Week 4 CAN – L&B Risk and Postpartum
Preterm Labour and Birth
Preterm
vs
Low-birth weight
 time of birth
 < 2500 g
not weight
Preterm labour
 Cervical changes and uterine contractions occurring btwn
20-37 weeks of pregnancy
Preterm birth:
 Any birth that occurs before 37 weeks of preg
Causes:
 Infections
 Idiopathic preterm births
 Sociodemographic factors
 poverty, low education, lack of social support, smoking,
Ø prenatal care, intimate partner violence, stress
Predicting preterm labour and birth
 Biochemical markers – Fetal fibronectins
 Endocervical length
Nursing Care Management:
Prevention
 Prevention strategies to address risk factors
 Education aims at health promo and disease preventions
 Educate about preterm labour signs
 Teach what to do if symptoms occur
 Women may ignore b/c of ignorance or they think it is
expected
 Bed rest
Early Recognition
 Gestational age between 20-37 weeks
 Uterine activity (contractions)
 Progressive cervical change (effacement 80%, dilation >2cm)
Lifestyle modifications
These activities should be curtailed
 Sexual activity
 Riding long distances (car or bus)
 Carrying heavy load
 Standing >50% of time
Heavy housework
 Climbing stairs
 Hard physical work
 Unable to stop and rest when tired
Tocolytics – to suppress uterine activity
 Afford opportunity to administer antenatal glucocorticoids
 Accelerate fetal lung maturity
 Not indicated if: Cord prolapse, chorioamnionitis,
Abruptio Placentae
 Reduce severity of sequalae in preterm births
Management of Inevitable Preterm Birth
 Labour progressed to cervical dilation 4cm → preterm birth
 Preterm birth in tertiary care centres lead to better outcomes
 Women at risk be transferred quickly
– give antenatal glucocorticoids before transfer
Preterm Premature Rupture of Membranes (PPROM)
 Membrane ruptures before 37 weeks gestation
 Often preceded by infections
 Cause unknown
 Women complains of sudden gush or slow leak of vaginal fluid
Dystocia
 abnormal slow progress of labour
 > 4 hours of < 0.5cm per hour of cervical dilation in active lab
 Dysfunctional labour from abnormal uterine contractions
 Cervical dilation, effacement, descent
Factors than can increase risk for uterine dystocia:
 Body build
 Uterine abnormalities
 Malpresentation and position of fetus
 Cephalopelvic disproportion (CPD)
 Overstimulation with oxytocin
Factors that can increase risk for dystocia:
 Maternal fatigue, dehydration, E imbalance, fear
 Inappropriate timing of analgesic or anaesthetic admin
 Dysfunction of uterine contractions
 Hypertonic or primary dysfunctional labour
 Hypotonic or secondary uterine inertia
 Pelvic dystocia
 contractures of pelvic diameter that reduce capacity of bony
pelvis, inlet mid-pelvis or outlet
 Soft Tissue Dystocia
 results from obstruction of birth canal by anatomical
abnormality other than bony pelvis
Psychological responses – body’s response to stress → dystocia
Abnormal Labour Patterns
 precipitous - < 3h from onset of contractions
Post term Pregnancy, Labour, and Birth
Maternal risk
 excessively large infant
 Increased risk: dysfunctional labour, birth canal trauma
 Interventions likely to be necessary
 Fatigue and psychological reactions
Fetal Risks
 Prolonged labour
 Shoulder Dystocia
 Birth trauma
 Asphyxia from macrosomia
Compromising effects of an aging placenta
Nursing Care Management
 Controversial
 Suggest induction at 41-42 weeks, while other up to 43 weeks
 With assessment of fetal well-being normal
Version
 Internal version and External Cephalic Version
Trial of labour
Inductions or augmentation
 Stimulation of uterine contractions after labour has started
but progress is unsatisfactory
 Oxytocin infusion, amniotomy, nipple stimulation
Oxytocin use
 Special caution:
 Multifetal presentation, breech presentation, part above
pelvic inlet, abnormal FHR, polyhydramnios, grand
multiparity, history of c-section, maternal cardiac disease
Cervical ripening methods
 Chemical agents – prostaglandins
 Amniotomy
 Mechanical methods
Forceps-assisted birth
Maternal indications
 Shorten second stage in event of dystocia
 Compensate for deficient expulsive efforts
 Reverse a dangerous condition
 Fetal indications
 Distress or certain abnormal presentations
 Arrest of rotation
 Delivery of head in a breech presentation
Vacuum-assisted birth
 Attachment of vacuum cup to fetal head, using negative
pressure to assist birth of head
 Risk to newborn of cephalohematoma, scalp lacerations,
subdural hematoma
Week 4 CAN – L&B Risk and Postpartum
Caesarean birth
