Ch 32 Labor and Birth Complications Flashcards
When does PROM occur?
Before 37 weeks gestation
What does PROM care focus on?
Prevention of infection
How do nurses prevent infection in patients with PROM?
Limit vaginal exams
Change bed pads frequently
Monitor fetus
What are 4 PROM complications?
Infection
Abruption
Retained placenta
maternal sepsis and death
What types on infection are mothers with PROM at risk for?
Chorioamnionitis
Endometritis
What are the fetal risks of PROM? (10)
Respiratory distress syndrome (RDS) Intraventricular Hemorrhage (IVH) Necrotizing enterocolitis (NEC) Fetal sepsis Malpresentation Cord prolapse Non-reassuring FHT Umbilical cord compression related to oligohydramnios Premature birth morbidity and mortality
What are the fetal risks of PROM in babies that are 36 or less weeks?
Respiratory distress syndrome (RDS)
Intraventricular Hemorrhage (IVH)
Necrotizing enterocolitis (NEC)
Fetal sepsis
Why does PROM cause fetal sepsis in babies less than 36 weeks?
Ascending pathogens
concerning PROM, the earlier the gestational age…
the more complications
What labs would you draw on a patient with PROM?
CBC
CRP
UA
GBS
A patient with PROM will be hospitalized on __ __
bed rest
What tools will be used to assess the baby in a mother with PROM?
Ultrasound
NST
What should the nurse monitor in PROM concerning infection?
Fluid changes…
- amount
- color
- odor
- consistency
In a patient with PROM, what should stop?
Vaginal exams unless indicated (usually done by HCP)
What weeks is magnesium sulfate given?
23 6/7 - 31 6/7
Why is magnesium sulfate given to a mother who has PROM?
For neural protection, to decrease cerebral palsy
What steroid might be given to a mother who has PROM?
Maternal corticosteroid administration for fetal lung maturation
If a patient has PROM, what should the nurse do for her?
Answer questions and anticipate birth
Provide psychological support for patient and family
How common is multiple gestation?
33.4 per 1000 births
What race has the highest incidence of multiple gestations?
African Americans
What are risk factors for multiple gestation?
Increased age
Higher parity
Family history of fraternal twins
Women who are tall and overweight
What are fraternal twins called?
Dizygotic
Dizygotic twins have…
two eggs and two sperm
What are identical twins called?
Monozygotic
Monozygotic twins have…
one egg and one sperm
How common are identical twins?
4 in every 1000 births
What are maternal complications of having multiple gestation?
UTI Threatened AB Anemia Gestational hypertension Preeclampsia/Eclampsia PROM Thromboembolism Placenta previa Placental abruption Placental disorders PTL and PTB
What are fetal/neonatal complications of multiple gestation?
Higher mortality rate IUGR Higher incidence of fetal anomalies Prematurity Abnormal presentations Cord accidents Cerebral palsy
What should the nurse do for a patient hospitalized with multiple gestation?
Monitor for complications FHR monitoring Prepare for birth, possible c section Advise neonatal staff Get additional staff Baby A, Baby B, Baby C
How many calories a day should a mother with multiple gestation consume?
3500 a day
How much should the mother consume concerning prenatal vitamins?
PNV daily
Additional 1-4mg folic acid daily
What should the nurse teach a mother who is having multiple gestation?
Frequent rest periods
Side-lying resting position
Body mechanics while lifting
Comfort measures: comfort rocking, good posture, pregnancy belt
How much amniotic fluid is considered normal?
500 mL
What are symptoms of polyhydramnios?
Shortness of breath
Edema in the legs
What are complications mothers are at risk for with polyhydramnios?
C section
Uterine dysfunction
Placental abruption
Postpartum hemorrhage
What are fetal complications for a mother with polyhydramnios?
Malformations Preterm birth Increased mortality rate Prolapsed cord Malpresentation
What is polyhydramnios?
Too much amniotic fluid around the baby
What is oligohydramnios?
