This document discusses potential complications that can arise during labor and delivery. It describes how high-risk factors can develop unexpectedly, causing stress, anxiety and pain in the client. It then outlines various fetal malpositions and malpresentations that can complicate labor, such as occiput posterior or transverse positions, breech presentations, or shoulder presentations. Finally, it discusses fetal distress and conditions that can cause it like cord compression, as well as methods for assessing and managing fetal heart rate patterns that indicate distress.
This document discusses potential complications that can arise during labor and delivery. It describes how high-risk factors can develop unexpectedly, causing stress, anxiety and pain in the client. It then outlines various fetal malpositions and malpresentations that can complicate labor, such as occiput posterior or transverse positions, breech presentations, or shoulder presentations. Finally, it discusses fetal distress and conditions that can cause it like cord compression, as well as methods for assessing and managing fetal heart rate patterns that indicate distress.
This document discusses potential complications that can arise during labor and delivery. It describes how high-risk factors can develop unexpectedly, causing stress, anxiety and pain in the client. It then outlines various fetal malpositions and malpresentations that can complicate labor, such as occiput posterior or transverse positions, breech presentations, or shoulder presentations. Finally, it discusses fetal distress and conditions that can cause it like cord compression, as well as methods for assessing and managing fetal heart rate patterns that indicate distress.
This document discusses potential complications that can arise during labor and delivery. It describes how high-risk factors can develop unexpectedly, causing stress, anxiety and pain in the client. It then outlines various fetal malpositions and malpresentations that can complicate labor, such as occiput posterior or transverse positions, breech presentations, or shoulder presentations. Finally, it discusses fetal distress and conditions that can cause it like cord compression, as well as methods for assessing and managing fetal heart rate patterns that indicate distress.
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Complicated Labor and Delivery
High risk factors may develop at
anytime during the course of labor in client who has been otherwise healthy throughout her pregnancy.
Clients Response to the onset of High- risk factors
1. Stress, fear and anxiety brought about by unexpected complications during labor may have profound effects on maternal and fetal outcome. 2. Maternal anxiety can increase tension, produce higher pain perception and may make labor contractions less effective. 3. Cathecholamines released during stress produce vasoconstriction that may negatively affect uterine blood flow. Problems with the Passenger 1. FETAL MALPOSITION A. Types of Malposition 1. Occiput Posterior Position - R or L Occiput Posterior occurs in about 25% of all term pregnancies but usually rotates to O.A. as labor progress - Failure to rotate is termed persistent occiput posterior. - Maternal risks include prolonged labor, potential for operative delivery extension of the episiotomy, or 3 rd and 4 th degree laceration of the perineum Maternal Symptoms Intense back pain in labor Dysfunctional labor pattern Prolonged active phase Secondary arrest dilatation Arrest of descent.
2. Occiput Transverse Position (O.T) - Incomplete rotation of O.P to O.A results in the fetal head being in a horizontal or transverse position. - Persistent O.T position occurs as a result of ineffective contractions or flattened bony pelvis. - In the absence of abnormal pelvic structure, vaginal delivery can be accomplished by stimulating contractions with Oxytocin (Pitocin) and application of Forceps for delivery. Nursing Care Nursing Diagnosis: Pain, Ineffective coping - Encourage mother to lie on her side opposite from the fetal back, which may help with rotation - Knee-chest position may facilitate rotation - Pelvic rocking may help with rotation - Apply sacral-counter pressure with heel of the hand to relieve back pain Medical Management 1. Forceps : metal instruments applied to the fetal head to facilitate delivery - Provides traction or a means of rotating fetal head - Risks are fetal ecchymosis or edema of the face, transient facial paralysis, maternal lacerations or episiotomy extensions.
2. Vacuum extraction : a suction cup applied to the fetal head to facilitate delivery - Provides traction to shorten the second stage of labor - Risks are newborn cephalhematoma, retinal hemorrhage and intracranial hemorrhage.
2. FETAL MALPRESENTATION - Refers to fetal presenting part other than vertex and includes breech, transverse, face, brow and sinciput. - Malpresentations may be identified late in pregnancy or may not be discovered until the initial assessment during labor. Related Factors: - The woman has had more than one pregnancy - There is more than one fetus in the uterus
- The uterus has too much or too little amniotic fluid - The uterus is not normal in shape or has abnormal growths such as fibroids - Placenta previa - The baby is preterm
A. Vertex Malpresentation a. Brow presentation - Fetal forehead is the presenting part - 50% convert to vertex or face presentation b. Face Presentation - The presenting part is the face - Palpation of the nose, mouth and eyes and chin through vaginal examination - Increased risk of prolonged labor and operative delivery - Anticipate vaginal delivery if the pelvis is adequate and the chin is in the anterior position - Anticipate cesarian delivery if chin is posterior or signs of fetal distress occurs.
c. Sincipital presentation - The sinciput presentation occurs when the larger diameter of the fetal head is presented - Labor progress is slowed with lower descent of the fetal head B. Breech Presentation a. Complete - The babys hip and knees are flexed so that the baby is sitting cross-legged with feet beside the bottom b. Frank - The babys bottom comes first, and the legs are flexed at the hip and extended at the knees with feet near the ears. - 65-70% of breech babies are in frank position c. Incomplete - One or both feet comes first with the bottom, at a higher position. This is rare at term but relatively common with premature fetuses. - Risk for umbilical cord prolapse
d. Kneeling Breech - The baby is in kneeling position, with one or both legs extended at the hips and flexed at the knees. This is extremely rare. Maternal Risks - Prolonged labor due to dec. pressure exerted by the breech on the cervix - Premature rupture of membranes may expose clients to infection - Cesarean forceps delivery - Trauma to birth canal during delivery from manipulation and forceps to free the fetal head - Intrapartum or postpartum hemorrhage Fetal Risks: - Umbilical cord prolapse - Entrapment of fetal head in incompletely dilated cervix - Aspiration and asphyxia at birth - Birth Trauma from manipulation and forceps to free the fetal head
Nursing Interventions: - Vaginal delivery of breech - Cesarean section - External cephalic version
C. Transverse Lie (Shoulder lie) - The acromium process is the presenting part. - Vaginal delivery is not considered. - Cesarian methos is the preferred method of delivery. Risk factors - Low birth weight - Multiple gestation - Polyhydramnios - Large pelvis - Rupture of membranes - External cephalic version Diagnosis - Compound presentation may be noted on an antepartum obstetrical ultrasound examination or palpated during cervical examination, typically during early labor. - Examiner will feel an irregular shape beside or in advance of the vertex or breech. Nursing care of clients with malpresentations - Assessment: Leopolds Maneuver - Nursing Diagnosis: Risk for injury Anxiety Fear Deficient knowledge Ineffective individual/family coping
Planning and Implementation - Observe closely for abnormal labor patterns - Monitor fetal heart rate and contractions continuously - Provide client/family teaching - Provide client support and encouragement - Anticipate forceps-assisted delivery - Anticipate CS for incomplete breech or shoulder presentation.
