Any episode of bleeding during pregnancy in an Rh-negative woman requires a Kleihauer–Betke test and the administration of Rh immunoglobulin (Murray and McKinney, 2011). Several types of anesthesia are used with women in labor and delivery. 6th ed. Maternal. Data indicate that there are few side effects for a single dose. 4. a. Fetal/neonatal complications are directly related to compression of the umbilical cord, and perinatal mortality increases as increased time elapses between cord prolapse and birth. b. Fetal anemia. Uterine abnormalities (e.g., bicornuate uterus). Fetal/neonatal. d. Safety measures for woman during and after seizures to prevent injury. ACOG Committee Opinion No. Potential complications with general anesthesia. 3. 3. ↑ Possibility repeat cesarean birth↑ Risk of uterine rupture a. 4. h. Perinatal death (10-fold increase). Amount and nature of bleeding. Prehydrate with 500 to 1000 mL IV fluid before spinal or epidural anesthesia to minimize hypotensive effects from sympathetic blockade. 2013. Fetal heart rate changes observed may include an abrupt occurrence of persistent, severe variable decelerations or bradycardia. e. Anemia from blood loss caused by incision of placenta and lack of full placental transfusion. Threatened and actual preterm labor including mode of delivery. 2012a. 2. Philadelphia: Elsevier Saunders; 2012:627–658. The severity of intrapartum fetal asphyxia can be classified by determining the short-term outcome as expressed by newborn encephalopathy and other newborn organ system complications. Observe fetal heart rate for signs of hypoxia (tachycardia, bradycardia, or late decelerations), which can occur with a sudden decrease in maternal BP. Document use of analgesic and transmit this information to the nursery nurse. 4. Click to read full answer.Simply so, what does intrapartum mean? Intermittent or constant menstrual-like cramping. Decreases peripheral vascular resistance and, therefore, increases uteroplacental perfusion. ↑ Risk hypertension↑ Risk cancer g. HELLP syndrome (i.e., hemolysis, elevated liver function test results, and low platelet count). definition of the postpartum period There is consensus that the postpartum period begins upon delivery of the infant. Boston, 2012, Pearson Prentice Hall, pp. Assessment of risk should be performed at the first and subsequent prenatal visits for preterm labor risk factors. Cesarean section is the preferred mode of delivery for a partial or complete placenta previa. 2. a. Hawkins JL, Bucklin BA. Asphyxia and Fetal Acidosis. 2. c. Respiratory distress syndrome caused by retained fluid in the lungs. Martin JA, Hamilton BE, Ventura SJ, et al. Burton GJ, Sibley CP, Jauniaux ERM. 3. Failure of presenting part of fetus to become engaged. If the measures noted above are not successful, and the cervix continues to efface and dilate, the following measures are important: In preexisting diabetes: Maternal (Francois and Foley, 2012; Navti and Konje, 2011). e. Support of respirations with airway, oxygen, and suctioning, and the correction of hypoxemia and/or acidemia. a. ↑ Inadequate nutrition/Inadequateweight gain↑ Risk of preterm labor/birth↑ Risk anemia↑ Risk preeclampsia 1. Philadelphia: Elsevier Saunders; 2012:445–478. c. IUGR or fetal anomalies, especially those related to CNS problems. 1. h. Notify the NICU and the neonatologist/pediatrician. b. b. In abruptio placentae, the placenta separates suddenly, prematurely, and in varying degrees from the uterine wall during pregnancy or labor. Neonatal herpesvirus type 2Hepatitis with jaundiceNeurologic abnormalities Preterm birth with an increase in neonatal morbidity and death. c. Causes of decreased uteroplacental blood flow include: (1) Maternal vasoconstriction in hypertension, cocaine abuse, diabetic vasculopathy, and smoking. ( in'tră-pahr'tŭm) During labor and delivery or childbirth. Poor diet A. In particular, the course focuses on the sections concerned with newborn care, which provide up-to-date evidence-based information and management of babies with a range of needs in the initial newborn period. 340. Maternal. Incidence: Incidence is 0.2% to 3% of all births. In the second half of pregnancy, the secretion of human placental lactogen and lactogen increases cellular resistance to insulin. Large for gestational age (LGA) Observe the neonate for side effects of maternal analgesia. (1) Maternal vasoconstriction in hypertension, cocaine abuse, diabetic vasculopathy, and smoking. Preconception counseling is recommended, with optimal control of blood glucose levels. If an ultrasound is performed at less than 20 weeks of gestation, a low-lying placenta may be noted. 