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Information

  1. GENERAL ASPECTS
    1. Pathophysiology—interference with normal processes and patterns of labor/birth result in maternal or fetal jeopardy (e.g., pretermlabor, dysfunctional labor patterns; prolonged [over 24 hours] labor; hemorrhage: uterine rupture/inversion, amniotic fluid embolus).
    2. Etiology:
      1. Preterm labor—unknown.
      2. Dysfunctional labor (dystocia: see The Intrapartum Experience):
        1. Physiological response to anxiety/fear/pain—results in release of catecholamines, increasing physical/psychological stress → myometrial dysfunction; painful and ineffectual labor.
        2. Iatrogenic factors: premature or excessive analgesia, particularly during latent phase.
        3. Maternal factors:
          1. Pelvic contractures.
          2. Uterine tumors (e.g., myomas, carcinoma).
          3. Congenital uterine anomalies (e.g., bicornate uterus).
          4. Pathological contraction ring (Bandl's ring).
          5. Rigid cervix, cervical stenosis/stricture.
          6. Hypertonic/hypotonic contractions.
          7. Prolonged rupture of membranes. Note: Intrauterine infection may have caused rupture of membranes or may follow rupture.
          8. Prolonged first or second stage.
          9. Medical conditions: diabetes, hypertension.
        4. Fetal factors:
          1. Macrosomia (LGA).
          2. Malposition/malpresentation.
          3. Congenital anomaly (e.g., hydrocephalus, anencephaly).
          4. Multifetal gestation (e.g., interlocking twins).
          5. Prolapsed cord.
          6. Postterm.
        5. Placental factors:
          1. Placenta previa.
          2. Inadequate placental function with contractions.
          3. Abruptio placentae.
          4. Placenta accreta.
        6. Physical restrictions: when confined to bed, flat position, etc.
    3. Assessment:
      1. Antepartal history.
      2. Emotional status.
      3. Vital signs, FHR.
      4. Contraction pattern (frequency, duration, intensity).
      5. Vaginal discharge.
    4. Analysis/nursing diagnosis:
      1. Anxiety/fear for self and infant related to implications of prolonged or complicated labor/birth.
      2. Pain related to hypertonic contractions/dysfunctional labor.
      3. Ineffective individual coping related to physical/psychological stress of complicated labor/birth, lowered pain threshold secondary to fatigue.
      4. High risk for injury related to prolonged rupture of membranes, infection.
      5. Fluid volume deficit related to excessive blood loss secondary to placenta previa, abruptio placentae, Couvelaire uterus, DIC.
    5. Nursing care plan/implementation:
      1. Goal: minimize physical/psychological stress during labor/birth. Assist woman in coping effectively:
        1. Reinforce relaxation techniques.
        2. Support couple's effective coping techniques/mechanisms.
      2. Goal: emotional support.
        1. Encourage verbalization of anxiety/fear/concerns.
        2. Explain all procedures—to minimize anxiety/fear, encourage cooperation/participation in care.
        3. Provide quiet environment conducive to rest.
      3. Goal: continuous monitoring of maternal/fetal status and progress through labor—to identify early signs of dysfunctional labor, fetal distress; facilitate prompt, effective treatment of emerging complications.
      4. Goal: minimize effects of complicated labor on mother, fetus.
        1. infoImagePosition change: lateral Sims'—to reduce compression of inferior vena cava.
        2. Oxygen per mask, as indicated.
        3. Institute interventions appropriate to emerging problems (see specific disorder).
    6. Evaluation/outcome criteria:
      1. Woman has successful birth of viable infant.
      2. Maternal/infant status stable, satisfactory.
  2. DISORDERS AFFECTING PROTECTIVE FUNCTIONS: Preterm labor—occurs after 20 weeks of gestation and before beginning of week 38.
    1. Pathophysiology—physiological events of labor (i.e., contractions, spontaneous rupture of membranes, cervical effacement/dilation) occur before completion of normal, term gestation.