Evaluation - The client and fetus have a safe labor and delivery - The client verbalizes understanding of the implications of the malpresentation
3. FETAL DISTRESS - Insufficient oxygen supply to meet the demands of the fetus. Causes: - Compression of the umbilical cord - Uteroplacental insufficiency caused by placental abnormalities or maternal condition - Multiple births - Shoulder dystocia - Umbilical cord prolapse - Nuchal cord - Abruptio placenta - Premature closure of the fetal ductus arteriosus - Meconium-stained amniotic fluid
Changes in Fetal heart rate baseline 1. Tachycardia 2. Bradycardia
Decreased or absence of variability of heart rate 3. A heart rate of less than 2-5 beats per minute causing a flattened appearance to heart rate 4. Indicates depression of the autonomic nervous system that controls the fetal sleep. Sedation, and hypoxia may affect variability
Late Decelaration pattern - FHR slows following the peak of a contraction and slowly returns to baseline rate during the resting phase. - Indicates fetal response to hypoxia from uteroplacental insufficiency - Considered omnious pattern regardless of the depth of the deceleration of the fetal heart rate and requires immediate intervention
Variable Deceleration pattern - FHR repeatedly decelerates below 90 bpm for over 60 seconds before returning to baseline - Indicates interference of fetal blood flow from cord compression - Leads to fetal hypoxia and low apgar scores unless steps are taken to correct it. NURSING CARE: Assessment: 1. Assess FHR baseline, variability, and pattern periodic changes
2. Assess contraction pattern and maternal response to labor NURSING DGNOSES 1. Decreased cardiac output (fetal) 2. Impaired gas exchange 3. Anxiety Planning and Implementation Late Deceleration Goal: - To improve maternal blood flow to the placenta a. Reposition the mother on her left side b. Administer O2 by face mask at 8-10pm c. Increase IV fluids d. Discontinue oxytocin infusion, if labor is being induced e. Notify the health care provider immediately.
Variable deceleration Goal: - To relieve pressure on the umbilical cord a. Reposition the mother on either side b. If not corrected, reposition to the opposite side c. Administer O2 by face mask at 8-10lpm d. Trendelenburg or knee-chest position, if not corrected. e. Perform vaginal examination and apply upward digital pressure on the presenting part to relieve pressure on the umbilical cord
EVALUATION - Fetal heart rate remains in normal range with adequate variability and absence of ominous periodic changes. - The client verbalizes that anxiety is decreased. - Family coping strategies are strengthened.
MEDICAL MANAGEMENT A. Amnioinfusion - FHR monitoring is required - Intrauterine catheter is inserted - Warmed sterile saline is delivered via the catheter using an infusion pump. - Infusion is continued until signs of cord compression disappear. B. Intrauterine Resuscitation - Administration of Terbutaline (Brethine), a tocolytic agent to stop uterine contractions and provide an opportunity for uteroplacental circulation to improve when fetal distress is present during the first stage of labor.
C. Prevention of Meconium Aspiration - If meconium is present during labor steps to prevent aspiration should be taken. - The nasopharynx of the infant is suctioned prior to delivery of the chest and abdomen. - Visualization of the larynx and vocal chords with deep suction is performed immediately after delivery and before first breath is taken. 4. Cord Prolapse What is an umbilical cord? - Is a flexible, tube-like structure that, during pregnancy, connects the fetus to the mother. - The umbilical cord is the babys lifeline to the mother. - It transports nutrients to the baby and also carries away the babys waste products. - It is made up of three blood vessels Cord Prolapse - Also called an umbilical cord prolapse - A very rare obstetrical emergency which can result in a birth injury or worse. - It is when the babys umbilical cord descends alongside or descends before his head. - Can be life-threatening to the baby since blood flow-and therefore oxygen- through his umbilical cord is usually compromised due to cord compression Contributing factors - Premature rupture of the amniotic sac - Polyhydramnios - Long umbilical cord - Fetal malpresentation - Multiparity - Multiple gestation
Assessment Monitor FHR to measure the babys heart rate (if the baby has prolapsed, may have bradycardia). The physician may conduct a pelvic examination and may see the prolapsed cord, or palpate the cord with his or her fingers. Priority Nursing Diagnoses Risk for impaired gas exchange Risk for injury Fear
PLANNING AND IMPLEMENTATION ACTION: To relieve pressure on the cord and restore fetal oxygenation A. Place mothers hip higher than her head 1. Knee-chest position 2. Trendelenburg position B. Perform sterile vaginal exam pushing fetal presenting part upward with fingers to relieve pressure on the cord 1. Administer O2 by face mask at 8-10 lpm 2. Maintain continuous electrical fetal monitoring 3. Prepare for rapid delivery vaginally, or by cesarean section 4. If cord protrudes through the vagina, determine that pulsation is present and apply sterile saline soaked dressing to prevent drying EVALUATION: 1. The fetal heart rate remains within normal range and without ominous sign 2. The fetus is safely delivered 3. The client and family verbalize understanding of the implications of prolapsed cord and the need for emergency maganement
PROBLEMS WITH PASSAGEWAY The Pelvis - Problems of the bony pelvis that can influence the progress of labor include: a. Contracted pelvis due to Avitaminos D or Ricketts in childhood
PRIMARY PROBLEMS Malpositioning can occur because the fetus head isnt engaged in the pelvis. CAUSE: - Small pelvis may be a result of rickets in the early life, a genetic predisposition, Pelvis isnt fully mature in young adolescent - Macrosomia > Inlet contraction occurs when narrowing of the anteroposterior diameter is less than 11 cm, or a maximum transverse diameter is 12cm or less. Outlet contraction, the transverse diameter narrows to at the outlet to less than 11cm Abnormal positions of the fetus can also cause CPD. Fetal anomalies such as hydrocephalus, hydrops fetalis and tumors of the fetal head. How it is detected? 1. Pelvic measurements - Every primigravida should have before week - Methods of performing clinical pelvimetry range from very simple to very complex. Simple digital examination of the pelvis allows the examiner to categorize it as probably adequate for an average sized baby, borderline, or contracted. Other methods include the following:
Measuring the diagonal conjugate. Insert 2 fingers into the vagina until they reach the sacral promontory. The distance from sacral promontory to the exterior portion of the symphysis is the diagonal conjugate and should be greater than 11.5cm Measure the bony outlet by pressuring your closed fist against the perineum. Compare the previously measured diameter of your fist to the palpable distance between the ischial tuberosities. Greater than 8cm bituberous is considered normal. Feel the ischial spines for their relative prominence or flatness. Spinal prominence narrows the transverse diameter of the pelvis. Feel the pelvic sidewalls to determine whether they are parallel (OK), diverging or (even better), or converging (bad). True outlet obstruction is fortunately rare.
