birthsobstetric emergencies高风险出生产科急症课件

High RiskBirths ObstetricEmergencies Chapter36 INTRAPARTALCOMPLICATIONS Interferencewithnormalprocessesamniotic fluidembolus DysfunctionalLabor PossibleCauses Catecholamines responsetoanxiety fear increasephysical psychologicalstress leadstomyometrialdysfunction painful ineffectivelabor Prematureorexcessiveanalgesia particularlyduringlatentphase Maternalfactors Fetalfactors Placentalfactors Physicalrestrictions positioninbed ASSESSMENT Antepartalhistory Emotionalstatus Vitalsigns FHR Contractionpattern frequency duration intensity Vaginaldischarge GOAL tominimizephysical psychologicalstressduringlabor birth Emotionalsupport PretermLabor Occursafter20weeksgestationandbefore38weeks Causesmaybefrommaternal fetal orplacentalfactors Prevention Primary closeobservationandeductioninS Soflabor Secondary prompt effectiveRxofassociateddisorders Tertiary suppressionofpretermlabor Tertiary suppressionofpretermlabor Bedrest Position side lying topromoteplacentalperfusion Hydration Pharmacological betaadrenergicagentstoreducesensitivityofuterinemyometriumtooxytocicincreasebldflowtouterus Ptmaybemaintainedathomewithadequatefollow up healthteaching CONTRAINDICATIONS forsuppressionoflabor Placentapreviaorabruptioplacenta Chorioamnionitis Erythroblastosisfetalis Severepreeclampsia Severediabetes brittle Increasingplacentalinsufficiency Cervicaldilationof4cmormore ROM dependsoncause ifsepsisexists NursingAssessment PTL MaternalVS Responsetomedication HypotensionTachycardia arrhythmiaDyspnea chestpainNausea vomitingSignsofinfection IncreasedtemperatureTachycardiaDiaphoresisMalaise Emotionalstatus denial guilt anxiety exhaustion Signsofcontinuing progressinglabor EffacementDilationStation vaginalexamONLYifindicatedbyothersignsofcontinuinglaborprogress Statusofmembranes FHR activity continuousmonitoring Ctx frequency duration strength ReportPROMPTLYtoMD Maternalpulseof110ormore Diastolicpressureof60mmHgorless Increaseinmaternaltemperature Respirationsof24ormore crackles rales Complaintofdyspnes Contractions increasingfrequency strength duration orcessationofctx Intermittentbackandthighpain Ruptureofmembranes Vaginalbleeding Fetaldistress IFLABORCONTINUES GOAL facilitateinfantsurvival emotionalsupport supportcomfortmeasures healthteaching DysfunctionalLaborPattern HypertoniclaborHypotoniclaborPrecipitatelaborlevel Chapter26 HYPERTONICDYSFUNCTION Increasedrestingtoneofuterinemyometrium diminishedrefractoryperiod prolongedlatentphase Nullipara morethan20hours Multipara morethan14hours Etiology unknown Theory ectopicinitiationofincoordianteuterinectx Assessment Onset earlylabor Contractions Continuousfundaltension incompleterelaxation Painful Ineffectual noeffacementordilation Signsoffetaldistress Meconium stainedfluid FHRirregularities MaternalVS Emotionalstatus Medicalevaluation toruleoutCPD Vaginalexamination x raypelvimetry ultrasonography InterventionswithHypertonicDysfunction Short actingbarbiturates toencouragerest relaxation IVfluids torestore maintainhydration fluid electrolytebalance IfCPD c s Provideemotionalsupport Providecomfortmeasures Preventinfection strictaseptictechnique Preparepatientforc sifneeded HYPOTONICDYSFUNCTION Afternormallaboratonset ctxdiminishinfrequency duration cervicaleffacement dilationslow cease Etiology Prematureorexcessiveanalgesia anesthesia epidural spinalblock CPD Overdistention hydramnios fetalmacrosomia multifetalpregnancy Fetalmalposition malpresentation Maternalfear anxiety Assessment Onset latentphase mostcommoninactivephase Contractions normalpreviously willdemonstrate Decreasedfrequency Shorterduration Diminishedintensity mildtomoderate Lessuncomfortable Cervicalchanges sloworcease Signsoffetaldistress rare Usuallylateinlabord tinfectionsecondarytoprolongedROM Tachycardia MaternalVS elevatedtemperature mayindicateinfection Medicaldiagnosis procedures