    2. Etiology—causes may be from maternal, fetal, or placental factors.
    3. Coexisting disorders:
      1. Infections that may cause PROM.
      2. PROM of unknown etiology.
      3. PIH (preeclampsia/eclampsia).
      4. Uterine overdistention.
        1. Polyhydramnios.
        2. Multifetal gestation.
      5. Maternal diabetes, renal or cardiovascular disorder, UTI.
      6. Severe maternal illness (e.g., pneumonia, acute pyelonephritis).
      7. Abnormal placentation.
        1. Placenta previa.
        2. Abruptio placentae.
      8. Iatrogenic: miscalculated EDD for repeat cesarean birth (rare).
      9. Fetal death.
      10. Incompetent cervical os (small percentage).
      11. Uterine anomalies (rare).
        1. Intrauterine septum.
        2. Bicornate uterus.
      12. Uterine fibroids.
      13. Positive fetal fibronectin assay (protein found in fetal tissue, membranes, amniotic fluid, and the decidua) found in cervical/vaginal fluid first half of pregnancy and normally absent through mid to late pregnancy (↑ risk of preterm labor by 20%).
    4. Prevention:
      1. Primary—close obstetric supervision; education in signs/symptoms of labor.
      2. Secondary—prompt, effective treatment of associated disorders (see II. C., The Intrapartum Experience).
      3. Tertiary—suppression of preterm labor.
        1. infoImageBedrest.
        2. Position: side-lying—to promote placental perfusion.
        3. Hydration.
        4. pillImage  Pharmacological (may require "informed consent"; follow hospital protocol). Beta-adrenergic agents, MgSO4 (recent studies show poor results with MgSO4), Procardia to reduce sensitivity of uterine myometrium to oxytocic and prostaglandin stimulation; increase blood flow to uterus.
        5. May be maintained at home with adequate follow-up and health teaching
    5. Contraindications for suppression: Labor is not suppressed in presence of:
      1. Placenta previa or abruptio placentae with hemorrhage.
      2. Chorioamnionitis.
      3. Erythroblastosis fetalis.
      4. Severe preeclampsia.
      5. Severe diabetes (e.g., "brittle").
      6. Increasing placental insufficiency.
      7. Progressive cervical dilation of 4 cm or more.
      8. Ruptured membranes (with maternal fever).
    6. Assessment:
      1. Maternal vital signs. Response to medication:
        1. Hypotension.
        2. Tachycardia, arrhythmia.
        3. Dyspnea, chest pain.
        4. Nausea and vomiting.
      2. Signs of infection:
        1. Increased temperature.
        2. Tachycardia.
        3. Diaphoresis.
        4. Malaise.
        5. Increased baseline fetal heart rate; ↓ variability.
      3. Contractions: frequency, duration, strength.
      4. Emotional status—signs of denial, guilt, anxiety, exhaustion.
      5. Signs of continuing and progressing labor. Note: Vaginal examination only if indicated by other signs of continuing labor progress:
        1. Effacement.
        2. Dilation.
        3. Station.
      6. Status of membranes.
      7. Fetal heart rate, activity (continuous monitoring).
    7. Analysis/nursing diagnosis:
      1. Anxiety/fear related to possible outcome.
      2. Self-esteem disturbance related to feelings of guilt, failure.
      3. Impaired physical mobility related to imposed bedrest.
      4. Knowledge deficit related to medication side effects.
      5. Ineffective individual coping related to possible outcome.
      6. Impaired gas exchange related to side effects of medication (circulatory overload; pulmonary edema).
      7. Diversional activity deficit related to imposed bedrest, decreased environmental stimuli.
      8. Altered urinary elimination related to bedrest.
      9. Constipation related to bedrest.
    8. Nursing care plan/implementation:
      1. pillImageGoal: inhibit uterine activity. Administer medications as ordered—terbutaline, magnesium sulfate, Procardia, Indocin.
      2. Goal: safeguard status.
        1. Continuous maternal/fetal monitoring.
        2. I&O—to identify early signs of possible circulatory overload.
        3. infoImagePosition: side-lying—to increase placental perfusion, prevent supine hypotension.
