child birth at risk 8

Maternal & Child Nursing Care, Third EditionLondon • Ladewig • Ball • Bindler • Cowen

Childbirth at Risk: Prelabor Complications

Learning Outcome

Explain the possible causes, risk factors, and clinical therapy for premature rupture of the

membranes or preterm labor in determining the hospital-based and community-based nursing care

management of the woman and her fetus-newborn.

Premature Rupture of Membranes (PROM) is Spontaneous Rupture of the Membranes Before the

Onset of Labor

• Preterm PROM (PPROM) is the rupture of membranes occurring before 37 weeks’ gestation

• Although the exact cause is unknown, PPROM is associated with infection, previous history of PPROM, hydramnios, multiple pregnancy, and a variety of other pregnancies

Premature Rupture of Membranes (PROM) is Spontaneous Rupture of the Membranes Before the

Onset of Labor

• PROM nursing care focuses on prevention of infection such as limiting vaginal exams and changing the bed pads frequently

• The fetus is monitored carefully

Preterm Labor (PTL): Labor That Occurs Between 20 and 36 Completed Weeks of Pregnancy

• Women who are at risk for PTL are taught to recognize its symptoms to prevent it

Preterm Labor (PTL): Labor That Occurs Between 20 and 36 Completed Weeks of Pregnancy

• Nursing care: tocolysis, monitoring for progression of labor, maintaining good uterine blood flow, maintaining side-lying position, potential IV infusion, maternal laboratory studies including CBC, C-reactive protein, vaginal cultures, fetal fibronectin (fFN), urine culture and an ultrasound may be obtained to determine cervical shortening or funneling, as well as assess fetal well-being

Learning Outcome

Compare and contrast abruptio placentae and placenta previa, including implications for the mother and fetus and nursing care.

Types of Abruptio Placentae

• Marginal– Placenta separates at its edges– Blood passes between fetal membranes and

uterine wall– Blood escapes vaginally

Types of Abruptio Placentae

• Central– Placenta separates centrally– Blood trapped between placenta and uterine

wall– Concealed bleeding

• Complete– Total separation– Massive vaginal bleeding

Abruptio Placentae

Maternal Implications of Abruptio Placentae

• Intrapartum hemorrhage• DIC• Hypofibrinogenemia• Ruptured uterus from overdistention• Fatal hemorrhagic shock

Maternal Implications of Abruptio Placentae

• Postpartum complications– Vascular spasm– Intravascular clotting– Hemorrhage– Renal failure– Fatal shock

Differential Signs and Symptoms of Placenta Previa and Abruptio Placentae

Fetal-Neonatal Implications of Abruptio Placentae

• Sequelae of prematurity• Hypoxia• Anemia• Brain damage• Fetal demise

Nursing Plan for Abruptio Placentae

• Maintain two large-bore IV sites – fluids and blood products as ordered

• Monitor fetus and uterine activity electronically– Assess resting tone every 15 minutes– Assess fetal status every 15 minutes

• Monitor for signs of DIC• Monitor Intake & Output and urine specific

gravity• Measure abdominal girth hourly, as

ordered

• Assess maternal cardiovascular status frequently– Vital signs every 5-15 minutes– Skin color and pulse quality hourly– Measure CVP hourly, as ordered

• Review and evaluate diagnostic tests• Prepare for cesarean, as needed• Neonatal resuscitation, as needed• Provide information and emotional support

Categories of Placenta Previa

• Total: The internal os completely covered• Partial: The internal os partially covered• Marginal: The edge of the os covered• Low-lying placenta: Implanted in lower

segment in proximity to the os

Classification of Placenta Previa

Implications of Placenta Previa

• Maternal psychologic stress• Transverse lie common• Changes in FHR• Meconium staining• Fetal compromise (hypoxia)• Cesarean birth• Neonatal anemia

Nursing Plan for Placenta Previa

• No vaginal exams!• Objectively and subjectively assess blood

loss, pain, uterine contractility• Continuous external monitoring of FHR

and uterine activity – no internal monitoring

• Monitor maternal vital signs and Intake & Output – every 5-15 minutes with active hemorrhage

• Obtain/evaluate labs• Maintain large – bore IV access-available

whole blood setup• Verify family’s ability to cope with anxiety

of unknown outcome• Provide information and emotional support

• Promote neonatal physiologic adaptation– Resuscitation as needed– Evaluate hemoglobin, cell count, erythrocyte

count– Administer oxygen and blood as needed

Learning Outcome

Explain the maternal and fetal-neonatal implications and the clinical therapy in determining the community-based and

hospital-based nursing care management of the woman with multiple gestation.

Multiple Gestation

• Care of woman with more than one fetus includes:– Frequent assessment of fetal heart tones of

each fetus– Education of mother about signs and

symptoms of preterm labor

Multiple Gestation

• Care of woman with more than one fetus includes:– Encouragement of mother to rest frequently

prior to birth– Preparation of equipment needed to care for

each individual newborn

Presentations in Utero

Learning Outcome

Compare the identification, maternal and fetal-neonatal implications, clinical therapy, and nursing care management of women

with hydramnios and oligohydramnios.

Implications of Hydramnios

• Maternal– Shortness of breath– Edema– Greatly increased cesarean rate– Uterine dysfunction– Abruptio placentae– Postpartum hemorrhage

Implications of Hydramnios

• Fetal-Neonatal– Malformations– Preterm birth– Increased mortality rate– Prolapsed cord– Malpresentation

Conditions Associated with Hydramnios

• Diabetes• Rh sensitization• Hydrops fetalis• Malformations of fetal swallowing• Neural tube defects with exposed

meninges

Conditions Associated with Hydramnios

• Anencephaly• Cardiac anomalies• Esophageal or duodenal atresia• Monozygotic, monochorionic twins• Large placenta

Assessment Findings Suspicious for Hydramnios

• Fundal height disproportionately large for dates

• Difficulty palpating fetus and auscultating FHR

• Tense, tight abdomen on inspection• Large spaces between fetus and uterine

wall on ultrasound

Nursing Plan with Hydramnios

• Provide information and emotional support• Maintain absolute sterility during

amniocentesis• Collaborate with social services if fetal

defect identified

Conditions Associated with Oligohydramnios

• Postmaturity• IUGR secondary to placental insufficiency• Major renal malformations

– Renal agenesis– Dysplastic kidneys– Lower urinary tract obstructive lesions

Implications of Oligohydramnios

• Dysfunctional labor with slow progress• Fetal deformation defects

– Adhesions– Skin and skeletal abnormalities– Pulmonary hypoplasia– Dysmorphic facies– Short umbilical cord

Implications of Oligohydramnios

• Umbilical cord compression• Head compression

Assessment Findings Suspicious for Oligohydramnios

• Fundal height small for dates• Fetus easily palpated and outlined• Fetus not ballottable• Variable decelerations• Reduced AFI on ultrasound

Nursing Plan for Oligohydramnios

• Provide information and encourage questions

• Evaluate EFM tracing for variable decels or nonreassuring fetal status

• Reposition mother to relieve cord compression

• Notify clinician of signs of cord compression

Nursing Plan for Oligohydramnios

• Evaluate newborn– Anomalies– Pulmonary hypoplasia– Postmaturity

child birth at risk 8

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