are weak. Occurs after 4cm dilation. Hypertonic dysfunction: Contractions are uncoordinated and erratic in their frequency, duration and intensity. Painful but ineffective. Usually occurs in the latent phase of labor. Occur before 4cm dilation. Ineffective maternal pushing: Ineffective pushing may result from the following conditions: Use of incorrect pushing techniques and positions Fear of injury because of pain and tearing sensations felt by the mother. Decreased or absent urge to push Maternal exhaustion Analgesia or anesthesia that suppresses the woman's urge to push. Psychological unreadiness to "let go" of her baby. b) Describe maternal and fetal risks during prolonged labor to precipitous labor Possible maternal and fetal problems in prolonged labor include the following: Maternal infection, intrapartum or postpartum-lf membranes have ruptured for a prolonged time because organisms ascend from the vagina Neonatal infection, which may be severe or fatal-lf membranes have ruptured for a prolonged time because organisms ascend from the vagina Maternal exhaustion Higher levels of anxiety and fear during a subsequent labor Precipitous labor is one in which birth occurs within 3 hours of its onset, (not the same as precipitate birth) Several conditions that are associated with precipitate labor can affect the mother or the fetus. These conditions may include: abruption placentae, fetal meconium, maternal cocaine use, postpartum hemorrhage, or low apgar scores for the infant. The fetus may suffer direct trauma such as intracranial hemorrhage or nerve damage during a precipitate labor. The fetus may become hypoxic because intense contractions with a short relaxation period reduce time available for gas exchange in the placenta c) Explain passage, passenger and the powers in the pathophysiology of dysfunctional labor Passage: The birth passage that consists of the maternal pelvis and soft tissue.The pelvic brim (linea terminalis) divides the bony pelvis into the false pelvis (top) and the true pelvis (bottom). The true pelvis is most important in childbirth and has three subdivisions: 1. The inlet or upper pelvic opening 2. The midpelvis or pelvic cavity 3. The outlet or lower pelvic opening

Problems associated with dysfunctional labor are: Dysfunctional labor may occur because C-variations with the passagebony pelvis (passage) or soft-tissue that inhibits fetal descent. A small pelvis or of in the maternal abnormally shaped pelvis may retard labor and obstruct fetal passage. During labor a full bladder can cause

soft tissue obstruction but reducing the available space in the pelvis and intensifies maternal discomfort (cathing may be needed), Passenger: The passenger is the fetus, membranes and placenta. Problems with the passenger associated with dysfunctional labor are related to: Fetal size Fetal presentation or position Mutifetal pregnancy Fetal anomalies Powers in the pathophysiology of dysfunctional labor are responses to excessive or prolonged stress which interfere with labor in several ways: 1. Increased glucose consumption reduces energy supply available for contracting the uterus. 2. Secretions of catecholamines (EPH, NPH) by the adrenal glands stimulate beta receptors which inhibit uterine contractions. 3. Adrenal secretions divert blood supply from the uterus and placenta to skeletal muscle. 4. Labor contractions and maternal pushing efforts are less effective because these powers are working against resistance of tense abdominal and pelvic muscles. 5. Pain perception is increased and pain tolerance is decreased, which further increase maternal anxiety and stress. Problems associated with powers: The powers of labor may not be adequate to expel the fetus because of the ineffective contractions and ineffective maternal pushing efforts. Possible causes are: Maternal fatigue Maternal inactivity Fluid and electrolyte imbalance Hypoglycemia Excessive analgesics or anesthesia Maternal catecholamines secreted in response to pain or stress Disproportion between the maternal pelvis and the fetal presenting part Uterine overdistension such as multiple gestation or hydroamnios. d) Develop nursing care for the patient experiencing dysfunctional labor. Nursing care should center around maternal needs and safety of the fetus. Reduce the risk of infections and indentify infections. Conserve maternal energy and promote coping skills Goals and expected outcome relate to detecting the onset of infection. Maternal temp will remain below 38C (100.4 F) The FHR will remain near the baseline and below 160bpm The amniotic fluid will remain clear and without a foul or strong odor Contractions must continue for labor to progress. Two goals or expected outcomes should be: Rest between contractions with muscles relaxed Use coping skills such as breathing and relaxation techniques.

Objective 16 The Student will analyze pre-term labor a) Define preterm labor Preterm laboronset of labor after 20 weeks and before the beginning of the 38th week of gestation. b) Identify risk factors Medical History: Low weight for height Obesity Uterine or cervical anomalies, uterine fibroids HX of cone biopsy DES exposure as a fetus Chronic illness (cardiac, renal, diabetes, clotting disorders, anemia, HTN) Peridontal disease Obstetric History: Previous pre-term labor Previous preterm birth Previous first trimester abortions (>2) Previous second trimester abortion History of previous pregnancy losses (>2) Incompetent cervix Cervical length 25mm or < at mid trimester of pregnancy Number of embryos implanted Present Pregnancy: Uterine distention (multi-fetal pregnancy, hydroamnios) Abdominal surgery during pregnancy Uterine irritability Uterine bleeding Dehydration Infection Anemia Incompetent cervix Preeclampsia/HELLP syndrome Preterm PROM (premature rupture of membranes) Fetal or placental abnormalities Lifestyle and demographics: Little or now prenatal care Improper nutrition < 18 yo or > 40 yo Low educational level Low socioeconomic status Smoking > 10 cigarettes daily Nonwhite Employment with long hours and/or standing for long periods of time Intimate partner violence Substance abuse

