Dystocia Dysfunctional Labor and Masectomy

difficult labor or birth

normal progress of dilation, effacement and descent is impeded....uterus simply isn't functioning as it should

• persistent non reassuring FHR patterns
• fetal acidosis
• meconium passage

ineffective contractions or ineffective maternal pushing efforts

nulli= 1 cm/hr cervical dilation, likely to push 1-2 hrs

multip=1.5cm/hr cervical dilation

propelling the fetus past the resistance of the woman's bony pelvis and soft tissues

• maternal fatigue and inactivity
• F&E imbalance
• dehydration
• hypoglycemia
• excessive analgesia
• big head/small pelvis
• abruption
• catecholamines

coordinated and regular but weak contractions

hypoglycemia,fatigue, excessive analgesia, anesthesia, multiples

occurs during active stage of labor

• reposition to upright to help with fetus descent
• hydration to correct F&E imbalances
• Pitocin
• effective pain management
• assist with ROM
• emotional comfort/therapeutic communicaiton

hemorrhage

uncoordinated contractions with an erratic duration and intensity and they are painful

• ineffective pushing techniques
• fear of injury/pain/tearing
• decreased/absent urge to push
• maternal exhaustion
• analgesia
• unreadiness to let go of baby

occurs during latent stage

• #1 pain relief
• warm showers to promote relaxation
• STOP PITOCIN/DONT GIVE
• Tocolytics to to reduce uterine resting tone

because uterine resting tone between contractions is high, reducing uterine blood flow which decreases fetal O2 supply....which causes constant pain

tocolytics

diverts blood from the uterus to muscles

fetus size and presentation

over 4000g or 8 lb 13 oz

• vacuum/forceps
• McRoberts maneuver
• supported squat
• suprapubic pressure
• check infants clavicles
• c section

when theres a problem with the passenger the mom is told to put her legs to her chest and apply pressure above the pubic bone

• OP and OT
• any presentation other than vertex

• position to hands and knees
• pelvic rock to encourage rotation
• side lying
• sitting, kneeling, rocking, standing
• birthing ball
• lunge techniques
• squatting to push open pelvis

squatting

• rop=left side
• lop= right side

cervical dilation and effacement will be slower

• uterine over distention (hypotonic dysfunction)
• abnormal presentation of one/both fetus
• great risk for cord compression/hypoxia
• maternal pp hemorrhage from uterine atony

• hydrocephalus
• neural tube defect
• omphalacele

full bladder....mom needs to void q1-2 hrs

• her perception of stress....more important thatn the actual existence of a threat
• hx of sexual abuse

• increased glucose consumption reduces energy supply
• maternal catecholmines can impair labor by interfering with adequate uterine contractility
• pain perception is increased and tolerance is decreased

• promote physical comfort/relaxation
• establish trusting relationship
• adjust light, noise and clean pt

• predicts the inducibility by evaluating:
• the position of the cervix as it relates to the vagina
• cervical consistency
• dilation
• effacement
• station of the presenting part

6-7 is a good score

• 0=firm
• 1=medium
• 2=soft

• 0= posterior
• 1=mid
• 2=anterior

• 0=0-30%
• 1=40-50
• 2=60-70
• 3=80+

• 0=0
• 1=1-2
• 2=3-4
• 3=5-6

after 20 weeks but before 37 weeks

• painful/pain free contractions coming every 15 min or less
• feeling of fetus balling up
• cramps similar to menstrual
• constant dull low backache
• pink/brown discharge
• pelvic pressure....feeling like urinating frequently
• feeling flu like
• feeling "not right"

fibrinectin isn't present between 22-35 weeks gestation....presence indicates a high likelihood of PTL

sterile speculum is inserted and specimen is collected

• no other exam done before or vaginal manipulation
• no lubricating gels

<35 mm in length at 24 weeks

• stop smoking and using drugs!!!
• early/constant pre natal care
• good diet and healthy weight
• prevent bladder infections
• no stress
• no infections