2. Presence of large caput succedaneum Management A. Trial Labor - If the pelvic measurements are borderline or just adequate - - may be allowed to continue if descent of the presenting part and dilatation of the cervix are occurring. - Nsg. Measures: - - Monitor FHR and uterine contractions -- Make sure that the urinary bladder is kept empty. -- After rupture of membranes, assess FHT carefully. -- Monitor progress of labor. -- Emphasize that its best for the baby to be born vaginally if possible. -- If the trial labor fails and CS is scheduled, explain why procedure is necessary. -- A woman having a trial labor may feel shes on trial herself. She may feel being misjudged and may be self-conscious if labor doesnt go well as hoped. -- When dilatation doesnt occur, the woman may feel discouraged and inadequate, as if shes somehow at fault. -- Remember to support the support person. -- Assure the parents that CS isnt an inferior method of birth. Remind them its an alternative method.
Problems with the Powers 1. Dystocia - Prolonged difficult labor and or delivery because of problems with the 4Ps RISK FACTORS: 1. Faults of the passenger a. Abnormal position b. Malpresentations c. Hydrocephaly d. Large fetus e. Abnormal lie f. Multiple pregnancy 2. Faults of the passageway a. Cervical inertia b. Contracted pelvis c. CPD Non-gynecoid pelvis d. Cervical scar tissue from previous surgery 3. Faults of the primary power a. Hypertonic uterine inertia b. Hypotonic uterine inertia 4. Faults of the person: poor psychosocial responses which are influenced by theses factors: a. Education and preparation b. Previous experiences c. Readiness d. Support systems e. Maternal position f. Race and culture g. Environment h. Socioeconomic status
TREATMENT - Bedrest - Sedation for hypertonicity - Stimulation with oxytocin for hypotonicity - Cesarean section - Forceps as indicated DIAGNOSIS - Vaginal exam - Leopolds Man - Pelvimetry - Ultrasound
NURSING IMPLEMENTATION - Prepare client for/ assist in various diagnostic exam. - Promote rest and comfort: quite darken room - Proper position for comfort: lateral - Monitor: a. Labor: uterine contractions and cervix b. Fetal well-being: FHT, movement, passage of meconium - Give reassurance and support INEFFECTIVE UTERINE FORCE Uterine contractions force the moving fetus through the birth canal. This process is aided by: - Hormones: estrogen and progesterone E and NE, oxytocin - Electrolytes: calcium, sodium and potassium - Proteins: actin and myosin - Prostaglandin
2 types of ineffective labor a. Primary (at the beginning of labor) b. Secondary (later in labor)
COMPLICATIONS - Hypertonic contractions - Hypotonic contractions - Uncoordinated contractions HYPERTONIC UTERINE CONTRACTION Are marked by an increase resting tone to more than 15mmHg Intensity of the contractions may be no stronger than with hypotonic contractions Tend to occur frequently Most commonly seen in the latent phase of labor May result in precipitous labor CAUSE: - Occurs because the muscle fibers of the myometrium dont repolarize after a contraction - Oxytocin administration can also cause hypertonic uterine contraction HOW IT IS DIAGNOSED? - Determined by the presence of painful uterine contractions that are either palpated or observed
- On the electronic monitoring the uterine contractions show a high resting tone, and a lack of relaxation between contractions is also present. - Fetal monitoring may reveal bradycardia and fetal distress in the form of late decelerations because the absence of uterine relaxation doesnt allow the best possible uterine filling - The woman wont be able to relax between contractions and may find it difficult to breathe with her contractions - Contractions are painful MANAGEMENT: - Uterine and fetal extrenal monitor applied for at least 15 min - Promote rest - Provide analgesia with a drug as morphine - Possibly sedation so the woman can rest. - Such as changing the linen and the patients gown, darkening room lights and decreasing noise and stimulation.
- Cesarean birth is necessary if decelerating FHR occurs.
HYPOTONIC UTERINE CONTRACTIONS The number of frequency of contractions is low. Strength of contractions does not rise above 25 mmHg. Usually occur during the active phase of labor. Tend to increase the length of labor because so many of theses contractions are necessary to achieve cervical dilatation. Can result in exhaustion
- Exhaustion can lead to: Ineffective contractions of the uterus, in creasing the womans chance for postpartum hemorrhage Risk of infection of the uterus and the fetus because of the extended period of cervical dilatation.
Cause:
- Analgesia has been administered too early (before cervical dilatation of 3-4cm) - Bowel or bladder distenton is present, preventing descent or engagement. - The uterus is overstretched due to multiple gestation, larger than normal single fetus, hydramnios, or grandmultiparity. How its detected The contractions arent normally painful because they arent intense. Lack of labor progression and cervical dilatation. Contractions are sufficient to dilate the cervix and wont register as intense on an electronic uterine contraction monitoring strip.
