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HIGH RISK OBSTETRICS

HIGH RISK OBSTETRICS. NUR 202 Mary Starkey Wallace. High Risk Obstetrics. A pregnancy in which the life or health of the mother or fetus is jeopardized by a disorder coincidental with or unique to pregnancy. High Risk Obstetrics. High Risk status for the mother extends through the puerperium

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HIGH RISK OBSTETRICS

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  1. HIGH RISK OBSTETRICS NUR 202 Mary Starkey Wallace

  2. High Risk Obstetrics A pregnancy in which the life or health of the mother or fetus is jeopardized by a disorder coincidental with or unique to pregnancy

  3. High Risk Obstetrics • High Risk status for the mother extends through the puerperium (6 weeks after childbirth)

  4. High Risk Obstetrics • Postbirth maternal complications are usually resolved within one month of birth, but……. • Perinatal morbidity may continue for months or years

  5. High Risk Obstetrics • Advances in management of disorders that affect pregnant women have resulted in a significant decrease in maternal mortality and morbidity rates

  6. High Risk Obstetrics • In the United States maternal mortality and morbidity rates remained the same for several years • In 1980-1998 the rate remained at 7- 8 per 100,000 pregnancies

  7. High Risk Obstetrics (cont) • In 2000 rate increased to 9.8 but • Increase attributed to change in reporting rather than an actual increase

  8. High Risk Obstetrics • Poses a problem for modern medical and nursing care • Emphasis on quality of life and wanted child • Reduced family size and number of unwanted pregnancies

  9. High Risk Obstetrics • Today emphasis on safe birth of normal infants who can reach their potential • Birth of a neonate who does not meet cultural, societal, or family norms and expectations many times results from high risk pregnancy

  10. High Risk Obstetrics • Three leading causes of maternal mortality have remained unchanged over last 50 years • They are 1) pregnancy induced hypertension 2) pulmonary embolism 3) hemorrhage

  11. High Risk Obstetrics • Factors strongly related to maternal death -age (younger than 20 and 35 or older) - lack of prenatal care -low educational attainment -unmarried status -nonwhite race

  12. High Risk Obstetrics • Ongoing research needed to identify extent that -financial -sociocultural -behavioral -educational factors affect perinatal morbidity and mortality

  13. Induction of Labor • Considered when ending the pregnancy -benefits woman or fetus -when labor and vaginal birth considered safe

  14. Contraindications to Induction • Any Contraindications to labor and vaginal birth such as -placenta previa (hemorrhage during labor) -vasa previa (umbilical cord vessels branch over amniotic sac rather than inserting into placenta; fetal hemorrhage possibility

  15. Contraindications to Induction(cont) -transverse fetal lie -umbilical cord prolapse (immediate delivery by cesarean indicated) -classic uterine incision -extensive surgery for fibroids

  16. Induction of Labor • Prior to induction assessment must indicate -fetal maturity -cervical readiness

  17. Induction of Labor • Fetal maturity bestdetermined by -early ultrasounds -accurate menstrual dating -amniotic fluid studies (L S Ratio 2:1)

  18. Induction of Labor • Cervical Readiness best evaluated by cervical exam • Bishop scoring system evaluates cervical readiness for labor

  19. Bishop Scoring System • Uses 5 factors to estimate cervical readiness for labor -dilation -effacement -fetal station -cervical consistency -cervical position

  20. Bishop Scoring System (cont) • Each factor is assigned a score of 0, 1, 2, or 3 according to specific criteria for each score • The numbers are then totaled for the composite score • Multipara usually has successful induction when score is 5 or higher • Primipara usually has successful induction if score is 7 or higher

  21. Bishop System of Cervical Scoring Assessment scoreDilation Effacement Fetal Consistency Position Position (cm)(%) station 0 0 0-30 -3 Firm Poster 1 1-2 40-50 -2 Medium Mid 2 3-4 60-70 -1 Soft Anter 3 5-6 ≥80%+1,+2, -- --

  22. Bishop System of Cervical Scoring • NOTE: Add the score for each of the clinical assessments • If the total score is greater than 8, the success of induction approaches that of spontaneous labor.

  23. Cervical Ripening • Cervix has to be ripe or soft prior to induction to make it likely to dilate with forces of labor • Cervical ripening is done most frequently the day before the morning of induction

  24. Cervical Ripening(cont) • Consists of effacement and softening of the cervix • May be used at or near term to enhance success of and reduce time needed for labor induction when continuing pregnancy is undesirable • May hasten beginning of labor or shorten course of labor

  25. Cervical Ripening(cont) • Prostaglandlin should be used cautiously in the presence of the following -asthma -glaucoma -ischemic heart disease -pulmonary disease -hepatic disease -renal disease

  26. Absolute Contraindications toCervical Ripening • Placenta or vasa previa • Transverse fetal lie • Prolapsed umbilical cord • Prior classic uterine incision or myomectomy that entered the uterine cavity • Pelvic structural abnormality • Active genital herpes infection • Invasive cervical cancer

  27. Relative Contraindications to Cervical Ripening • Abnormal fetal heart rate patterns • Breech presentation • Maternal heart disease • Multifetal pregnancy • Polyhydramnios • Presenting part above the pelvic inlet • Severe maternal hypertension

  28. Cervical Ripening(cont) • Prostaglandin Agents used for cervical ripening… -dinoprostone (Prepidil, Cervidil) -misoprostol (Cytotec)

