Chapter 21 Flashcards
Abnormal or difficult Labor
Dystocia
The term “failure to progress” refers to
- lack of progression of cervical dilation, lack of fetal descent, or both
Factors that increases risk for dystocia
- epidural, excessive analgesia
- hydramnios
- exhaustion
- long first stage of labor
- anything that sounds wrong
indications of cesarean birth
- Labor dystocia
- Abnormal FHR
- malpresentation
- multiple gestation
- macrosomia
Uterus never fully relax, more than one uteriin pacemaker sends signals
Hypertonic contraction
Uterus relax too much
hypotonic contraction
uterus contracts so frequently and with such intensity causing rapid birth
Precipitate labor
Hypertonic uterine dysfunction, describe how this affects labor
- prolongs latent phase, does not dilate normally staying at 2 to 3 cm.
- compromises placental perfusion causing oxygen reduction for fetus
- causes maternal exhaustion due to slow progress and constant and painful contractions
Describe Hypertonic Uterine dysfunction
- talk about the pressure
- affects nulliparous women more than multi.
- occurs in latent phase of first stage (<4 cm dilation)
- force of contraction is in midsection instead of in the fundus
- loss of downward pressure
- women become discouraged with lack of progress
Describe Hypotonic Uterine dysfunction
- occurs during active labor
- contractions become poor in quality lacks intensity to dilate and efface the cervix.
- major complication is hemorrhage after birth
Factors associated with hypotonic uterine dysfunction
- overstretching uterus
- large fetus, multi gestation
- hydramnios
- excessive analgesia
- bowel or bladder distention
What are some manifestations of hypotonic uterine dysfunction
- weak contraction, easilly distended fundus in peak contraction
- contractions become more infrequent and briefer
Slower than normal labor pogress
Protraction disorder
Complete cessation of progress
arrest disorder
labor that is completed within 3 hours from start of contraction to birth
Precipitate Labor
Some characteristics of Precipitate labor
- Soft perineal tissue that allow for rapid stretch and fast fetal descent
- or abnormally strong uterine contraction
- can lead to lacerations or potential uterine rupture, fetal head trauma and hypoxia
regarding passenger, what increases the risk of dystocia
- any presentation that is not occiput anterior
- increased size
common problems in fetal passenger
- occiput posterior
- breech position
- multiple gestation
- macrosomia
Nursing interventions for hypertonic uterine dysfunction
- bed rest and sedation to relax and reduce pain
- monitor fetal status (FHR)
- hydration through IV
- If normal labor pattern not achieved, plan surgical birth
Nursing interventions for Hypotonic Uterine dysfunction
-if normal labor pattern is not achieved?
- amniotomy and/or augmentation of labor can be ordered (Oxytocin)
- Monitor Fetal status
- If normal labor pattern not achieved, plan surgical birth
Precipitate Labor Therapeutic care and nursing interventions
- Close monitoring
- use of scheduled induction to control labor (tocolytics)
Effects of Persistent occiput posterior position in labor and fetus
- longer labor with more back pain
- expect more caput succedaneum and molding
Nursing interventions for Persistent occiput posterior position
- labor will proceed, support mother (expect long labor, usually second stage), comfort measures
- anticipate forceps use or manual rotation at end of second stage
- encourage maternal reposition(sitting kneeling, lunges, rocking, all fours position etc)
- if rotation not achieved, prep for cesarean birth
- low back counter pressure, lateral abdominal stroking
- describe woman’s progress to avoid discouragement
in face and brow presentation, when would you do cesarean birth
- in face, vaginal birth is possible. Cesarean birth is done if head rotated backwards
- cesarean birth for brow unless head flexes
if vertex position not achieved
expect cesarean birth
when would you attempt cephalic version to reduce breech presentation
at 36 to 38 weeks gestation but before the start of labor
describe shoulder dystocia
Delivery of head without the neck appearing
Theraputic techniques for Shoulder dystocia
-why would you need additional personal?