Management 1. If hypotonicity is the only abnormal factors (including ruling out CPD or poor fetal presentation by sonogram), then rest and fluid intake should be encouraged. 2. If the membranes havent ruptured spontaneously, rupturing them at this point may be helpful. 3. Oxytocin may be administered IV to augment labor causing the uterus to contract more effectively. 4. If hypertension occurs, discontinue oxytocin and notify practitioner. Uncoordinated contractions Occur erratically, such as one on top of another followed by a long period without any. May occur so closely that they dont allow good filling time. The lack of regular pattern of contractions makes it more difficult for the woman to rest or to use breathing exercises between contractions.
Cause With uncoordinated contractions, more than one pacemaker may initiate contractions. Receptor points in the myometrium act independently of the pacemaker.
How it is detected Application of a fetal external monitor. Allows assessment of the rate, pattern, resting tone and fetal response to contractions, revealing an abnormal pattern. Usually detected within 15 minutes. (Longer time span may be necessary to show disorganized pattern of early labor.) Management Oxytocin administration may be helpful to stimulate a more and effective and consistent pattern of contractions with better, lower resting tone. If hypertension occurs, discontinue oxytocin and notify physician. Postpartal Hemorrhage Postpartal hemorrhage is the loss of blood totaling 500ml or more within a 24 hour period Can be late already after 24 hours until 6 weeks puerperium Causes: - Uterine atony - Retained placental frag. - Lacerations - DIC A. Uterine atony. - Relaxation of the uterus - Typical cause of postpartal hemorrhage RISK FACTORS: - Overdistended uterus - Fatigue uterus (tocolytics such as Mg and Calcium channel blocker) - Obstructed uterus: Accreta and Inccreta Nursing Interventions: - Palpate the womans fundus and frequent intervals - Frequently assess the lochia and vital signs Therapeutic Mgt: - Attempt uterine massage to encourage contraction - Infusion of oxytocin to help the uterus remain in tone - Offer oxygenation without the doctors order 2l/min - Position her in supine position B. Lacerations - Tears of birth canal are common and maybe considered normal consequence of normal delivery - Vaginal trauma most common with surgical or assisted vaginal deliveries. 3 types of Lacerations: a. Vaginal arterial bleeding (bright red) b. Cervical occur when the women bear down in no time. c. Perinial Risk Factors: - Delivery of large infants - Intrumentations or intrauterine manipulation - Episiotomy - Precipitate birth
- Primigravida Cervix is not stretched Dont know what to do - Use of lithotomy position Increased tension on the perineum
Therapeutic Mgt: A. Cervical lacerations: - Very difficult to repair because of severe bleeding
- Maybe necessary for the women to be given by anesthetic to relax the uterine muscle and prevent pain. B. Vaginal Lacerations - Are hard to repair because they vaginal tissues are friable - Rare, easier to assess than cervical lacerations because they viewed. - Packing that is left too long leads to stasis and infection * Packing - putting up cervical OS to stop the oozing of blood. - Diet high in fluid and stool softener maybe administered for the first week. * Enema diagnostics of the LGI tract
Know the degrees of lacerations and the types of lacerations and the types of nursing interventions.
C. Retained placental fragments - Occurs when the placenta does not deliver entirely - Keeps from the uterus from contraction that causes severe bleeding. (Deliver the placenta do controlled contraction, place your palm in the fundus so that thee uterus would not invert that will cause bleeding.) Assessment: - If an undetected retained fragment is present, bleeding will be apparent in immediate postpartal period Risk Factors: - Uterine surgery - Premature surgery - Prolonged placental delivery
Therapeutic Mgt: - D and C - Methotrexate maybe prescribe - Observe the color of the lochia discharge
D. Disseminated Intravascular Coagulation - Deficiency in clotting ability caused by vascular injury - Fibrinogen protein that helps blood coagulation - DIC causes more clots in the circulation Risk factors: - Multipara - Episiotomy - Prolonged labor - Macrosomia - Multiple gestation - Abruptio placenta Symptoms - Uncontrolled bleeding - Decreased blood pressure - Increased heart rate - Decreased RBC count - Swelling and pain in tissues in the vaginal and perinial area
Examination - Inspect the vagina and cervix fro bleeding source - Estimation of blood loss - Pulse rate and BP measurement - Clotting factors of the blood should be examined. ( D-dimer) Treatment - Medication (Oxytocin, Methergine) - Manual massage of the uterus to stimulate contractions - Removal of placental pieces - Examination of the uterus - Hysterectomy - Replace loss of blood and fluids Puerperal Infection Refers to a bacterial infection following childbirth Maybe referred to as puerperal or postpartum fever Genital tract, particularly the uterus is the most commonly infected site. In some cases infection can spread to other points in the body-fatal. 1. Endometritis - The primary cause of postpartum infection. - E. coli, K. pneumoniae and Proteus are the most frequently identified organisms. - Endometritis occurring on postpartum day 1 or 2 most frequently caused by group A streptococci. - If infection develops on day 3 or 4 it is most commonly caused by enteric bacteris - If infection develops more than 7 days after delivery it is most frequently caused by Chlamydia trachomatis. - Infection following C/S is most frequently caused by Bacteriodes species. RISK FACTORS: - C/S - Young age - Low socioeconomic status - Prolonged labor - Prolonged rupture of membranes - Multiple vaginal exam - Placement of intrauterine catheter - Preexisting infection - Twin delivery - Manual removal of the placenta Assessment A benign temperature elevation may occur on the first postpartal day, particularly if the woman is not drinking fluid. Fever may manifest on the 3 rd and 4 th
Urinary Tract Infection Bacterial inflammation of the bladder or urethra RISK FACTORS: - C/S - Forceps delivery - Vacuum delivery - Induction of labor - Cathetherization - PIH - Length of hos. stay - Epidural anesthesia - Prev. uti during preg Assessment Bladder infections: - Frequent urination - Nocturia - Urethritis - Dysuria - Pain at the midline suprapubic region(sharp) - Pyuria - Hematuria - Pyrexia - Cloudy-foul smelling urine
- Urinary incontinence - Maybe asymptomatic Kidney Infection - Emesis - Back, side or groin pain - Abdominal pain or pressure - Shaking chills and high spiking fever - Night sweats - Extreme fatigue - Excessive thirst
Diagnostic tests Obtain a clean catch urine Urine culture CBC
Therapeutic management Encourage to drink large amount of fluids Oral analgesic for pain Treatment with antibiotic is 3-7 days Wound infection Include infection of the perineum developing at the site of an episiotomy or laceration, as well as the abdominal incision after a c/s Diagnosed on the basis of: erythema, warmth, tenderness, induration and purulent discharges from the incision site with or without fever.