        4. Report promptly to physician:
          1. Maternal pulse of 110 or more.
          2. Diastolic pressure of 60 mm Hg or less.
          3. Respirations of 24 or more; crackles (rales).
          4. Complaint of dyspnea.
          5. Contractions: increasing frequency, strength, duration, or cessation of contractions.
          6. Intermittent back and thigh pain.
          7. Rupture of membranes.
          8. Vaginal bleeding.
          9. Fetal distress.
      3. Goal: comfort measures.
        1. Basic hygienic care—bath, mouth care, cold washcloth to face, perineal care.
        2. Back rub, linen change—to promote relaxation.
      4. Goal: emotional support.
        1. Encourage verbalization of guilt feelings, anxiety, fear, concerns; provide factual information.
        2. Support positive self-concept.
        3. Keep informed of progress.
      5. Goal: provide quiet diversion. Television, reading materials, handicrafts (may not be able to focus well if on magnesium therapy).
      6. Goal: health teaching.
        1. Explain, discuss proposed management to suppress preterm labor.
        2. Describe, discuss side effects of medication.
        3. Explain rationale for bedrest, position.
    9. If labor continues to progress:
      1. Goal: facilitate infant survival.
        1. pillImageAdminister betamethasone, as ordered, 24 to 48 hours before birth—to increase/stimulate production of pulmonary surfactant.
        2. pillImageGive antibiotic to mother to ↓ chance of neonatal sepsis.
        3. Notify NICU—to increase chances for fetal survival; ensure prompt, expert management of neonate; and provide information and support to parents.
        4. Monitor progress of labor to identify signs of impending birth. Note: May give birth before complete (10-cm) dilation.
        5. Consider transfer to high-risk facility.
        6. Prepare for birth, or cesarean birth if infant less than 34 to 36 weeks of gestation.
      2. Goal: emotional support.
        1. Do not leave woman (or couple) alone.
        2. Encourage verbalization of anxiety, fear, concern.
        3. Explain all procedures.
      3. Goal: comfort measures. Note: Analgesics used conservatively—to prevent depression of fetus/neonate.
      4. Goal: support effective coping techniques. Encourage/support Lamaze (or other) techniques—coach, as necessary; discourage hyperventilation.
      5. Goal: health teaching—for severe preterm birth.
        1. Discuss need for episiotomy, possibility of outlet forceps–assisted birth—to reduce stress on fetal head, or
        2. Prepare for cesarean birth—to reduce possibility of fetal intraventricular hemorrhage.
        3. Give rationale for avoiding use of medications to reduce contraction pain.
    10. Immediate care of neonate:
      1. Goal: safeguard status.
        1. Stabilize environmental temperature—to prevent chilling (isolette or other controlled-temperature bed).
        2. Suction, oxygen, as needed; may need intubation.
        3. pillImageParenteral fluids, as ordered—to support normal acid-base balance, pH; administer antibiotics, as necessary.
        4. Arrange transport to high-risk facility, as necessary.
      2. Goal: continuous monitoring of status.
        1. Electronic monitors—to observe respiratory and cardiac functions.
        2. Blood samples—to monitor blood gases, pH, hypoglycemia.
    11. Postpartum care: Goal: emotional support.
      1. Facilitate attachment—photos, if baby transferred or mother unable to visit.
      2. If couple, foster sense of mutual experience and closeness.
      3. Help her/them maintain a positive self-image.
      4. Encourage touching of infant before transport to nursery or high-risk facility; father/partner may accompany infant and report back to mother.
      5. Encourage early contact—to facilitate mother's need to ventilate her feelings.
      6. Assist parent(s) with grieving process, if necessary.
      7. Refer to support group if necessary.
    12. Other—as for any woman who is postpartum.
    13. Evaluation/outcome criteria:
      1. Woman verbalizes understanding of medical/nursing recommendations and treatments.
      2. Woman complies with medical/nursing regimen.
      3. Woman experiences no discomfort from side effects of therapy.
      4. Woman experiences successful outcome—labor inhibited.
      5. Woman carries pregnancy to successful termination.
      6. If preterm birth occurs, woman copes effectively with outcome (physiologically compromised neonate, neonatal death).
  3. GRIEF AND CHILDBEARING EXPERIENCE.
    The loss of a pregnancy or a newborn, or the birth of a child who is physiologically compromised (preterm, congenital disorder) is a crisis situation. The unexpected outcome can cause the parent(s) to suffer a sense of loss of self-esteem, self-concept, positive body image, feelings of worth (see Postpartum depression/psychosis, The Postpartum Period).