• 3 cm is the point of no return....
• avoid sex/orgasm
• avoid breast stimulation
• bedrest with BRP
• stay hydrated
• fetal monitor
• cerclage

• magnesium sulfate IV
• Terbutaline SQ or PO
• Nifidepine
• Indomethacin

given at 24-34 weeks to prevent RDS.

must start 24 hours before birth and within 7 days...so repeat after 7 days.

given to mom IM and newborn ET

rupture of the amniotic sac earlier than the end of the 37th week of gestation with or without contractions

• infections
• incompetent cervix
• hydraminos
• hormonal changes
• weak amniotic sac
• recent intercourse
• maternal stress
•  nutritional deficiencies

• cord prolapse
• infection
• potential need for premature delivery

• no sex
• no breast stimulation
• bedrest with BRP
• confirm rupture
• prevent infection/temp q4h
• iv antibiotics as ordered
• monitor uterine contractions
• no vaginal exams

NO!!

• Nitrazine-pH sensitive....blue is positive
• Ferning
• LS ration 2:1
• pH of vaginal fluid
• vaginal culture
• fetal fibrinectin

failure of the shoulders to complete external rotation and is impacted above the maternal symphisis pubis

turtle sign

requires urgent attention by physician

• umbilical cord compression
• clavicles crepitus, deformity, bruising
• nerve injury to brachial plexus

nerve injury to brachial plexus causing flaccid muscle tone....most resolve without intervention a few weeks pp

• entrapment of cord
• inability of childs chest to expand properly
• severe brain damage or death if child not delivered within minutes

McRoberts maneuver....sharply flexing the legs upon the maternal abdomen causing the pubic symphysis to rotate and the sacrum to straighten out

fibrous, glandular breast tissue....

usually one lump that palpates as firm, moveable and rubber.

seen in teens and 20yo

treatment is follow up mammograms, sometimes excision

fibrosis or thickening of normal breast tissue with cystic enlargement of the glands

multiple, smooth, tender, cystic feeling

pain and tenderness associated with menstrual cycle

• fine needle aspiration or open biopsy
• decrease fat, caffeine, sodium, chocolate

breast problems seen in women approaching menopause

dilation of collecting ducts with inflammation

occurs just before or during menopause

• nipple discharge
• nipple retraction
• nipple ulceration
• edema
• palpable lump
• **all require dx mammogram, stereotactic needle biopsy and possibly surgery

• teaching....
• how to care for drain
• change dressings
• pain management
• how to handle sensory alterations (numbness, burning, phantom pain)
• how to avoid restricted range of motion

prior to surgery....with reinforcement of teachings after the procedure is complete and she is awake and alert

• keep it clear
• show her how to empty and decompress the JP drain....also strip the tube to keep it clot free

• oral opioids or ibuprofen/acetamoniphen
• PCA sometimes

sensory alterations like numbness and burning in her chest and arm....refer to a pain management Dr.

keep on moving and do your arm exercises....go to PT

hematoma....look for pooling of blood under the skin, hard and swollen, tender to touch

flap necrosis-dark purple or black skin

infection-red, warm purulent drainage

occurs with removal of lymph nodes

Avoid saying never and say "when possible"....

• BP and blood draws on opposite arm
• nothing tight
• use electric shaver for under arms
• wear heavy duty mit for cooking
• SPF 15 at least
• sleep on back or non surgical side
• minimize carrying heavy things with that side

• surgical side feels heavy/full
• tight feeling skin on surgical side
• less movement in surgical sides hand/wrist
• larger surgical side....cant fit in to sleeve
• tight wring or watch on surgical side, but hasn't gained weight

• prop arm up with small pillow
• squeeze a small ball

• swelling lasting longer than 1 week
• redness
• heat
• fever
• swollen lymph nodes

• covered by insurance
• can be warn once drains are removed
• fitted for at 6 weeks after surgery and is well healed