RISKFACTORS: (Perineal) - May become apparent on the 3 rd and 4 th day - Infected lochia - Fecal contamination of the wound - Poor hygiene RISK FACTORS: (Abdominal) - S. aureus from the skin - Obese - DM - Tx w/cortecosteroids - Hypertension - Chorioamnionitis - Prolonged labor, prolonged rupture, prolonged OR time, abdominal twin delivery, excessive blood loss
Assessment Perineal: - Erythema and edema accompanied with purulent discharge - Inordinate amount of pain - Hematoma Abdominal: (develop around postoperative day 4) - Erythema, warm, tender and indurated - Purulent drainage may or may not be obvious may release a serosanguineous or purulent fluid Treatment Perineal: - NSAIDs - Sitz bath - Broad spectrum antibiotic Abdominal: - Incision and drainage - Antibiotics Mastitis Inflammation of the mammary gland
RISK FACTORS: - Milk stasis and cracked nipples contribute to the influx of skin flora - Incomplete emptying of the breast - Improper nursing technique Assessment Fever Chills Myalgias Erythema Warmth Swelling Breast tenderness Therapeutic management Antibiotic Continue with breastfeeding Apply cold or ice compress Use a supportive bra For milk stasis: - Moist heat - proper positioning of the infant - Massage - manual expression of milk - Fluids rest - analgesics
Thromboembolic Disorder A group of disorders that caused by blood clots in the blood vessels. May travel through the bloodstream and block an artery. 3 types: 1. Superficial Thrombophlebitis - inflammation of the wall of the vein located close to the skin surface (superficial). It may be accompanied by blood clot formation and may be uncomfortable, but not dangerous.
2. Deep vein Thrombosis - involves formation of a blood clot in the deep veins of calves, legs or pelvis.
3. Phlebothrombosis - involves blood clot formation without the vein inflammation.
CAUSE: Virchow's triad: venous thrombosis occurs via three mechanisms: 1. decreased flow rate of the blood 2. damage to the blood vessel wall 3. increased tendency of the blood to clot (hypercoagulability).
RISK FACTORS: Varicose vein Injury to the vein such as injection Obesity Smoking Age greater than 35 y.o History of 3 or more pregnancies Prolonged labor and use of forceps or c/s Polycythemia Immobility: long trips, bedridden Use of oral contraceptive Categories a. Superficial Thrombophlebitis - is a common inflammatory-thrombotic process that may occur spontaneously or as a complication of medical or surgical interventions. - Sterile thrombophlebitis limited to the superficial veins rarely is life threatening, but a thorough diagnostic evaluation is mandatory because many patients with superficial phlebitis also have occult deep vein thrombosis (DVT).
Superficial phlebitis with infection, such as phlebitis originating at an intravenous catheter site, is referred to as septic thrombophlebitis. This clinical entity requires special diagnostic and therapeutic approaches that are different from those applicable to sterile phlebitis. SIGNS AND SYMPTOMS: - Develop within the first 3 days postpartum period - Tender, painful area along a vein in the calf - Reddened area - Vein is enlarged and highly visible - Area is warm and cordlike to touch - Extremity may be swollen - Woman reports pain when walking
DIAGNOSIS: - Based on the signs and symptoms b. Deep vein thrombophlebitis - is the formation of a blood clot ("thrombus") in a deep vein. Deep vein thrombosis commonly affects the leg veins (such as the femoral vein or the popliteal vein) or the deep veins of the pelvis SIGNS AND SYMPTOMS - Develop signs and symptoms during pregnancy or at any time during the postpartum period - Increase calf pain - Leg swollen visibly - Thigh and calf circumference is larger than the other leg
- Pedal edema - Area is warm, tender and red - Positive with homans sign - Arterial spasms - Chills, low-grade fever, malaise, stiffness of the affected leg - Pain on ambulation
Statistic The risk of venous thrombosis and pulmonary embolism in otherwise healthy women is considered highest during pregnancy and the puerperium. Indeed, the risk of pulmonary embolism has been estimated to be as much as four- to sixfold higher during pregnancy (Christiansen and Collins, 2006; Marik and Plante, 2008). The incidence of all thromboembolic events averages about 1 per 1000 pregnancies, and about an equal number are identified antepartum and in the puerperium. In a recent study from Norway of more than 600,000 pregnancies, Jacobsen and colleagues (2008) reported that deep-venous thrombosis alone was more common antepartum whereas pulmonary embolism was more common in the first 6 weeks postpartum. The frequency of venous thromboembolic disease during the puerperium has decreased remarkably as early ambulation has become more widely practiced.
