RN Notes Abruptio Placenta
RN Notes Abruptio Placenta
RN Notes Abruptio Placenta
Abruptio Placenta
Description
1.
2.
Etiology
The cause of abruptio placenta is unknown.
Risk factors include:
Uterine anomalies
Multiparity
Preeclampsia
Previous cesarean delivery
Renal or vascular disease
Pathophysiology
2.
Nursing Management
Continuously evaluate maternal and fetal physiologic
status, particularly:
Vital signs
Bleeding
Electronic fetal and maternal monitoring tracings
Signs of shock-rapid pulse, pallor, cold and most skin,
decrease in blood pressure
Decreasing urine output
Never perform a vaginal or rectal examination or take any
action that would stimulate uterine activity.
Assess the need for immediate delivery. If the client is in
active labor and bleeding cannot be stopped with bed rest, emergency
cesarean delivery may be indicated.
3.
4.
5.
Anemia in Pregnancy
Description
1.
Pathophysiology
1.
Assessment Findings
1.
1.
2.
3.
The APGAR Scoring System was developed by Dr. Virginia APGAR as a method
of assessing the newborns adjustment to extrauterine life. It is taken at one
minute and five minutes after birth. With depressed infants, repeat scoring every
five minutes as needed. The one minute score indicates the necessity for
resuscitation. The five minute score is more reliable in predicting mortality and
neurologic deficits. The most important is the heart rate, then the respiratory rate,
the muscle tone, reflex irritability and color follows in decreasing order. A heart
rate below 100 signifies an asphyxiated baby and a heart rate above 160
signifies distress.
Assess
HEART RATE
Absent
Below 100
Above 100
RESPIRATION
Absent
Slow
Good crying
MUSCLE TONE
Flaccid
Some flexion
Active motion
REFLEX IRRITABILITY
No Response
Grimace
Vigorous cry
COLOR
Body pink,
extremities blue
SCORE:
Birth Asphyxia
Description
1.
2.
3.
4.
5.
Maternal causes include amnionitis, anemia, diabetes, pregnancyinduced hypertension, drugs, and infection.
Uterine causes include prolonged labor and abnormal fetal
presentations.
Placental causes include placenta previa, abruption placental,
and placental insufficiency.
Umbilical causes include cord prolapsed and cord entanglement.
Fetal causes include cephalopelvic disproportion, congenital
anomalies, and difficult delivery.
Pathophysiology
1.
Unless vigorous resuscitation begins promptly, irreversible multiorgan tissue changes will occur, possibly leading to permanent damage
or death.
2.
During the 24 hours after successful resuscitation, the newborn is
vulnerable to post-asphyxial syndrome.
Assessment Findings
1.
2.
3.
4.
5.
6.
7.
8.
Cesarean Delivery
Description
1.
woman may have a vertical skin incision and a low transverse uterine
incision, particularly if she is very obese.
4.
In subsequent pregnancies and delivery, a trial of labor and
vaginal birth is increasingly regarded as safe and appropriate as long
as cephalopelvic disproportion does not exist and the previous incision
was low transverse.
5.
Elective, repeat cesarean may be performed in the absence of a
specific indication for operative delivery when either the physician or
the client is unwilling to attempt vaginal delivery.
6.
Anesthesia may be general, spinal, or epidural; preoperative and
postoperative care will vary accordingly.
Uterine incisions for cesarean birth. The abdominal and uterine incisions do not
always match. VBAC, Vaginal birth after cesarean
Positioning
Supine, with a small roll under the right hip (to reduce vena cava
compression); arms extended on armboards.
Incision sites
C-section tray
Delivery forceps
Cord clamp
Supplies/ Equipment
Basin set
Blades
Suction
Neonatal receiving unit
Self-contained oxygen
I.D bands
Bulb syringe
Solutions
Sutures
Procedure
1.
2.
3.
4.
5.
6.
7.
The babys airways are suctioned with the bulb syringe, and the
baby is completely delivered and placed upon the mothers abdomen.
8.
The umbilical cord is double clamped and cut.