Too little amniotic fluid around the baby
What are maternal complications with oligohydramnios?
Dysfunction labor with slow progress
Hypertensive disorders
What are fetal deformation defects with oligohydramnios?
Ahesions Skin and skeletal Pulmonary hypoplasia Umbilical cord compression Head compression
What conditions can cause polyhydramnios?
Diabetes
Rh sensitization
Malformations of fetal swallowing
What are the major malformations of oligohydramnios?
Renal agenesis
Dysplastic kidneys
Lower urinary tract obstructive lesions
What is a major malformation of polyhydramnios?
Malformation of fetal swallowing
If a mother has polyhydramnios and a fetal defect has been identified, what should the nurse do?
Consult with social services
What is the nursing care for a mother with polyhydramnios?
Provide information and extra support
Maintain sterility during amniocentesis
Monitor FHR during procedure
What reading on the monitor should the nurse notify the HCP if the mother. has oligohydramnios?
Variable decelerations (cord compression)
What should the nurse be looking for on the monitor for a patient who has oligohydramnios?
Variable decelerations
Non-reassuring fetal status
What are nursing care of patients with oligohydramnios?
Provide information and encourage questions
Evaluate FHR monitor
Reposition mother to relieve cord compression
What should the nurse assess on a baby whose mother had oligohydramnios?
Anomalies
Pulmonary hypoplasia
Post-maturity
What are the types of dysfunctional labor?
Prolonged labor
Tachysystolic labor
Hypotonic labor
What is tachysystolic labor?
Uterine contractions greater than 6 in 10 mins, lasting longer than 2 mins, OR resting tone increases
What are the maternal risks for tachysystolic labor?
Uterine muscle cell anoxia Fatigue Stress and poor coping Dehydration Infection Prolonged labor
What are the fetal/neonatal risks of tachysystolic labor?
non-reassuring fetal status
Prolonged pressure on the fetal head
What can prolonged pressure on the fetal head (due to tachysystolic labor) cause?
Cephalohematoma
Caput succedaneum
Excessive molding
What causes the non-reassuring fetal status during tachysystolic labor?
increased uterine tone interferes with uteroplacental exchange
What is the major cause of tachysystolic labor?
Pitocin administration (induction/augmentation)
What is the first thing the nurse should do if a patient has tachysystolic labor?
Stop Pitocin if infusing
What drug will the nurse administer to a patient who is tachysystolic labor?
terbutaline sulfate
What does terbutaline sulfate do?
Relaxes uterine smooth muscle
What is the MOA of terbutaline sulfate?
Selective B2 agonist
What are the nursing implications of a patient in tachysystolic labor?
Stop Pitocin Rest Terbutaline sulfate monitor fatiuge Monitor FHR and contractions Provide information and support
What type of questions might a patient with tachysystolic labor have?
Cause
Implications
Treatment
What are institute supportive measures for tachysystolic labor?
Position changes with pillow Quiet soothing environment Touch/massage ygeine Hydrotherapy Sedation Relaxation Visualization Music
What are risks for hypotonic labor?
Maternal exhaustion Stress and poor coping Prolonged labor postpartum hemorrhage from insufficient uterine contractions following birth Intrauterine infection
What are potential complications for the fetus during hypotonic labor?
Non-reassuring fetal status due to prolonged labor
Fetal sepsis
Why can prolonged labor cause fetal sepsis?
Pathogens ascending
What should the nurse be monitoring in a patient with hypotonic labor?
Vital signs
FHR
Contractions
I&Os
What should the nurse be assessing in a patient with hypotonic contractions?
Amniotic fluid for meconium
Bladder for distention
Signs of infection
What is nursing care for a patient with hypotonic contractions?
Encourage voiding every 2 hrs Catheterize as needed with regional block decrease vaginal exams (infection) Start Pitocin per HCP Emotional support Supportive measures
What is a regional block?
Also called nerve block, consists of infiltrating a peripheral nerve and blocking transmission
What are supportive measures for a patient with hypotonic labor?