6. Ross MG, Ervin MG, Novak D. Placental and fetal physiology. Both glyburide and metformin are being utilized in the pregnant woman; glyburide is considered superior to metformin as it does not cross the placenta and there is a decreased incidence of neonatal hypoglycemia. 1. c. Toxic reaction. Fetal tachycardia, often seen with fetal hypoxia, is analogous to an adult’s “blowing off CO, Conversely, fetal bradycardia resulting from hypoxia or anoxia leads to an increased CO. Fetal pH during labor is usually 0.1 to 0.15 unit less than the maternal pH; this difference increases the transport of acidophilic substances from the mother to the fetus and reduces albumin binding of drugs, resulting in a more free drug in the fetal bloodstream. c. Hypotension or hypertension. This. 3. If prolapse has occurred (Steer and Danielian, 2011): a. Notify neonatology and pediatrician. Potential complications with general anesthesia. a. Hypotension. Fetal growth disorders. 2. Administer IV analgesics slowly; give during a uterine contraction to minimize amount of drug the fetus receives. American College of Obstetricians and Gynecologists: Screening and diagnosis of gestational diabetes. Birth should take place in a facility with a neonatal intensive care unit (NICU). Women at high risk for GDM (severe obesity, strong family history of type 2 diabetes mellitus, previous history of gestational diabetes, impaired glucose metabolism, or glycosuria) should be screened at the first prenatal visit, because GDM may be asymptomatic or evidenced only by subtle changes. d. Fetal pH during labor is usually 0.1 to 0.15 unit less than the maternal pH; this difference increases the transport of acidophilic substances from the mother to the fetus and reduces albumin binding of drugs, resulting in a more free drug in the fetal bloodstream. However, up to 50% of cases occur with fetuses less than 4000 g (Gherman, 2011; Lanni and Seeds, 2012). g. Continuous maternal assessment, including assessment for uterine contractions and signs of placental abruption. 5. Management if fetus is stable and maternal hematologic status can be maintained: a. Ultrasonography to locate placenta and determine degree of placental separation and location of hematoma. 7. (4) Increase in the use of oxytocin (Hawkins and Bucklin, 2012). d. Intrapartum or neonatal death. Premature placental aging, placental infarction, and decrease in amniotic fluid. e. Preterm fetus. St. Louis: Elsevier Saunders; 2011:1037–1051. Diffusing distance. Respiratory depression. (5) Tachysystole (>5 contractions in 10 minutes, averaged over 30 minutes) (American College of Obstetricians and Gynecologists [ACOG], 2010). The greater the concentration gradient, the faster will be the rate of diffusion. Decreased blood flow to the uterus or within the intervillous spaces will decrease the transport of substances to and from the fetus. 1. (b) Ringing in ears. b. Cardiopulmonary failure and pulmonary edema. A number of maternal factors have been associated with an increased incidence of preterm labor: maternal age (<15 or >35 years), socioeconomic effects (lower socioeconomic status or educational level, African American race, poor nutrition, inadequate prenatal care), medical/obstetric history (use of assisted reproductive technologies, anemia, preexisting or gestational hypertension or diabetes, previous preterm birth, prior stillbirth, grand multiparity, one or more midtrimester pregnancy losses, pregnancy termination, short interpregnancy interval, uterine anomalies and cervical insufficiency, systemic and genitourinary tract infections, hydramnios, immunologic factors, placental abruption, and placenta previa), and lifestyle factors (use of alcohol, cigarettes, and illicit drugs such as cocaine, and domestic violence or other stressors) (Perry et al., 2010). (4) Decreased maternal blood flow in intervillous spaces resulting from edema of the placental villi. h. Notify the NICU and the neonatologist/pediatrician. REFERENCES ACOG and the Society for Maternal Fetal Medicine recommend that women with a singleton pregnancy, who have had a previous episode of a singleton spontaneous preterm labor or birth, or premature rupture of membranes, should