Maternal child health nursing

1. Maternal child health nursing Module 6

2. Objectives • Abnormal labor/delivery, obstetric procedures/surgery, immediate postpartum mother/baby/family care

3. Risks of labor and birth • Fetal distress resulting from: • Hypoxia • Prolapsed cord or compressed cord • Placental abruption • Placenta previa • Hypertonic uterus • Placental insufficiency

4. Risks of labor and birth • Fetal hypoxia related to: • Prolapsed or compressed cord • Umbilical cord may drop down between presenting part and open cervix • Cord may be pressed between fetus and maternal part

5. Risks of labor and birth • Fetal hypoxia related to meconium • Hypoxic response • Hyperactive GI and relaxed anal sphincter in hypoxia • Contributes to respiratory distress in neonate • May require neonatal resuscitation, suctioning

6. Head compression reflected in EFM tracing: note “mirror image”

7. Uteroplacental insufficiency

8. Preterm labor and birth • Mechanisms of preterm labor still unknown • Maternal, fetal problems • Delivery less than 37 weeks • lungs • Fat (including brown fat) • Circulation: impaired adaptation to newborn • Digestive system • Renal system

9. Preterm labor and birth • Delivery less than 37 weeks (cont’d) • Acid/base imbalances • Neurological immaturity • Posture, color, head size, skin/fat, lanugo, pliable cartilage (ears), undescended testes, small labia majora, weak/thin cry, immature or absent reflexes

10. Preterm labor and birth • NICU care • Morbidity/mortality 3 to 4 times higher • Problems and successes depend upon maturity at delivery and presence/absence of underlying disorders • FON p 917 nursing care plan • Terbutaline

11. Premature rupture of membranes • Break in amniotic sac before 37th week • Risk factors: genital tract infection, smoking during pregnancy, hx PROM in previous pregnancies, bleeding during more than one trimester, • Complications: infection, prolapsed cord, placental abruption, fetal immaturity factors • Nursing care

12. Postterm delivery • Postterm gestation: 42 weeks or more • Risk for placental insufficiency • Fetal hypoxia, malnutrition • Asphyxia, respiratory distress, hypoglycemia • May be SGA, AGA, or LGA

13. Dystocia • Dysfunctional labor • Pelvic structure variations • Immaturity • malnutrition • Obesity (soft tissues) • Fetal variations • Mother’s responses

14. Fetal distress • s/s: tachycardia/bradycardia, non-reassuring FHR pattern on EFM • Rate • Variability • decelerations • Hypoxia • Uteroplacental insufficiency • compressed umbilical cord

15. Fetal distress • Intolerance of labor • Uteroplacental insufficiency or hypoxia during pregnancy and/or labor/delivery • Electronic fetal monitoring, Doppler, fetoscope can provide information about the FHR that guides interventions

16. Fetal distress • Factors in uteroplacental insufficiency, hypoxia • Insufficient gas/nutrient exchange between mother and fetus • Restricted oxygenation d/t impaired or pressured umbilical cord

17. Fetal distress • Nursing management • Depends on underlying cause, stage of labor • Support oxygenation of mother and fetus • Position change, IV fluids, 02 by mask or NC, DC or decrease pitocin drip • Prepare for emergency or urgent delivery • Distressed fetus likely to require respiratory support after delivery

18. Electronic fetal monitoring • First attempted in early 20th century • Linked electrical pattern of fetal heart rate/rhythm to predictable fetal status • Electrical signals received into transmitter placed on maternal abdomen or via fetal scalp electrode • Internal scalp electrode can only be done after ROM, sufficient cervical dilation. • Used with tocotransducer over focal point of contractions

19. EFM cont’d • Heart rate and contraction pattern displayed on screen • relationship between contractions and FHR • Toco can’t measure contraction intensity • Subjective • palpation • Nurse responsible for accurate interpretation, nursing intervention and communication to midwife/physician

20. Doppler • Developed for fetal monitoring in 1960s • Bounces high-pitched sound waves off fetal heart, translating signals into auditory signal examiner can hear • Pros: Smaller unit, more transportable; easily heard rate/rhythm • Cons: examiner needs skill to hear and recognize deceleration patterns

21. Fetoscope • FHR auscultation discussed as early as 17th century in Europe • Allows examiner to ausculatate fetal heart rate • Doesn’t require advanced technology or electricity • Cons similar to Doppler interpretation

22. Abnormal duration of labor • Prolonged labor • Lasting longer than usual • Length of time depends on nullipara vs multipara • Interventions depend on fetal and maternal well-being, also membrane status • May be decreased by activity, relaxation measures, or instrumented or surgical delivery

23. Abnormal duration of labor • Precipitate labor/birth: • Less than 3 hours from onset cxns to birth • Hypertonic uterus • Multiparity • Maternal and fetal complications relate to causative factors • Maternal: uterine rupture, lacerations, amniotic fluid embolism, postpartum hemorrhage • Fetal: hypoxia, intracranial hemorrhage

