ch 32 alterations in labor and birth, OB emergencies

Question 1

5 causes dystocia

Answer 1

-dysfunctional labor
-alterations in pelvic structure
-fetal causes
-position of woman
-psychological responses

Question 2

risk factors for dystocia

Answer 2

-overweight
-short stature (<5 ft)
-uterine abnormalities
-fetal malpositions/presentations/CPD
-uterine overstimulation w/ oxytocin
-maternal fatigue, dehydration, electrolyte imbalance, fear
-early admin analgesic
-use of continuous epidural
-other (advanced maternal age, h/o infertility, h/o prior fetal version, masculine characteristic)

Question 3

CPD

Answer 3

cephalopelvic disproportion

Question 4

2 types dysfunctional labor

Answer 4

-protracted/prolonged: slower than expected
-arrest: progress stops

Question 5

type of dysfunctional labor (stage 1, latent phase):
-frequent, painful, inefficient contractions
-Tx: therapeutic rest

Answer 5

hypertonic uterine dysfunction

Question 6

type of dysfunctional labor (stage 2):
-normal progress initially, then stalls
-contractions become weak/inefficient or stop
-assess status, possible augmentation

Answer 6

hypotonic uterine dysfunction

Question 7

fetal causes dystocia

Answer 7

-anomalies
-macrosomia/CPD
-malposition
-malpresentation
-multifetal gestation

Question 8

3 complications dystocia

Answer 8

-maternal lacerations
-fetal injuries/fractures
-neonatal asphyxia

Question 9

nursing interventions for dystocia

Answer 9

-positioning and movement
-pain and anxiety management
-labor support
-environmental control
-pt and family teaching
-open glottis pushing
-patient advocacy

Question 10

labor that lasts <3 hours from onset of Cxs to time of birth

Answer 10

precipitous labor

Question 11

what might precipitous labor be associated with

Answer 11

hypertonic uterine Cxs:
-placental abruption
-uterine tachysystole
-recent cocaine use

(increased risk trauma to mom and baby)

Question 12

medical procedures for dystocia

Answer 12

-external cephalic version (before baby is engaged)
-operative vaginal birth (forceps, vacuum)

Question 13

fetal risk with use of vacuum during birth

Answer 13

increased risk for jaundice due to blood buildup in head

Question 14

how many times can a hcp try to use vacuum extraction if it pops off

Answer 14

3 times total
then switch to forceps or C/S

Question 15

induction v augmentation of labor

Answer 15

induction: starting labor
augmentation: labor already started, helping it move along

Question 16

how many weeks EGA does woman have to be to have elective induction

Answer 16

39 wks

Question 17

maternal indications for medically indicated induction

Answer 17

-pregnancy complications (HTN)
-fetal death
-chorio

Question 18

fetal indications for medically indicated induction

Answer 18

fetal jeopardy:
-maternal complications (DM, GDM, HTN)
-post term (42 wks EGA)
-IUGR
-Rh sensitization
-chorio
-term ROM without labor

Question 19

contraindications for induction

Answer 19

-acute severe fetal distress (C/S)
-malpresentation
-floating presenting part (not engaged)
-uncontrolled hemorrhage
-previa
-some previous uterine incisions

Question 20

relative contraindications for induction (with caution)

Answer 20

-grandmultiparity (G>5, increased risk PPH)
-multiple gestations
-suspected CPD
-breech
-inability to monitor FHR (obesity, previa)

Question 21

purpose of bishop score

Answer 21

assess readiness of cervix prior to induction

Question 22

what bishop score is considered successful, and equivalent to spontaneous labor

Answer 22

8+

Question 23

what is evaluated in bishop score (5)

Answer 23

-dilation
-effacement
-station
-cervical consistency (firm, medium, soft)
-cervical position (posterior, midposition, anterior)

Question 24

methods to facilitate cervical ripening (3 mechanical, 2 chemical)

Answer 24

MECHANICAL (stimulates cervix to release prostaglandins)
-balloon catheter
-hydroscopic dilator
-amniotic membrane stripping/sweeping (separates chorion from uterus)

CHEMICAL:
-misoprostol (cytotec)
-dinoprostone (prepidil gel, cervidil insert)

Question 25

adverse effects of prostaglandins (misoprostol, dinoprostone)

Answer 25

-headache
-fever
-N/V/D
-hypoTN
-uterine tachysystole
-fetal passage meconium

Question 26

absolute contraindication for use of cytotec

Answer 26

previous uterine scar

Question 27

contraindications for use of dinoprostone (prepidil, cervidil)

Answer 27

-asthma
-glaucoma
-hypoTN/HTN

CAUTION WITH:
-cardiac/renal/hepatic disease
-anemia
-diabetes
-epilepsy
-GU infections

Question 28

indications of use for oxytocin

Answer 28

-induction
-augmentation
-prophylaxis against PPH
-treat PPH

Question 29

what does steady state of a med mean

Answer 29

max effect of med is reached

Question 30

how long does it take for oxytocin to reach steady state

Answer 30

40 minutes

Question 31

considerations for admin of oxytocin

Answer 31

given IVPB
always given at port closest to skin
documented in mIU/min

Question 32

S+S uterine tachysystole

Answer 32

-5+ contractions in 10 mins
-contractions longer than 2 mins
-less than 1 minute resting time between Cxs

