1. The intrapartum period extends from the beginning of contractions that cause cervical dilation to the first 1 to 4 hours after delivery of the newborn and placenta.
2. Intrapartum care refers to the medical and nursing care given to a pregnant woman and her family during labor and delivery.
GOALS OF INTRAPARTUM CARE
1. To promote physical and emotional well-being in the mother and fetus.
2. To incorporate family-centered care concepts into the labor and delivery experience.
NATIONAL HEALTH GOALS
Labor and birth are both high-risk periods for mother and the fetus. Several national health goals speak to this risk. They are:
1. To reduce the number of fatal deaths to 3.3 / 100,000 live births from a baseline of 7.1/100,000.
2. To reduce number of fatal deaths at 20 or more weeks gestation to 4.1 / 1,000 live births from a base line of 6.8 / 1,000.
3. To reduce fatal and infant deaths during the prenatal period (28 weeks gestation to 7 days after birth) to 4.5 / 1,000 live births from a baseline of 7.5 / 1,000 live births (Department of Health and Human Services, 2000)
FACTORS AFFECTING THE INTRAPARTUM EXPERIENCE
1. Previous experience with pregnancy
2. Cultural and personal expectations
3. Pre-pregnant health and biophysical preparedness for childbearing
4. Motivation for childbearing
5. Socioeconomic readiness
6. Age of mother
7. Partnered versus unpartnered status
8. Extend of parental care
9. Extend of childbirth education
Intrapartum Care: Phenomena And Process Of Labor And Deliver
A. ONSET OF LABOR
1. Labor is the process by which the fetus and products of conception are expelled as the result of regular, progressive, frequent, strong uterine contractions.
2. Theoretically labor is thought to result from:
a. Progesterone deprivation
b. Oxytocin stimulation
c. Fatal endocrine control
d. Uterine deciduas activation (release of a complex cascade of bioactive chemical agents into amniotic fluid)
B. FACTORS AFFECTING LABOR
1. PASSAGEWAY. This refers to the adequacy of the pelvis and birth canal in allowing fetal descent; factors include:
a. Type of pelvis (for example, gynecoid, android, anthropoid, or platypelloid)
b. Structure of pelvis (for example, true versus false pelvis)
c. Pelvic inlet diameters
d. Pelvic outlet diameters
e. Ability of the uterine segment to distend the cervix to dilate, and the virginal canal and introitus to distend.
1. Labor is the process by which the fetus and products of conception are expelled as the result of regular, progressive, frequent, strong uterine contractions.
2. Theoretically labor is thought to result from:
a. Progesterone deprivation
b. Oxytocin stimulation
c. Fatal endocrine control
d. Uterine deciduas activation (release of a complex cascade of bioactive chemical agents into amniotic fluid)
B. FACTORS AFFECTING LABOR
1. PASSAGEWAY. This refers to the adequacy of the pelvis and birth canal in allowing fetal descent; factors include:
a. Type of pelvis (for example, gynecoid, android, anthropoid, or platypelloid)
b. Structure of pelvis (for example, true versus false pelvis)
c. Pelvic inlet diameters
d. Pelvic outlet diameters
e. Ability of the uterine segment to distend the cervix to dilate, and the virginal canal and introitus to distend.
2. PASSENGER. This refers to the fetus and its ability to move through the passage way, which is based on the following:
a. Size of the fetal head and capability of the head to mold the passageway.
b. Fetal presentation – the part of the fetus enters to maternal pelvis first (for example, cephalic [vertex, face, brow]: breech [frank, single or double footing complete]; or shoulder [transverse, lie])
c. Fetal attitude – the relationship of fetal parts to one anther.
d. Fetal position – the relationship of a particular reference points of the presenting part and the maternal pelvis, described with a series of three letters (side of maternal pelvis [L, left; R, right; T, transverse], presenting [O, occiput; S, sacrum; Sc, scapula; M, mentum], and the part of the maternal pelvis (A, anterior; P, posterior].
a. Size of the fetal head and capability of the head to mold the passageway.
b. Fetal presentation – the part of the fetus enters to maternal pelvis first (for example, cephalic [vertex, face, brow]: breech [frank, single or double footing complete]; or shoulder [transverse, lie])
c. Fetal attitude – the relationship of fetal parts to one anther.
d. Fetal position – the relationship of a particular reference points of the presenting part and the maternal pelvis, described with a series of three letters (side of maternal pelvis [L, left; R, right; T, transverse], presenting [O, occiput; S, sacrum; Sc, scapula; M, mentum], and the part of the maternal pelvis (A, anterior; P, posterior].
3. POWER. This refers to the frequency duration and strength of uterine contraction to cause complete cervical effacement and dilation.
4. PLACENTAL FACTORS refers to the site of placental insertion.
5. PSYCHE refers to the client’s psychological state, available support systems, preparation.
4. PLACENTAL FACTORS refers to the site of placental insertion.
5. PSYCHE refers to the client’s psychological state, available support systems, preparation.
C. SIGNS AND SYMBOLS OF IMPENDING LABOR (premonitory signs)
1. Lightning is the descent of the fetus and uterus into the pelvic cavity 2 to 3 weeks before the onset of labor.
2. Braxton hicks contractions are irregular, intermittent contractions that have occurred throughout the pregnancy; become uncomfortable, and produce a drawing pain in the abdomen and groin.
3. Cervical changes, include softening “ripening” and effacement of the cervix that will cause explosion of the mucus plug (bloody show) and increased vaginal discharge.
4. Rupture of amniotic membranes may occur before the onset of labor if the woman suspects that her membranes have ruptured, she should contact her health care provider and go to the labor suite immediately so that she may be examined for prolapsed cord – a life-threatening condition for the fetus.
5. Burst of energy or increased tension and fatigue may occur before the onset of labor.
6. Weight loss of about 1 to 3 pounds may occur 2 to 3 days before the offset of labor.
7. Urinary frequency returns.
8. Backache.
1. Lightning is the descent of the fetus and uterus into the pelvic cavity 2 to 3 weeks before the onset of labor.
2. Braxton hicks contractions are irregular, intermittent contractions that have occurred throughout the pregnancy; become uncomfortable, and produce a drawing pain in the abdomen and groin.
3. Cervical changes, include softening “ripening” and effacement of the cervix that will cause explosion of the mucus plug (bloody show) and increased vaginal discharge.
4. Rupture of amniotic membranes may occur before the onset of labor if the woman suspects that her membranes have ruptured, she should contact her health care provider and go to the labor suite immediately so that she may be examined for prolapsed cord – a life-threatening condition for the fetus.
5. Burst of energy or increased tension and fatigue may occur before the onset of labor.
6. Weight loss of about 1 to 3 pounds may occur 2 to 3 days before the offset of labor.
7. Urinary frequency returns.
8. Backache.
D. CHARACTERISTICS OF TRUE LABOR
1. Contractions occur at regular intervals (Client and Family Teaching 9-1)
2. Contractions start in the black and sweep around to the abdomen, increase in intensity and durations and gradually have shortened intervals.
3. Walking intensifies contractions.
4. “Bloody show” (pink-tinged mucus released from the cervical canal as labor starts) is usually present.