Disgnostics The gold standard is intravenous venography, which involves injecting a peripheral vein of the affected limb with a contrast agent and taking X-rays, to reveal whether the venous supply has been obstructed. Because of its invasiveness, this test is rarely performed. Real-time and color doppler ultrasound - non-invasive diagnostic method and is commonly used. - Plethysmography - D-Dimer test
Nsg. management 1. Woman may continue breastfeeding while receiving Heparin 2. Discontinue breastfeeding if woman is receiving coumadin 3. Examine extremity for obvious prominent veins 4. Check for Homans sign 5. Promote early ambulation 6. Instruct client to avoid rubbing or massaging the affected extremity 7. Increase fluid intake 8. Bed rest 9. Apply moist heat warm compress to decrease inflammation 10. Teach women not wearing constricting clothing
Complication Pulmonary embolism - is a blockage of the main artery of the lung or one of its branches by a substance that has travelled from elsewhere in the body through the bloodstream (embolism). Usually this is due to embolism of a thrombus (blood clot) from the deep veins in the legs, a process termed venous thromboembolism. Signs and symptoms Sudden, sharp chest pain on inspiration Orthopnea Cyanosis Tachycardia Tachypnea Low blood pressure Sudden death
Treatment Anticoagulant Oxygen therapy Analgesia
Postpartum Psychiatric Disorders A disorder during postpartum characterized by disturbance in a mothers thoughts, emotions and behavior During postpartum period, about 85% of women experience some type of mood disturbance. Symptoms are mild and short-lived, however 10-15% of women develop more significant symptoms of depression or anxiety. Etiology Unknown Based on multifactorial model Psychologically, result from the stress of the peripartum period and the responsibilities of child rearing Sudden decrease in the endorphins of labor Diagnosis Postpartum thryroid dysfunction Low free serum tryptophan Risk factors Undesired pregnancy Feeling unloved by mate Age younger than 20 years Unmarried status Medical indigence Low self-esteem Economic problems with housing or income Poor relationship with husband or boyfriend Being part of a family with 6 or more siblings Limited parental support Past or present evidence of emotional problems Women with a history of PPD and postpartum psychosis
3 Categories 1. Postpartum Blues 2. Postpartum Depression 3. Postpartum Psychosis Postpartum Blues Onset is from first to fourth days after birth Symptoms typically peak on the fourth or fifth day after delivery and may last for a few hours or a few days, remitting spontaneously within two weeks of delivery Sadness and tears are the common symptoms. While these symptoms are unpredictable and often unsettling, they do not interfere with a womans ability to function Etiology - Probable hormonal changes - Stress of life changes Treatment - No specific treatment is required. - If symptoms of depression persist for longer than two weeks, patient should be evaluated to rule out a more serious mood disorder. Postpartum Depression Typically emerges over the first two to three postpartum months or may even be present for longer than one year but may occur at any point after delivery. Some women actually note the onset of milder depressive symptoms during pregnancy Symptoms Depression or sad mood Tearfulness Loss of interest in usual activities Feelings of guilt Feelings or worthlessness or incompetence Fatigue Sleep disturbance Change in appetite Poor concentration Suicidal thoughts Generalized anxiety is common, some women develop panic attacks or hypochondriasis Postpartum OCD has also been reported ETIOLOGY: - Hx of previous depression - Hormonal response - Lack of social support Risk factors - Hx. of depression - Troubled childhood - Low self-esteem - Stress in the home or at work - Lack of effective support people Treatment Counselling Drug therapy Non-pharmacological therapies are useful in the treatment of postpartum depression. - Cognitive-Behavioral therapy - Interpersonal therapy Conventional antidepressant medications - Fluoxetine, sertraline, fluvoxamine and venlafaxine
Postpartum Psychosis Most severe form of Postpartum psychiatric illness A rare event that occurs in aapprox. 1-2 per 1000 women after childbirth Occurs in the first postpartum year and refers to a group of severe and varied disorders that elicit psychotic sypmtoms Earliest signs are restlessness, irritability, and insomnia Women exhibit a rapidly shifting depressed or elated mood, disorientation or confusion and erratic or disorganized behavior. Delusional beliefs are common and often center on the infant Auditory hallucinations may also occur ETIOLOGY - Possible activation of previous mental illness - Hormonal changes - Family history of bipolar disorder Referring to counseling Safeguarding the mother from injury to self or newborn Considered a psychiatric emergency that typically requires inpatient treatment
Care of Couple with problems of infetility Infertility the inability to conceive a child or sustain a pregnancy to birth. Subfertility said to exist when a pregnancy has not occurred after at leats 1 year of engaging in unprotected coitus a. Primary there have been no previous conceptions b. Secondary there has been a previous viable pregnancy but the couple is unable to conceive at present. Sterility the inability to conceive because of a known condition, such as the absence of a uterus.
Male Subfertility Factors - Disturbance in spermatogenesis (production of sperm cells) - Obstruction in the seminiferous tubules, ducts, or vessels preventing movement of spermatozoa. - Qualitative or quantitative changes in the seminal fluid preventing sperm motility (movement of sperm) Development of autoimmunity that immobilizes sperm Problems in ejaculation or deposition preventing spermatozoa from being placed close enough to a womans cervix to allow ready penetration and fertilization
1. Inadequate sperm count The sperm count is the number of sperm in a single ejaculation or in a milliliter of semen. N 20 million per milliliter of seminal fluid or 50 million per ejaculation Atleast 50% of sperm motile and 30% should be normal in shape and form. Spermatozoa must be produced and maintained at a temperature to be fully motile Any condition that significantly increases body temperature: - Chronic infection e.g tuberculosis or recurrent sinusitis - Actions that increase scrotal heat e.g working at desk jobs or driving a great deal everyday (salesmen or motorcyclists) - Frequent use of hot tubs or saunas may also lower sperm counts appreciably. - Cryptorchidism - Varicocele
2. Obstruction or impaired sperm motility - Obstruction may occur at any point along the pathway that spermatozoa must travel to reach the outside: seminiferous tubules, epididymis, vas deferens, the ejaculatory duct or the urethra. Mumps orchitis Epididymitis
Tubal infections such as gonorrhea or ascending urethral infection can result in this type of obstruction because of adhesions form and occlude sperm transport. Congenital stricture of the spermatic duct BPH Vasectomy Autoimmune reaction Hypospadias Epispadias Extreme Obesity
3. Ejaculation Problems Erectile dysfunction inability to achieve erection Primary erectile dysfunction if the man has never been able to achieve reection and ejaculation Secondary erectile dysfunction if the man has been able to achieve ejaculation in the past but now has difficulty Premature ejaculation ejaculation before penetration