9.
The baby is wrapped in a sterile receiving blanket and transferred
to the warming unit for immediate assessment and care.
10.
Once the bay has been safely delivered, the emergent phase of
the procedure has been ended.
11.
Using a nonecrushing clamp, the uterine wall is grasped for
traction during closure.
12.
The closure is performed in two layers with a heavy absorbable
suture, using a continuous stitch, the second overlapping the first.
13.
Following closure of the uterus, the bladder flap is
reperitonealized with a running suture, and the uterus is pushed back
inside the pelvic cavity.
14.
The cavity is irrigated with warm saline, and closed in layers.
15.
Skin is closed with the surgeons preference. If a tubal ligation is
to be performed, it is done prior to the abdominal closure sequence.
Perioperative Nursing Considerations
1.
a.
b.
Placenta previa
Abruptio placental
3. Fetal factors
a.
b.
c.
d.
2. Prepare the client for cesarean delivery in the same way whether the
surgery is elective or emergency. Depending on hospital policy:
Table 1
Client and Family Teaching
Explain to the mother, her partner, and other family members that recovery
from a surgical cesarean delivery is slower, and often more painful, when
compared with recovery from a normal vaginal delivery. The following
considerations must be taken into account:
Difficulty with normal ADLs (e.g., dressing, bathing, toileting, and so on).
Difficulty with providing normal newborn care (e.g., lifting, carrying, bathing,
and dressing the newborn) and the need for assistance in caring for the
newborn.
Circumcision
Definition
The excision of the foreskin (prepuce).
Circumcisions are commonly performed on the male infant at
birth or shortly thereafter. However, the uncircumcised adult may
experience difficulty in retracting the prepuce from the glans of the
penis because of a stricture (phimosis), which requires surgical
intervention, or circumcision may be performed to treat recurrent
balanitis or as a religious rite.
Positioning
Basin set
Blades
Needle counter
Catheter
Gauze roll and impregnated gauze strips
Solutions
Procedure
1.
2.
3.
4.
5.
6.
7.
1.
Cord Prolapse
Description
1.
Etiology
1.
2. Clinical manifestations
Nursing Management
1. Identify prolapse cord and provide immediate intervention.
1.
2.
3.
4.
5.
Positioning
Gynecologic pack
Instrumentation
D&C tray
Supplies/ Equipment
Padded stirrups
Telfa
Perineal pad
Suction
Lubricant
Procedure Overview
1.
2.
3.
4.
5.
6.
7.
8.
1.
Dysfunctional Labor
Description
1.
1.
3.
4.
5.
1.
Etiology
1.
1.
2.
3.
Vaginal bleeding.
Hypotonic uterus.
Excessive blood loss, which may produce hypotension, thread
pulse, pallor, restlessness, dyspnea, and chills.
Nursing Management
1. Assist with appropriate treatment to prevent complications.
Ectopic Pregnancy
Description
5.
Blood samples for hemoglobin value, blood type, and group, and
crossmatch.
Nursing Management
1. Ensure that appropriate physical needs are addressed and monitor for
complications. Assess vital signs, bleeding, and pain.
2. Provide client and family teaching to relieve anxiety.
Explain the condition and expected outcome.
Fetal Skull
Importance of the fetal skull
1.
2.
3.
1.
2.
3.
4.
5.
6.
Sphenoid
Ethmoid
Temporal
Frontal
Occipital
Parietal
The frontal, occipital and the parietal cranial bones could either be fetal
presenting part if the presentation is vertex.
Membrane Spaces
During birth, bones move and overlap with each other to allow the fetal head to fit
through the birth canal which is a process termed as molding. Molding is made
possible because of the presence of the suture lines. Without these structures a
fetus head cannot pass through the birth canal. There are different types of
sutures:
Biparietal 9.25 cm
Bitemporal 8 cm
Bimastoid 7 cm
Anteroposterior (AP) diameter
Which one of these diameters is presented at the birth canal depends on the
degree of flexion, which is known as the ATTITUDE, the fetal head assumes prior
to delivery.
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