Session #19: Variations, Complications and Interventions (Pregnancy & Labor): 2/11
Time
8:1511:00
Includes
15
minute
break
Time
8:15
Learner Objectives
Learner Objectives: At the end of the session, the learner will be
able to:
1. Differentiate between a “variation” and a “complication” in
labor.
2. List variations or complications of late pregnancy which may
affect the course of a woman’s pregnancy, labor, or birth.
3. Describe cervical readiness for induction.
4. List variations or complications of labor and birth that may
affect the type of medical care needed
5. List medically indicated interventions and circumstances when
they might be needed.
6. Discuss the concept of ‘trade-offs’ vs. risks and benefits.
7. State an appropriate reply if a client states that she wants
continuous electronic fetal monitoring because it is safer for her
baby.
150 teaching minutes plus 15 minute break.
Topic
Introduction
AV Aids
Amnihook
Business card with BRAIN
All intervention gadgets.
Bells
Pregnancy Complication Cards.
Case study
Keychain lady
Williams Obstetrics & Problem Pregnancies Books
Content
SLIDE: A word on Variations and Complications Explain difference.
Slide: Jeopardy!
4
mins
Variations and
Complications of Late
Pregnancy
I.
SLIDE: Gestational Diabetes & Essential Diabetes
A.
B.
C.
D.
E.
Per
compli
cation
II.
Description: Too much maternal insulin gets to baby, creating a larger, more fragile baby.
SLIDE: Big Baby.
Diagnosis: Glucose Tolerance Test
Complicating factors : Large, fragile babies SLIDE Big Baby
Prevention & Treatment: Diet, exercise, insulin
Role of doula: Listening, inquiry about diet, informational needs.
SLIDE: Gestational and Essential Hypertension
A.
B.
C.
D.
Diagnosis: 140/90, swelling & pitting edema, protein in the urine, liver enzymes elevated
Complicating factors: SGA babies and maternal seizures.
Prevention & Treatment: High protein diet, beta blockers, bed rest, delivery of baby.
Doula’s role: Same as above
III. SLIDE: Breech presentation
A.
B.
Diagnosis: Ultrasound or leopold’s maneuvers. 25% at 28 weeks. 3% -7% at term.
Complicating factor: Riskier delivery, higher chance of birth injury or death depending on
position and depending on care provider skill.
Notes
C.
D.
Prevention & Treatment: Positioning, light and sounds, abdominal massage, acupuncture,
homeopathics, massage, Webster’s Technique, ECV, moxabustion and acupuncture,
cesarean.
Doula’s role: Attend ECV, provide referrals for turning breech babies.
IV. SLIDE: Premature birth
A.
B.
C.
D.
E.
V.
SLIDE Prelabor rupture of membranes
A.
B.
C.
D.
VI.
Diagnosis: labor before 37 weeks. 12%
Risk factors: Previous pt labor, multiples, UTI, smoker, poor nutrition, stress, drug use.
Complicating factor: expensive NICU stay, immature lungs and temp. reg, immature
nervous system, no suck-swallow, lack of maternal immunities, more interventions and
isolation from parents touch.
Prevention & Treatment: Consistent prenatal care, social work needs met, decrease
stress, watch diet. Terbutiline, bed rest.
Doula’s role: May not have had enough time for all prenatal meetings, informational
support, help parents gather support.
Diagnosis: Mother or test in hospital.
Complicating factors: open route for bacteria to ascend, increased risk of fetal distress
during labor.
Treatment: Induction after a reasonable about of time (24 hours?). Length of time varies
depending on mother’s health risks and care provider’s preferences.
Doula’s role: Provide support and information for family who may have to drastically change
their plans.
SLIDE: Prolonged pregnancy.
A.
B.
C.
D.
E.
Facts: 4% of women give birth on their due date. Primips go an average of 8 days past
their due date, Multips go an average of 3 days past their due date.
Complicating factors: placental insufficiency, large baby, still birth, meconium aspiration.
Asses fetal well-being: NSTs, BPP
Treatment: Induction
Doula’s role: Provide informational support and lots of active listening for parents who are
trying to avoid induction.
VII. SLIDE: Genital Herpes
F.
G.
H.
I.
J.
Genital herpes. Cesarean. Valtrex in third trimester.
Placenta abruption
Placenta previa
Intra-uterine growth restriction
Poly or oligohydraminos
VIII. SLIDE: Placenta Abruption
K.
L.
M.
N.
Genital herpes. Cesarean. Valtrex in third trimester.
Placenta abruption
Placenta previa
Intra-uterine growth restriction
O.
IX.
Poly or oligohydraminos
SLIDE: Placenta Previa
P.
Q.
R.
S.
T.
X.
Genital herpes. Cesarean. Valtrex in third trimester.
Placenta abruption
Placenta previa
Intra-uterine growth restriction
Poly or oligohydraminos
IntraUterine Growth Restriction?
U.
V.
W.
X.
Y.
Genital herpes. Cesarean. Valtrex in third trimester.