    1. Assessment:
      1. Response to loss of the "fantasy child"/real child.
        1. Behavioral—anger, hostility, depression, disinterest in activities of daily living, withdrawal.
        2. Biophysical—somatic complaints (stomach pain, malaise, anorexia, nausea).
        3. Cognitive—feelings of guilt.
      2. Knowledge/understanding/perception of situation.
      3. Coping abilities, mechanisms.
      4. Support system.
    2. Analysis/nursing diagnosis:
      1. Ineffective family coping: compromised related to psychological stress due to fear for infant, guilt feelings, impact on self-image.
      2. Ineffective individual coping related to anxiety, stress.
      3. Ineffective family coping: disabling related to disturbance in intrafamily relations secondary to individual coping deficits, recriminations.
      4. Altered parenting related to lack of effective bonding secondary to emotional separation from infant, feelings of guilt.
      5. Dysfunctional grieving related to guilt feelings, impact of loss on self-concept.
      6. Disturbance in body image, self-esteem, role performance related to perceived failure to complete gestational task, produce perfect, healthy infant; associated with sleep deprivation.
      7. Social isolation related to severe coping deficit, dysfunctional grieving, disturbance in self-esteem.
    3. Nursing care plan/implementation:
      1. Goal: emotional support.
        1. Provide privacy; encourage open expression/verbalization of feelings, fears, concerns, perceptions.
        2. Crisis intervention techniques.
      2. Goal: facilitate bonding, effective coping, or anticipatory grieving processes.
        1. Encourage contact and participation in care of premature or compromised infant.
        2. Keep informed of infant's status.
        3. Provide realistic data.
      3. Goal: health teaching.
        1. Clarify misperceptions, as appropriate.
        2. Discuss, demonstrate infant care techniques (e.g., feeding infant who has cleft lip or palate).
        3. Refer to appropriate community resources.
    4. Evaluation/outcome criteria:
      1. Woman verbalizes recognition and acceptance of diagnosis.
      2. Woman verbalizes understanding of relevant information regarding treatment, prognosis.
      3. Woman makes informed decision regarding infant care.
      4. Woman demonstrates comfort and increasing participation in care of neonate.
      5. Woman shows evidence of culturally appropriate bonding (eye contact, cuddles, calls infant by name).
  4. DISORDERS AFFECTING COMFORT, REST, MOBILITY: DYSTOCIA
    1. Definition—difficult labor.
    2. bulbImageGeneral aspects—there are 6 Ps that affect the progress of labor: Mother—"3 Ps": psych, placenta, position and Fetus—"3 Ps": power, passageway, passenger
      1. Pathophysiology—see specific disorders.
      2. Etiology—due to effects of three other factors that affect the FETUS:
        1. POWER: forces of labor (uterine contractions, use of abdominal muscles).
          1. Premature analgesia/anesthesia.
          2. Uterine overdistention (multifetal pregnancy, fetal macrosomia).
          3. Uterine myomas.
          4. Grandmultipara.
        2. PASSAGEWAY: resistance of cervix, pelvic structures.
          1. Rigid cervix.
          2. Distended bladder.
          3. Distended rectum.
          4. Dimensions of the bony pelvis: pelvic contractures.
        3. PASSENGER: accommodation of the presenting part to pelvic diameters.
          1. Fetal malposition/malpresentation.
            1. Transverse lie.
            2. Face, brow presentation.
            3. Breech presentation.
            4. Persistent occipitoposterior position.
            5. CPD.
          2. Fetal anomalies.
            1. Hydrocephalus.
            2. Conjoined ("Siamese") twins.
            3. Meningomyelocele.
          3. Fetal size: macrosomia.
      3. Hazards:
        1. Maternal:
          1. Fatigue, exhaustion, dehydration—due to prolonged labor.
          2. Lowered pain threshold, loss of control—due to prolonged labor, continued uterine contractions, anxiety, fatigue, lack of sleep.
