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HYPOTONIC UTERINE DYSFUNCTION 200-260 goals for montevideo units GRANDMULTIPS are at risk (takes longer for oxytocin to work) Moms with strong fear (they secrete a lot of cathecolamine) Little to no cervical effacement Manage pt anxiety Manage pt Initiate oxytocin and continue to increase PRECIPITOUS LABOR Labor from onset to deliver LESS THAN 3 hours Who’s at risk ? Multips, hx of precipitous labor, hypertonic contractions but no dysfunction (causing cervical effacement rapidly : increased bloody show) Apply gentle pressure on the head RISKS : lacerations (guide baby out slowly) , hematoma, PP hemorrhage Baby : risk for resp depressions, at risk for bruising. Nursing Actions : IV, continuous fetal monitoring HKIT - IM cytotec, bag of oxytocin, hemabete, methergine, rectal cytotec, needles, alcohol swab, FETAL DYSTOCIA : problem with fetal size, position, Complications : neonatal asphyxia, fetal injuries (bruising), maternal lacerations RISK FACTORS : macrosomic baby, small mother, fetal anomaly Assessment findings : FHR (breech : FHR above umbilicus, MGMT : monitor labor and progress, CEPHALO DISPROPORTION (CPD) Factors : fetal size, presentation, position ( size and shape) Quality of uterine contractions Assessment finding : LABOR INTERVENTIONS Labor induction Criteria : not in labor but need to start it. (39 weeks unless there is a medical necessity) Severe preeclampsia, uncontrolled GDM, Indications : fetal demise, past 40 weeks, PROM (premature rupture of membranes), gestation htn, chorio, oligohydramnions Contraindications : Position, HIV ( viral load over 1000), herpes (if any active sores are occurring), placenta previa, OXYTOCIN INDUCTION Most common worldwide agent for labor induction Endogenous : natural | Synthetic : lab made (high alert med | high risk COSIGN) COSIGN (anytime starting, stopping, or titrating medication) Increase 2 mil U every 20 mins until your reach adequate uterine activity If higher risk for | half life of oxytocin is 10 MINUTES NOT PIGGYBACKING MED TACHYSYSTOLE More than 5 contractions in 10 minutes over a 30 minute window Nursing Actions : CAT 1 tracing, oxygen, reposition, fluid bolus, if doens’t work half rate of pitocin, if still not working then turn off the pitocin CAT 2 or 3 : fluid bolus, oxygen 10 L/minus non-rebreather | turn off oxytocin | give medication (tocolytic | TERBUTALINE) s/e tachy, decreased resp rate, anxiety, arrhythmias | WAIT 30 min to an hour to have CAT 1 tracing and then resume oxytocin BISHOP SCORE (shows us what medication to give them ) More than 8 favorable score (high chance of giving Score of 6 or less | unfavorable cervix | NEED CERVICAL RIPENING AGENTS CERVICAL RIPENING (for 6 or less) Mechanical (used more because it has no side effects) Balloon Pharmacological Cytotec - 25 mg vaginally, 50 mg PO if membranes ruptured Cervidil - vaginally inserted AROM (artificial rupture of membranes) time it (18 to 24 hours) EXTERNAL CEPHALIC VERSION Indications : breech representation to reposition to vertex position Abdominal binder after Labor augmentation Indication : To lengthen and strengthen contraction, if pt request it and cervix is already dilated Contraindications : Placenta previa, herpes pt RISKS : tachysystole Med MGMT : continuous fetal monitoring, iv fluids, COMPLEMENTARY THERAPIES to stimulate labor Acupuncture , massage Bowel stimulation : castor oil Herbal preparations : dates, black tea, Sexual intercourse (increased release of oxytocin) sperm has prostaglandins OPERATIVE VAGINAL DELIVERY Forceps and Vaccum Indications : fetal distress, crowning, maternal exhaustion, Laboring down : positioning may help with pushing Contraindications : hydrocephalus. Primi Risks: lacerations, hematoma Baby risk : skull fractures, bruising, cephalhematoma Nursing actions: H-kit, NICU, 3 pop off rule : any more than 3 causes excess damage to baby head (TOLAC) Trial of labor after cesarean Vaginal birth after cesarean (VBAC) Benefits - decreased risk for infx, decreased bleed, less pain, INDICATIONS : tolac | only 2 c section ONLY LOW TRANSVERSE CUT ( NO CLASSICAL OR VERTICAL CUTS) Contraindications : previa, herpes, previous classical incision Risks: uteral rupture, higher risk of uterine rupture Nursing actions : slower oxy 1 mil units, q30 min Consent must be done OBSTETRICAL EMERGENCIES Shoulder Dystocia Turtle sign Risk factors : unpredictable and unavoidable | GDM | macrosomia | long 2nd stage of labor | rapid weight gain towards end of pregnancy | Assessment findings : Turtle sign (head retracts into perineum | fetal asphyxiation) McRoberts : hyperflexing the legs and internally rotate moms knees | opens up pelvic outlet releasing the shoulder | SUPRAPUBIC pressure Neonate complications of shoulder dystocia Fracture of humerus or clavicle Erbs palsy Umbilical cord prolapse Risk factors - IUGR baby, polyhydramnios, multips, Findings - occult, pulsing, drop in FHR, Ruptured Vasa Previa Velamentous cord insertion Risk factors - ivf preg, low lying placenta in twin preg, C-section at 35 weeks | what to give to mom? Coriticosteroid | BETHAMETHASONE OR celestone Uterine Rupture Opens up or rupture From trauma, drugs, use of oxytocin Severe burning pain | abdomen is rigid | tachysystole | prolonged decels | hemorrhage / hypovolemic shock Actions - pt left lateral position | 2 large bore iv , bolus | educate pt on what is happening |