Ambulation Position changes Quiet, soothing environment Touch/massage Personal Hygiene
What is precipitous labor?
Labor lasting less than 3 hrs resulting in rapid birth
What are contributing factors to precipitous labor?
Multiparty Large pelvis Previous precipitous labor Small fetus Recent cocaine use
What are maternal implications of precipitous labor?
Loss of coping
Lacerations due to rapid decent
Postpartum hemorrhage
Why does precipitous labor cause postpartum hemorrhage?
Undetected lacerations
Uterine atony
What are the fetal implications of precipitous labor?
Non-reassuring fetal status or hypoxia
Cerebral trauma from rapid decent
Pneumothorax
Branchial plexus injuries
Why can precipitous labor cause fetal hypoxia?
Decreased uteroplacental circulation due to intense uterine contractions
Who is at risk for precipitous labor?
Accelerated cervix dilation
Intense uterine contractions with little relaxation in between
What should a nurse do for a patient with/at risk for precipitous labor?
Monitor closely if previous history Have precipitous pack available/prepare Stay in the patients room Supportive, quiet environment Monitor Pitocin
What should the nurse do if a patient with precipitous labor become tachysystolic?
discontinue Pitocin give terbutaline Turn to left side Administer O2 Watch FHR for abnormal
What is a prolonged pregnancy?
294 days or 42 weeks past the first day of LMP
Extremely preterm baby:
at or before 25 weeks
Very preterm baby:
at less than 32 weeks
Moderatley preterm baby:
between 32 and 34 weeks
Late preterm baby:
34-36 6/7 weeks
Full term baby:
39-40 6/7 weeks
Post-term baby:
Beyond 42 weeks
What are risks for the mother of a post-term pregnancy?
Probable labor induction Large for gestational age infant Forceps/vacuum assisted birth or c section Psychologic stress Infection
What are the risk factors for post-term pregnancy?
Primigravidas
History of prolonged pregnancy
Fetal anencephaly or placental sulfatase deficiency
What is primigravida?
A woman who is pregnant for the first time
What is anencephaly?
A baby born without parts of the brain or skull
What is placental sulfatase insufficiency?
genetic disorder of metabolism
What are the risks for the infant with post-term pregnancy?
Decreased placental perfusion Oligohydramnios Meconium aspiration Low 5 min APGAR Dysmaturity syndrome or LGA
What does oligohydramnios cause a baby that is post-term pregnancy?
At risk for cord compression and possible meconium aspiration
What will a baby born post-term look like?
Dry peeling skin Little old men look minimal lanugo or vernix Deep creases on feet Prominent nipple and breast tissue
What is lanugo?
Fine soft hair that covers the baby’s body
What is vernix?
White, waxy substance found coating the skin of the newborn
What is community care of the patient that is post-term pregnancy?
Education
Fetal kick counts
When a post-term pregnant patient comes into the hospital, when should they deliver?
induce at 41 weeks or continue with expectant management (NST or Biophysical profile)
What should the nurse do for the patient who is post-term pregnant in the hospital?
FHR monitoring Leopold maneuver Assess labor progression Coping strategies Comfort measures
What is the nurse looking for on the FHR monitor with a patient who is post-term pregnant?
Variable decelerations
Why would the nurse do the Leopold’s maneuver for a post-term pregnant patient?
Estimate fetal size
What is the nurse monitoring for when assessing labor progression in a patient who is post-term pregnant?
Failure to descend (large gestational age)
What is the most common malposition?
Occiput posterior position
Why does malposition occur?
Occurs due to fetus not rotating
Malposition is most common in an __ pelvis
android
What are the s/s of malposition?
Intense back pain Dysfunctional labor Hypotonic labor Arrest of dilation Arrest of fetal descent FHR head far laterally on abdomen Wide, diamond-shape fontanelle in anterior portion of pelvis
What could cause a patient to need a c section due to malposition?
Cephalopelvic disproportion (CPD)
What is cephalopelvis disproportion?