          3. Intrauterine infection—due to prolonged rupture of membranes and frequent vaginal examinations.
          4. Uterine rupture—due to obstructed labor, hyperstimulation of uterus.
          5. Cervical, vaginal, perineal lacerations—due to obstetric interventions.
          6. Postpartum hemorrhage—due to uterine atony or trauma.
        2. Fetal:
          1. Hypoxia, anoxia, demise—due to decreased O2 concentration in cord blood.
          2. Intracranial hemorrhage—due to changing intracranial pressure.
    3. Hypertonic dysfunction
      1. Pathophysiology—increased resting tone of uterine myometrium; diminished refractory period; prolonged latent phase:
        1. Nullipara—more than 20 hours.
        2. Multipara—more than 14 hours.
      2. Etiology—unknown. Theory—ectopic initiation of incoordinate uterine contractions.
      3. Assessment:
        1. Onset—early labor (latent phase).
        2. Contractions:
          1. Continuous fundal tension, incomplete relaxation.
          2. Painful.
          3. Ineffectual—no effacement or dilation.
        3. Signs of fetal distress:
          1. Meconium-stained amniotic fluid.
          2. FHR irregularities.
        4. Maternal vital signs.
        5. Emotional status.
        6. Medical evaluation: vaginal examination, x-ray pelvimetry, ultrasonography—to rule out CPD (rarely used).
      4. Analysis/nursing diagnosis:
        1. Pain related to hypertonic contractions, incomplete uterine relaxation.
        2. Anxiety/fear for self and infant related to strong, painful contractions without evidence of progress.
        3. Ineffective individual coping related to fatigue, exhaustion, anxiety, tension, fear.
        4. Impaired gas exchange (fetal) related to incomplete relaxation of uterus.
        5. Sleep pattern disturbance related to prolonged ineffectual labor.
      5. Nursing care plan/implementation:
        1. Medical management:
          1. pillImageShort-acting barbiturates—to encourage rest, relaxation (see Chapter 8. Physiological Integrity).
          2. Intravenous fluids—to restore/maintain hydration and fluid-electrolyte balance.
          3. If CPD, cesarean birth.
        2. Nursing management:
          1. Goal: emotional support—assist coping with fear, pain, discouragement.
            1. Encourage verbalization of anxiety, fear, concerns.
            2. Explain all procedures.
            3. Reassure. Keep couple informed of progress.
          2. Goal: comfort measures.
            1. infoImagePosition: side-lying—to promote relaxation and placental perfusion.
            2. Bath, back rub, linen change, clean environment.
            3. Environment: quiet, darkened room—to minimize stimuli and encourage relaxation, warmth.
            4. Encourage voiding—to relieve bladder distention; to test urine for ketones.
          3. Goal: prevent infection. Strict aseptic technique.
          4. Goal: prepare for cesarean birth if necessary.
      6. Evaluation/outcome criteria:
        1. Relaxes, sleeps, establishes normal labor pattern.
        2. Demonstrates no signs of fetal distress.
        3. Successfully completes uneventful labor.
    4. Hypotonic dysfunction during labor
      1. Pathophysiology—after normal labor at onset, contractions diminish in frequency, duration and strength; lowered uterine resting tone; cervical effacement and dilation slow/cease.