5. Cervix becomes effaced and dilated.
6. Sedation does not stop contractions.
1. Contractions occur at regular intervals (Client and Family Teaching 9-1)
2. Contractions start in the black and sweep around to the abdomen, increase in intensity and durations and gradually have shortened intervals.
3. Walking intensifies contractions.
4. “Bloody show” (pink-tinged mucus released from the cervical canal as labor starts) is usually present.
5. Cervix becomes effaced and dilated.
6. Sedation does not stop contractions.
E. CHARACTERISTICS OF FALSE LABOR
1. Contractions occur at regular intervals (Client and Family Teaching 9-1)
2. Contractions starts in the back and sweep around to the abdomen, intensify remains the same or is variable, and the intervals remain long.
3. Walking does not intensify contractions and often relief.
4. Blood show usually is not present, if present, it is usually brownish rather than right red and may be due to a recent pelvic examination or intercourse.
5. There are no cervical changes.
6. Sedation tends to decrease the number of contractions.
F. STAGES OF LABOR
1. The FIRST STAGE of labor begins with the onset of regular contractions which cause progressive cervical dilation and effacement. It ends when the cervix is completely effaced and dilated. It is composed of a latent, an active, and a transition phase.
a. Latent phase. This phase begins with the onset of regular contractions and effacement and dilation of the cervix 3 to 4 cm. It lasts an average of 6.4 hours for multiparas. Contractions become increasingly stronger and more frequent.
b. Active phase. Dilation continues from 3 to 4 cm to 7 cm. Contractions become stronger, more frequent, longer, and more painful.
c. Transition phase. The culmination of the first stage is the transition phase during which the cervix dilates from 8 to 10 cm. The intensity, frequency, and durations of contractions peak and there is an irresistible urge to push.
2. SECOND STAGE (expulsive stage)
a. The second stage begins with complete dilation of the cervix and ends with delivery of the newborn. Durations may differ among primiparas (longer) and multiparas (shorter), but this stage should be completed within 1 hour after complete dilation.
b. Contractions are severe at 2 to 3 minute intervals, with a duration of 50 to 90 seconds.
c. The newborns exists the birth canal with help from the following cardinal movements or mechanisms of labor (figure 9-2)
i. Descent
ii. Flexion
iii. Internal Rotation
iv. Extension
v. External Rotation (restitution)
vi. Expulsion
d. “Crowning” occurs when the newborns head or presenting part appears at the vagina; opening
e. Episiotomy (surgical incision in perineum) may be done to facilitate delivery and avoid laceration of the perineum.
1. The FIRST STAGE of labor begins with the onset of regular contractions which cause progressive cervical dilation and effacement. It ends when the cervix is completely effaced and dilated. It is composed of a latent, an active, and a transition phase.
a. Latent phase. This phase begins with the onset of regular contractions and effacement and dilation of the cervix 3 to 4 cm. It lasts an average of 6.4 hours for multiparas. Contractions become increasingly stronger and more frequent.
b. Active phase. Dilation continues from 3 to 4 cm to 7 cm. Contractions become stronger, more frequent, longer, and more painful.
c. Transition phase. The culmination of the first stage is the transition phase during which the cervix dilates from 8 to 10 cm. The intensity, frequency, and durations of contractions peak and there is an irresistible urge to push.
2. SECOND STAGE (expulsive stage)
a. The second stage begins with complete dilation of the cervix and ends with delivery of the newborn. Durations may differ among primiparas (longer) and multiparas (shorter), but this stage should be completed within 1 hour after complete dilation.
b. Contractions are severe at 2 to 3 minute intervals, with a duration of 50 to 90 seconds.
c. The newborns exists the birth canal with help from the following cardinal movements or mechanisms of labor (figure 9-2)
i. Descent
ii. Flexion
iii. Internal Rotation
iv. Extension
v. External Rotation (restitution)
vi. Expulsion
d. “Crowning” occurs when the newborns head or presenting part appears at the vagina; opening
e. Episiotomy (surgical incision in perineum) may be done to facilitate delivery and avoid laceration of the perineum.
3. THIRD STAGE (placental stage)
a. This stage begins with delivery of the newborn and ends with delivery of the placenta. It occurs in two phases – placental separation and placental expulsion.
b. Signs of placental separation include the uterus becoming globular, the fundus rising in the abdomen, lengthening of the cord, and increased bleeding (trickle or gush)
c. Contraction of the uterus controls uterine bleeding and aids placental separation and explanation.
d. Generally, oxytocic drugs are administered to help the uterus contract.
a. This stage begins with delivery of the newborn and ends with delivery of the placenta. It occurs in two phases – placental separation and placental expulsion.
b. Signs of placental separation include the uterus becoming globular, the fundus rising in the abdomen, lengthening of the cord, and increased bleeding (trickle or gush)
c. Contraction of the uterus controls uterine bleeding and aids placental separation and explanation.
d. Generally, oxytocic drugs are administered to help the uterus contract.
4. FOURTH STAGE (recovery and bonding)
a. This stage lasts form 1 to 4 hours after birth.
b. The mother and newborn recover from the physical process of birth.
c. The maternal organs undergo initial readjustment to the nonpregnant state.
d. The newborn body systems begin in the midline of the abdomen with the fundus midway between the umbilicus and symphysis pubis.
Intrapartum Care: First And Second Stages Of Labora. This stage lasts form 1 to 4 hours after birth.
b. The mother and newborn recover from the physical process of birth.
c. The maternal organs undergo initial readjustment to the nonpregnant state.
d. The newborn body systems begin in the midline of the abdomen with the fundus midway between the umbilicus and symphysis pubis.
A. Maternal Assessment
1. A complete health history should include.
a. Name
b. Age
c. Physician
d. Weight
e. Allergies
f. Blood type and Rh factor
g. Previous medical conditions
h. Prenatal problems
i. Gravida and para status
j. Estimated date of delivery
k. Prenatal education
l. Method of newborn feeding
2. Screening to risk factors is essential and should include:
1. A complete health history should include.
a. Name
b. Age
c. Physician
d. Weight
e. Allergies
f. Blood type and Rh factor
g. Previous medical conditions
h. Prenatal problems
i. Gravida and para status
j. Estimated date of delivery
k. Prenatal education
l. Method of newborn feeding
2. Screening to risk factors is essential and should include:
a. Bleeding
b. Premature of membranes (if ruptured, determine time of the note color and odor, if any)
c. Hydramnios
d. Abnormal presentations
e. Multiple gestations
f. Prolapsed cord
g. Preparations labor
h. Meconium, stained amniotic fluid
i. Fetal heart irregularities
j. Postmaturity
b. Premature of membranes (if ruptured, determine time of the note color and odor, if any)
c. Hydramnios
d. Abnormal presentations
e. Multiple gestations
f. Prolapsed cord
g. Preparations labor
h. Meconium, stained amniotic fluid
i. Fetal heart irregularities
j. Postmaturity
3. Physical Assessment
a. Material vital signs, weight, and cardiac and respiratory status are monitored. The frequency of maternal vital signs and respiratory status assessment is as follows.
- First stage latent: Blood pressure (BP), pulse, and respirations are assessed every hour (if the BP is greater than 140/90 or if the pulse is greater than 10, contact the primary care provider). Temperature is assessed every 4 hours (every 2 hours if the membranes are ruptured)
- First stage active: BP, pulse, and respirations are assessed every hour.