Female Subfertility Factors: - Anovulation (faulty or inadequate production of ova) - Problems of ova transport through the fallopian tubes to the uterus - Tumors or poor endometrial development - Nutrition, body weight and exercise 1. Anovulation - Turners syndrome (hypogonadism) no ovaries to produce ova - Hormonal imbalance caused by Hypothyroidism that interferes with hypothalamus pituitary-ovarian intreaction - Chronic or excessive exposure to X-rays or radioactive substances, general ill health, poor diet and stress - Nutrition, body weight and exercise influence the blood glucose/insulin balance
- When glucose or insulin are too high, they can disrupt the production of FSH and LH - Nutrition: eating slowly digested carbohydrate foods such as brown rice, pasta, dark bread, beans and fiber rich vegetables increase fertility - Eating protein is important but from plant sources: beans, tofu, soy beans and nuts - Exercising 30 minutes a day help regulate blood glucose levels - Stress reduces Hypothalamic secretion of Gonadotropin releasing hormone which then lowers the LH and FSH - Women who are excessively lean and anorexic can reduce pituitary hormones such as FSH and LH ( termed hypogonadotropic hypogonadism) - Polycystic Ovary syndrome ovaries produce excess testosterone lowering the FSH and LH
2. Tubal transport problems - Develops because scarring has developed in the fallopian tubes (Chronic PID) - Ruptured appendix or from abdominal surgery that spread to fallopian tubes and left adhesions - Tubal ligation
3. Uterine problems - Fibromas(leiomyomas) - Endometriosis 4. Cervical problems - Stenotic cervical os - Inflammation of the cervix 5. Vaginal problems - Infection of the vagina cause the pH to become acidotic limiting or destroying the motility of the sperm
Fertility assessment 1. Health History 2. Physical assessment 3. Fertility testing a. Semen analysis - 2-4 days of abstinence the man ejaculates by masturbation into a clean, dry specimen jar. Then number of sperm are counted and examined under the microscope
- ave. ejaculation should produce 2.5-5ml of semen. (Ave. normal sperm count is 50-200 million per milliliter) - may be repeated after 2-3 months because spermatogenesis is an ongoing process and 30- 90days is needed for new sperm to reach maturity b. Sperm penetration assay and antisperm antibody testing - Rarely necessary - Determine whether a mans sperm, once they reach the ovum can penetrate it effectively
c. Ovulation Monitoring - BBT record the temp atleast 4 months, take her temp every morning before getting out of bed or engaging in any activity d. Ovulation determine by strip - Can be used in place of BBT - A woman dips a test strip into a midmorning urine specimen and then compares it with the kit instructions for a color change - Purchased OTC, easy to use, have the advantage of marking the point just before ovulation occurs rather than just after ovulation as in the case of BBT
e. Tubal patency - Determine the patency of fallopian tubes and assess the depth and consistency of the endometrial lining a. Sonohysterography b. Hysterosalpingography
4. Advanced surgical Procedures a. Uterine endometrial biopsy b. Hysteroscopy c. Laparoscopy Subfertility management 1. Correction of underlying problems a. Increasing sperm count and motility b. Reducing the presence of infection c. Hormone therapy d. Surgery 2. Assisted Reproductive Techniques a. Therapeutic Insemination
Gestational Age Variaton 1. SGA - Birth weight of infants falls below the 10 th
percentile on intrauterine growth curve. - Maybe be preterm, term and postterm ETIOLOGY: 1. Chromosomal problems - Down syndrome - Congenital anomalies
- Acute infectious problems - UTI - Genital tract abnormalities Physical characteristics - Inadequate amount of surfactnt - Poorly developed sucking and gag reflexes - Unstable heart regulation - Low resistance to infection - Immature CNS, renal and liver system
- Increased capillary fragility - Excessive lanugo Complications - RDS - PDA - Hypothermia and cold stress - Neonatal NEC - Feeding difficulties - Marked insensible water loss - Infection: low WBC count
- Apnea - Hypoglycemia - Jaundice 4. Postterm - Infant born on the 42 nd weeks or above ETIOLOGY - Uncertain
Physical characteristics - Can be large, small or appropriate size; usually in good condition alert, active - In postmaturity: long and thin in appearance Dry, cracked and desquamating skin Nails extending beyond fingertips Placental insufficiency Absent vernix and lanugo Malnourished and dehydrated Depleted subcutaneous fat old man wrinkled appearance
Often meconium-stained skin, nails and cord Alert Complications - CPD - Birth trauma - Expose to hazards of OCT - Tolerated stress of labor poorly - Meconium aspiration - Cold stress - Hypoglycemia - Seizures Immediate Management Respiratory parameters 1. Observe respiratory rate, rhythm, and depth. a. Initially, rate increase without a change in rhythm b. Flaring of nares and expiratory grunting are early signs of RDS 2. Increase in Apical pulse rate. 3. Subcostal and xiphoid retractions progress to intercostal, substernal and clavicular retractions 4. Color a. Progresses from pink to circumoral pallor to circumoral cyanosis to generalized cyanosis b. Increased intensity of acrocyanosis 5. Progressive respiratory distress a. Chin tug (chin pulled down and in with mouth opening wider-auxiliary muscles of respiration are used). b. Abdominal seesaw breathing patterns c. Distinguish between apneic episodes (15 seconds or longer) and irregular breathing (cessation of breathing for 5-10seconds) 6. Falling body temperature. 7. Progressing anoxia leading to cardiac decompensation and failure. 8. Increased muscle flaccidity: frog-like position D. Nutrition 1. Assess readiness and ability to feed: swallowing, gag reflexes 2. Screen for hypoglycemia 3. Observe for congenital dysfunction and anomalies related to tracheoesophageal fistula, anal atresia and metabolic disorders
4. Check amount and frequency of elimination 5. Assess for vomiting or regurgitation; a preterm infants stomach capacity is small, and overfeeding can occur. 6. Check mucous membranes, urine output, and skin turgor to identify fluid and electrolyte imbalances. a. Skin turgor over abdomen and inner thighs b. Sunken fontanel c. Urinary output of less than 30 ml per day
E. Temperature regulation 1. Assess infants temperature: frequently done with a skin probe for continuous monitoring of temperature in infants at high risk for complications 2. Check coolness or warmth of body temperature and extremities. 3. Detect early signs of cold stress. a. Increased physical activity and crying b. Increased RR
c. Increased acrocyanosis or generalized cyanosis along with mottling of the skin(cutis mamorata) d. Male with descended testes: presence of cremasteric reflex(testes pulled back up into the inguinal canal on exposure to cold) 4. Monitor infants temperature a. Axillary temperature: 36.5C b. Place a temperature skin probe on infant while he or she is in the radiant warmer or isolette. Nursing Interventions Goal: To maintain respiratory functioning. A. Provide gentle physical stimulation to remind infant to breathe. 1. Gently rub the infants back 2. Lightly tap the infants feet B. Ensure patency of respiratory tract 1. Maintain open airway by means of nasal, oral or pharyngeal suctioning 2. Position to promote oxygenation. a. Elevate head 10 degrees with neck slightly extended by placement of a small folded towel under the shoulders. b. Flex and abduct infants arms and place at sides. c. Avoid diapers or adhere them loosely. d. Do not place in prone position. C. Assist infants respiratory efforts.