  29. Cervical Ripening(cont) • Dinoprostone (such as Cervidil or Prepidil Gel) can be inserted as a suppository into the vagina (intravaginally). • It can also be given as a gel that is gently squirted into the opening of the cervix (intracervically

  30. Cervical Ripening(cont) • Dinoprostone should be administered with the patient in or near a labor and delivery suite • The patient is expected to remain recumbent for the first 30 minutes and should be monitored for a further 30 to 120 minutes • When contractions occur, they usually appear within 60 minutes and peak within four hours

  31. Cervical Ripening(cont) • The optimal interval for administering another dose has not been determined • Six hours is commonly used • The gel should be kept refrigerated and brought to room temperature immediately before use • The manufacturer recommends that no more than three doses be administered per 24 hours

  32. Cervical Ripening(cont) • Misoprostol (Cytotec) is a pill taken by mouth or placed in the vagina (using a smaller dose) • It is a medication currently approved for treating ulcers; • Using it for cervical ripening is a widely accepted but unlabeled use of this medication

  33. Cervical Ripening(cont) • (Misoprostol) Cytotec is an effective, safe and inexpensive agent for cervical ripening and labor induction • Prepidil and Cervidil cost $150 and $175 per insert, respectively, whereas a 100-µg Cytotec tablet costs $0.60.

  34. Cervical Ripening(cont) • Misoprostol is a synthetic analog of PGE1. • When given orally it is rapidly absorbed by the gastrointestinal tract and undergoes de-esterification to its free acid • This state is responsible for its clinical activity • The total systemic bioavailability of vaginally administered misoprostol is three times greater than that of orally administered misoprostol

  35. Cervical Ripening(cont) • Dose is one-quarter of 100 mcg (25 mcg) tablet vaginally • A 100 mcg tablet not scored • Hospital pharmacy should prepare the 25 mcg dose for greater accuracy

  36. Cervical Ripening(cont) • Maternal outcomes such as the need for cesarean delivery because of FHR abnormalities, the arrest of labor or the need for tocolytic administration, are not significantly different between misoprostol and dinoprostone.

  37. Cervical RipeningMechanical • MECHANICAL MODALITIES • All mechanical modalities share a similar mechanism of action—namely, some form of local pressure that stimulates the release of prostaglandins • The risks associated with these methods include infection (endometritis and neonatal sepsis have been associated with natural osmotic dilators), bleeding, membrane rupture, and placental disruption.

  38. Cervical RipeningMechanical (cont) • Hygroscopic dilators absorb endocervical and local tissue fluids, causing the device to expand within the endocervix and providing controlled mechanical pressure • The products available include natural osmotic dilators (e.g., Laminaria) and synthetic osmotic dilators (e.g.,Lamicel) • The main advantages of using hygroscopic dilators include outpatient placement and no FHR-monitoring requirements.

  39. Cervical RipeningMechanical (cont) • Balloon devices provide mechanical pressure directly on the cervix as the balloon is filled • A Foley catheter (26 Fr) or specifically designed balloon device can be used

  40. Cervical RipeningSurgical • SURGICAL METHODS • Stripping of the Membranes. Stripping of the membranes causes an increase in the activity of phospholipase A2 and prostaglandin F2 (PGF2) as well as causing mechanical dilation of the cervix, which releases prostaglandins.

  41. Stripping of Membranes • Gloved finger inserted into internal os and rotating 360 degrees twice separating amniotic membranes lying against lower uterine segment • Does not require monitoring or other assessments - Often done as outpatient service • May not induce labor - if labor is initiated, it typically begins within 48 hours • May cause bleeding

  42. Amniotomy • A pelvic examination is performed to evaluate the cervix and station of the presenting part • The fetal heart rate is recorded before and after the procedure. • The presenting part should be well applied to the cervix

  43. Amniotomy (cont) • A cervical hook is inserted through the cervical os by sliding it along the hand and fingers (hook side toward the hand) • The membranes are scratched or hooked to effect rupture • The nature of the amniotic fluid is recorded (clear, bloody, thick or thin, meconium)

  44. Amniotomy (cont) • Amniotomy increases the production of, or causes a release of, prostaglandins locally • Risks associated with this procedure include umbilical cord prolapse or compression, maternal or neonatal infection, FHR deceleration, bleeding from placenta previa or low-lying placenta, and possible fetal injury.

  45. Pitocin Infusion • Usually effective at producing contractions - may cause hyperstimulation of the uterus • Requires small, precise dosage (infusion pump) • Maximum rate and dosing interval based on facility protocol, clinician order, individual situation, and maternal-fetal response

  46. Pitocin Infusion (cont) • Palpating uterus essential, unless IUPC in place • May initially decrease blood pressure

  47. Pitocin (cont) • Oxytocin increases intracellular calcium levels, stimulating contractions in myometrial smooth muscle • Oxytocin is the preferred pharmacologic agent for inducing labor when the cervix is ripe

  48. Pitocin Infusion (cont) • Commonly used Guidelines for Oxytocin Administration from American College of Obstetricians and Gynecologists are as follows… • Dilute 10-20 Units in 1000 ml of balanced isotonic solution as piggyback per IV pump

  49. Pitocin Infusion (cont) • After adequate contraction pattern established • Cervix dilated to 5 to 6 cms • Oxytocin may be reduced by increments similar for induction

  50. Pitocin Infusion (cont) • Uterus more sensitive to Oxytocin as labor progresses • Due to increased sensitivity Pitocin administration titrated to uterine and fetal response

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