Large baby or in difficult position, or too small for mother’s pelvis to pass
What complications may arise from a forceps or vacuum assisted birth?
Lacerations
Episiotomy
What is an episiotomy?
A surgical cute made at the opening of the vagina during childbirth to aid in delivery and preventer rupture of tissues
What is molding?
In a head first delivery, the pressure of the vagina may distort the shape of the baby’s head
What are complications of malposition?
Prolonged labor C section Lacerations/episiotomy Cephalohematoma Modling Edema and bruising of the face
What are maternal position changes that can be used in malposition?
Knee to chest
Side to side
Pelvic rocking
Support and coping mechanisms
Describe a breech frank presentation
Flexion at top of thighs, knees extended
Feet up by head
Buttocks present
Describe a breech complete presentation
Thighs AND knees flexed
Feet and buttocks present
Sort of looks like criss cross apple sauce
Describe footling breech presentation
Thighs and knees both extended
Foot or both feet present
Baby more straight
Describe kneeling breech presentation
Thighs extended, knees flexed
Knees present
What is an external cephalic version?
procedure to try to move your baby if they are in a breech position to the head-down position.
What are contraindications to external cephalic version?
Preeclampsia, 3rd trimester bleeding Rupture of membranes Oligohydramnios Previous uterine surgery Multiple gestation Non-reassuring NST IUGR Nuchal cord
Can a preeclamptic patient have an external cephalic version?
no
What is the criteria a patient must meet to have an external cephalic version?
36 weeks or greater
Reactive NST
Breech is not engaged
What maternal conditions are associated with breech presentation?
Preterm birth Placenta previa Hydramnios Multiple gestation Uterine anomalies (bicoruate uterus)=
What fetal conditions are associated with breech presentation?
Anenchaly
Hydrocephaly
What is the main risk of breech presentation?
Increased risk of prolapsed cord
What are the additional risks of breech presentation?
Increased perinatal morbidity and mortality Cervical spinal cord injuries Birth trauma (especially head) Asphyxia Non-reassuring fetal status
Why does a breech position cause an increased risk of cervical spinal cord injuries?
Hyperextension of fetal head during vaginal birth
What should a nurse assess on the fetal monitor during an umbilical cord prolapse?
Non-reassuring fetal status
Decelerations (variables)
How long should a nurse assess the fetal monitor during an umbilical cord prolapse?
At least a full minute after rupture of membranes for several contractions
What happens if a loop of cord is discovered?
Examiner’s gloved fingers must remain in vagina to provide firm pressure on fetal head until birth
When a patient has a prolapsed umbilical cord, what are the indicated nursing care?
Oxygen via face mask 10l/min Monitor FHR Knee to chest position trendelenburg Transport to delivery or OR room in trendelenburg
When is an external cephalic version performed?
36-38 weeks
What happens if the external cephalic version is unsuccessful?
C section
The potential for prolapsed cord is associated with which type of breech?
Footling because increased space
If multiple gestation and breech, labor may be
double step up
What is fetal macrosomia?
Newborn weighing more than 4500 g
How is fetal macrosomia identified?
Palpation of fetus in utero (Leopold’s maneuver)
Ultrasound of fetus
X-ray pelvimetry
Fetal macrosomia is associated with what conditions?
Obesity DM Prior history of macrosomia Male fetus Grand multiparous Prolonged gestation Hispanic background
What are maternal risks for macrosomia?
Cephalopelvic disproportion (CPD)
Prolonged labor
Lacerations
Postpartum hemorrhage
What type of lacerations is macrosomia associated with?
Third and fourth degree lacerations or extension of episiotomies
What are the additional fetal risks of macrosomia?
Meconium aspiration Asphyxia Hypoglycemia Polycythemia Hyperbilirubinemaia
What are the three main fetal risks of macrosomia?
Shoulder dystocia
Upper brachial plexus injury
Fractured clavicle
What are the concerns with fetal macrosomnia?