Question 33

interventions for uterine tachysystole with oxytocin infusion for category 1 FHR

Answer 33

-side lying position
-IV fluid bolus LR
-decrease oxytocin by half if uterine activity not returned to normal after 10 mins
-discontinue oxytocin if not normal after another 10 mins

Question 34

interventions for uterine tachysystole with oxytocin infusion for category 2 or 3 FHR

Answer 34

-discontinue oxytocin immediately
-side lying position
-IV fluid bolus LR
-O2 10L/min
-possibly give terbutaline
-notify hcp

Question 35

guidelines before admin of oxytocin

Answer 35

-verify woman understands indications, risks and benefits
-verify order
-implement order
-comfort and position for woman
-fetal monitoring atleast 15 mins before
-bathroom before

Question 36

goal for contractions with oxytocin infusion

Answer 36

-200-220 MVU (only can monitor if have IUPC)
-contraction q2-3min lasting 80-90 secs, strong

Question 37

nursing considerations for oxytocin (assessments and frequency)

Answer 37

-EFM continuous
-VS q30-60mins and with dose change
-FHR and contraction pattern q15mins and with change in dose (2nd stage labor: q5mins)
-monitor I&O (limit IV to 1000 mL/8 hr)

Question 38

side effect of oxytocin?
max mainline IV infusion?

Answer 38

water retention
1000 mL/8hr

Question 39

what is the low dose of oxytocin

Answer 39

-1 mu/min start
-increase 1-2 mu/min q30min

Question 40

what is the high dose of oxytocin

Answer 40

-6 mu/min start
-increase 6 mu/min q15-20min

Question 41

adverse effect high doses oxytocin

Answer 41

increased C/S rates due to fetal distress

Question 42

alternative methods to induce labor

Answer 42

-herbals (black cohosh, evening primrose oil, blue cohosh, castor oil)
-acupuncture

*ask because she might have faster response to oxytocin induction

Question 43

VBAC

Answer 43

vaginal birth after C/S

Question 44

TOL/TOLAC

Answer 44

trial of labor (after C/S)

Question 45

standard preop care for C/S

Answer 45

-NPO 8-12 hrs
-consent
-anesthesia preop
-IV
-foley
-preop meds (Abx, antacids)
-SCDs

Question 46

intraop care for C/S: positioning

Answer 46

-tilt
-foley
-SCDs
-legs secured
-bovie pad
-blankets

Question 47

intraop care for C/S: time out

Answer 47

-pt and procedure ID w/ indication
-consents
-preop meds
-blood if needed
-drug and food allergies
-neonatal team

Question 48

2 types skin incisions for C/S

Answer 48

-transverse
-vertical

Question 49

who can’t do TOLAC/VBAC (3)

Answer 49

woman who had previous C/S with:
-low vertical uterine incision
-J shape uterine extension
-T shape uterine extension

Question 50

3 types uterine incisions for C/S
+2 extensions

Answer 50

-low transverse
-low vertical
-classical

extensions:
-J shape
-T shape

Question 51

postpartum care for C/S mom

Answer 51

-pain management
-intestinal gas management
-diet
-ambulation, foley, SCDs
-peri care, breast care
-fundal and lochia assessments

Question 52

possible causes meconium stained amniotic fluid (3)

Answer 52

-post term
-breech presentation
-hypoxia-induced peristalsis

Question 53

intervention for meconium stained amniotic fluid before birth

Answer 53

-early recognition
-prep for neonatal resuscitation/intubation

Question 54

intervention for meconium stained amniotic fluid immediately after birth

Answer 54

ASSESS
-good cry, tone, HR>100: wipe face and mouth, bulb suction
-depressed resps, decreased tone, HR<100: tracheal suction with ET tube

Question 55

risk factors shoulder dystocia

Answer 55

-**diabetes (esp uncontrolled glucose during 2nd half pregnancy)
-prior macrosomia
-obesity
-AMA (>35 yo)
-excessive weight gain in pregnancy
-abnormal pelvis
-post term

Question 56

S+S shoulder dystocia

Answer 56

-prolonged 2nd stage labor
-protracted/arrest of descent
-pronounced fetal head molding
-head delivers, shoulders don’t
-no external rotation
-“turtle sign” (head retracting back into pelvis)

Question 57

dangers of shoulder dystocia

Answer 57

-fractures (esp humerus or clavicle)
-asphyxia
-brachial plexus damage

Question 58

nursing intervention for shoulder dystocia

Answer 58

-McRoberts maneuver: legs onto chest, suprapubic pressure
-other positions: hands/knees, squatting

Question 59

maternal complications shoulder dystocia

Answer 59

-uterine atony and PPH
-vaginal and perineal tears
-episiotomy with extension
-endometritis

Question 60

nursing documentation for shoulder dystocia

Answer 60

-delivery time (time between head and shoulders)
-anesthesia
-all maneuvers in order they occurred
-consultants
-infant/maternal status at completion

Question 61

OB emergency: occurs when cord lies below presenting part of fetus

Answer 61

prolapsed umbilical cord

Question 62

contributing factors to prolapsed umbilical cord

Answer 62

-long cord (>100 cm)
-malpresentation (breech)
-transverse lie
-unengaged presenting part