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indications for induction of labor
history of rapid or silent labors, precipitate birthcoexisting medical disordersPROM (24 hr before labor)congenital anomalypostterm pregnacy with nonreactive NSTintrauterine fetal death
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nursing care for induction of labor
amniotomy (breaking water)oxytocininternal fetal monitoring
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when performing assess?
- "taco"
- Time
- Amount
- Color
- Odor
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dystocia
abnormal labor pattern in which abnormalities occur with the power, the passenger, or the passage
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causes of dystocia
- dysfunctional labor (or uterine ctx's)
- alterations in passage
- fetal causes
- ineffective pushing
- psychological responses
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dysfunctional labor (hypertonic)
- usually occurs before 4cm dilation
- most often in primipara, fearful, anxious
- pain out of proportion to intensity and effectiveness
- frequent, uncoordinated, poor resting tone
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potential maternal problems with hypertonic labor
- maternall loss of control and fatigue
- stress in coping abilities
- dehydration and increased risk of infection if labor is prolonged
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potential fetal problems with hypertonic labor
- fetal asphyxia
- cephalhematoma, caput succedaneum, or excessive molding
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hypertonic nursing care
provide comfort and supportsupportive measures (shower, position change, walking, mouth care, relaxation exercises and meds)education
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Hypotonic dysfunctional labor
- usually occurs after 4cm dilation following normal latent/early active labor
- causes may be CPD, malpresentation/position, overdistention of uterus
- CTX's infrequent; normal resting tone
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potential maternal problems with Hypotonic labor
maternal loss of control and exhaustion
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fetal problems with hyptonic labor
infection of amniotic sac
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medical management of hypotonic labor
rule out CPD
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nursing management for hypotonic labor
- rest, analgesia if no CPD or ROM
- often normal labor will resume after sleep or rest
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problems with powers include
- abnormal patterns
- lax abdominal wall
- ineffectice pushing (secondary)
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abnormal patterns r/t problems with powers
- prolonged latent
- protracted active
- secondary arrest
- protracted descent, arrest of descent, failure of descent
- precipitous labor
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lax abdominal wall
- def
- tx
- displaces fetal head; prevents engagement
- sculteus binder
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ineffective pushing
- caused by
- tx
- anesthesia, exhaustion, malpresentation/position
- may require forceps or vacuum extraction
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alterations in pelvic structure
- pelvic dystocia
- soft-tissue dystocia
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pelvic dystocia
- pelive size and/or shape
- midplane most common problem
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soft-tissue dystocia
- any tissue other than bone that impedes descent
- placenta previa, fibroids, adipose tissue
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fetal factors affecting normal labor
- anomalies
- CPD
- malposition
- malpresentation
- multifetal pregnancy
- shoulder dystocia
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postterm pregnancy - maternal risk
- perineal damage due to the increased size of the fetus
- maternal hemorrhage
- cesarean birth
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postterm pregnancy - fetal risk
- decrease in uterine-placental-fetal circulation (due to placental changes)
- oligohydramnios
- meconium staining
- SGA or LGA
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precipitous labor
labor and birth that last less than 3 hrs; hypertonic, tetanic CTX
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potential problems with precipitous labor
- uterine rupture, abruptio placenta
- post partal hemorrhage
- fetal hypoxia and deathtrauma (laceration of cervix, vagina and perineum)
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what to do in shoulder dystocia
- implement McRoberts maneuver
- place woman's legs in exaggerated flexion into abdomen (apply suprapubic pressure - NEVER apply fundal pressure)
- be prepared to place woman in knee chest or lateral position
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breech presentation (most common malpresentation)
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frank breech presentation
fetal thighs flexed at the hips, legs extended, feet close to face
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complete breech presentation
fetal thighs and hips are flexed
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incomplete breech presentation
one or both htighs are not flexed; knee, foot or feet is/are presenting part
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episiotomy
- def
- protects
- types
- surgical incision reduces possibility of laceration
- portects fetal head from pressure exerted by resistant perineum
- midline, mediolateral
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indications for forceps and vacuum assited birth
- fetal distress
- maternal needs
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criteria for forceps or vacuum assisted birth
- engaged fetal head
- ruptured membranes
- full dilation
- absence of CPD
- anesthesia
- empty bladder
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types of forcep/vacuum assisted birth
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criteria for vaginal breech delivery
- frank or complete breech withouth hyperextension of the head
- fetal weight less than 3500gms
- adequate pelvic size
- gestational age of 36-42 wks
- experienced birth attendant and pediactric support
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crieria for c-section
- absence of labor when fetal status requires prompt delivery
- premature fetus whose condition requires minimal stress
- previous hx of perinatal death or child with birth injury
- inadequate pelvis
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problems with cord
- cord prolapse
- congenital of absence with artery (associated with other anomalies)
- abnormal insertions
- abnormal lengths
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abnormal cord length
- short
- long
- umbilical hernias, abruption, cord rupture
- transient variables, true knots
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cord prolapse
- types
- factors that increase risk
occult, in front of head, complete
- presenting part at high station
- small fetal size or abnormal presentation
- hydramnios
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interventions for cord prolapse
- relieve pressure on cord
- - push head off cord
- - knee chest position
- - elevate hips
- deliver expediently
- - C-section
- - vaginally
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problems with membranes and fluid
- chorioamnionitis
- fluid imbalance (poly and oligohydramnios)
- amniotic embolism/anaphalactoid syndrome
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chorioamnionitis
- def
- s&s (report promptly)
- interventions
- infection of membranes and fluid
- fetal tachycardia, maternal fever, amniotic fluid abnormalities
- medical and nursing care depends on Sx, maternal and fetal response
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hydramnios (polyhydramnios)
- def
- cause
- 2 types
- s&S
- result in
- over 2000 ml
- cause unknown, associated with fetal anomalies - may be associated with increased placental function
- chronic and acute
- SOB, LE edema d/t VC compression
- fetal anomalies, preterm birth
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management of polyhydramnios
- if severe or symptomatic
- tx:
- hospitalization
- Arom, indomethacin
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arom
- def
- risk
- needle amniotomy, amniocentesis
- abruption, prolapsed cord,
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indomethacin used to
decrease fetal urine output = <amniotic fluid
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oligohydramnios
- def
- risks
- causes
- less than normal fluid; AFI of <500cc (measure on US)
- risks of skin, muskuloskeletal abnormalities, pulmonary hypoplasia
- reduced cushioning effect during labor may lead to cord compression
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Pregnancy induced hypertension
- occurance
- manifestations
- occurs in 5-8% of all pregnancies (most common hypertensive disorder in pregnancy/second leading cause of maternal death)
- preeclampsia and eclampsia
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preeclampsia
- defined as increase BP after 20 wks gestation accompanied by proteinuria
- 140/90 or diff of 15 from norm
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eclampsia
occurance of a seizure in a woman with preeclampsia who has no other cause for a seizure
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maternal risks with pregnancy induced HTN
- can impact?