receive progesterone supplementation (17α-hydroxyprogesterone caproate) (ACOG, 2008). a. a. Decreased placental function can in turn adversely affect the fetus. Monitor fetal heart rate continuously and palpate cord lightly for continued pulsation. With maternal hypotension, turn the woman onto her left side, increase IV infusion of fluids, and closely monitor the fetal heart rate and maternal BP. Ketoacidosis in the second and third trimesters. f. Use the Woods’ corkscrew maneuver, in which both hands are inserted internally to rotate the posterior shoulder to the anterior position for delivery under the pubic bone, with the maneuver repeated for the other side. However, in many cases the fetus reverts to breech (. Before any decision is made about induction of labor, amniocentesis is performed to determine the lecithin/sphingomyelin ratio and the presence of phosphatidylglycerol. c. IUGR or fetal anomalies, especially those related to CNS problems. With significant bleeding, placement of IV lines with 16- to 18-gauge catheters for blood administration. Obstetrics: Normal and problem pregnancies. Monitor the woman’s BP after administration of spinal or epidural anesthetic; monitor fetal heart rate after any type of regional anesthesia. Indomethacin is given prior to 32 weeks, orally, and use is restricted to 2 to 3 days. c. Hypoxemia. 2. 2. A. Obstetrics: Normal and problem pregnancies. St. Louis: Elsevier Saunders; 2011:795–811. b. Seizure precautions. Fetal. 2. (a) Increase IV fluids. Place wedge under woman’s right hip to displace the uterus to the left to avoid supine hypotension and fetal hypoxia. Intrapartum care for women with existing medical conditions or obstetric complications and their The fetus. 3. The placenta is the connection between the maternal and embryonic circulatory systems, facilitating metabolic and nutrient exchange. However, in many cases the fetus reverts to breech (Penn, 2011). Perform usual interventions to prepare the woman for operative delivery. c. Hypotension. In: Gabbe SG, Niebyl JR, Simpson JL, eds. In: Gabbe SG, Niebyl JR, Simpson JL, eds. Although effective in lowering BP, this drug has many side effects and alternative medications are preferred. As this is a major obstetric emergency that must be acted upon quickly and occurs infrequently, multidisciplinary simulation drills should be instituted in the facility (Gherman, 2011). Notification of anesthesia department and NICU. NICE guideline: Intrapartum care draft scope CONFIDENTIAL 5 of 16 1 Groups that will not be covered 2 • Women in labour who are identified before or during labour to be at high 3 risk, or whose baby is at high risk, of complications or adverse outcomes. Martin JA, Hamilton BE, Ventura SJ, et al. Follow Neonatal Resuscitation Program protocols for neonatal care following birth. Report clinical findings immediately to the physician or midwife. Studies indicate a 40% decrease in the preterm birth rate of women who had a previous preterm birth, when given 17α-hydroxyprogesterone caproate. Signs of hypovolemic shock as bleeding increases. Cytomegalovirus 2. Malpresentations and shoulder dystocia. j. Maternal emotional support. b. These have the potential to affect placental functions of respiration, nutrition, excretion, and hormone production. 1. High risk pregnancy: Management options. It is recommended that its use be limited to between 24 and 32 weeks of gestation. Bed rest in left lateral position, close assessment of abdomen for rigidity and pain, and close assessment of vaginal bleeding. Monitor the newborn infant after surgery for complications. (2) Use of antihypertensives is indicated when systolic BPs are greater than 160 mm Hg or diastolic BPs are greater than 110 mm Hg: (a) Labetalol hydrochloride. 1. • general information as outlined in the NICE guideline on intrapartum care for healthy women and babies • how their medical condition may affect their care . 3. (2) Hypoglycemia, hypocalcemia, and hypomagnesemia; (4) Complications resulting from decreased blood flow, erythrocyte hemolysis, and thrombosis; (6) Birth injuries: fractured clavicles, intracranial bleeding, facial nerve paralysis, brachial palsy, and skull fractures. Incidence: The incidence is 1 in 200 births in the United States (March of Dimes, 2012a. (b) Maintain airway and ventilation. Primary goals of management include prevention of seizures (via limitation of stimuli and drug therapy), prevention of complications (via frequent systems assessments and laboratory studies), and birth of a live infant. Assessment after artificial or spontaneous rupture of membranes. Incidence: Placental abruption occurs in 1 in 100 pregnancies (March of Dimes, 2013). a. Intrapartum complications include the following: Fetal growth retardation (30%) Nonreassuring fetal heart rate patterns (30%) Placental abruption (23%) b. Potential complications with regional anesthetics. Births: Final data for 2010. 