ch. 32 labor birth complications

Question 1

preterm labor and birth

Answer 1

preterm labor: regular contractions along with a change in cervical effacement or dilation or both or presentation with regular uterine contractions and cervical dilation of atleast 2 cm.
- any birth that occurs between 20-36 weeks gestation

Question 2

decreasing rates of preterm birth in the last decade is due to

Answer 2

1) improved fertility practices that reduce the rusk for higher oder multiple gestations
2) quality improvement programs that limit scheduled preterm births to only those with valid indications
3) increased efforts to prevent recurrent preterm birth

Question 3

subcategories of preterm labor and birth

Answer 3

1) very preterm (<32 weeks of gestation)
2) moderately preterm (32-34 weeks of gestation)
3) late preterm (34-26 weeks of gestation)

Question 4

preterm birth vs. low birth weight

Answer 4

• preterm birth or prematurity: length of gestation regardless of birth weight
• more dangerous than birth weight alone because less time in the uterus correlates with immaturity of body systems
• low birth weight: </= 2500 grams at birth
• causes: intrauterine growth restriction (IUGR)

Question 5

sponteneous vs. indicated preterm birth

Answer 5

• spontaneous: 75% of preterms birth
• indicated: 25% of preterm births

Question 6

causes of spontaneous preterm labor and birth

Answer 6

• multifactoral; multiple pathologic processes
• infection is the only definitive factor (preterm labor)
• congenital structural abnormalities of the uterus
• placental causes (placenta previa/abruptio placentae)
• maternal and fetal stress
• uterine overdistention
• allergic reaction
• decrease in progesterone (maintains pregnancy)

Question 7

predicting spontaneous preterm labor and birth

Answer 7

• RF
• cervical length: 2nd trimester U/S, >30 mm in the 2/3 trimester unlikely to give birth prematurely (shorten/tunneling cervix)
• fetal, fibronectin test: fFN is a glycoprotein “glue” found in plasma and produced during fetal life
• test is used to predict who will NOT go into preterm labor d/t high negative predictive value

Question 8

PTL interprofessional care mgmt

Answer 8

1) assessment: patient teaching (medical leave)

2) interventions:
- prevention
- early recognition and diagnosis

3) lifestyle modifications
- activity restriction (no evidence to support bedrest, should NOT be routinely recommended)
- restriction of sexual acitivty (trigger PTB)
- home care

4) suppression of uterine activity
- tocolytic medications: terbutaline, magnesium sulfate, endomethacin

5) promotion of fetal lung maturity:
- antenatal glucocorticoids (betamethacine)

6) mgmt of inevitable preterm birth: fetal and early neonatal loss

Question 9

prelabor rupture of membranes

Answer 9

spontaneous rupture of amniotic sac and leakage of fluid prior to the onset of labor at any gestation age

1) PPROM: membranes rupture before 37 weeks of gestation
- complicates approximately 3% of all pregnancies in the US
- often preceded by infection (chorioamniotitis)

Question 10

PROM vs PPROM interprofessional care mgmt

Answer 10

• determined individually for each women (gestational age)
• PPROM at less than 32 weeks is managed expectantly or conservatively
• vigilance for signs of infections
• fetal assessment
• antenatal glucocorticoids for all women with preterm PROM between 24 and 34 weeks of gestation
• 7 day course of broad spectrum antibiotics (ampicillin, gentomycin)
• administering mag sulfate for fetal neuroprotection

Question 11

amniotic sac rupture, what to look out for

Answer 11

watch temperature for infection

Question 12

chorioamniotitis

Answer 12

• bacterial infection of the amniotic cavity
• major cause of complications for mothers and newborns at any gestational age (sepsis)
• occurs in approximately 1-5% term births but in as many as 25% preterm births
• diagnosed by the clinical findings of maternal fever, maternal and fetal tachycardia, uterine tenderness, and foul odor of amniotic fluid
• neonatal risks
• treatment

4 signs:
- fever
- tachycardia
- uterine tenderness
- strong vaginal odor

Question 13

posterm pregnancy (postdates)

Answer 13

• pregnancy greater than or equal to 42 weeks gestation
  (less than 0.25% of all births in the US)

maternal/fetal risks:
- severe perineal injuries
- increased maternal morbidity
- labor and birth interventions more likely
- abnormal fetal growth (macrosomia)
- operative birth and shoulder dystocia, leading to fetal injury
- cord compression resulting in hypoxemia
- increased risk of meconium aspiration
- post-maturity syndrome: fetus stops grow, placenta stops function, will lose weight, wrinkly skin