Medication used in treatment: Drug therapy may be required if the vomiting becomes severe. These medications are: Phenergan (Promethazine) Benadryl (Diphenhydramine) Pepcid or Zantac (famitodine, ranitidine) Nexium or Prilosec (someprazole, omeprazole) Reglan or Zofran (metoclopramide, ondansetron) Methylprednisolone Risk to Mother and Fetus: Maternal risks are loss of 5% or more of prepregnancy weight, dehydration, ketosis, acid-base imbalance, electrolyte imbalance. Metabolic alkalosis may develop due to large amounts of HCL acid are lost in the vomitus. Vit. K loss can cause coagulation problems and thiamine loss can cause encephalopathy.

Hypertensive Disorders: Preeclampsiasystolic BP of > = to 140mm Hg or diastolic BP of >=90mmHg occurring after 20 weeks of pregnancy accompanied by proteinuria and edema Eclampsiaprogression of preeclampsia to generalized seizures that cannot be attributed to other causes. Seizures may occur postpartum. Gestational hypertensionBP elevation after 20 weeks of pregnancy that is not accompanied by protienuria. Can progress to preeclampsia Management: Early identification allows intervention before the condition reaches the seizure stage in most cases. Magnesium sulfate is the drug of choice to control eclamptic seizures. Women are monitored carefully for ruptured membranes, signs of labor or abruption placentae. Activity restrictions apply and blood pressure is monitored 2-4 times a day at home and weight should be taken each day. Monitor urine output for protein daily and a diet ample in protein and calories. Pathophysiology of Hypertensive disorders: Preeclampsia is a result of generalized vasospasm. During pregnancy, vascular volume and cardiac output increase significantly. Despite the increases, blood pressure does not rise in normal pregnancy. Peripheral vascular resistance decreases because of the effects of certain vasodilator, such as protacyclin and endothelium derived releasing factor. In preeclampsia however, peripheral vascular resistance increases because some women are sensitive to angiotensin II and a decrease in vasodilators. Medications used in treatment: Apresoline (hydralazine) is used if the systolic BP is >=160mmHg or diastolic BP is >=110mmHg. It relaxes arterial smooth muscle to reduce blood pressure. Other medications such as nifedipine, or labetalol may be used. Magnesium sulfate is used to prevent seizures. Phenytoin (Dilantin, Diphenylan) are sometimes used. Lasix may be given if pulmonary edema develops. Risk to Mother and Fetus: Vasopsasm decreases the diameter of the blood vessels, which results in endothelial cell damage. Vasoconstriction results in impeded blood flow thus causing elevated blood pressure. As a result, circulation to all parts of the body is decreased. The fetus is likely to experience intrauterine growth restriction and persistent hypoxemia and acidosis when maternal blood flow through the placenta is reduced.

c.

HELLP Syndrome: Acronym for "hemolysis, elevated liver enzymes, and low platelets". Life-threatening occurance that complicates about 10% of pregnancies. Half have severe preeclampsia although Htn is not present.

C Management: women should be managed in a setting with intensive care facilities available. Treatment
includes magnesium sulfate to control seizures and hypdralazine to control the blood pressure. Fluid

c) Explain methods used to predict preterm labor

Methods used to predict preterm labor: Cervical lengthmeasured by transvaginal ultrasound. PROM in previous birthsassessment and HX of predisposition to subsequent pregnancies Fetal fibronectin (fFN)a protein found in the fetal tissues is normally found in the cervical and vaginal secretions until 16-20 weeks gestation and again at or near term. If it appears too early, it suggests that labor may begin similar to the way cardiac enzymes rise in the person with at Ml. Infectionsoften increase the risk for preterm membrane rupture or birth even if the woman has no S/S initially. d) Explain multidisciplinary measures used to prevent/control preterm labor Initial measures to stop preterm labor: Indentify and treat infections, identify other causes of preterm labor that may be treatable, and reducing anxiety. Hydration with IV fluids may be chosen if maternal dehydration is a factor but not used to prevent preterm contractions. Some drugs are also used to stop preterm labor (magnesium sulfate) Limiting activity usually by relaxing in a side-lying or semi-sitting position increases placental blood flow and reduces fetal pressure on the cervix. e) Discuss tocolytics, beta-adrenergic agents and corticosteroids TocolvticsAdvantages used to reduce preterm labor is not clear. Most likely ordered if preterm labor occurs before the 34th week of gestation (respiratory and other complications in fetus are high during this time). The lowest possible dose to inhibit contractions is used. Beta-adrenergic(Brethine) stimulates beta-adrenergic receptors of the SNS. Action results primarily in bronchodilation and inhibition of uterine muscle activity. Increases pulse rate and widens pulse pressure. Causes tachycardia in mother and fetus. Magnesium sulfateused to treat PIH to prevent seizures it has the effect of quieting uterine activity and often used to inhibit preterm labor. Corticosteroids(Dex, Betamethasone) acceleration of fetal lung maturity to reduce the incidence and severity of respiratory distress syndrome. Studies suggest that antenatal steroids can also reduce the incidence of intraventricular hemorrhage and neonatal death in the preterm infant. Given between 24 to 24 weeks gestation because of the high incidence of RDS that affect infants of this age. f) Develop nursing care for the patient who is experiencing pre-term labor Nursing care includes interventions related to drug therapies used to inhibit preterm labor (see above) or antibiotic drug therapy. If labor cannot be halted then care is given similar to that of the laboring woman with the additional care to prepare for a preterm infant needs at birth. Support for anticipatory grieving may be needed if the infant is very immature and expected to die. Interventions focus on providing information to decrease anxiety and fear related to the unknown. Promoting expression of concern about problems in pregnancy. Teaching what may occur during a preterm birth (visit the NICU).