-First stage transition: BP and respirations are assessed every 30 minutes.
-Second stage: BP, and pulse are assessed every 5 to 15 minutes.
b. Fundal height is measured.
c. Status of labor (that is, contractions [onset, frequency, duration, and intensify], membranes, bleeding, cervical dilation, and fetal descent) is determined.
d. The client’s need for comfort, analgesia, or anesthesia is assessed continuously (see section III and IV).
-First stage transition: BP and respirations are assessed every 30 minutes.
-Second stage: BP, and pulse are assessed every 5 to 15 minutes.
b. Fundal height is measured.
c. Status of labor (that is, contractions [onset, frequency, duration, and intensify], membranes, bleeding, cervical dilation, and fetal descent) is determined.
d. The client’s need for comfort, analgesia, or anesthesia is assessed continuously (see section III and IV).
4. Psychosocial assessment should include anxiety, childbirth educations, support systems, and client’s response to labor.
5. Labor progress assessment should include:
a. Palpation or electronic monitoring (external with tocodynamometer and internal with intrauterine pressure catheter) is performed to assess the duration, frequency, and intensify of contractions. The frequency of contraction assessment is as follows.
- First latent – every 30 minutes
- First stage active – every 15 to 30 minutes
- First stage transition – every 15 minutes
- Second stage – each contraction
5. Labor progress assessment should include:
a. Palpation or electronic monitoring (external with tocodynamometer and internal with intrauterine pressure catheter) is performed to assess the duration, frequency, and intensify of contractions. The frequency of contraction assessment is as follows.
- First latent – every 30 minutes
- First stage active – every 15 to 30 minutes
- First stage transition – every 15 minutes
- Second stage – each contraction
e. Sterile vaginal examination is performed to assess cervical (opening of external or from closed to 10 cm) and cervical effacement (thinning and shortening of the cervix, as measured from 0% [thick] to 100% [paper thin] effaced).
f. Station is determined (that is, the relationship of the presenting part to the pelvic ischial spines).
A. Fetal Assessment
1. Inspect the maternal abdomen to determine fetal lie – the relationship of the long axis (spine) of the fetus to the long axis of the mother. Fetal lie can longitudinal or transverse.
a. Longitudinal lie is when the long axis of the fetus is parallel to the long axis of the mother.
b. Transverse lie is when the long axis of the fetus is perpendicular to the long axis of the mother.
b. Transverse lie is when the long axis of the fetus is perpendicular to the long axis of the mother.
2. Palpate the abdomen using the four Leopold Manuevers to determine fetal position and possible size.
3.Montior fetal status
a. Auscultate the FHR every 30 minutes during the first stage latent; every 15 minutes during first stage active and stage transition; every 5 to 15 seconds.
b. Assess changes in FHR to identify the following.
- Early deceleration – slowing of the FHR early on the contraction. It is considered benign, minor the contraction and has a characteristics V or U pattern.
- Late deceleration – an indication of fetal hypoxia due to uteroplacental insufficiency. It usually begins at the peak of the contraction and ends after the contraction ends.
- Variable deceleration – a transient decrease in FHR before, during or after the contraction. It indicates cord compression and has a characteristics V or U pattern.
- Bradycardia – an FHR less than 100 beats per minutes or a drop of 20 beats per minutes below baseline. In indicates cord compression or placental separations.
- Tachycardia – an FHR greater than 160 beats per minute. It indicates fetal distress if it persists for more than 1 hour is accompanied by late deceleration.
- Loss of beat-to-beat variability – indicates fetal reaction to maternal drugs, fetal sleep, or fetal demise.
c. Assess fetal acid-base status with fetal blood sampling or fetal scalps stimulations.
b. Assess changes in FHR to identify the following.
- Early deceleration – slowing of the FHR early on the contraction. It is considered benign, minor the contraction and has a characteristics V or U pattern.
- Late deceleration – an indication of fetal hypoxia due to uteroplacental insufficiency. It usually begins at the peak of the contraction and ends after the contraction ends.
- Variable deceleration – a transient decrease in FHR before, during or after the contraction. It indicates cord compression and has a characteristics V or U pattern.
- Bradycardia – an FHR less than 100 beats per minutes or a drop of 20 beats per minutes below baseline. In indicates cord compression or placental separations.
- Tachycardia – an FHR greater than 160 beats per minute. It indicates fetal distress if it persists for more than 1 hour is accompanied by late deceleration.
- Loss of beat-to-beat variability – indicates fetal reaction to maternal drugs, fetal sleep, or fetal demise.
c. Assess fetal acid-base status with fetal blood sampling or fetal scalps stimulations.
4. Continually assess the fetal response to the pain-relief methods used.
A. NURSING DIAGNOSIS
1. Health-Seeking behaviors
2. Anxiety
3. Ineffective Individual Coping
4. Pain
5. Risk for Injury
6. Risk for Ineffective airway clearance (newborn)
7. Risk for Hypoxia
1. Health-Seeking behaviors
2. Anxiety
3. Ineffective Individual Coping
4. Pain
5. Risk for Injury
6. Risk for Ineffective airway clearance (newborn)
7. Risk for Hypoxia
B. PLANNING AND OUTCOME IDENTIFICATION
1. The woman will be property admitted to the labor and delivery unit.
2. The woman will be partner will understand normal labor process and progress.
3. The woman and the partner will implement good coaching, breathing and other …
4. The woman will receive physical, emotional, and pharmacologic support as needed.
5. The woman will experience maximum safety.
6. The woman will be prepared for the birth of her child.
7. The newborn will receive essential immediate care.
8. The newborn and parents will experience early contact.
C. IMPLEMENTATION
1. The woman will be property admitted to the labor and delivery unit.
2. The woman will be partner will understand normal labor process and progress.
3. The woman and the partner will implement good coaching, breathing and other …
4. The woman will receive physical, emotional, and pharmacologic support as needed.
5. The woman will experience maximum safety.
6. The woman will be prepared for the birth of her child.
7. The newborn will receive essential immediate care.
8. The newborn and parents will experience early contact.
C. IMPLEMENTATION
1. Perform admission procedures.
a. Collect urine specimen and other samples for laboratory testing as prescribed (such as hemoglobin, hematocrit, serologic tests for syphilis, and type and cross-match if indicated)
b. Perform perineal preparation and enema, if indicated.
c. Notify attending physician or midwife, and report status.
d. Obtain informed consent from the client.
a. Collect urine specimen and other samples for laboratory testing as prescribed (such as hemoglobin, hematocrit, serologic tests for syphilis, and type and cross-match if indicated)
b. Perform perineal preparation and enema, if indicated.
c. Notify attending physician or midwife, and report status.
d. Obtain informed consent from the client.