Placenta abruption
Placenta previa
Intra-uterine growth restriction
Poly or oligohydraminos
9:00
5
mins
Trade Offs vs Risks
SLIDE: Trade-Offs vs Risks and Benefits
Before we discuss induction of labor, now is a good time to think about discussing “tradeoffs” rather than risks and benefits. Describing interventions such as induction in terms of
trade-offs is a more neutral and comprehensive way to describe what a woman gets and
what she gives up with various procedures. What one woman may perceive as a” risk” may
not be seen that way at all by another. Women perceive tradeoffs differently from one
another. One woman’s “risk” may be another’s “benefit.”
Induction of Labor
XI.
9:05
10
mins
Induction – A useful tool for most of the above
A.
SLIDE: Bishop Score Need to asses baby and mother’s readiness for induction
B.
Carefully weigh pros and cons of continuing pregnancy.
C.
Inductions can take as long as 2-4 days.
D.
Medical methods of induction:
1.
2.
3.
4.
5.
6.
E.
SLIDE:
SLIDE:
SLIDE:
SLIDE:
SLIDE:
SLIDE:
Sweeping membranes (light, not usually effective)
Cytotech (misoprostol)
Cervical ripening (cervadil) via prostaglandins
Cervical dilators (balloon catheter, laminiara)
Pitocin
AROM **PASS OUT AMNIHOOK**
Natural alternative (probably less effective than medical)
1.
2.
3.
4.
Sex
Nipple/colon stimulation
Accupuncture/acupressure
Teas, tinctures, herbs, homeopathics
9:15
9:15
–
9:30
10
mins
5.
6.
Emotionally connecting with baby.
BREAK
Variations, Complications
and Interventions
HAND OUT CASE STUDY
I.
SLIDE What is the difference between a variation and a complication?
A. Variations often respond to less invasive interventions or simply need time to
resolve.
B. Complications require medical intervention for positive outcomes
II.
SLIDE What is an Intervention?
III.
SLIDE Difference between medical interventions and alternative treatments
•
•
•
•
IV.
Read story
A. Work on Learning Tasks
9:40
20
mins
Have few if any risks or side effects.
Are less invasive than medical interventions.
Often rely on time to work.
Are probably better for addressing variations
Learning Task #1
SLIDE: Identify Variations, Complication and Interventions
Read the case study on your own.
1. Note everything that looks like a possible Variation, Complication or medical
Intervention.
First stage variations and complications:
1. Prodromal labor & cervical dystocia
2. Maternal fear and anxiety
3. Precipitous labor (grandma’s)
4. Posterior or malpositioned baby
5. Painful labor due to malposition
6. Maternal exhaustion
7. Prolonged active phase
8. Fetal distress
9. Maternal fear and trauma issues
10. Lack of physical and emotional support
11. Lack of informational support
12. Waited until variations became complications.
Second stage complications, variations & interventions
1. Same as above, plus
2. Prolonged pushing stage
3. Short cord
4. Fear of pushing, pooping or tearing
Third stage complications, variations
1. Hemorrhage
2. Placenta doesn’t detach properly
3. Loss of blood pressure (pale, fainting, dizzy, clammy)
4. Uterine atony
10:00
15
mins
Learning Task #2
2. Discuss any differences amongst yourselves. Why is one person’s variation another
person’s complication?
10:15
35
mins
SLIDE: Describe the difference between variations and complications.
1. With your tablemates, compare your answers. Did you find all the same variations
and complications?
Learning Task #3
SLIDE: Identify Medical Interventions Used and Possible Less-Invasive alternatives.
1. Reconvene back to the larger group. As a group, list where medical interventions were used
to fix complications
2. List ideas where less invasive, earlier interventions could have fixed the variations in labor.
Intervention
Risk
Alternative
SLIDE Morophine
for sleep
Stopping labor, feeling
drunk, not working,
readily crosses placenta
in the same dose
wine, bath, massage,
tens, talking.
SLIDE: IV
Over-hydration,
discomfort and
psychological stress,
potential for limiting
mobility and feeling like
an infirm patient. This is
one of those little
interventions that can
psychologically limit
mobility, feel like a patient
food!, water, juice,
Recharge
SLIDE: Fentanyl
for relaxation and
pain
Not working, slowing
labor.
Visualizations, bath,
massage, talking.
SLIDE AROM
Increase malposition.
Labor on a time clock
Time, movement,
relaxation
for hydration
Intervention
alternatives
on page
10.1
Speed labor
Show hook!
SLIDE Epidural
Pain relief
Decrease in participation.
Passive.
Bath, take charge
routine
SLIDE Pitocin
Increase in fetal distress
Increase
contraction strength
Increase in cesarean
section
Nipple stim,
herbs/tinctures
Increase
SLIDE IUPC
Placental abruption
Direct monitoring of
baby
Slide O2
Feeling like a patient,
smell, discomfort
Slide Internal
Monitor
Invasive, must rupture
membranes
Some nurses use their
hands
Direct read on
baby’s heart rate.
Show Scalp
electrode
Slide Vacuum
extractor
10:50
Bruising, increase risk of
jaundice, upset baby,
increase risk of perineum
damage
Squatting, toilet sitting,
not pushing before
mother feel the urge to
do so.
SLIDE: Client wants CEFM..What would you say?
SLIDE: BRAIN
Hand out
card
3. What questions can families ask to make informed choices?
Benefits
Risks
11:00
Alternatives
Intuition
Nothing
B
R
A
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N