2. In: 4th ed. (1) Signs and symptoms. A number of maternal factors have been associated with an increased incidence of preterm labor: maternal age (<15 or >35 years), socioeconomic effects (lower socioeconomic status or educational level, African American race, poor nutrition, inadequate prenatal care), medical/obstetric history (use of assisted reproductive technologies, anemia, preexisting or gestational hypertension or diabetes, previous preterm birth, prior stillbirth, grand multiparity, one or more midtrimester pregnancy losses, pregnancy termination, short interpregnancy interval, uterine anomalies and cervical insufficiency, systemic and genitourinary tract infections, hydramnios, immunologic factors, placental abruption, and placenta previa), and lifestyle factors (use of alcohol, cigarettes, and illicit drugs such as cocaine, and domestic violence or other stressors) (Perry et al., 2010). Indomethacin is given prior to 32 weeks, orally, and use is restricted to 2 to 3 days. 2. Risk scoring systems, designed to screen women during pregnancy, have a predictive value of only 17% to 34%. (3) Erythroblastosis fetalis. 4. d. Hypovolemia. Assessment of risk should be performed at the first and subsequent prenatal visits for preterm labor risk factors. High risk pregnancy: Management options. Assessment of newborn infant for the following: Possible adverse drug effects on neonate: When maternal administration of high doses of magnesium sulfate occurs near the time of birth, the newborn must be observed for 24 to 48 hours for signs of magnesium toxicity (respiratory depression and neuromuscular depression, as evidenced by weakness, lethargy, hypotonia, flaccidity, and poor suck) (Davidson et al., 2012). 6. b. Fetal anoxia leading to long-range neurologic complications. The Essential Newborn Care Course (ENCC) is a WHO training program that works to ensure that health workers have the skills and knowledge to provide appropriate care at the most vulnerable period in a baby’s life. Keep the examining hand in vagina to push the presenting part away from the cord and to relieve cord compression until birth of fetus. In the second half of pregnancy, the secretion of human placental lactogen and lactogen increases cellular resistance to insulin. The woman should begin taking 0.4 mg of folic acid daily, and continue through the first trimester, to reduce the risk for neural tube defects. However, emergency cesarean delivery may be preferable, especially if the cervix is not fully dilated and the fetus exhibits signs of potential compromise. Observe fetal heart rate for decreased variability, and anticipate hypotonus in the newborn. Fetal factors contributing to the development of preterm labor may include fetal congenital anomalies and complications from multifetal gestation (Perry et al., 2010). 2. Additional risk factors include uterine fibroids or malformations, rapid uterine decompression associated with polyhydramnios and multifetal pregnancy, increased parity, chorioamnionitis and intrauterine infections, inherited or acquired thrombophilias, preterm premature rupture of membranes, and maternal cigarette smoking (Francois and Foley, 2012). Any edema that develops in the placental villi increases the distance between the fetal capillaries within the villi and the maternal arterial blood in the intervillous spaces, thus slowing the diffusion rate of substances between the maternal and fetal circulations. Additional risk factors include uterine fibroids or malformations, rapid uterine decompression associated with polyhydramnios and multifetal pregnancy, increased parity, chorioamnionitis and intrauterine infections, inherited or acquired thrombophilias, preterm premature rupture of membranes, and maternal cigarette smoking (Francois and Foley, 2012). Hypoglycemia, hypocalcemia, and hypomagnesemia. Intrapartum asphyxia or intrauterine asphyxia can be suspected by signs of fetal stress, passage of meconium