Early decelerations
Lack of fetal decent
Labor dysfunction
Non-reassuring fetal status
What is a possible fetal complication of macrosomnia?
Shoulder dystocia
What is the nursing care for fetal macrosomnia?
Fundal massage after birth to prevent hemorrhage from over-distended uterus
Close monitoring of vital signs
IV Pitocin
What is anaphylactoid syndrome of pregnancy?
Small tear in the amnion or chorion high in the uterus, small amount of amniotic fluid gets in there and enters the maternal system as an amniotic fluid embolism
What are the signs/symptoms to look out for, for anaphylactoid syndrome of pregnancy?
Dyspnea Cyanosis Frothy Sputum Chest pain Tachycardia Hypotension Mental confusion Massive hemorrhage
What are complications of anaphylactoid syndrome of pregnancy?
Sudden onset respiratory distress Acute hemorrhage Circulatory collapse Cor pulmonale Hemorrhagic shock Coma/death Fetal death if birth not immediate
What is the nursing care for a patient with anaphylactoid syndrome of pregnancy?
Get emergency response team Positive pressure O2 Large bore IV CPR if needed Prepare for c section Prep for CVP line insertion Administer blood Family support
What is cephalopelvic disproportion?
CPD - occurs when fetus is larger than pelvic diameter.
What is used to determine CPD?
Clinical and x ray pelvimetry used to determine smallest diameter through which fetal head must pass
CPD: What is the shortest AP diameter?
<10cm
CPD diagonal conjugate
<11.5 cm
CPD greatest transverse diameter
<12 cm
CPD: what determines that the pelvis is contracted?
Shortest AP diameter: <10cm
Diagonal conjugate: <11.5 cm
Greatest transverse diameter: <12 cm
Labor is usually __ in the presence of CPD
prolonged
Is vaginal birth possible foe CPD?
Yes, depends on type of CPD
What should the nurse suspect for a patient with CPD?
Cervical dilation and effacement slow
Delayed engagement, lack of descent
Head is not well applied to cervix
Labor prolonged
What should the nurse assess for a patient with CPD?
Adequacy of pelvis
FHR monitor
What should a nurse do for patient with CPD?
Frequent position changes - sitting, squatting, rolling from side to side, knee to chest
Frequent vaginal exams Keep partner informed Explain procedures Support measures Prepare c section
What is retained placenta?
Retention of placenta beyond 30 minutes after birth
How frequent is retained placenta?
1-2% of vaginal births
If the uterus does not expel, what should happen?
Manual removal from uterus
What happens if the provider is unable to remove the placenta manually?
Curettage
What happens if curettage is not successful in removing the placenta from the uterus?
Hysterectomy
What is the nursing care during a hysterectomy?
Prep for surgery
Monitor blood loss
Monitor vital signs
Emotional support
When is an amniotomy used?
Induce or augment labor
Apply fetal or contraction monitors
Assess color and composition of amniotic fluid
What is the nursing care during an amniotomy?
Pad bed Assess fetal presentation, position, and station Position patient FHR monitor Note color, amount, odor, any blood or meconium Cleanse and dry perineal area Decrease # cervical exams Reassure patient
When is a ROM performed?
Only when the head is at zero station
What is an amnioinfusion?
Instilling saline into the amniotic cavity using an intrauterine catheter
What type of fluid is used during an amnioinfusion?
Warmed normal saline or lactated ringers
How is the fluid during an amnioinfusion instilled?
Through pump or intrauterine pressure catheter (IUPC)
What should the nurse monitor for during an amnioinfusion?
Meconium that will be thin and clear
Variable decelerations - the amnio should cushion the cord
What are three methods of induction?
Stripping of the membranes
Cervical ripening
Pitocin induction
What are complementary methods of induction?
Sex
Nipple/breast stimulation
Herbal use
Mechanical dilation of cervix with balloon catheters
How does intercourse stimulation induction?
Prostaglandin in semen, female orgasm stimulates uterine contractions
How does breast/nipple stimulation cause induction?