2. Provided client and family teaching throughout the first and second stages.
a. Explain how activity toileting and hydration needs will be met during labor.
b. Explain equipment that will be used to monitor vital signs, labor and fetal status.
c. Explain the normal process and progress of labor and delivery to the woman and her support person.
d. Explain to the woman, that as the fetus descends in the birth canal, she will feel increased rectal pressure or the urge to push.
e. Coach the woman regarding effective pushing effort. Explain the importance of assuming a position that facilitates exclusive efforts, maintains placental perfusion and prevents or alleviates cord compression.
a. Explain how activity toileting and hydration needs will be met during labor.
b. Explain equipment that will be used to monitor vital signs, labor and fetal status.
c. Explain the normal process and progress of labor and delivery to the woman and her support person.
d. Explain to the woman, that as the fetus descends in the birth canal, she will feel increased rectal pressure or the urge to push.
e. Coach the woman regarding effective pushing effort. Explain the importance of assuming a position that facilitates exclusive efforts, maintains placental perfusion and prevents or alleviates cord compression.
3.Reinforce coaching, breathing, and other relaxation measures.
4. Provide physical, emotional, and pharmacologic support as needed throughout the first and second stages.
a. Provide pleasant, comfortable, surroundings
b. Collaborative with the client and birth attendant to determine the most effective method of pain relief during each stage of the intrapartum period.
c. Provide pharmacologic support as prescribed (see Drug Chart 9-1, page 134)
d. Provide support during contractions by coaching breathing, giving back rubs and offering cool cloths.
e.Assist the client with pushing as indicated.
a. Provide pleasant, comfortable, surroundings
b. Collaborative with the client and birth attendant to determine the most effective method of pain relief during each stage of the intrapartum period.
c. Provide pharmacologic support as prescribed (see Drug Chart 9-1, page 134)
d. Provide support during contractions by coaching breathing, giving back rubs and offering cool cloths.
e.Assist the client with pushing as indicated.
5.Promote safety during the first and second stages of labor.
a. If the client’s membranes are ruptured and the fetal head is not engaged, position the mother prevent cord prolapse.
b.Assess hydration status to avoid dehydration.
c. Offer the client an opportunity to avoid every 1 to 2 hours to prevent trauma to the bladder during pushing and birth of the newborn.
d. Interpret changes in the electronic fetal and maternal monitor strip, and take appropriate action.
a. If the client’s membranes are ruptured and the fetal head is not engaged, position the mother prevent cord prolapse.
b.Assess hydration status to avoid dehydration.
c. Offer the client an opportunity to avoid every 1 to 2 hours to prevent trauma to the bladder during pushing and birth of the newborn.
d. Interpret changes in the electronic fetal and maternal monitor strip, and take appropriate action.
6. Prepare for the birth of the newborn.
a. Prepare for delivery when the perineal area is bulging in a primipara and when the cervix is dilated 7 to 8 cm in a multipara.
b. Prepare the delivery area with equipment and supplies.
c. Place the client in the birthing position.
d. Assist the attending physician or nurse, midwife with the birth; help the support person to be supportive, and check all vital signs and FHR.
a. Prepare for delivery when the perineal area is bulging in a primipara and when the cervix is dilated 7 to 8 cm in a multipara.
b. Prepare the delivery area with equipment and supplies.
c. Place the client in the birthing position.
d. Assist the attending physician or nurse, midwife with the birth; help the support person to be supportive, and check all vital signs and FHR.
7. Implement immediate newborn care.
a. Establish and maintain a patent airway; suction with a bulb syringe or a De Lee mucus trap, and place the newborn on his side.
b. Compensate for poor newborn thermoregulation.
i. Dry the newborn immediately with a warm blanket
ii. Place the newborn under a radiant warmer
iii. Wrap the newborn in a warmed, dry blanket, a/or place the newborn on the mother’s skin.
c. Determine the Apgar score at 1 and 5 minutes after delivery.
d. Inspect the umbilical cord for two arteries and one vein.
e. Weigh and measure the newborn as his condition stabilizes.
f. Footprint the newborn’s and fingerprint the mother.
g. Record the newborn’s first voiding and stool passage.
h. Assess the newborn’s gestational age.
i. Administer prophylactic eye medication to protect the conjunctiva from infection.
j. Administer vitamin K (phytonadione [AquaMEPHYTON], if prescribed.
k. Encourage initial parent-newborn bonding by placing the newborn in the mother’s arms with skin-to-skin contact.
a. Establish and maintain a patent airway; suction with a bulb syringe or a De Lee mucus trap, and place the newborn on his side.
b. Compensate for poor newborn thermoregulation.
i. Dry the newborn immediately with a warm blanket
ii. Place the newborn under a radiant warmer
iii. Wrap the newborn in a warmed, dry blanket, a/or place the newborn on the mother’s skin.
c. Determine the Apgar score at 1 and 5 minutes after delivery.
d. Inspect the umbilical cord for two arteries and one vein.
e. Weigh and measure the newborn as his condition stabilizes.
f. Footprint the newborn’s and fingerprint the mother.
g. Record the newborn’s first voiding and stool passage.
h. Assess the newborn’s gestational age.
i. Administer prophylactic eye medication to protect the conjunctiva from infection.
j. Administer vitamin K (phytonadione [AquaMEPHYTON], if prescribed.
k. Encourage initial parent-newborn bonding by placing the newborn in the mother’s arms with skin-to-skin contact.
D. OUTCOME EVALUATION
1. The woman is properly admitted to the labor and delivery unit.
2. The woman and her partner use their knowledge of normal labor process and progress.
3. The woman and her partner implement food coaching breathing and other relaxation measures.
4. The mother receives physical, emotional, and pharmacologic support as needed and verbalizes increases comfort.
5. The woman experiences maximum safety, and there are no complications.
6. The woman is prepared for the birth of her child.
7. The newborn receives essential immediate care.
8. Parents hold and explore their infant.
Intrapartum Care: Third And Fourth Stages Of Labor2. The woman and her partner use their knowledge of normal labor process and progress.
3. The woman and her partner implement food coaching breathing and other relaxation measures.
4. The mother receives physical, emotional, and pharmacologic support as needed and verbalizes increases comfort.
5. The woman experiences maximum safety, and there are no complications.
6. The woman is prepared for the birth of her child.
7. The newborn receives essential immediate care.
8. Parents hold and explore their infant.
A. Assessment during the third and fourth stages on the following:
1. Maternal physiologic adjustment, including vital signs, bladder uterine firmness uterine fundus, perineum, and amount and color of lochia.
2. Maternal emotional adjustment.
3. Newborn physiological adjustment, including respiratory effort and maintenance of body temperature.
4. Signs of parents-newborn attachment.
5. Mother’s and newborn’s breast-feeding attempts, if the mother is breast-feeding.
B. Nursing diagnosis
1. Risk for Injury (Mother)
2. Ineffective Thermoregulation (newborn)
3. Risk for infection
4. Pain
5. Ineffective Breast-feeding
6. Altered Family Coping
1. Maternal physiologic adjustment, including vital signs, bladder uterine firmness uterine fundus, perineum, and amount and color of lochia.