vaginalexamination x raypelvimetry ultrasonography ToruleoutCPD mostcommoncause Management Amniotomy artificialROM Oxytocinaugmentationoflabor IfCPD prepareforc s Emotionalsupport comfortmeasures preventinfection PrecipitateLabor Laborthatprogressesrapidlyandendswiththedeliveryoccurringlessthan3hoursaftertheonsetofuterineactivity Rapidlaboranddelivery FetalMalpresentationandMalposition BreechpresentationShoulderpresentationFacepresentationMalpositions Chapter26 BreechPresentations Fetaldescentinwhichthefetalbuttocks legs feet orcombinationofthesepartsisfoundfirstinthematernalpelvis Labortendstobelongerandmoredifficultduetoasofterpresentingpart thatdoesnotfillthebirthcanalcompletely Increaserisksforfetaloutcome ShoulderPresentation Fetaldescentinwhichtheshoulderprecedesthefetalheadinthematernalpelvisaloneoralongwiththeftalarmandhand Vaginallyundeliverable FacePresentation Fetaldescentinwhichhyperextensionofthefetalheadandneckallowsthefetalfacetodescendintothematernalpelvis asopposedtoflexionthatresultsinfetalvertexpresentation Browpresentation occurswhentheareabetweentheanteriorfontanelleandthefetaleyesdescendsfirst Malpositions Persistentoccipitoposteriorposition Persistentoccipitotransverseposition Resultfromfetalrotationasthefetusdescendsthroughthepelvis Possibleprecipitatingfactorsaremacrosomiaandpelvicabnormalities Resultsinincreaseddiscomfort particularlybacklabor prolonged abnormallabor softtissueinjury lacerations oranextensiveepisiotomyincision MaternalandFetalStructuralAbnormalities Cephalopelvicdisproportion CPD Macrosomia Chapter26 DYSTOCIA Difficultlabor Causes 3Ps formother Psych Placenta Position 3Ps forfetus Power Passageway Passenger POWER forcesoflabor uterinecontractions useofabdominalmuscles Prematureanalgesia anesthesia Uterineoverdistension multifetalpregnancy fetalmacrosomia Uterinemyomas PASSAGEWAY Resistanceofcervix pelvicstructures Rigidcervix Distendedbladder Distendedrectum Dimensionsofthebonypelvis oelviccontractures PASSENGER accommodationofthepresentingparttopelvicdiameters Fetalmalposition malpresentation Fetalanomalies Fetalsize HazardswithDystocia MATERNAL 1 Fatigue exhaustion dehydration 2 Loweredpainthreshold lossofcontrol 3 Intrauterineinfection Uterinerupture Cervical vaginal perineallacerations Postpartumhemorrhage FETAL Hypoxia anoxia demise Intracranialhemorrhage PlacentalAbnormalities PlacentapreviaAbruptioplacentaeOtherplacentalabnormalities Chapter26 PLACENTAPREVIA Abnormalplacementofplacentasothatitpartiallycoversthecervix dilatationresultsinbleeding whichcanbeofhemorrhagicproportions Theplacentaislocatedoverorveryneartheinternalcervicalos Severehemorrhagecanresultfromdigitalpalpationoftheinternalos Previaisaseriousbutuncommoncomplication occurringin 3 5 ofpregnancies Advancedmaternalageandmultiparityincreasetherisk Painlesshemorrhageissymptomaticofprevia oftenaroundtheendofthe2ndtrimester Clinicaldiagnosisisreachedthroughultrasoundexaminationinwhichtheplacentaislocalizedinrelationshiptothecervix Manualexaminationiscontraindicated Managementofpregnancydependsongestationalage PLACENTALABRUPTION Prematureseparationoftheplacentafromtheuterinewall usuallyresultsinmaternalhemorrhageandfetalcompromise Classifiedas partial or total TotalAbruption fetaldeathisinevitable PartialAbruption thefetushasachanceofsurvival Separationof 50 isincompatiblewithfetalsurvival GradingofPlacentalAbruptions GradeI Slightvag bleeding someuterineirritability MaternalBPisunaffected therearenormalfibrinogenlevels FHRhasanormalpattern GradeII Externalbleedingismildtomoderate Theuterusisirritable Tetanicctxmaybepresent MaternalBPismaintained FHRshowssignsofdistress Maternalfibrinogenlevelisdecreased GradeIII Thebleedingmaybesevere maybeconcealedinsomeinstances Uterinectxaretetanicandpainful Maternalhypotensionmaybepresent Thefibrinogenlevelisgreatlydecreased therearecoagulationproblems Diagnosis