Endogenous oxytocin release
Which complementary method should the nurse not participate in?
Intercourse and nipple/breast stimulation
Which complementary method is not supported by research?
Herbal use
What is the mechanical method of stripping of membranes?
Gloved finger inserted into internal os and rotated 360 degrees twice: separating amniotic membranes lying against lower uterine segment
Where is stripping of membranes done?
Typically as outpatient service and does not require fetal monitoring
What are some disadvantages of stripping of membranes?
May not induce labor
May cause bleeding and cramping
What are indications for induction of labor?
DM Non-reassuring antepartum testing Preeclampsia or eclampsia PROM Chorioamnionitis Post-term (especially with oligohydramnios) IUFD IUGR Alloimmunization
What is IUFD?
Intrauterine fetal demise
What is alloimmunization?
Induction of immunity in response to foreign antigens encountered through exposure to cells or tissues from a genetically different member of the same species
What can cause alloimmunization?
Blood transfusions
What are contraindications to induction?
Client refusal Placenta previa Floating fetal presenting part Prior uterine incision that could preclude a TOL (trial of labor) Active genital herpes Prolapsed umbilical cord Acute, severe non-reassuring fetal status Absolute CPD
What is the ACOG recommendation for inductions?
Inductions prior to 39 weeks should be avoided whenever possible due to fetal maturity issues
What score on the bishop chart is favorable to induction?
8 or greater
Should a patient with a known sensitivity have cervical ripening?
No
Should a patient with a non-reassuring FHT have cervical ripening?
No
Should a patient with unexplained bleeding during pregnancy have cervical ripening?
No
Should a patient with a suspected CPD have cervical ripening?
No
Should a patient with current Pitocin running have cervical ripening?
No
Should a patient with a suspicion that they shouldn’t have a vaginal birth have cervical ripening?
No
Should a patient with a history of c section have cervical ripening?
No
Should a patient with uterine scarring have cervical ripening?
No
Should a patient with a history of uterine rupture have cervical ripening?
No
What three conditions should be a caution for cervical ripening?
History of asthma or glaucoma
Rupture of membranes
Breech presentation
What medication is given to induce cervical ripening?
Cervidil
What is the generic name of cervidil?
dinoprostone
When should cervidil be given?
When induction is indicated but not emergent
Where is cervidil given?
Its administered inpatient
What should the nurse do when giving cervidil?
Monitor FHR for at least 2 hours after giving
What should the nurse do if hyperstimulation or non-reassuring FHT occur after giving cervidil?
Remove insert and give terbutaline for hyperstimulation
What is the generic name of cytotec?
Misoprostol
What is the brand name of misoprostol?
Cytotec
Should a patient with indicated induction receive cytotec in the 2nd trimester?
No
Should a patient with indicated induction receive cytotec in the 3rd trimester?
Yes
What is the initial dose of cytotec?
25 mcg, which is 1/4 of a tablet
How frequent should the nurse give cytotec?
No more than every 3-6 hrs
When can Pitocin be administered after cytotec?
4 hours from last dose of cytotec
What are nursing care for patients who received cytotec inpatient?
Continuous FHR monitoring
Have terbutaline available
A patient is having contractions 3 in every 10 mins, can she have cytotec?
NO
What is a major absolute contraindication of cytotec?
Significant maternal history of asthma
What readings on the FHT would contraindicate cytotec?
fetal tachycardia
If a woman has bleeding during pregnancy, can cytotec be used?
NO
What obstetrical history would contraindicate the use of cytotec?
Placenta previa
Prior c section
Uterine scar
What vaginal assessment finding by the nurse would contraindicated cytotec?
Meconium passage
What happens if the mother becomes hyper sensitized to Pitocin?
Decreased placental perfusion and non-reassuring fetal status
What should a nurse consider when titrating Pitocin?
Facility protocol
Clinician order
Individual situation
Maternal-fetal response
When Pitocin is infusion, the nurse should palpate the uterus except when…
IUPC is in place
What should be noted about Pitocin and blood pressure?