or meconium staining, monitoring the fetal heart rate, or through taking fetal blood samples. Estimation of fetal weight and fetal heart rate. Philadelphia: Elsevier Saunders; 2012:23–41. The end is less well defined, but is often considered the six to eight weeks after delivery because the effects of pregnancy on many systems have … Control of current seizure and prevention of recurrent seizures with administration of IV magnesium sulfate. Note history of allergies to local anesthetics. Screening should be repeated at 24 to 28 weeks of gestation, or when hyperglycemia is evident. If general anesthesia is used for surgery, may result in uterine atony with subsequent postpartum bleeding. 1. ↑ Spontaneous abortion a condition where the placenta is implanted close to or covers…. In: James D, Steer P, Weiner C, Gonik B, eds. Endotracheal tube and cricoid pressure are techniques used by the anesthesiologist to prevent aspiration. b. Conversely, fetal bradycardia resulting from hypoxia or anoxia leads to an increased CO2 level. Thyroid disorder (2) Severe preeclampsia is not an indication for cesarean section, and the vaginal route is preferred. When appropriate and not contraindicated, tocolytics should be used to allow enough time for antenatal corticosteroid therapy to benefit the fetus and/or for transfer of the mother to a hospital with a level III nursery. Note history of allergies to local anesthetics. Each pregnancy and delivery is different, and problems may arise. Additional risk factors include uterine fibroids or malformations, rapid uterine decompression associated with polyhydramnios and multifetal pregnancy, increased parity, chorioamnionitis and intrauterine infections, inherited or acquired thrombophilias, preterm premature rupture of membranes, and maternal cigarette smoking (Francois and Foley, 2012). a. 2. c. Cervix <2 cm dilatation/<80% effaced: Diagnosis uncertain. 6. (c) Slurring of speech. In: Gabbe SG, Niebyl JR, Simpson JL, eds. This may be used while a therapy with a slower onset of action is being started, or to stop contractions during the initial evaluation of the patient to assist in the diagnosis of preterm labor. Cord is protruding from vagina or is palpable on vaginal examination. Fetal/neonatal. 4. ACOG Committee Opinion No. 6. Washington, DC: American College of Obstetricians and Gynecologists; September 2011. 1. c. Cervix <2 cm dilatation/<80% effaced: Diagnosis uncertain. b. b. Hypovolemic shock. d. Drowsiness and dizziness. a. e. Cesarean section is the preferred mode of delivery for a partial or complete placenta previa. Other associated and predisposing factors include previous placenta previa, increasing parity or maternal age, prior cesarean birth, living in higher altitudes, cigarette smoking, maternal race (Asian women have the highest incidence), multifetal gestation, and prior curettage. A transient decrease in BP often occurs. 3. (b) Sensation of inability to breathe. c. Concentration gradients are maintained when dissolved substances are removed from the plasma by metabolism, cellular uptake, or excretion. In an occult prolapse, cord is not visible or palpable but is located between the presenting part and the pelvis or cervix. h. Vaginal birth can be planned if the placenta is greater than 2 to 3 cm from the cervical os (Francois and Foley, 2012). g. Time of delivery is based on the clinical picture but generally recommended at 37 weeks when fetal lung maturity is documented. In: James D, Steer P, Weiner C, Gonik B, eds. e. Polycythemia, hyperviscosity, and hyperbilirubinemia. a. 2. The fetal presenting part does not fill the pelvic inlet well, and the cord slips past it, often when the membranes rupture. Although the first bleeding episode may be slight in amount, more blood is usually lost in subsequent episodes. In: James D, Steer P, Weiner C, Gonik B, eds. 4. St. Louis: Elsevier Saunders; 2011:1185–1190. A. Frequent assessment of maternal vital signs and fetal heart tones, and palpation of abdomen. Preparation of the abdomen for surgery (clipping of hair around incision site) and insertion of an indwelling urinary catheter. High risk pregnancy: Management options. 4. 1. Placental/fetal. D. Placental transport mechanisms. 