2. Maternal emotional adjustment.
3. Newborn physiological adjustment, including respiratory effort and maintenance of body temperature.
4. Signs of parents-newborn attachment.
5. Mother’s and newborn’s breast-feeding attempts, if the mother is breast-feeding.
B. Nursing diagnosis
1. Risk for Injury (Mother)
2. Ineffective Thermoregulation (newborn)
3. Risk for infection
4. Pain
5. Ineffective Breast-feeding
6. Altered Family Coping
C. Planning and Outcome Identification
1. Physiologic adaptation will be achieved by the new mothers
2. Physiologic adaptation will be achieved by the newborns.
3. Potential complications will be detected.
4. Comfort measures will be provided as needed.
5. An opportunity to breast-feed will be provided.
6. A parent-newborn relationship and family integration will be established.
7. Accurate documentation of intrapartum care will be maintained.
1. Physiologic adaptation will be achieved by the new mothers
2. Physiologic adaptation will be achieved by the newborns.
3. Potential complications will be detected.
4. Comfort measures will be provided as needed.
5. An opportunity to breast-feed will be provided.
6. A parent-newborn relationship and family integration will be established.
7. Accurate documentation of intrapartum care will be maintained.
D. IMPLEMENTATION
1.Promote maternal physiologic adaptation
a. Initiate fundal massage gently, with adequate support to the lower uterine segment.
b. Evaluate vaginal bleeding and vital signs.
2. Promote newborn physiologic adaptation.
a. Suctions secretions from the newborn’s nose and mouth as necessary to maintain respirations.
b. Maintain the newborn’s temperature by placing him in skin-to-skin contact with mother covering him with warm blankets, or using a radiant warmer
Intrapartum Complications: Essential ConceptsA. Problems that can be anticipated because of maternal and fetal conditions or that can be stabilized and corrected without emergency intervention are increasingly managed in facilities designed to accommodate high-risk maternal and fetal clients.1.Promote maternal physiologic adaptation
a. Initiate fundal massage gently, with adequate support to the lower uterine segment.
b. Evaluate vaginal bleeding and vital signs.
2. Promote newborn physiologic adaptation.
a. Suctions secretions from the newborn’s nose and mouth as necessary to maintain respirations.
b. Maintain the newborn’s temperature by placing him in skin-to-skin contact with mother covering him with warm blankets, or using a radiant warmer
B. When the expectant mother is the best “incubator” for the high risk newborn, she may be transported to a tertiary care facility before the onset of the labor and the actual birth.
C. Because intrapartun emergencies commonly develop rapidly, on-the-spot nursing assessment and intervention are crucial.
D. Principles of nursing care during normal labor apply to complicated labor as well.
Intrapartum Complications
A. ASSESSMENT
1. Health History
a. Elicit a description of symptoms, including onset, duration, location and precipitating factors or events. Cardinal signs and symptoms may include:
1. Health History
a. Elicit a description of symptoms, including onset, duration, location and precipitating factors or events. Cardinal signs and symptoms may include:
- A sudden gush of fluid from the vagina
- Any copious vaginal bleeding
- Presence of uterine contractions with or without abdominal pain
- Decreased fetal movement
b. Explore maternal and family history for risk factors fro intrapartum complication.
- Any copious vaginal bleeding
- Presence of uterine contractions with or without abdominal pain
- Decreased fetal movement
b. Explore maternal and family history for risk factors fro intrapartum complication.
- Age younger than 18
- History of preterm labors
- Poor obstetric history
- Multiple pregnancy
- Hydramnios
- Smoking
- Poor hygiene
- Poor nutrition
- Employment
- History of preterm labors
- Poor obstetric history
- Multiple pregnancy
- Hydramnios
- Smoking
- Poor hygiene
- Poor nutrition
- Employment
Family risk factors may include:
- History of diabetes
- History of complications of birth in other family members.
- History of diabetes
- History of complications of birth in other family members.
c. Assess the family’s responses to high-risk pregnancy, labor, and a potential crisis situation.
d. Assess maternal, paternal, and family bonding, and the potential for perinatal loss and grief.
d. Assess maternal, paternal, and family bonding, and the potential for perinatal loss and grief.
2.Physical Examinations
a. Vital signs
- Measure maternal blood pressure, pulse and respirations in the presence of vaginal fluid leakage, or bleeding to assess for infection.
- Measure maternal vital signs to identify presence of shock.
- Monitor fetal heart rate (FHR) to determine fetal status.
a. Vital signs
- Measure maternal blood pressure, pulse and respirations in the presence of vaginal fluid leakage, or bleeding to assess for infection.
- Measure maternal vital signs to identify presence of shock.
- Monitor fetal heart rate (FHR) to determine fetal status.
b. Inspection
- Inspect the perineum for characteristics of vaginal discharge. Observe for color, odor, consistency, and amount
- Observe size and shape of the uterus
- At delivery, visually inspect the placenta for abnormal characteristics.
- Inspect the perineum for characteristics of vaginal discharge. Observe for color, odor, consistency, and amount
- Observe size and shape of the uterus
- At delivery, visually inspect the placenta for abnormal characteristics.
c. Palpation
- Monitor uterine activity to determine progress of labor.
- Evaluate the cervix for readiness for, or progress in, labor. Do not perform a vaginal examination if bleeding is present.
- Monitor uterine activity to determine progress of labor.
- Evaluate the cervix for readiness for, or progress in, labor. Do not perform a vaginal examination if bleeding is present.
3.Laboratory and diagnostic studies
a. Ultrasound is used to determine fetal status, localize the placenta, and determine amniotic fluid volume.
b. Kleihauer-Betke or fetal cell blood test is used to determine whether the blood cells are maternal or fetal. Maternal cells remain colorless when stained. Fetal cells become purple-pink when stained.
c. Nitrazine test tape and presence of ferning are used to determine if there is rupture of the amniotic sac. Nitrazine paper turns green-blue in the presence of amniotic fluid. On microscopic examination of a sample of fluid, a ferning pattern, similar to frost on window, appears on the dried slide. This is characteristic of a high-estrogen fluid.
d. Electronic urine monitoring will demonstrate the presence of uterine contractions.
e. Complete blood count will document the presence of anemia infection.
b. Kleihauer-Betke or fetal cell blood test is used to determine whether the blood cells are maternal or fetal. Maternal cells remain colorless when stained. Fetal cells become purple-pink when stained.
c. Nitrazine test tape and presence of ferning are used to determine if there is rupture of the amniotic sac. Nitrazine paper turns green-blue in the presence of amniotic fluid. On microscopic examination of a sample of fluid, a ferning pattern, similar to frost on window, appears on the dried slide. This is characteristic of a high-estrogen fluid.
d. Electronic urine monitoring will demonstrate the presence of uterine contractions.
e. Complete blood count will document the presence of anemia infection.
B. NURSING DIAGNOSIS
- In addition to complication-specific diagnosis, the following nurses diagnoses are common to care of the at-risk intrapartum client.
- In addition to complication-specific diagnosis, the following nurses diagnoses are common to care of the at-risk intrapartum client.
1. Anxiety
2. Fear
3. Ineffective Compromised Family Coping
4. Anticipatory Grieving
5. Self-Esteem Disturbance
6. Spiritual Distress
7. Knowledge Deficit
8. Pain
9. Risk for Injury
2. Fear
3. Ineffective Compromised Family Coping
4. Anticipatory Grieving
5. Self-Esteem Disturbance
6. Spiritual Distress
7. Knowledge Deficit
8. Pain
9. Risk for Injury
C. PLANNING AND OUTCOME IDENTIFICATION
1. Threats to optimal physical and emotional pregnancy outcome will be determined.
2. The client will be physically comfortable, and the client and family will have a healthy response to their high-risk pregnancy status and potential complications.