24. Prolapsed cord • FON p 811 Fig 26-6 • Umbilical cord slips down into birth canal before fetal presenting part does, causing fetal distress, hypoxia • Pressure may be relieved by examiner’s (sterile!) gloved fingers lifting presenting fetal part off of cord or changing mom’s position • Risk after ROM, especially PROM or rush of fluids • Emergency delivery indicated

25. Position change for prolapsed cord

26. Labor induction/augmentation • Induction starts labor contractions • Augmentation strengthens contractions already in progress • Indications: prolonged time after ROM, severe PIH, postterm pregnancy, hx precipitous labor (to prevent out-of-hospital delivery), complications • Methods: amniotomy, prostaglandin gel, oxytocin stimulation

27. Labor induction/augmentation • Nursing management • Monitor effects on FHR, pattern; palpate contractions, ensure adequate monitoring and appropriate nursing responses, I&O balance, timely record-keeping

28. Obstetric procedures • Amniotomy • Artificial rupture of membranes (ROM) • Sterile • hook • Episiotomy • Incision made in perineum to make the birthing passage bigger • Measured in degrees

29. OB procedures: Forceps • Forceps are spoon-like instruments designed to fit around fetal skull and apply traction for delivery • Multiple types for multiple fetal stations • May be used to delivery head in breech • Require skill to avoid too much pressure to fetal skull or damaging maternal tissues • Monitor FHR

30. OB procedures: Forceps

31. OB procedures: Vacuum extraction • Traction on fetal head using negative pressure vacuum cup • Criteria: vertex presentation, ruptured membranes, full dilation, no cephalopelvic disproportion • Common: caput succedaneum (newborn scalp edema) and bruising

32. Obstetric procedures • Cesarean delivery • Incision • Anesthesia • Scheduled vs unscheduled • Vaginal birth after c-section (VBAC)

33. C-section • Incision (external and uterine) • Vertical • Horizontal • Internal dissolving sutures (uterine) • Closure of outer incision and cauterization of bleeding vessels • Staples • Dressing • Nursing care: dressing, incision care, staple removal, education

34. C-section • Anesthesia • Epidural • Spinal • General • Scheduled vs unscheduled • VBAC and TOLAC • Vaginal birth after cesarean • Trial of labor after cesarean

35. C-section • Epidural • Sterile procedure • Injection into epidural space surrounding spinal cord • Anesthetic: lidocaine and epinephrine • Initial trial injection, then continual infusion by pump • Infusion settings set and usually adjusted only by anesthesia provider

36. Epidural

37. Epidural

38. Epidural • Risks: decreased maternal blood pressure -> decreased fetal oxygenation, headache, allergic reaction, decreased maternal movement, decreased respiratory status, decreased push ability • Benefits: anesthesia from contractions and delivery, consciousness, fewer side effects • Nursing care

39. Spinal • Placement similar to epidural • One-time injection, lasts through surgery • Useful for C-section if anesthesia not in place for labor • Medication placed next to spinal cord • Less medication needed • Fewer side effects

40. General • General anesthesia • Rarely used • Complications include: respiratory depression (mother or baby), uterine relaxation, risk of aspiration • Postpartum: interrupted bonding, infection, pain • Nursing care after C-section

41. C-section and later births • Scheduled vs unscheduled • VBAC • After 1-2 C-sections (ACOG) • TOLAC (trial of labor after cesarean) Vaginal births attempted after previous C-section are considered by most practitioners as higher-risk May not be attempted if standing C-section team unavailable

42. Nursing care prior/after C-Section • Pre-operatively: • Monitor V/S • Assess status and changes • Assess FHR, cxns, pain, bleeding, amniotic fluid • Assess pain control with epidural/spinal placement, circulation and motor • Place Foley catheter after anesthesia placed, chart amount, color of urine • Educate regarding procedures, expectations • Follow hospital pre-op checklist

43. Nursing care pre/post c-section • Post-operatively • Monitor vital signs, pain control, level of consciousness, returning motor, sensation of lower extremities, bleeding • Address changes quickly and report to practitioner • Chart baselines and changes • Support mother’s return to independence and efforts to care for baby

44. Postpartum care

45. Immediate postpartum care • Newborn • Airway, breathing, circulation • Warmth • Identification • APGAR score • 1 and 5 minutes • 8-10 total score optimal • < 7 indicates need for intervention

46. APGAR score sheet

47. Acrocyanosis

48. Immediate postpartum care: mom • Needs after vaginal delivery vs C-section delivery similar: • Fluid balance: • bleeding • intake (IV, PO) • output (Foley? Toilet? Edema? Retention?) • Pain or discomfort • Uterine cramping and tone • Perineal pain • Back pain

49. Immediate postpartum care: mom • Needs (cont’d) • Medication side effects: • Nausea/vomiting • Itching • Disorientation, confusion, dizziness • Hunger: • Cravings, cultural foods, demands • Bowel elimination • Last BM? C-section moms at increased risk for ileus • Diarrhea or constipation? • Stool softeners, not laxatives

50. Immediate postpartum needs: mom • Bonding and breastfeeding • Privacy, calm, unhurried time with newborn • Delay nonessential newborn interventions • Assist with breastfeeding or refer to someone who can • Promote bonding within family • May need to help family figure out how to set visitation boundaries • Rest