It may initially DECREASE blood pressure
Pitocin is still given after birth to…
decrease bleeding
A patient with preeclampsia needs to progress in labor, can the nurse give her pitocin?
NO
A patient that needs to progress in labor has a predisposition to uterine rupture, can she have Pitocin?
NO
A patient that needs to progress in labor has CPD, can she have Pitocin?
NO
A patient that needs to progress in labor has malpresentation or malposition of the fetus, can Pitocin be administered?
NO
A patient that needs to progress in labor shows a cord prolapse, can she have Pitocin?
NO
A patient that needs to progress in labor has a history of multiple cesarean sections, can Pitocin be administered?
NO
A patient that needs to progress in labor is preterm, can Pitocin be used?
NO
A patient that needs to progress in labor has a rigid, not ripe cervix. Can Pitocin be used?
NO
A patient that needs to progress in labor has a total placental previa. Can Pitocin be used?
NO
A patient that needs to progress in labor shows non-reassuring status on the FHR monitor. Can the nurse administer Pitocin?
NO
What are the four things the nurse should ASSESS for after administering Pitocin for induction/augmentation?
Continiour FHR monitoring
I&Os
Vital signs and pain level
Cervical exams
How often should the nurse assess vital signs and pain when administering Pitocin?
With every increase of Pitocin
What is the nurse watching for when assessing the FHR monitor after administering Pitocin for induction?
Baseline, variability, periodic changes (accelereations/delecelerations)
Uterine contractions frequency, duration, and strength
If after administering Pitocin for induction, the patient begins to have abnormal FHR monitor readings, what should the nurse do next?
Discontinue the Pitocin
What should the nurse teach the patient when administering pitocin for induction of labor?
Purpose of procedure
Procedure details
Breathing and relaxation techniques
Comfort measures
What factors can predispose women to an episiotomy?
Lithotomy and other recumbent positions
Sustained breath holding during second stage of labor
Arbitarty time limit place by physical during second stage of labor
Macrosomic fetus, OP position, shoulder dystocia, forces/vacuum assisted birth
How does sustained breath holding during the second stage of labor predispose the patient to episiotomies?
Causes excessive and rapid perineal stretching
How can a side-lying position prevent the need for an episiotomy?
Slows bath, diminishes tears
Why should there be gradual expulsion on infant be used?
To prevent need for episiotomy
What are 4 tips during labor that can be used to prevent the need for an episiotomy?
Perineal massage during pregnancy for nullips
Natural positioning during labor
Warm compresses on perineal and firm counter pressure
Avoidance of immediate pushing after epidural placement
What position should be avoiding to prevent the need for an episiotomy?
Lithotomy or pulling back on legs
What is another name for a forceps-assisted birth?
Instrument or operative vaginal birth
What are the 3 types of forceps-assisted birth?
Outlet
Low
midforceps
When is an outlet forceps-assisted birth used?
Applied when fetal skull has reached perineum, fetal scalp is visible, and sagittal suture is not more than 45 degrees from midline
When is a low forceps assisted birth used?
Applied when leading edge (presenting part) of fetal skull is at station of 2+ of more
When is a mid forceps assisted birth used?
Applied when fetal head is engaged
When is the fetus considered to be engaged?
at zero station
A patient is struggling with birth, she also has heart disease, can she have a forceps assisted birth?
YES
A patient is struggling with birth, she also has pulmonary edema, can she have a forceps assisted birth?
YES
A patient who has in infection is struggling with birth, can she have a forceps assisted birth?
YES
A patient suffering from maternal exhaustion is struggling with birth. Can she have a forceps assisted birth?
YES
A patient on the FHR monitor is showing non-reassuring fetal status. Can she have a forceps assisted birth?
YES
A patient with premature placental separation is struggling with birth. Can she have a forceps assisted birth?
YES
A patient is having a prolonged second stage of labor. Can she have a forceps assisted birth?