      2. Etiology:
        1. Premature or excessive analgesia/anesthesia (epidural block or spinal block).
        2. CPD.
        3. Overdistention (polyhydramnios, fetal macrosomia, multifetal pregnancy).
        4. Fetal malposition/malpresentation.
        5. Maternal fear/anxiety.
      3. Assessment:
        1. Onset—may occur in latent phase; most common during active phase.
        2. Contractions: normal previously, demonstrate:
          1. Decreased frequency.
          2. Shorter duration.
          3. Diminished intensity (mild to moderate).
          4. Less uncomfortable.
        3. Cervical changes—slow or cease.
        4. Signs of fetal distress—rare.
          1. Usually occur late in labor due to infection secondary to prolonged rupture of membranes.
          2. Tachycardia.
        5. Maternal vital signs may indicate infection (↑ temperature).
        6. Medical diagnosis—procedures: vaginal examination.
      4. Analysis/nursing diagnosis:
        1. Knowledge deficit related to limited exposure to information.
        2. Anxiety/fear related to failure to progress as anticipated; fear for fetus.
        3. High risk for injury (infection) related to prolonged labor or ruptured membranes.
      5. Nursing care plan/implementation:
        1. Medical management:
          1. Amniotomy—artificial rupture of membranes.
          2. pillImageOxytocin augmentation of labor—intravenous infusion of oxytocin to increase frequency, duration, strength, and efficiency of uterine contractions (see Induction of labor, The Intrapartum Experience).
          3. If CPD, cesarean birth.
        2. Nursing management:
          1. Goals: emotional support, comfort measures, prevent infection—same as for Hypertonic dysfunction (see The Intrapartum Experience).
          2. Other (see Induction of labor, The Intrapartum Experience).
      6. Evaluation/outcome criteria:
        1. Reestablishes normal labor pattern.
        2. Experiences successful birth of viable infant.
  5. DISORDERS AFFECTING FLUID-GAS TRANSPORT: maternal
    1. Uterine rupture
      1. Pathophysiology—stress on uterine muscle exceeds its ability to stretch.
      2. Etiology:
        1. Overdistention—due to large baby, multifetal gestation.
        2. Old scars—due to previous cesarean births or uterine surgery.
        3. Contractions against CPD, fetal malpresentation, pathological retraction ring ( Bandl's ).
        4. Injudicious obstetrics—malapplication of forceps (or application without full effacement/dilation).
        5. Tetanic contraction—due to hypersensitivity to oxytocin (or excessive dosage) during induction/augmentation of labor.
      3. Assessment:
        1. Identify predisposing factors early.
        2. Complete rupture
          1. Pain: sudden, sharp, abdominal; followed by cessation of contractions; tender abdomen.
          2. Signs of shock; vaginal bleeding.
          3. Fetal heart tones—absent.
          4. Presenting part—not palpable on vaginal examination.
        3. Incomplete rupture
          1. Contractions: continue, accompanied by abdominal pain and failure to dilate; may become dystonic.
          2. Signs of shock.
          3. May demonstrate vaginal bleeding.
          4. Fetal heart tones—absent/bradycardia.
      4. Prognosis
        1. Maternal—guarded.
        2. Fetal—grave.
      5. Analysis/nursing diagnosis:
        1. Pain related to rupture of uterine muscle.
        2. Fluid volume deficit related to massive blood loss secondary to uterine rupture.
        3. Anxiety/fear related to concern for self, fetus.
        4. Altered tissue perfusion related to blood loss secondary to uterine rupture.
        5. Altered urinary elimination related to necessary conservation of intravascular fluid secondary to blood loss.
        6. Anticipatory grieving related to expected loss of fetus; inability to have more children.
      6. Nursing care plan/implementation:
        1. Medical management:
          1. pillImageSurgical—laparotomy, hysterectomy.
          2. Replace blood loss—transfusion, packed cells.
          3. pillImageReduce possibility of infection—antibiotics.
        2. Nursing management:
          1. Goal: safeguard status.
            1. Report immediately; mobilize staff.
            2. Prepare for immediate laparotomy.
            3. Oxygen per mask—to increase circulating oxygen level.
            4. Order STAT type and crossmatch for blood—to replace blood loss.
            5. Establish IV line—to infuse fluids, blood, medications.
            6. Insert indwelling catheter—to deflate bladder.
            7. Abdominal prep—to remove hair, bacteria.
            8. Surgical permit (informed consent) for hysterectomy.
          2. Goal: emotional support—to allay anxiety (woman and family).
            1. Encourage verbalization of fears, anxiety, concerns.
            2. Explain all procedures.
            3. Keep family informed of progress.
      7. Evaluation/outcome criteria:
        1. Experiences successful termination of emergency; minimal blood loss.
        2. Postoperative status stable.
    2. Amniotic fluid embolus (anaphylactoid syndrome)
      1. Pathophysiology: acute cor pulmonale—due to embolus blocking vessels in pulmonary circulation; massive hemorrhage—due to DIC resulting from entrance of thromboplastin-like material into bloodstream.