3. The client and family will understand their pregnancy complication and the necessary treatment.
2. The client will be physically comfortable, and the client and family will have a healthy response to their high-risk pregnancy status and potential complications.
3. The client and family will understand their pregnancy complication and the necessary treatment.
D. IMPLEMENTATION
1. Assess maternal and fetal physiologic status to detect early maternal and fetal changes requiring early intervention.
a. Perform ongoing assessment during the intrapartum period.
b. Expect the unexpected, and be prepared to provide critical care nursing if needed.
c. Accurately document the assessed problem and subsequent nursing interventions and their effectiveness.
a. Perform ongoing assessment during the intrapartum period.
b. Expect the unexpected, and be prepared to provide critical care nursing if needed.
c. Accurately document the assessed problem and subsequent nursing interventions and their effectiveness.
2. Provide physical emotional support
a. Observe the client and family for emotional response and ability to cope with discomfort and pain.
b. Provide comfort measures.
c. Coordinate physical care for client with emotional needs of the client and family.
d. Assess and support the client’s and family’s psychosocial and emotional needs, particularly in relation to potential loss and grief.
e. Encourage and support coping mechanisms, including aspects of loss and grief.
E.OUTCOME EVALUATION
a. Observe the client and family for emotional response and ability to cope with discomfort and pain.
b. Provide comfort measures.
c. Coordinate physical care for client with emotional needs of the client and family.
d. Assess and support the client’s and family’s psychosocial and emotional needs, particularly in relation to potential loss and grief.
e. Encourage and support coping mechanisms, including aspects of loss and grief.
E.OUTCOME EVALUATION
1. The client and fetus maintain normal physiological status; any deviations that arise are identified and corrected early.
2. The couple demonstrates greater comfort, decreased fear and anxiety, increased used of coping techniques.
3. The client and partner express understanding of their pregnancy complication and the necessary procedures to be performed.
2. The couple demonstrates greater comfort, decreased fear and anxiety, increased used of coping techniques.
3. The client and partner express understanding of their pregnancy complication and the necessary procedures to be performed.
A. DESCRIPTION. PROM is rupture of chorion and amnion before the onset of labor. The gestational age of the fetus and estimates of viability affect management.
B. ETIOLOGY. The precise cause and specific predisposing factors are unknown.
C. PATHOPHYSIOLOGY.
1. PROM is associated with malpresentation, possible weak areas in the amnion and chorion, subclinical infection, and possibly incompetent cervix.
2. Basic and effective defense against the fetus contracting an infection is lost the risk of ascending intrauterine infection, known as chorioamnionitis, is increased.
3. The leading cause associated with PROM is infection.
4. When the latent period (time between rupture of membranes and onset of labor) is less than 24 hours, the risk of infection is low.
B. ETIOLOGY. The precise cause and specific predisposing factors are unknown.
C. PATHOPHYSIOLOGY.
1. PROM is associated with malpresentation, possible weak areas in the amnion and chorion, subclinical infection, and possibly incompetent cervix.
2. Basic and effective defense against the fetus contracting an infection is lost the risk of ascending intrauterine infection, known as chorioamnionitis, is increased.
3. The leading cause associated with PROM is infection.
4. When the latent period (time between rupture of membranes and onset of labor) is less than 24 hours, the risk of infection is low.
D.ASSESSMENT FINDINGS
1. Clinical manifestations
a. PROM is marked by amniotic fluid gushing from the vagina. The fluid may trickle or leak from the vagina in the absence of contractions.
b. Pooling of amniotic fluid in the vagina will be visualized during a speculum examination.
c. Maternal fever, fetal tachycardia, and malodorous discharge may indicate infection.
a. PROM is marked by amniotic fluid gushing from the vagina. The fluid may trickle or leak from the vagina in the absence of contractions.
b. Pooling of amniotic fluid in the vagina will be visualized during a speculum examination.
c. Maternal fever, fetal tachycardia, and malodorous discharge may indicate infection.
2.Laboratory and diagnostic study findings. Rupture of the membranes is confirmed by the following.
a. Ferning is evident.
b. Nitrazine test tape turns blue-green
a. Ferning is evident.
b. Nitrazine test tape turns blue-green
E. NURSING MANAGEMENT
1.Prevent infection and other potential complications.
a. Make an early and accurate evaluation of membrane status, using sterile speculum examination and determination of ferning. Thereafter, keep vaginal examinations to a minimum to prevent infection.
b. Obtain smear specimens from vagina and rectum as prescribed to test for betahemolytic streptococci, organisms that risk to the fetus.
c. Determine maternal and fetal status, including estimated gestational age. Continually assess for signs of infection.
d. Maintain the client on bed rest if the fetal head is not engaged. This method may prevent cord prolapsed if additional rupture and loss of fluid occur. Once the fetal head is engaged, ambulation can be encouraged.
1.Prevent infection and other potential complications.
a. Make an early and accurate evaluation of membrane status, using sterile speculum examination and determination of ferning. Thereafter, keep vaginal examinations to a minimum to prevent infection.
b. Obtain smear specimens from vagina and rectum as prescribed to test for betahemolytic streptococci, organisms that risk to the fetus.
c. Determine maternal and fetal status, including estimated gestational age. Continually assess for signs of infection.
d. Maintain the client on bed rest if the fetal head is not engaged. This method may prevent cord prolapsed if additional rupture and loss of fluid occur. Once the fetal head is engaged, ambulation can be encouraged.
2. Provide client and family education.
a. Inform the client, if the fetus is at term, that the chances of spontaneous labor beginning are excellent; encourage the client partner to prepare themselves for labor and birth.
b. If labor does not begin or the fetus is judged to be preterm or at risk for infection, explain treatments that are likely to be needed.
a. Inform the client, if the fetus is at term, that the chances of spontaneous labor beginning are excellent; encourage the client partner to prepare themselves for labor and birth.
b. If labor does not begin or the fetus is judged to be preterm or at risk for infection, explain treatments that are likely to be needed.
A.DESCRIPTION. Preterm labor is labor that begins after 20 weeks gestation and before 37 weeks gestation.
B. ETIOLOGY. Among the many causes of preterm labor are:
1. PROM
2. Preeclampsia
3. Hydramnios
4. Placenta previa
5. Abruptio placentae
6. Incompetent cervix
7. Trauma
8. Uterine structural anomalies
9. Multiple gestation
10. Intrauterine infection (chorioamniotics)
11. Congenital adrenal hyperplasia
12. Fetal death
13. Maternal factors, such as stress (physical and emotional), urinary tract infection, and dehydration
B. ETIOLOGY. Among the many causes of preterm labor are:
1. PROM
2. Preeclampsia
3. Hydramnios
4. Placenta previa
5. Abruptio placentae
6. Incompetent cervix
7. Trauma
8. Uterine structural anomalies
9. Multiple gestation
10. Intrauterine infection (chorioamniotics)
11. Congenital adrenal hyperplasia
12. Fetal death
13. Maternal factors, such as stress (physical and emotional), urinary tract infection, and dehydration
C. PATHOPHYSIOLOGY. T he uterine begins the process of contraction prior to term gestational age.
D. ASSESSMENT FINDINGS. Clinical manifestations of preterm labor are basically the signs of true labor that occur when the gestational age of the fetus is greater than 20 and less than 37 weeks.
1. Low back pain
2. Suprapubic pressure
3. Vaginal pressure
4. Rhythmic uterine contractions
5. Cervical dilation and effacement
6. Possible rupture of membranes
7. Expulsion of the cervical mucus plug
8. Bloody show
1. Low back pain
2. Suprapubic pressure
3. Vaginal pressure
4. Rhythmic uterine contractions
5. Cervical dilation and effacement
6. Possible rupture of membranes
7. Expulsion of the cervical mucus plug
8. Bloody show
E.NURSING MANAGEMENT
1.Assess the mother’s condition and evaluate signs of labor.
a. Obtain a thorough obstetric history.
b. Obtain specimen for complete blood count and urinalysis.
c. Determine frequency, duration and intensity uterine contractions.
d. Determine cervical dilation and effacement.
e. Assess status of membranes and bloody show.
1.Assess the mother’s condition and evaluate signs of labor.
a. Obtain a thorough obstetric history.
b. Obtain specimen for complete blood count and urinalysis.
c. Determine frequency, duration and intensity uterine contractions.
d. Determine cervical dilation and effacement.
e. Assess status of membranes and bloody show.
2. Evaluate fetus from distress, size and maturity (sonography and lecithin-sphingomyelin ratio).
3. Perform measures to manage or stop preterm labor.
a. Place client on bed rest in the side-lying position.
b. Prepare for possible ultrasonography, amniocentesis, tocolytic drug therapy, steroid therapy.
c. Administer tocolytic (contraction-inhibiting) medication as prescribed.
d. Assess for side effects of tocolytic therapy (such as decreased maternal blood pressure, dyspnea, chest pain and FHR exceeding 180 beats/minute)
4. Provide physical and emotional support. Provide adequate hydration.
a. Place client on bed rest in the side-lying position.
b. Prepare for possible ultrasonography, amniocentesis, tocolytic drug therapy, steroid therapy.
c. Administer tocolytic (contraction-inhibiting) medication as prescribed.
d. Assess for side effects of tocolytic therapy (such as decreased maternal blood pressure, dyspnea, chest pain and FHR exceeding 180 beats/minute)
4. Provide physical and emotional support. Provide adequate hydration.
A.DESCRIPTION
1. Cord is descent of the umbilical cord into the vagina ahead of the fetal presenting part with resulting compression of the cord between the presenting part and the maternal pelvis.
2.Cord prolapsed is an emergency situation; immediate delivery will be attempted to save the fetus.
3. It occurs in 1 of 200 pregnancies
B. ETIOLOGY
1. This problem occurs most frequently in prematurity, rupture of membranes with fetal presenting part unengaged, and shoulder or footling breech presentations.
2. It may allow rupture of the amniotic membranes because the fluid rush may carry the cord along toward the birth canal.
1. Cord is descent of the umbilical cord into the vagina ahead of the fetal presenting part with resulting compression of the cord between the presenting part and the maternal pelvis.
2.Cord prolapsed is an emergency situation; immediate delivery will be attempted to save the fetus.
3. It occurs in 1 of 200 pregnancies
B. ETIOLOGY
1. This problem occurs most frequently in prematurity, rupture of membranes with fetal presenting part unengaged, and shoulder or footling breech presentations.
2. It may allow rupture of the amniotic membranes because the fluid rush may carry the cord along toward the birth canal.
C. PATHOPHYSIOLOGY. Compression of the cord results in the compromise or cessation of fetoplacental perfusion.
D.ASSESSMENT FINDINGS
1. Associated findings
a. Cord prolapsed may be occult and occur any time in the labor process, even when the amniotic membranes are intact.
b. Client reports feeling the cord within the vagina
2.Clinical manifestations
a. Fetal bradycardia with deceleration during contraction
b. The umbilical cord seen or felt during a vaginal examination
1. Associated findings
a. Cord prolapsed may be occult and occur any time in the labor process, even when the amniotic membranes are intact.
b. Client reports feeling the cord within the vagina
2.Clinical manifestations
a. Fetal bradycardia with deceleration during contraction
b. The umbilical cord seen or felt during a vaginal examination
E.NURSING MANAGEMENT
1. Identify prolapsed of the cord and provide immediate intervention
a. Assess a laboring client often if the fetus is preterm or small for gestational age, if the fetal presenting part is not engaged, and if the membranes are ruptured.
b.Periodically evaluate FHR, especially after rupture of membranes (spontaneous or surgical), and again in 5 to 10 minutes.
c. If cord prolapsed is identified, notify the physician and prepare for emergency cesarean birth.
d. If the client is fully dilated, the most emergent delivery route may be vaginal. In this case, encourage the client to push and assist with the delivery as follows.
- Lower the head of the bed and elevate the client’s hips on a pillow, or place the knee-chest position to minimize pressure on the cord.
- Apply oxygen at 10 to 12 L/minutes
- Apply firm upward manual pressure to the presenting part of the fetus and relieve pressure from the cord.
- Assess cord pulsations constantly
- Gently wrap gauze soaked in sterile normal saline solution around the prolapsed cord.
2.Provide physical and emotional support.
3. Provide client and family education.
Intrapartum Complications: Uterine Rupture1. Identify prolapsed of the cord and provide immediate intervention
a. Assess a laboring client often if the fetus is preterm or small for gestational age, if the fetal presenting part is not engaged, and if the membranes are ruptured.
b.Periodically evaluate FHR, especially after rupture of membranes (spontaneous or surgical), and again in 5 to 10 minutes.
c. If cord prolapsed is identified, notify the physician and prepare for emergency cesarean birth.
d. If the client is fully dilated, the most emergent delivery route may be vaginal. In this case, encourage the client to push and assist with the delivery as follows.
- Lower the head of the bed and elevate the client’s hips on a pillow, or place the knee-chest position to minimize pressure on the cord.
- Apply oxygen at 10 to 12 L/minutes
- Apply firm upward manual pressure to the presenting part of the fetus and relieve pressure from the cord.
- Assess cord pulsations constantly
- Gently wrap gauze soaked in sterile normal saline solution around the prolapsed cord.
2.Provide physical and emotional support.
3. Provide client and family education.
A. DESCRIPTION
1. Uterine rupture is tearing of the uterus, either complete (rupture extends through entire uterine wall and uterine contents spill into the abdominal cavity) or incomplete (rupture extends through endometrium and myometrium, but the peritoneum surrounding the uterus remains intact).
2. Small tears may be asymptomatic and may heal spontaneously, remaining undetected until the stress and strain or a subsequent labor.
B.ETIOLOGY
1. Traumatic uterine rupture may be caused by injury from obstetric instruments, such as uterine sound or curette used in abortion.
2. Rupture also may result from obstetric intervention, such as excessive fundal pressure, forceps delivery, violent bearing-down, tumultuous labor, and fetal shoulder dystocia.
3. Spontaneous uterine rupture is most likely to occur after previous uterine surgery or with grand multiparity combined with the use of oxytocic agents, cephalopelvic disproportion, malpresentation, or hydrocephalus.
C. PATHOPHYSIOLOGY
1. The most common pathologic factors is a preexisting scar that results in a weakened or defective myometrium that does not stretch; this is most frequently identified in spontaneous uterine rupture.
2. Some episodes of rupture are due to traumatic disruption of the uterine surface.
3. More severe ruptures pose the risk of irreversible maternal hypovolemic shock of subsequent peritonitis, consequent fetal anoxia, and fetal or neonatal death.
1. Uterine rupture is tearing of the uterus, either complete (rupture extends through entire uterine wall and uterine contents spill into the abdominal cavity) or incomplete (rupture extends through endometrium and myometrium, but the peritoneum surrounding the uterus remains intact).
2. Small tears may be asymptomatic and may heal spontaneously, remaining undetected until the stress and strain or a subsequent labor.
B.ETIOLOGY
1. Traumatic uterine rupture may be caused by injury from obstetric instruments, such as uterine sound or curette used in abortion.
2. Rupture also may result from obstetric intervention, such as excessive fundal pressure, forceps delivery, violent bearing-down, tumultuous labor, and fetal shoulder dystocia.
3. Spontaneous uterine rupture is most likely to occur after previous uterine surgery or with grand multiparity combined with the use of oxytocic agents, cephalopelvic disproportion, malpresentation, or hydrocephalus.
C. PATHOPHYSIOLOGY
1. The most common pathologic factors is a preexisting scar that results in a weakened or defective myometrium that does not stretch; this is most frequently identified in spontaneous uterine rupture.
2. Some episodes of rupture are due to traumatic disruption of the uterine surface.
3. More severe ruptures pose the risk of irreversible maternal hypovolemic shock of subsequent peritonitis, consequent fetal anoxia, and fetal or neonatal death.
D.ASSESSMENT FINDINGS
- Clinical manifestations vary from mild to severe, depending on the site and extend of the rupture, degree of extrusion of the uterine contents, and intraperitoneal evidence or absence of spilled amniotic fluid and blood. They include:
1. Abdominal pain
2. Vaginal bleeding (is not always present)
3. Nonreassuring FHR pattern
4. Palpation of fetal parts under the skin
5. Signs of hypovolemic shock (with complete uterine rupture)
- Clinical manifestations vary from mild to severe, depending on the site and extend of the rupture, degree of extrusion of the uterine contents, and intraperitoneal evidence or absence of spilled amniotic fluid and blood. They include:
1. Abdominal pain
2. Vaginal bleeding (is not always present)
3. Nonreassuring FHR pattern
4. Palpation of fetal parts under the skin
5. Signs of hypovolemic shock (with complete uterine rupture)
E. NURSING MANAGEMENT
1.Monitor for the possibility of the uterine rupture
a. In the presence of the predisposing factors, monitor maternal labor pattern closely for hypertonicity or signs of weakening uterine muscle.
b. Recognizing signs of impending rupture, immediately notify the physician, and call for assistance.
1.Monitor for the possibility of the uterine rupture
a. In the presence of the predisposing factors, monitor maternal labor pattern closely for hypertonicity or signs of weakening uterine muscle.
b. Recognizing signs of impending rupture, immediately notify the physician, and call for assistance.
2. Assist with rapid intervention.
a. If the client has signs of possible uterine rupture, vaginal delivery is generally not attempted.
b. If symptoms are not sever, emergency laparotomy is performed to attempt immediate delivery of the fetus and then establish homeostasis.
c. Implement the following preparations for surgery.
- Monitor maternal blood pressure, pulse, and respiration; also monitor fetal heart tones.
- If the client has a central venous pressure catheter in place, monitor pressure to evaluate blood loss and effects of fluid and blood replacement.
-Insert a urinary catheter for precise determinations of fluid balance.
- Obtain blood for possible acidosis.
- Administer oxygen, and maintain a patent airway.
3.Prevent and manage complications. Take this steps in order to prevent or limit hypovolemic shock.
a. Oxygenate by providing 8 to 10 L/minute using a closed mask.
b. Restore circulating volume using one or more intravenous lines.
c. Evaluate the cause, response to therapy, and fetal condition.
d. Remedy the problem by preparing the client for surgery and administering antibiotics.
a. If the client has signs of possible uterine rupture, vaginal delivery is generally not attempted.
b. If symptoms are not sever, emergency laparotomy is performed to attempt immediate delivery of the fetus and then establish homeostasis.
c. Implement the following preparations for surgery.
- Monitor maternal blood pressure, pulse, and respiration; also monitor fetal heart tones.
- If the client has a central venous pressure catheter in place, monitor pressure to evaluate blood loss and effects of fluid and blood replacement.
-Insert a urinary catheter for precise determinations of fluid balance.
- Obtain blood for possible acidosis.
- Administer oxygen, and maintain a patent airway.
3.Prevent and manage complications. Take this steps in order to prevent or limit hypovolemic shock.
a. Oxygenate by providing 8 to 10 L/minute using a closed mask.
b. Restore circulating volume using one or more intravenous lines.
c. Evaluate the cause, response to therapy, and fetal condition.
d. Remedy the problem by preparing the client for surgery and administering antibiotics.
4.Provide physical and emotional support.
a. Provide support for the client’s partner and family members once surgery has begun.
b. Inform the partner and family how they will receive information about the mother and newborn.
Intrapartum Complications: Placenta Accretaa. Provide support for the client’s partner and family members once surgery has begun.
b. Inform the partner and family how they will receive information about the mother and newborn.
A. DESCRIPTION. Placenta accrete is an uncommon condition in which the chorionic villi adhere to the myometrium. It can be exhibited as:
1. Placenta Accreta – the placental chorionic will adhere to the superficial layer of the uterine myometrium.
2. Placenta Increta – the placental chorionic will invade deeply into the uterine myometrium.
3. Placenta Pecreta – the placental chorionic will go through the uterine myometrium and often adhere to abdominal structures such as the bladder or intestine)
2. Placenta Increta – the placental chorionic will invade deeply into the uterine myometrium.
3. Placenta Pecreta – the placental chorionic will go through the uterine myometrium and often adhere to abdominal structures such as the bladder or intestine)
B. ETIOLOGY. Predisposing factors are prior uterine surgery and placenta previa.
C. PATHOPHYSIOLOGY. Implantation in an area of defective endometrium with no zone separation between the placenta and the myometrium.
D. ASSESSMENT FINDINGS.
1.Associated findings. Placenta accrete is usually diagnosed in the immediate postpartum period when the placenta fails to separate.
2. Clinical manifestations
a. Placenta fails to separate
b. Profuse hemorrhage may result depending on the portion of placenta involved.
1.Associated findings. Placenta accrete is usually diagnosed in the immediate postpartum period when the placenta fails to separate.
2. Clinical manifestations
a. Placenta fails to separate
b. Profuse hemorrhage may result depending on the portion of placenta involved.
E. NURSING MANAGEMENT
1.Identify placenta accrete in the client. Be aware of the client’s risk status.
2. Assist with rapid treatment and intervention. Be prepared for a dilation and curettage or hysterectomy.
3. Provide physical and emotional support.
4. Provide client and family education.
1.Identify placenta accrete in the client. Be aware of the client’s risk status.
2. Assist with rapid treatment and intervention. Be prepared for a dilation and curettage or hysterectomy.
3. Provide physical and emotional support.
4. Provide client and family education.
No comments:
Post a Comment