1. Monitor oxygen pressure. a. Anywhere 21%-100% oxygen is administered to maintain the PO2 around 50 to 80mmHg. b. Avoid high concentrations of oxygen for prolonged periods: leads to complications of retrolental fibroplasia and bronchopulmonary dysplasia. 2. Positive end-expiratory pressure helps keep alveoli open at the end of expiration by providing positive pressure. 3. Continuous positive airway pressure (CPAP) counteracts the tendency of the alveoli to collapse by providing continuous distending airway pressure. D. Monitor oxygen therapy. 1. Pulse oximeter
Goal: To provide adequate nutrition A. Detect hypoglycemia and treat immediately: administer 5% dextrose in water IV if infant is unable to tolerate oral feeding. B. Oral feeding: initial feeding 1. Use sterile water: 1-2ml for a small infant 2. Use preemie nipple 3. Feedings are small amount and increased in frequency.
C. Detect complications that arise with feeding the preterm infant as a result of: 1. Weak or absent sucking and swallowing reflexes 2. Poor gag reflex leading to aspiration 3. Incompetent cardiac sphincter 4. Increased incidence of vomiting and development of abdominal distention 5. Inability to absorb essential nutrients. 6. Excessive water loss through evaporation from the skin and respiratory tract
Respiratory Distress - Formerly termed Hyaline membrane disease. Cause: 1. Low level or absence of surfactant - Surfactant is a phospholipid that normally lines the alveoli and resists surface tension on expiration to keep alveoli from collapsing on expiration.
Note: - High pressure is required to fill the lungs with air for the first time and overcome the pressure of lung fluid.
At birth
Decrease surfactant
Areas of hypoinflation
Increase pulmonary resistance
Lungs poorly perfused
Poor gas exchange
Hypoxia Inc CO2 level
Release lactic acid Formation of the hyaline membrane on alveolar surface
Further prevents the exchange of O2 and CO2 at the alveolar capillary membrane
Leads to severe acidosis
Vasocontriction
Dec. pulmonary perfusion
Further limits surfactant production (this vicious cycle continues until the O2-CO2 exchange in the alveoli is no longer adequate to sustain life Assessment Tachypnea (more than 60 cpm) Nasal flaring Sternal and subcostal retractions Seesaw breathing Apneic spells Abnormal breath sounds:rales and rhonchi Chin tug Expiratory grunting
- An ominous sign and indicates impending need for respiratory assistance - Grunting sound occurs as a result of air pushing past a partially closed glottis. - Accompanied by whining or moaning sound Cyanosis
Diagnostics Chest x-ray ABG Blood culture Lumbar puncture (R/O CNS problems) Determine Lecithin/Sphingomyelin ratio Treatment Surfactant Resplacement - Synthetic surfactant is sprayed into the lungs by a syringe through an endotracheal tube at birth Oxygen administration with ventilator - CPAP - PEEP Additional therapy - Pancuronium (Pavulon)
Meconium aspiration syndrome Meconium is present as early as 10 weeks gestation Infant with hypoxia in utero has a vagal reflex relaxation of the rectal sphincter which releases meconium into the amniotic fluid Babies in breech position may expel meconium because from the pressure on the buttocks Mecoinum can cause severe Respiratory distress in 3 ways: 1. Can bring about inflammation of bronchioles because it is foreign substance 2. It can block small bronchioles by mechanical plugging 3. It can cause decrease surfactant production through lung cell trauma Assessment Apgar score is low Tachypnea Retractions Cyanosis Chest retractions Barrel chest Coarse bronchial sound
Therapeutic Management Suction the infant with bulb syringe while at the perineum Tracheal suction Oxygen administration with ventilation Chest physiotherapy with clapping and vibration
Neonatal Sepsis Refers to the presence of bacteria in the bloodstream Risk factors: 1. Prematurity 2. Invasive procedure 3. Immature immunological system 4. Maternal antepartal infection 5. Intrapartal maternal infection
assessment Apathy Lethargy, poor temperature control Poor feeding Abdominal distention Diarrhea Cyanosis Irregular respirations: Apnea Hyperbilirubinemia Diagnostics Blood culture and sensitivity CBC Chest x-ray Viral studies Lumbar puncture Treatment Medications: 1. Antibiotics 2. Antiviral 3. Antifungal Supportive treatment: 1. Oxygen 2. IV therapy 3. Regulation of fluids and electrolytes Hyperbilirubinemia Is a condition in which there is too much bilirubin in the blood. When RBC break down, a substance called bilirubin is formed. Babies are not easily able to get rid of the bilirubin and it can build up in the blood and other tissues and fluids of the babys body. Because bilirubin has a pigment or coloring, it causes a yellowing of the babys skin and tissues. This is called jaundice. - Hemolytic disease of the newborn - Rh Incompatibility - ABO incompatibility
Signs and Symptoms - Yellow sclerae - Yellow skin - Anemia - Enlarged spleen - Normal colored stools
- Fatigue - Light colored stools - Dark urine - Lethargy - Poor feeding - Mental retardation - Less mature - Rigidity - Tremors - ataxia Risk Factors: - Prematurity - Asian ancestry - Maternal diabetes - Kernicterus Diagnostic tests: - CBC - Coombs test Direct coombs test Indirect coombs test - Measurement of levels of specific types of bilirubin - Reticulocyte count *Diagnosis - Jaundice and elevated levels of serum bilirubin confirm the diagnosis of hyperbilirubinemia - Inspection of the neonate is a well-lit room (without yellow or gold lighting) reveals yellowish skin coloration particularly in the sclerae
Treatment - Phototherapy - Initiation of early feeding - Exchange transfusion - Albumin transfusion - Drug therapy Compications - Jaundice - Serious brain damage - Kernicterus - Severe anemia Nursing Management - Isotonic IV fluids - Supplemental oxygen - Cardiac monitoring - Nasogastric suction - Bladder catheterization - ERCP papillotomy - Interferon: Cortecosteroids Medical management - Penicillamine - Phenobarbital
Sudden Infant death syndrome Is the sudden unexplained death in infant Tends to occur at a higher than usual rate in the infants of: - Adolescent mothers - Highly closely spaced pregnancy - Underweight - Preterm - Bronchopulmonary dysplasia - Infants of narcotic independent mothers
Unknown Possible contributing factors: - Viral respiratory or botulism infection - Distorted familial breathing pattern - Possible lack of surfactant in alveoli - Sleeping prone
Peak ages of incidence are between 2 weeks and 1 year of age.