- CNS changes include
- intracerebral hemorrhage
- most organ systems, causing serious complications
- hyperreflexia, headache, eclamptic seizure
- rare complication, but is the most common cause of death in women with severe preeclampsia and eclampsia
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fetal risks with HTN
- preterm birth (15% of all preterm births are a result of preeclampsia)
- small for gest age
- placental abruption
- may be over sedated at birth d/t maternal meds
- may have hypermagnesmia d/t maternal tx w/ mag sulfate
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nursing care for PIH
- urine dipsticks for protein q shift
- blood pressure eval q 1-4 hrs
- daily weight
- bed rest
- corticosteroids
- anticonvulsants
- assess deep tendon reflexes and clonus
- assess for HA, blurred vision and epigastric pain
- if on mag sulfate chek urine output q 1 hr (should be more than 30cc/hr)
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first sign of mag toxicity
decrease DTR
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changes in fetal heart rate baseline:
- fetal tachycardia
- fetal bradychardia
baseline greater than 160 bpm for at least a 10 min period
baseline less than 110 bpm for at least a 10 min period
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Which comment made by a client would indicate the client's ability for safe care during the last trimester of pregnancy with mild preeclampsia?
The client state "I will:
A. report any SOB to my MD
B. report any HA or blurr vision to MD
C. limit my fluid intake after 3 pm
D. limit my salt intake during this time
B
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non-reassuring FHR pattern
- severe variable deccelerations
- late deccelerations of any magnitude
- absence of variability, bradycardia (70 or less)
- prolonged decceleration lasting 2 min but less than 10 min
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severe variable deccelerations consist of
FHR below 70 lasting 30-45 sec accompanied by a rising baseline or decreasing variability
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interventions for non-reassuring tracing
- document and report findings accurately and promptly to MD
- continuous monitroing of mom/fetus
- change position
- provide O2
- increase IV fluids
- provide information to mom/family
- admin tocolytic if ordered
- prepare for immediate delivery
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variable deccelerations
- occurance
- d/t?
- occur anytime withing the ctx
- due to cord compression
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with variale decceleration you should do what first
if that doesn't work?
- change position to move fetus off of chord
- 1. give O2, 2. give fluid, 3. amnion fusion
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interventions for variable decelerations
- d/c pitocin
- change position
- perform vag exam
- O2 per face mask
- amnionfusion
- if uncorrected, deliver
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late decelerations
- occurance
- d/t
- occur after the beginning, peak, and end of ctx
- due to placental insufficiency
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late deceleration interventions
- FIRST
- SECOND
- then...
- D/C pitocin
- put in side lying position
- give O2
- maintain or increase IV fluids
- if hypotensive, correct
- fetal pH sampling
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early decelerations
- occurance
- d/t
- simultaneously with ctx
- vagal nerve stimulation caused by the fetal head
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interventions for early decelerations
position change
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shock associated with pregnancy related complications
- hypvolemic
- septic
- cardiogenic
- neurogenic
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hypvolemic shock
- def
- d/t
loss of volume
- ectopic pregnancy
- previa and abruption
- uterine rupture
- PP hemorrhage
- obsteteric surgery
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septic shock
- def
- caused by
decreased blood vessel function
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cardiogenic shock
- def
- caused by
decrease pump function
- cardiac tamponade
- PE
- thrombophlebitis
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neurogenic shock
- def
- caused by
overwhelmed neuro regulatory capacity
- uterine inversion
- electroyte imbalance
- drug toxicity
- aspiratino
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S/S hypovolemic shock
- tachypnea, tachycardia, weak thready pulse
- hypotn
- increased cap refill (>4 sec)
- oliguria (<30cc/hr)
- cool, clammy skin
- pallor, peripheral cyanosis
- hypothermia
- anxiety, restlessness, thirst, feeling chilled, disorientation
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S/S of Septic shock
- tachycardia; hyperdynamic pulse
- tachypnea, resp alkalosis
- hypotn
- cerebral ischemia
- polyuria
- hyperthermia (early)
- palpitations, faintness, apprehension, stupor, disorientation
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OB emergency interventions
- large bore IV
- O2 admin
- floey cath
- admin of blood, blood products, tx coaglopathy, DIC
- promote fetal/newborn well-being
- prepare, assist with emergency delivery
- assess, monitor for changes, fluid overload
- CPR if necessary w/n 4 min
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