      2. Etiology—amniotic fluid (with any meconium, lanugo, or vernix) enters maternal circulation through open venous sinuses at placental site; travels to pulmonary arterioles. Triggers cardiogenic shock and anaphylactoid reaction.
        1. Rare.
        2. Associated with: tumultuous labor, abruptio placentae, artificial ROM, placement of intrauterine catheter.
      3. Prognosis—poor; often fatal to mother.
      4. Assessment:
        1. May occur during labor, at time of rupture of membranes, or immediately postpartum.
        2. Sudden dyspnea and cyanosis.
        3. Chest pain.
        4. Hypotension, tachycardia.
        5. Frothy sputum.
        6. Signs of DIC:
          1. Purpura—local hemorrhage.
          2. Increased vaginal bleeding—massive.
          3. Rapid onset of shock.
      5. Analysis/nursing diagnosis:
        1. Impaired gas exchange related to pulmonary edema.
        2. Risk for fluid volume deficit related to DIC.
        3. Anxiety/fear for self and fetus related to severity of symptoms, perception of jeopardy.
      6. Nursing care plan/implementation:
        1. Medical management:
          1. pillImageIV heparin, whole blood.
          2. Birth: immediate, by forceps, if possible; or cesarean birth.
          3. Digitalize, as necessary.
        2. Nursing management:
          1. Goal: assist ventilation.
            1. infoImagePosition: semi-Fowler's.
            2. Oxygen under positive pressure.
            3. Suction prn.
          2. Goal: facilitate/expedite administration of fluids, medications, blood.
            1. Establish intravenous line with large-bore needle.
            2. pillImageAdminister heparin, fluids, as ordered.
          3. Goal: restore cardiopulmonary functions, if needed. Cardiopulmonary resuscitation techniques.
          4. Goal: emotional support of woman, family.
            1. Allay anxiety, as possible.
            2. Explain all procedures.
            3. Keep informed of status.
      7. Evaluation/outcome criteria:
        1. Dyspnea relieved.
        2. Bleeding controlled.
        3. Successful birth of viable infant.
        4. Uneventful postpartum course.
  6. DISORDERS AFFECTING FLUID-GAS TRANSPORT: fetal
    1. Fetus in jeopardy—general aspects:
      1. Pathophysiology—maternal hypoxemia, anemia, ketoacidosis, Rh isoimmunization, or decreased uteroplacental perfusion.
      2. Etiology—maternal:
        1. Preeclampsia/eclampsia, PIH.
        2. Heart disease.
        3. Diabetes.
        4. Rh or ABO incompatibility.
        5. Insufficient uteroplacental/cord circulation due to:
          1. Maternal hypotension/hypertension.
          2. Cord compression:
            1. Prolapsed.
            2. Knotted.
            3. Nuchal.
          3. Hemorrhage; anemia.
          4. Placental problem:
            1. Malformation of the placenta/cord.
            2. Premature "aging" of placenta.
            3. Placental infarcts.
            4. Abruptio placentae.
            5. Placenta previa.
          5. Postterm gestation.
          6. Maternal infection.
          7. Polyhydramnios.
          8. Hypertonic uterine contractions.
        6. Premature rupture of membranes (PROM) with chorioamnionitis.
        7. Dystocia (e.g., from CPD).
      3. Assessment—intrapartum:
        1. Amniotic fluid examination—at or after rupture of membranes. Signs of fetal distress: meconium stained, vertex presentation—due to relaxation of fetal anal sphincter secondary to hypoxia/anoxia. Note: Fetus "gasps" in utero—may aspirate meconium and amniotic fluid.