maybemadebyultrasound butfrequentlythediagnosisismadeandconfirmedatdelivery byinspectionoftheplacenta UmbilicalCordAbnormalities VelamentousinsertionofthecordUmbilicalcordcompressionUmbilicalcordprolapse Chapter26 VelamentousInsertionoftheCord Conditionwheretheumbilicalcordjoinstheplacentaattheedge ratherthanthetypicalinsertioninthecenter Canresultinchronicalteredfetalperfusion CanleadtotraumaandcompressionduringL D resultinginruptureandhemorrhage PROLAPSEDUMBILICALCORD Corddescentinadvanceofpresentingpart compressioninterruptsbloodflow exchangeoffetal maternalgases Leadstofetalhypoxia anoxia death ifunrelieved Etiology SROMorAROM Excessiveforceofescapingfluid hydramnios Malposition breech compoundpresentation transverselie PretermorSGAfetus allowsspaceforcorddescent Assessment Visualizationofcordoutside orinside vagina Palpationofpulsatingmassonvaginalexam Fetaldistress variabledecelerationandpersistentbradycardia Nursinginterventions Reducepressureoncord Increasematernal fetaloxygenation O2permask 8 10liters Protectexposedcord continuouspressureonpresentingparttokeeppressureoffcord Identifyfetalresponsetothesemeasures reducethreattofetalsurvival moniotrFHRcontinuously Expediteterminationofthreattofetus prepareforimmediatevaginalorc s Supportmotherandsignificantother trytoexplainthingswhilemobilizingdeliveryteam AmnioticFluidAbnormalities PolyhydramniosOligohydramniosAmnioticfluidembolism Chapter26 SummaryofDangerSignsDuringLabor Contractions strong every2min orless lasting90sec ormore poorrelaxationbetweenctx Suddensharpabdominalpainfollowedbyboardlikeabdomenandshock abruptioplacentaoruterinerupture Markedvaginalbleeding FHRperiodicpatterndecelerations late variable absent BaselineFHR Bradycardia 160bpm Amnioticfluid Amount excessive diminished OdorColor meconiumstainedorparticulate port wine yellow 24hrormoresinceROM Maternalhypotension POSTPARTUMCOMPLICATIONS Chapter37 PostpartumHemorrhage Definition Morethan500ccofbloodlossaftervaginalbirth Morethan1000ccofbloodlossafterC S Bloodlossisoftenunderestimatedbyupto50 ACOG 1998 Subjective 1causeofPPHemorrhage UterineAtony RiskFactorsforPPHemorrhage UterineAtony MarkedhypotoniaoftheuterusOverdistendeduterusAnesthesiaandanalgesiaPrevioushistoryofuterineatonyHighparityProlongedlabor oxytocin inducedlaborTraumaduringlaborandbirth RiskFactorsforPPHemorrhage LacerationsofthebirthcanalRetainedplacentalfragmentsRuptureduterusInversionoftheuterusPlacentaaccretaCoagulationdisordersPlacentalabruption RiskFactorsforPPHemorrhage PlacentapreviaManualremovalofaretainedplacentaMagnesiumsulfateadministrationduringlabororpostpartumperiodEndometritisUterinesubinvolution Lacerations Cervix vagina perineum Suspectedwhenbleedingcontinuesdespiteafirm contracteduterinefundus Characteristics bleedingcanbeaslowtrickle anoozing orfrankhemorrhage Influencingfactors structural maternal fetalLacerations themostcommoncauseofinjuriesinthelowerportionofthegenitaltract RetainedPlacenta Causes PartialseparationofnormalplacentaEntrapmentofthepartiallyorcompletelyseparatedplacentabyuterineconstrictionringMismanagementofthe3rdstageoflaborAbnormaladherenceoftheentireplacentaoraportionofplacentatotheuterinewallTypes NonadherentretainedplacentaAdherentretainedplacenta InversionoftheUterus Rare butlifethreatening 1in2000 2500births Mayrecurwithadditionalbirths Contributingfactors FundalimplantationofplacentaVigorousfundalpressureExcessivetractionappliedtocordUterineatonyLeiomyomasAbnormallyadherentplacentaltissue UterineSubinvolution Causes RetainedplacentalfragmentsPelvicinfectionSignsandsymptoms ProlongedlochialdischargeIrregularorexcessivebleedingHemorrhagePelvicexamrevealsauterusthatislargerthannormalandmaybeboggy AssessingCardiacOutput PPH NURSINGASSESSMENTS Palpationofpulses rate quality equality AuscultationInspectionObservation MedsusedtoRxPPHemorrhage Oxytocin Pitocin Methylergonovine Methergine