YES
A patient received a heavy regional block and is having ineffective pushing. Can she have a forceps assisted birth?
YES
What are the maternal risks associated with forcep assisted deliveries?
Laceration of birth canal Extension of midline episiotomy into anus Increased bleeding Brusing Infection PP hemorrhage Perineal edema Anal incontinence
What are the FETAL risks associated with forceps assisted deliveries?
Bruising and edema Facial lacerations Brachial plexus Caput succedaneium Cephalohematomas Transient facial paralysis Cerebral hemorrhage Fractures Brain damage Fetal death
What can a cephalohematoma cause in a newborn?
Subsequent hyperbilirubinema
What is the nursing care for a forceps delivered birth?
Explain procedure Assure adequate anesthesia in place Breathing techniques during application of forceps Continuous FHR monitoring Instruct patient to push with UC Assessment of mom and baby after birth
What does a forceps assisted birth look like?
Rn instructs patient to push with uterine contractions, physician applies downward, outward for on forceps
How does a vacuum extraction birth work?
Assists birth by applying suction to fetal head
What is the maximum amount of time that a vacuum assisted birth should be used?
8-10 minutes
How is the vacuum assisted birth used?
Progressive decent with first 2 pulls
Why is the vacuum assisted birth limited?
To prevent cephalohematomas and jaundice
Why does a vacuum assisted birth carry the risk of cephalohematomas and jaundice?
Because of the reabsorption of bruising at cup attachment site
What type of birth would a patient with a complete previa need?
C section
What type of birth would a patient with CPD need?
c section
What type of birth would a patient with a placental abruption need?
c section
What type of birth would a patient with active genital herpes need?
c section
What type of birth would a patient with an umbilical cord prolapse need?
c section
What type of birth would a patient with FTP need?
c section
What does FTP mean?
Failure to progress
A patient has non-reassuring fetal status, what type of birth do they need?
c section
A patient with a previous classical c section will need…
c section from there on
If a patient has an obstruction of the birth canal they will need…
a c section
What maternal medication conditions will a c section most likely be needed?
Cardiac disorders Severe respiratory disease CNS disorders (increased ICP) HIV infection Mental disorders Altered state of consciousness
What are three types of c section incisions?
Low transverse incision
Classical incision
Low vertical incision
What is the nursing prep for a c section?
Explain procedure Establish IV lines FHR monitoring Administer meds Place indwelling catheter Perform abdominal prep and scrub May or may not obtain consent
What should the nurse assess after a c section?
Bowel sounds Heart and respiratory system Homan's sign (unless contraindicated) Pain level Bladder Lochia Fundus Vital signs
How often after a c section should the nurse assess pain level?
Hourly and with pain medication administration
How long is a foley in place for after a c section?
At least 24 hrs
How should the fundus feel after a c section?
Firm
How long is a pressure dressing on the c section site after surgery?
for 24 hrs
What does TOLAC stand for?
trial of labor after c section
Who is able to have a TOLAC?
A patient with 1-2 previous c sections and a low transverse incision ONLY
These women have higher neonatal death rates and lower success rates of TOLAC
Obese and morbidly obese women
What must a woman’s uterus look like for a TOLAC?
Absence of other uterine scars or history of uterine rupture
What is contraindicated during a TOLAC?
Prostaglandin agents
Why can women on prostaglandin agents NOT have a TOLAC?
Increased risk of uterine rupture
What is the nursing care during a TOLAC?
IV Immediate access to OR Continous FHR monitoring NPO or clear liquid diet Support for couples Follow protocol
If a patient is high risk and doing a TOLAC, what may be required?
Internal fetal monitoring
What is the McRobert’s maneuver step 1?
Legs flexed onto abdomen causes rotation of pelvis, alignment of sacrum, and opening of birth canal
What is McRobert’s maneuver part 2?
Suprapubic pressure applied to fetal anterior shoulder
When is the McRobert’s maneuver applied?
In case of shoulder dystocia during childbirth