C Full Care plan for preterm labor Pg. 720-721 in the text

Objective 17 The Student will explain obstetrical emergencies. a) Describe the following conditions: uterine rupture, uterine inversion, prolapsed umbilical cord, amniotic fluid embolous, and trauma Uterine rupturea tear in the wall of the uterus occurs because the uterus cannot withstand the pressure against it. May preceded labor's onset. Three variations exist: 1. Complete rupture: direct communication between the uterine and peritoneal cavities. 2. Incomplete rupture: rupture in the peritoneum covering the uterus or into the broad ligament but not the peritoneal cavity. 3. Dehiscence: a partial separation of an old uterine scar. Little or no bleeding may occur. No S/S may exist and the rupture may be found during a subsequent C-section birth or abdominal surgery. Uterine inversionsuterus is completely or partly turned out, usually during the third stage of labor. Uncommon but potentially fatal. Can be caused by: 1. 2. 3. 4. 5. 6. 7. Pulling on the umbilical cord before the placenta detaches from the uterine wall Fundal pressure on an incompletely contracted uterus after birth Fundal pressure during birth Increased intraabdominal pressure An abnormally adherent placenta Congenital weakness of the uterine wall Fundal placenta implantation

Prolapsed umbilical cord(aka cord compression) cord slips downward after the membranes rupture subjecting it to compression between the fetus and pelvis. May occur when membranes initially rupture or long after. This interruption in the blood flow through the cord interferes with fetal oxygenation and is potentially fatal. Amniotic fluid embolous(aka Anaphylactoid Syndrome) occurs when amniotic fluid is drawn into the maternal circulation and carried to the woman's lungs. Fetal particulate matter in the fluid obstructs pulmonary vessels....leading to hypoxemia. Abrupt respiratory distress, depressed cardiac function and circulatory collapse occur rapidly. Thrombo-rich amniotic fluid interferes with normal blood clotting and is often fatal (50% maternal death rate during the acute episode). Survivors may have neurological deficits. The mothers well being takes precedence in this case. If cardiac arrest occurs, survival is highly unlikely and the fetus may be delivered to improve survival odds for the baby. Traumausually occurs from accidents, assault or suicide. Battering is a significant cause of maternal-fetal trauma during pregnancy. As the uterus grows it protrudes and becomes a larger target for trauma. Trauma may not be fatal but infant neurological deficits may be found after birth. The most common cause of fetal death is death of the mother. b) Identify the multi-disciplinary management in obstetrical emergencies

When cord prolapsed occurs the priority is to relieve pressure on the cord to improve blood flow through it until delivery. Prompt actions reduce cord compression and increase oxygenation to the C fetus: Position the womans hips higher than her head to shift the fetal presenting part toward her diaphragm a) Knee-chest position b) Trendelenburg position c) Hips elevated with pillows while side lying Avoid or minimize manual palpation or handling of the cord Ultrasound exam may be used to confirm presence of fetal heart activity before csection delivery. In uterine ruptures the management is to stabilize the mother and fetus and perfom cesarean delivery and blood is replaced as needed. Uterine inversion is managed by quick action to reduce maternal morbidity and mortality. Birth attendant tries to replace the uterus through the vagina into a normal position. If that is not possible, then a laparotomy with replacement is done. Hysterectomy may be needed. Therapuetic management for amniotic fluid embolous is medical and includes the following: CPR support Oxygen with mechanical ventilation Fluid volume expanders; blood transfusions as indicated Hemodynamic monitoring to guide therapeutic interventions Vasopressor therapy Blood component therapy such as fibrinogen packed RBC's platelets, fresh frozen plasma to correct coagulation defects. c) Develop nursing care for the patient who has an obstetrical emergency Nurse must remain calm while working quickly during this time and acknowledging the womans anxiety. Explanations must be simple.

Stay alert to S/S of uterine rupture. Notify the birth attendant if hypertonic contractions occur\e and maintain m

Nursing care of the trauma victim is focused first on maternal and then on fetal stabilization.