Ergotrate ProstaglandinF2 Prostin 15M Hemabate Emergency HemorrhagicShock Assessments Respirations rapidandshallowPulse rapid weak irregularBP decreasing latesign Skin cool pale clammyUrinaryOutput decreasingLevelofConsciousness lethargytocomaMentalstatus anxietytocomaCentralvenouspressure decreased Emergency HemorrhagicShock Intervention SummonassistanceandequipmentStartIVperstandingorders largeborepreferable Ensurepatentairway administeroxygenContinuetomonitorstatus Coagulopathies IdiopathicThrombocytopenicPurpura ITP vonWillebrandDisease atypeofhemophilia factorVIIIdeficiency mostcommoncongenitalclottingdefectofwomeninchildbearingyears DisseminatedIntravascularCoagulation DIC apathologicformofclotting diffuse Includesplatelets fibrinogen prothrombin andfactorsVandVII ThromboembolicDisease formationofclot s inbloodvesselscausedbyinflammationorpartialobstructionofthevessel PostpartumInfection Antepartalfactors Hxofpreviousvenoustrhombosis UTI mastitis pneumoniaDiabetesmellitusAlcoholismDrugabuseImmunosuppressionAnemiaMalnutrition IntrapartalFactors CesareanbirthPROMChorioamnionitisProlongedlaborBladdercatheterizationInternalfetaloruterinepressuremonitorMultiplevaginalexamsafterROM IntrapartalFactors continued EpiduralanesthesiaRetainedplacentalfragmentsPPhemorrhageEpisiotomyorlacerationsHematomas TypesofPPInfection Endometritis mostcommon usuallybeginsasalocalizedinfectionattheplacentalsite butcaninvolveentireendometrium Woundinfections c sincision episiotomy repairedlacerationsite UTIs 2 4 ofPPwomen Mastitis 1 ofBFmoms usually1st SequelaeofChildbirthTrauma UterineDisplacement prolapseCystoceleandRectoceleUrinaryIncontinenceGenitalFistulas PPPsychologicComplications MoodDisorders withorwithoutpsychoticfeatures iftheonsetoccurswithin4weeksofchildbirth BabyBlues occursinupto70 ofPPmomsPostpartumDepressionPostpartumPsychosis High RiskNewborn Family Chapter26 InfantsWithSpecialNeeds PrioritiesInitiation maintenanceofrespirationsEstablishmentofextrauterinecirculationControlofbodytemperatureIntakeofadequatenourishmentEstablishmentofwasteeliminationEstablishmentofaninfant parentrelationshipPreventionofinfectionProvisionofdevelopmentalcareformental socialdevelopment High RiskInfants Mayneedresuscitationatbirth MostinstitutionsrequireAHACertificationinNeonatalResuscitationofallpersonnelatdeliveriesRequirementsmayinclude WarmthOxygenIntubationSuctioning SmallforGestationalAge SGA Definition birthweightisbelowthe10thpercentileonanintrauterinegrowthcurveforthatageinfant Infantcouldbepreterm term orpostterm Havedifficultymaintainingbodywarmthd tlowfatstores maydevelophypoglycemiafromlowglucosestores LargeforGestationalAge LGA Definition birthweightisabovethe90thpercentileonanintrauterinegrowthchartforthatgestationalage Infantcouldbepreterm term orpostterm OftenareIDM infantsofdiabeticmothers andparticularlypronetohypoglycemiaorbirthtrauma PretermInfants Definition bornbefore37weeksofgestation Particularproblems respiratoryfunction anemia jaundice persistentpatentductusarteriosus intracranialhemorrhage Low birthweightinfants thoseweighting1500 2500grams Very low birthweightinfants thoseweighing1000 1500grams Extremely very low birthweightinfants thoseweighingbetween500 1000grams Allsuchinfantsneedintensivecarefromthemomentofbirth Risks neurologicafter effectscausedbybeingsocriticallyclosetotheageofviability PosttermInfants Definition bornafter42weeksgestation Particularproblems establishingrespirations meconiumaspiration hypoglycemia temperatureregulation andpolycythemia RespiratoryDistressSyndrome Commonlyoccursinpreterminfantsfromadeficiencyorlackofsurfactantinthealveoli Withoutsurfactantthealveolicollapseonexpiration requireextremeforceforreinflation PrimaryRx syntheticsurfactantreplacementatbirthbyETtubeinsufflation followedbyoxygenandventilatorysupport TransientTachypnea Atemporaryconditioncausedbyslowabsorptionoflung