Question 14

postterm pregnancy, labor and birth interprofessional care mgmt

Answer 14

• controversial
• perinatal morbidity and mortality increase greatly beginning at 41 weeks of gestation

1) more frequent feta assessment, testing:
- NST
- CST
- BPP
- modified BPP
- women is encouraged to assess fetal activity daily, assess for signs of labor, and keep appointments with her obstetric health care provider

Question 15

dysfunctional labor (dystocia)

Answer 15

dystocia: lack of progress in labor for any reason

dysfunctional labor: long, difficult, or abnormal labor
- most common indications for c-birth; responsible for approximately 1/3 of all c-births

review:
5 factors that affect labor:
- power
- passage
- passenger
- maternal position
- psychologic responses

Question 16

dysfunctional labor (dystocia) causes

Answer 16

1) abnormal uterine activity
a) latent phase disorders:
- hypertonic uterine dysfunction
- therapeutic rest (off pitocin)
b) active phase disorder
- protraction disorders: progress in labor is slower than normal (cause: hypotonic uterine dysfunction)
- arrest disorders: no progress in labor initially makes normal progress into the active phase of first stage labor but then the contractions become weak and inefficient or stop altogether

2) assessment of uterine activity using an intrauterine pressure catheter (IUPC)

3) secondary powers:
- problems with bearing down efforts

4) abnormal labor patterns:
- friedman’s classification of “normal” labor patterns
- updates evidence based awareness of “normal” labor patterns; modern labor progresses more slowly

5) precipitous labor:
- labor that lasts less than 3 hours from the onset of contractions to the time of birth
- occurs in approximately 3% of all births in the US

Question 17

dysfunctional labor (dystocia) causes: alterations in pelvic structure

Answer 17

1) pelvic dystocia:
- contractures of pelvic diameter that reduce the capacity of the bony pelvis, inlet, midpelvis, or outlet

2) soft tissue dystocia:
- results from obstruction of the birth passage by an anatomic abnormality other than that of bony pelvis

Question 18

dysfunctional labor (dystocia) causes: fetal causes, position of the woman, psychologic responses

Answer 18

1) fetal causes:
- anomalies
- cephalopelvic disproportion (CPD), aka fetopelvic disproportion
- malposition
- malpresentation
- multifetal pregnancy

2) position of the woman:
- maternal position alters relationship between uterine contractions, fetus, and mother’s pelvis

3) psychologic responses:
- hormones and neurotransmitters released in response to stress can cause dystocia
- sources of stress and anxiety vary

Question 19

dysfunctional labor (dystocia) causes: interprofessional care mgmt

Answer 19

1) risk assessment is a continual process in the laboring woman

2) many interventions for dysfunctional labor are implemented collaboratively with other members of the interprofessional health care team

3) when providing care for a woman who is experiencing labor or birth complications; all members of the health care team are responsible for complying with professional standards of care

Question 20

obesity

Answer 20

obese pregnant women are at increased risk for complications:
- spontaneous abortion and stillbirth
- pregnancy associated HTN disorders
- gestational diabetes
- fetal cognitive abnormalities
- cesarean birth
- venous thromboembolism
- increased incidence of postterm pregnancy and longer labor

Question 21

obesity interprofessional care mgmt

Answer 21

1) intrapartum challenges:
- standard furniture often not large enough
- fetal monitoring can be difficult (requiring internal monitor)
- routine procedures require more time and effort
- mobility is often a problem (weight ball, shower)

2) postoperative challenges:
- increased risk for blood clot formation
- keeping the incision clean and dry to prevent wound infection and promote healing (DVT)
- pannus: large roll of abdominal dat causes area to retain moisture

Question 22

obstetric procedures

Answer 22

1) external cephalic version (ECV):
- an attempt to turn the fetus from a breech or shoulder presentation to a vertex presentation for birth
- at 36-37 weeks, the success rate for ECV is approximately 65% and the risk for cesarean birth is reduced by 50%
- US scanning is done before ECV is attempted
- multuple contraindications to ECV

2) internal version
- rarely used, safety questionable

Question 23

obstetric procedures: induction of labor

Answer 23

1) the chemical or mechanical initiation of uterine contractions before their spontaneous onset for the purpose of brining about birth

2) labor may be induced either electively or for indicated reasons

3) elective induction of labor:
- labor is initiated without a medical indication
- many are for the convenience of the woman or her obs health care provider
- risks: increased rates of c-birth, increased neonatal morbidity, increased cost

should not be initiated until the woman raches 39 weeks completed weeks of gestation
- bishop’s score (rating system used to evaluate inducibility or cervical ripeness)

Question 24

obstetric procedures: induction of labor cervical ripening methods, amniotomy, oxytocin