        2. Fetal activity:
          1. Hyperactivity—due to hypoxemia, elevated CO2.
          2. Cessation—possible fetal death.
        3. Methods of monitoring FHR:
          1. Fetoscope.
          2. Phonocardiography with microphone application.
          3. Internal fetal electrode—attached directly to fetus through dilated cervix after membranes ruptured.
          4. Doppler probe using ultrasound flow.
          5. Cardiotocograph—transducer on maternal abdomen transmits sound.
        4. Abnormal FHR patterns (see Figure 4-10. Fetal Heart Rate (FHR) Decelerations and Nursing Interventions).
          1. Persistent arrhythmia.
          2. Persistent tachycardia of 160 or more beats/min.
          3. Persistent bradycardia of 100 or fewer beats/min.
          4. Early deceleration—due to vagal response to head compression.
          5. Late deceleration—due to uteroplacental insufficiency.
          6. Variable deceleration—due to cord compression.
          7. Decreased or loss of variability in FHR pattern.
        5. Medical evaluation—procedures: fetal blood gases, pH (rarely performed).
          1. Purpose—to identify fetal acid-base status.
          2. Requirements for:
            1. Ruptured membranes.
            2. Cervical dilation.
            3. Engaged head.
          3. Procedure—under sterile condition, sample of fetal scalp blood obtained for analysis.
          4. Signs of fetal distress:
            1. pH less than 7.20 (normal range is 7.3–7.4).
            2. Increased CO2
            3. Decreased PO2
      4. Analysis/nursing diagnosis:
        1. Impaired gas exchange, fetal, related to decreased placental perfusion/insufficient cord circulation.
        2. Altered tissue perfusion related to hemolytic anemia.
        3. High risk for fetal injury related to hypoxia.
    2. Prolapsed umbilical cord
      1. Pathophysiology—cord descent in advance of presenting part; compression interrupts blood flow, exchange of fetal/maternal gases → fetal hypoxia, anoxia, death (if unrelieved).
      2. Etiology:
        1. Spontaneous or artificial rupture of membranes before presenting part is engaged.
        2. Excessive force of escaping fluid, as in polyhydramnios.
        3. Malposition—breech, compound presentation, transverse lie.
        4. Preterm or fetus who is SGA—allows space for cord descent.
      3. Assessment:
        1. Visualization of cord outside (or inside) vagina.
        2. Palpation of pulsating mass on vaginal examination.
        3. Fetal distress—variable deceleration and persistent bradycardia.
      4. Analysis/nursing diagnosis:
        1. Impaired gas exchange, fetal, related to interruption of blood flow from placenta/fetus.
        2. Anxiety/fear, maternal, related to knowledge of fetal jeopardy.
      5. Nursing care plan/implementation:
        1. Goal: reduce pressure on cord.
          1. infoImagePosition: knee to chest; lateral modified Sims' with hips elevated; modified Trendelenburg.
          2. With gloved hand, support fetal presenting part.
        2. Goal: increase maternal/fetal oxygenation: oxygen per mask (8–10 L/min).
        3. Goal: protect exposed cord: continuous pressure on the presenting part to keep pressure off cord.
        4. Goal: identify fetal response to above measures, reduce threat to fetal survival: monitor FHR continuously.
        5. Goal: expedite termination of threat to fetus: prepare for immediate cesarean birth.
        6. Goal: support mother and significant other by staying with them and explaining.
      6. Evaluation/outcome criteria:
        1. FHR returns to normal rate and pattern.
        2. Uncomplicated birth of viable infant.
  7. SUMMARY OF DANGER SIGNS DURING LABOR
    1. Contractions—strong, every 2 minutes or less, lasting 90 seconds or more; poor relaxation between contractions.
    2. Sudden sharp abdominal pain followed by boardlike abdomen and shock—abruptio placentae or uterine rupture.
    3. Marked vaginal bleeding.
    4. FHR periodic pattern decelerations—late; variable; absent variability (see Figure 4-10. Fetal Heart Rate (FHR) Decelerations and Nursing Interventions).
    5. Baseline.
      1. Bradycardia (<100 beats/min).
      2. Tachycardia (>160 beats/min).
    6. Amniotic fluid.
      1. Amount: excessive; diminished.
      2. Odor.
      3. Color: meconium stained; port-wine; yellow.
      4. 24 hours or more since rupture of membranes.
    7. Maternal hypotension, or hypertension.