 Immediate postop care
 Pain relief and discharge teaching/planning
 Vaginal birth after section
Shoulder Dystocia
 Head is born but should is stuck, likely NB experience injury
 Mother’s primary risk from excessive blood loss b/c
laceration, extension of episiotomy or endometritis
Prolapse umbilical cord
 cord lies below presenting part of fetus
 Long cord, malpresentation (breech) transverse lie,
unengaged presentation part
Ruptured Uterus
 VERY SERIOUS OB INJURY
 Caused by separation of scar of prev C-section, uterine
trauma, congenital uterine anomaly
Amniotic fluid embolism
 Sudden death
 debris enter CV system
 Triggers a rapid complex series of patho events
Post Partum Period
 Period after 4th stage of labour and lasts 6 weeks (varies)
Uterus
 Involution: return or uterus to nonpregger state
 Fundus descends 1-2 cm every 24 hours
 Subinvolution: failure of uterus to return
 common causes retained placental pieces or infection
 Contractions
 Oxytocin released (b/c breastfeeding) strengthen and
coordinate uterine contractions, (afterpains)
Cervix
 Soft immediately after birth
 Within 2-3 days, it is shorted
 Lacerations delay production of estrogen which influences
cervical mucus production → ↑risk for infection
Vagina and perineum
 gradually returns to size by 6-10 weeks
 episiotomies heal within 2-3 wks
 hemorrhoids and anal varicosities are common
 Recommend Kegel exercises – 6 months to regain tone
Abdomen
 Abd wall is relaxed – still looks pregnant
 return takes about 6 wks
Placental Hormones
expulsion of placenta → dramatic changes to hormone levels
 ex. Significantly lower blood sugar levels
 estrogen and progesterone levels drop lowest @ 1 wk
Pituitary hormones and ovarian function
 lactating and non lactating women differ in timing of first
ovulation and menstruation
 when lactating, serum prolactin levels remain elevated and
suppress ovulation
 70% of non-breastfeeding mothers menstruate within first 12
weeks
Urine Components
 no more glycosuria
 May have lactosuria in lactating women
 Elevated BUN due to autolysis of involuting uterus
Diuresis
 Within 12 hours of delivery
 Profuse often occurs at night for first 2-3 days
Urethra and bladder
 Full bladder can displace uterus → excess bleeding
 Decrease urge to void → encourage scheduling void q2hr
Appetite
 Most new mother are very hungry
 If BF, ensure moms know to eat for more nutrients for both
baby and herself - elf Care momma
Bowel evacuation
 spontaneous bm may take 2-3 days
 offer laxative to help with the first bm
Breasts
 Breastfeeding mothers
 Before lactation, a yellowish fluid, colostrum can be
expressed
 Tenderness may persist for 48 hours after start of lactation
 Non Breastfeeding moms
 Engorgement can occur but also resolves spontaneously
 Cool ice pack, fresh cabbage leaves to reduce swelling
Blood Volume
 Returns to normal 2 weeks post partum
 Decreases due to
 Blood loss in childbirth
 Diaphoresis and diuresis within first 2-3 days
 Elimination of placenta, diverting 500-750 mls of blood
 Rapid reduction in sze of uterus = more blood into CV system
Cardiac Output
 Remains increased for 48hrs after childbirth
 CO generally returns within 6 wks,
 SV+end-diastolic volume+SVR = remain elevated for 12 weeks
Vitals
 HR and BP normal within few days
 Respiratory function to normal by 6-8 days
 Risk for orthostatic hypotension for 48 hr
d/t engorgement of organs
Blood Components
 Hemoglobin and hematocrit: ↑ up to 72 hours
 WBC count: elevated 10-14 days w/o infection then to norm
 Coagulation: normally elevated during pregnancy, ↑ DVT risk
Post Partum Chill
 first 2 hours
 uncontrollable shaking
 Offer warm blanket and reinforce it is normal
Headaches – careful assessment
 may be caused by PIH, stress, and leakage of cerebrospinal
fluid into extradural space during epidural or spinal anesthesia
Hyperpigmentation of areolae and linea nigra and varies whether
it fades or not
Immune system
 Mom may need rubella vaccine or Rho(D) to prevent RH
isoimmunization
Nursing care focuses on transition to parenting
 Woman’s physiological recovery
 Psychological well-being
 Impact of birth experience
 Maternal self-image
 Adaptation to parenthood
 Family structure and functioning
 Impact of cultural diversity
 Ability to care for herself and baby
 Needs of other family members, strategies in plan of care to
assist family in adjusting to baby
Discharge teaching
 self-management and signs of complication
 sexual activity and contraception
 prescribed medications
 routine mother and baby check ups