4th ed. Assessment for presence of polyhydramnios or lack of engagement of presenting part. e. In the first trimester, screening for nuchal translucency, free β-human chorionic gonadotropin (β-hCG) and pregnancy-associated plasma protein A (PAPP-A) should be offered (Fraser and Farrell, 2011). f. Disseminated intravascular coagulation. If an ultrasound is performed at less than 20 weeks of gestation, a low-lying placenta may be noted. Postural exercise, in which the woman assumes either the knee–chest or an elevated-hip posture several times a day to help the fetus turn from breech to cephalic presentation, has been suggested, but is not supported in the literature (Penn, 2011). Fetal/neonatal complications are directly related to compression of the umbilical cord, and perinatal mortality increases as increased time elapses between cord prolapse and birth. Placental. B. 1. Severe preeclampsia is characterized by a BP of 160/110 mm Hg or above. Obstetrics: Normal and problem pregnancies. C. Clinical presentation. Serial ultrasounds to confirm diagnosis, rule out IUGR, and monitor fetal growth. Postural exercise, in which the woman assumes either the knee–chest or an elevated-hip posture several times a day to help the fetus turn from breech to cephalic presentation, has been suggested, but is not supported in the literature (Penn, 2011). a. Trauma to the birth canal from rapid forceps delivery. d. Medications. Observe the woman for side effects and monitor the fetal heart rate with the electronic fetal monitor or via intermittent auscultation. Rubella (first trimester) 3. The exact cause of preterm labor is unknown, although chorioamnionitis and other infections such as periodontitis and bacterial vaginosis have been implicated. Insufficient or later antenatal care↑ Risk preterm birthPoor nutrition↑ Risk preeclampsia Diethylstilbestrol (DES) exposure Cervix 2 to 3 cm dilatation/<80% effaced: Preterm labor likely but not established. In the neonate: Power; uterine contraction 2. ACOG Committee Opinion No. In: James D, Steer P, Weiner C, Gonik B, eds. In: Gabbe SG, Niebyl JR, Simpson JL, eds. A placenta that is not keeping pace with fetal growth or that has decreased functional area as a result of infarct or separation does not allow optimal transport of materials between the fetus and the mother. 4. 2. Twin-to-twin transfusion syndrome (donor twin). A transient decrease in BP often occurs. ↓ Basal metabolic rate (BMR), goiter, myxedema d. Congenital anomalies such as myelomeningocele and anterior abdominal wall defects. b. Decreased variability of the fetal heart rate, sinusoidal pattern (Stadol). 321-322. Birth should take place in a facility with a neonatal intensive care unit (NICU). In addition: Frequent assessment of vaginal bleeding, with pad counts and/or weighing of pads. A continuation of the frank breech position for a period of time after the birth. a. If the provider is experienced in breech delivery, he or she may plan a delivery as long as specific guidelines are followed and the woman is provided with informed consent regarding maternal and neonatal risks (. a. IUGR. Management: use of IV antihistamine such as diphenhydramine (Benadryl). Philadelphia: Elsevier Saunders; 2012:779–824. Proteinuria (≥300 mg/dL in a 24-hour urine collection) due to decreased renal perfusion resulting in the development of glomerular capillary endotheliosis. Hawkins JL, Bucklin BA. 3. Hypertension. b. a. Abruptio placentae. g. Continuous maternal assessment, including assessment for uterine contractions and signs of placental abruption. Factor Fetal/neonatal. CONDITIONS RELATED TO THE INTRAPARTUM PERIOD 5. (a) Cardiorespiratory support. 1. Maternal vasodilatation caused by vasodilators, antihypertensives, and regional anesthetics with sympathetic blockade actions. Compare: antepartum, postpartum. If shoulder dystocia occurs, the physician or midwife will: Use the McRoberts maneuver (maternal hip flexion; an exaggerated lithotomy position). ACOG and the Society for Maternal Fetal Medicine recommend that women with a singleton pregnancy, who have had a previous episode of a singleton spontaneous preterm labor or birth, or premature rupture of membranes, should receive progesterone supplementation (17α-hydroxyprogesterone caproate) (, Although episodes of suspected preterm labor are widely treated with bed rest, hydration, and pelvic rest, there is little evidence that these interventions are effective (. Cesarean delivery. a. Macrosomia (weight >4000 g) with possible traumatic vaginal birth, such as with shoulder dystocia, and subsequent birth trauma. Assessments on admission to labor and delivery: