eeee oe ° WHAT TS IT? ‘Onset of labor anywhere between 20-37 weeks ‘gestation PRETERM LABOR RISK FACTORS Previous preterm labor or promature birth, particularly in the most recent pregnancy or in more than one previous pregnancy Pregnancy with twins, tnplets or other multiples Problems with the uterus, cervix or placenta Smoking cigarettes or using ilicit drugs Certain inections, particulary of the amniotic fluid and lower genital tract Some chroric conditions, such as high blood pressure and diabetes Stressful lite events, such as the death of a loved one Too much amniotic fluid (polyhydramnios) Vaginal bleeding during pregnancy Presence of a fetal birth detect {An interval of ess than six montns between pregnancies Infection of tissues that surround and. seth (periodontal disease) eeoaes oe o68 Q)simplenursing ASSESSMENT © Regular or frequent sensations of abdominal tightening (contractions) Constant low, dull backache —_Asensation of pelvic or lower abdominal pressure 4 Mild abdominal eramps & Vaginal spotting or light bleeding & Preterm rupture of membranes — ina gush or a continuous trickle of fluid after ‘the membrane around the baby breaks or tears 4% Acchange in type of vaginal discharag — watery, mucus-ike or bloody PREVENTION ‘Seek regular prenatal care. Eat a healthy diet ‘Avoid risky substances. Consider pregnancy spacing. Be cautious when using assisted reproductive technology (ART) i«CATMENT Terbutaline: Tocolytic Magnesium sulfate Betamothasone : to stimulate maturation of babies lungs. Hydration Treatment of UTCOMPLICATIONS : PLACENTA PREVIA WaT AM 17 % Three types: Marginal, partial, x and total : Common cause of bleeding during the second half of pregnancy é — Good maternal prognosis it hemonthage can be controlled rm % Usually necessitates pregnancy . termination if bleeding is heavy ‘Fetal prognosis dependent on gestational age and amount of blood lost; risk of death greatly PATHO Improper implantation of the placenta in the lower uterine segment has ‘caused partial or total coverage of the cervical os.With development of the lower uterine segment and gradual changes in the cervix during the third trimester, shearing forces at the ‘attachment site lead to partia| detachment and bleeding NISK FACTORS Advanced maternal age (over age 35) Defective vascularization of the decidua Endometriosis, Multipanty Infertility treatments Multiple pregnancy Previous uterine surgery or cesarean birth Smoking Male fetus Cocaine use History of placenta previa High altitudes Uterine abnormaities inhibiting normal ‘embryonic implantation (such as prior curettage or the presence of uterine POSE EEE EEE EEE reduced by frequent monitoring and prompt management ASSESSMENT Painless bleeding Soft, nontender uterus Fetal malpresentation Minimal descent of fetal presenting part Good fetal heart tones Possible contractions * * * * * * COMPLICATIONS Cord being the presenting part, possible cord prolapse Fetal hypoxia or blood loss Preterm delivery Dystocia Anemia Hemorrhage Abruptio placentae Disserninated intravascular coagulation Shock Placenta accreta, increta, percreta Intrauterine growth restriction Abnormal fetal presentation Kidney damage Cerebral ischemia Maternal or fetal death t * COSTS EEE EOE O ED MEDICATIONS LV. fluids, such as lactated Ringer solution or normal saline solution, using a large-bore catheter (Oxygen Fresh frozen plasma and platelets, as necessary, for coagulation problems Tocolytics, such as terbutaline sulfate, calcium channel blockers, or magnesium sulfate short-term to halt preterm labor and to allow time for doses of betamethasone dipropionate (Diprolene) Betamethasone dipropionate to enhance fetal lung maturity ifless than 34 weeks! od TER VENTIONS Pad counts, the patient should not saturate more than one pad an nour. Monitor blood counts Monitor fetal iert tenes Monitor contractions Prepare for c-section Do not perform cervical exams° + ° * * * LABOR POSITIONS a ANTICIPATORY STGNS OF LABOR Lightening or sense that the baby has “dropped” Increased frequency, intensity of Braxton Hicks contractions Gastrointestinal disturbances Expelling the mucus plug Feeling a burst of energy Clinical signs es Ripening (softening) ¥So-rront thinning) of the cervix MATERNAL ADAPTATION 10 LABOR * * eoee * oo 6 68 & 6% Maternal physiologic adaptation Increased demand for oxygen uring the first stage of labor Increased heart rate Increased cardiac output Increased respiratory rate Gastrointestinal and urinary systems are affected Laboratory values impact FETAL ADAPTATION 10 LABOR Increase in intracranial pressure Placental blood flow temporarily interrupted at peak of uterine contractions. ‘Stresses cardiovascular system; resuits in slowly decreasing pH throughout labor Passing through the birth canal is beneficial in two ways ‘Stimulates surfactant production; helps clear respiratory passageways Ecchymosis :a discoloration of the skin resulting from bleeding underneath, typically caused by bruising.(°P5 Edema: swelling ‘Caput succedaneum:serosanguinous, subcutaneous, ‘extraperiosteal fluid collection with poorly defined margins ‘caused by the pressure of the presenting part of the scalp against the dilating cervix {tourniquet effect of the cervix) ‘during delivery.‘ ‘Cephalohematoma: is a traumatic subperiosteal haematoma that occurs undemeath the skin, in the periosteum of the infant's skull bone. Gephalohematoma ‘does not pose any risk to the brain cells, but it causes unnecessary pooling of the blood from damaged blood vessels between the skull and inner layers of the skin. THE FOUR P’S OF LABOR Passageway: Pelvic shape Passenger: fetus Powers: contractions Psyche eoee x FETAL LTE Longitudinal lie: Long axis ofthe Fetus is parallel to ‘maternal long axis or ‘tween longitudinal and transverse lie ‘Transverse lie: Long axis of fetus is perpendicular to oe ‘maternal long axis FETAL PRESENTATION Foremost part of the fetus that enters the pelvic inlet Three main presentations % Head: Cephalic presentation & Feet or buttocks: Breech presentation Shoulder: Shoulder presentation FETAL ATTITUDE Relationship of fetal parts to one another 4 Flexion (ovoid shape):Most favorable for vaginal delivery Military (no flexion or extension) Brow or frontum (partial extension) % Face (tll extension) THE SIMPLEST WAY TO PASS NURSING SCHOOL O)sinpleNursingLABOR READINESS NIPENING OF THE CERVLX FETAL READINESS LABOR INDICATORS ‘A-*Ripe” cervix: Prerequisite for successful ‘The Fetus should be mature. There are several ways to assess induced labor. Bishop score is most often maturity: used to determine readiness for labor ‘®@ =38 weeks’ gestation © Five factors evaluated, each factor @ Fetal lung maturty is major point of consideration scored 0 to 3 ® Measuring the lecithia/spningomyelin (L/S) ratio via @ Score 28: Associated with “, amniocentesis assesses lung maturity. An L/S ratio greater successful oxytocin-induced labor is than 2 indicates fetal lung maturtty. Score 35: “Unripe” cervix or s unfavorable q Never schedule an induction without ™ INDUCTION OF LABOR asking the bishop score. Artificial rupture of membranes (AROM) ~ amniotomy Causes release of prostaglandins, wrich enfiance labor ‘Nursing interventions METHODS OF CERVICAL RIPENING “pS, Socanentny anes Wlscor Mechanical methods _ Monitoring fetal neat rate Se Meee Vora: Oxytocin induction of labor ® —Ingerting a cathoter into the cervix and TV oxytocin (Pitacin) is the most common agent inflating the balloon holds 30-80c¢ of fluid * used’ [Vine intiated: Infusion pump required Laminaria: Cervical dilators “seaweed” + Pharmacologic methods Baseline fetal heart assessment before induction The RN can titrate the PIT until fetal distress ‘occurs, however they must cal the HCP to obtain 4 Prostaglandin E, (dinoprostone) Cerviil(stringy'tampon like) Prepiail (gel) ‘an order to decrease the PIT Prostaglandin E, (misoprostol) (can cause rough labor) Cytotec ASSISTED DELIVERY POTENTIAL COMPLICATIONS OF Episiotomy: Perineal surgical incision to enlarge the vaginal OXYTOCIN INDUCTION LV PITOCIN ‘opening immediately pre birth , Forceps: Instruments wth curved, blunted blades are placed Potential risk for C-section doubles around the head of fetus to facilitate rapid delivery @ Primigravidas versus multi gravidas & —— Hyporstimulation of uterus leading to one ° ° ° * tw ave cepsare more common han mi an conacton te rote amour substantia est ¢ Rett! cations: atu; ceria cron pero between car Dow ime vows, Ge 02 concata pronged secon stage oar foviet vamesc Woaus ¢ Ronesourhgtaalsne Water retention may ease 3 nt rar sgn ypon perlareicnd vacuum, agaist dlyeny AN ste, Schone ae EEE a ee ee Gents convtions ita ma % — Gan be hazardous to infant, causing | Congestive heart failure; death pening of Servx or HOM Jocument fetal heart rate before and after ROM Communicate changes as needed ae a SRG on ~ ¢ Seimteeuuisiie uring tons i QF este ntns ana any cig Se ei eee WY 3 y : POTENTIAL COMPLICATIONS OF OPERATIVE VAGINAL DELIVERY Neonalal cephalohematoma retinal, subdural, and subgaleal hemorrhage occur more frequontly with vacuum eniracton han with forceps Facial bruising, facial nerve injury, skull ractues, and seizures: More common with forceps Potential maletnal comolcaliong Extension of episicomy into anal sphincter Uterine rupture, perineal pan, lacerations, hematomas, urinary retention, anemia, and renospitalzaton sooo & HE SVPLEST WAY TO PASS NURSING SCHOOL O)simpleNursingWaal 15 111 Extreme elevation in blood pressure during pregnancy with the presence of protein in the urine after 20 weeks of gestation. HaGnesT SULFATE Vasodilator & sedative Monitor for pulmonary edema + Monitor for signs of mag toxicity: decreased DTRS, BP, respiration, decreased LOC. Labor will halt: have oxytocin ready if indicated. oe CARE Decrease environmental stimuli. This decreases the risk of seizures. Initiate seizure precautions Monitor mom and baby oe NCLEX T1P! Blood pressure that exceeds 140/90 millimeters of mercury (nm Ha) or greater,documented on two occasions, at least four hours apart , is abnormal. PREECLAMPSIA Sooo oo ASSESSMENT Sudden weight gain Swelling of the face and hands Headache Blurry vision Hyperreflexia ‘Clonus ( seizures) ° * * * ° * TYPES 4 Mild : 30/15 mmng off of baseline six hours apart. Increase the amount of protein in the diet because they are spilling it into the urine. Glomerular damage is present % Severe: 160/110 mmHg 6 hours apart. May have an episode of seizure activity. Have mag sulfate ready. INTERVENTIONS Magnesium sulfate: have calcium gluconate at bedside. Monitor for sedation and byporetioxia, % Seizure precautions % Safety checks RISK FACTORS istory of preeclampsia. Chronic hypertension. First pregnancy. New paternity ‘Age. Tho risk of preeclampsia is higher for very young pregnant women as well as pregnant women older than 40. Obesity. ‘Multiple pregnancy. Presclamy ‘common in women who are carrying twins, triplets or other multiples. Interval between pregnancies. Having babies Jess than two years or more than 10 years apart leads to a higher risk of preeclampsia. In vitro fertilization. Your risk of preeclampsia is increased if your baby was conceived with in vitro fertilization, Uterus or cervix problems ‘Thyroid cisease oooee PREVENTION % Seok regular prenatal care. © Avoid known miscamage risk factors — such as smoking, drinking alcohol and leit drug use. © Take a dally muttivitamin ® Limit your catteine intake. A recent study found that drinking more than two caffeinated beverages a day appeared to be associated with a higher risk of miscamage. ASSESSMENT ® Cardinal signs are Spotting and cramping together Tissue expulsion from the vagina RISKS ‘Age. Women older than age 35 have a higher risk of miscarriage than do younger women. At age 35, you have about a 20 percent risk. At age 40, the risk is, about 40 percent. And at age 45, i's about 80 peroent, Previous miscarriages. Women who have had two or more consecutive miscarriages are at higher risk of miscarriage. Chronic conditions. Wornen who have a chronic condition, such as uncontrolled diabetes, have a higher risk of miscarriage. Uterine or cervical problems. Certain uterine abnormalities or weak cervical issues (incompetent Cervix) might increase the risk of miscarriage. ‘Smoking, alcohol and illicit drugs. Women who smoke during pregnancy have a greater risk of miscarriage than do nonsmokers. Heavy alcohol use and ilicit drug use also increase the risk of miscarriage. Weight. Being underweight or being overweight has been linked with an increased rsk of miscarriage. Invasive prenatal tests. Some invasive prenatal genetic tests, such as chorionic villus sampling and amniocentesis, carry a slight risk of miscarriage, TREATMENT — Monitor HeG Levels, a decrease is indicative of miscarriage. — Polvicrrest ® Bed rest —Ifitis sure that a miscarriage is ‘happening : prepare to start an IV, administer blood & D&C toy “a os en 4 Q)simpleNursingPAIN MANAGEMENT DURING LABOR PAIN @ Individual & subjective % Sensory experience FACTORS INFLUENCING PAIN Physiologic Psychological Emotional Environmental Sociocultural eeeee GENERAL CONCEPTS OF PAIN Pain threshold: Level of pain negessary for an individual 1o perceive pain % Pain tolerance: Ability of an individual to withstand pain, once recognized PRINCIPLES OF PAIN RELIEF DURING LABOR “Women are more satisfied when they have control over the pain experience Caregivers commonly underrate the severity of pain Women who are prepared for labor usually report a more satistying experience than do ‘women who are not prepared OPIOIDS Medications with opium-like properties (also known as narcotic analgesics); the most frequently administered medications to provide analgesia during labor. (ex.:Demerol IV, IM) ‘Advantages Increased ability for a woman to cope with labor Medications may be nurse-administered Disadvantages Frequent occurrence of uncomfortable side effects Nausea and vomiting; pruritus; drowsiness; neonatal depression Pain not completely eliminated % Possible overdose NON PHARMACOLOGICAL PAIN INTERVENTIONS Continuous labor support Comfort measures Relaxation techniques @ Patterned breathing Attention focusing/concentration Movement and positioning Touch and massage Water therapy: hypnosis, intradermal water injections. Acupressure and acupuncture eeee ANESTHESIA % Local: Used to numb the perineum just before birth, allowing for episiotomy and repair © Regional: Blocks a group of sensory nerves, supplying a particular organ or body area General :Not frequently used in OB due to risks involved Complications of anesthesia — Hypotension Total spinal blockade (rare) Inadvertent injection into the bloodstream Spinal headache ® Prurtus % Respiratory distress ° Fatal complications of anesthesia Failed intubation Aspiration — Malignant hyperthermia: is a disease that causes a SimpleNursing THE SIMPLEST WAY TO PASS NURSING SCHOOL ‘ast nse in body temperature and severe muscle ‘contractions when someone with the cisease gets {general anesthesia. Its passed down throuah families! ~ o, 1h iL ‘© Can Stock Photo