Answer 24

1) cervical ripening:
- chemical agents
- mechanical and physical methods
- alternative methods

2) amniotomy

3) oxytocin:
- hormone normally produced by the posterior pit gland, which stimualtes uterine contractions and aids in milk let down
- synthetic oxytocin (pitocin) may be used either to induce labor or to augment labor that is progressing slwoly because of inadequate uterine contractions
- uterine tachysystole: too many contractions, tx: terbutaline, >5 contractions in 10 minutes

Question 25

obstetric procedures: augmentation of labor

Answer 25

1) stimulation of uterine contractions after labor has started spontaneously and progress is unsatisfactory

2) common augmentation methods include oxytocin infusion and amniotomy

3) the most used regimen in the US for administering oxytocin is to begin with a starting dose of 1 milliunit/minute and to increase by 1-2 milliunits/minute
- no more frequently than every 30-40 minutes

Question 26

obstetric procedures: operative vaginal birth

Answer 26

• performed using either forceps or a vacuum extractor
• vacuum: assisted birth, aka vacuum extraction
• medical mgmt
• nursing interventions

Question 27

obstetric procedures: cesarean birth overview

Answer 27

• birth of a fetus through a transabdominal incision of the uterus to preserve the well-being of the mother and her fetus
• birth data for 2020: indicate that the cesarean birth rate in the US was 31.8%, remaining very high
• VBAC: vaginal birth after cesarean
• TOLAC: trial of labor after cesarean`

Question 28

obstetric procedures: caesarean birth indications

Answer 28

1) elective caesarean birth: fear of labor
- referred to as caesarean on maternal requests, refers to a primary caesarean birth without medical or obstetric indication

2) scheduled cesarean birth:
- reasons for scheduled cesarean births

3) unplanned cesarean births

4) forced cesarean birth:
- maternal fetal conflict
- ethical implications

Question 29

obstetric procedures: cesarean birth

Answer 29

• immediate post op care
• post op postpartum care
• nursing interventions
• trial of labor (TOL)
• vaginal birth after cesarean (VBAC) (success 60-80%)

Question 30

obstetric emergencies: meconium stained amniotic fluid

Answer 30

(a) indicates: fetus has passed stool prior to birth
(b) dark green
(c) causes:
- normal physiological function of maturity
- hypoxia induced peristalsis
- umbilical cord compression
- breech presentation normal (post maturity)
(d) interprofessional care mgmt
- presence of a interprofessional team skilled in neonatal resuscitation is required

Question 31

obstetric emergencies: shoulder dystocia

Answer 31

• head is born, but ANTERIOR SHOULDER cannot pass under pubic arch
• 0.2% = 0.3% all vaginal births are complicated by shoulder dystocia
• newborn more likely to experience birth injuries r/t asphyxia, brachial plexus damage, and fracture
• mother’s primary risk: UTERINE RUPTURE, other maternal risk: operative injury, blood transfusion, hysterectomy, endometritis, death

1) interprofessional care mgmtL
- MCROBERTS maneuver (legs up past head ++ pressure on pubic bone)
- suprapubis pressure
- gaskin maneuver (all 4s)

Question 32

obstetric emergencies: prolapsed umbilical cord

Answer 32

1) occurs when cord lies below the presenting part of the fetus

2) contributing factors:
- long cord (longer than 100cm)
– malpresentation (breech)
- transverse lie
- unengaged presenting part

3) interprofessional care mgmt:
- prompt recognition
- pressure off cord
- position change to keep pressure off of the cord
- trendelenburg push presenting part up, sterile gloves in vagina displace cord

Question 33

obstetric emergencies: uterine rupture

Answer 33

1) symptomatic disruption and separation of the layers of the uterus or previous scar
- indidence of uterine rupture is approximately 1%
- most frequent causes of uterine rupture during: separation of scar of a previous classical cesarean birth (up/down cut), uterine trauma (eg accidents, surgery)

2) uterine dehiscence:
- incomplete uterine rupture; separation of a prior scar

3) interprofessional care mgmt:
- prevention is the BEST treatment

Question 34

obstetric emergencies: amniotic fluid embolus (AFE)

Answer 34

1) aka anaphylactoid syndrome of pregnancy (ASP)

2) rare but devastating complication of pregnancy characterized by the sudden, acute onset of hypotension, hypoxia, and hemorrhage caused by coagulopathy

3) one of two cases of AFE are estimated to occur in 100,000 births

4) the exact factor that initiates AFE has not been identified
- in the past, particles of fetal debris found in amniotic fluid were thought to be responsible for initiating the syndrome; however, fetal debris can be found in th pulmonary circulation of most healthy laboring women