- empty woman’s bladder
- McRoberts Maneuver and suprapubic pressure
- resuscitation team available
- immediate therapies required due to cord compression
- additional personnel are often needed, make room
What to assess for after shoulder dystocia birth
- Crepitus,
- deformity
- Erb palsy
- bruising
Which positions for shoulder dystocia
- squatting position
- all fours
- lateral recumbent position
Multiple gestation Therapeutic techniques
- separate FHR monitoring
- assess second fetus lie after first fetal birth and clamping
- anticipate cesarean birth (common)
Macrosomia therapeutic techniques
- cesarean birth is often planned when diagnosis is made before onset of labor, especially for primigravida women
- vacuum and forceps are often used
a procedure in which the fetus is rotated from the breech to the cephalic presentation
External cephalic version
obstruction of fetal descent by fetal shoulders after birth of the head
Shoulder dystocia (obstetric emergency)
Most common complication of multigestation
hemorrhage
In terms of passageway, what can cause arrest of fetal descent
- soft tissue dystocia
- contraction of mid pelvis
hormones related to anxiety that lead to dystocia
- Catecholamine which lead to myometrial dysfunction
- Norepi and Epi can lead to uncoordinated or increased uterine activity
Risk factors for dystocia
- Short stature
- Hydramnios
- obesity, macrosomia
- uterine abnormalities
- malpresentations
- pelvic shapes
- oxytocin overstimulation
- maternal exhaustion and anxiety
key aspect of diagnosing dystocia
patience is key. Dystocia is diagnosed after some time after labor begins not at the beginning
cervical dilatation per hour
1 cm per hour
when the membrane ruptures
assess for cord prolapse
Throughout labor
- assess fluid balance, monitor intake and output
- assess for bladder, every 2 hours, and bowel distention. void often
reducing stress
- blankets, pillows, backrub
- lower light and reduce noise
- reposition every 30 min
- warm shower if not contraindicated
labor beginning at 20 to 37 weeks gestation
preterm labor
drugs that promote uterine relaxation interrupting uterine contraction
tocolytic drugs( can prolong pregnancy for 2 to 7 days)
Therapies for preterm labor
-why would yo give steroids
- Tocolytic Drugs
- steroids to help lung maturity
- single dose of corticosteroids is recommended for pregnant women between 24 to 34 who are at risk for preterm labor (requires 24 hours to become effective)
contraindications for tocolytic drug use
- abruptio placenta, fetal distress, eclampsia or severe preeclampsia, vaginal bleed,
- dilation >6
- chorioamnionitis
- FGR
tocolytic drugs
- magnesium sulfate (asses DTR, RR, hypotension)
- indomethacin (No give peptic ulcer patients, give with food, can affect ductus arteriosus, not for >32 week gestation)
- betamethasone (2 doses 24 hours apart)
- nifedipine (Hypotension, tachycardia)
subtle signs and symptoms of preterm labor
- change or increase in vaginal discharge (include mucus, blood, water)
- pelvic, pushing down, pressure and low back ache, cramps
- UTI
- N/V, diarrhea
- uterine contractions (more than six per hour)
Risk factors for preterm labor
- Low socioeconomic status
- African American
- Alcohol, smoking, drugs
- history of preterm birth, multi gestation,
- short intervals between pregnancies
- STI, infections, hypertension, stress, cervical insufficiency, placental problems
Lab tests for preterm labor
- CBC
- Urinalysis
- amniocenteses (assess lung maturity and presence of chorioamnionitis)
- Fetal Fibronectin (marker for impending membrane rupture within 7 to 14 days if >0.5)
- cervical measurement (3 cm means less likely pretem, 2.5 cm means more likely)
Nursing interventions for preterm labor
- Supportive care (monitor VS, FHR, limiting vaginal examination)
- tocolytic therapy (presence of contractions and uterine change of 2 cm dilation or 80% effecament needed before able to prescribe)
patient education to prevent preterm labor
- Avoid long travels
- avoid extraneous activity (heavy liftin, hard physical work (mild exercise is good like walking)
- 18 months between pregnancies
- no smoking, alcohol, drugs
- reduce stress
- reduce sex if experiencing symptoms of pretem labor
if experiencing S&S of preterm labor, what to do
- stop what youre doing and rest for 1 hour
- empty bladder
- lie down on side
- drink water
- if contraction present, call provider and describe sensation
What is considered post term
beyond 42 weeks gestation
Issues that come with post term births
- Trauma secondary to macrosomia
- dystocia (shoulder dystocia)
- hemorrhage
- brachial plexus injury
- wasting due to placentla aging
- oligohydramnios due to amniotic fluid draining at 38 weeks
Nursing interventions for post term
- ensure accuracy of estimated date of birth
- continued monitoring of fetal status
- if meconium stain is present, report immediately
- either wait or induce birth, be sure to support and educate
nursing assessments for post term status
- daily kick counts
- non stress test 2x weekly
- weekly cervical examination
the stimulation of uterine contractions vie medical or surgical means before onset of spontaneous labor
Labor Induction
guidelines for labor induction
- only for a clear medical indication
- patients being induced should not be left unattended
- performed only when CPD is ruled out
- close monitoring of FHR and contraction pattern
Contraindications for labor induciton
- complete placenta previa
- abruptio placenta
- transverse fetal lie
- umbilical cord prolapse
- myomectomy
- vaginal bleed
- abnormal fhr
define cervical ripening
- cervix softens by breakdown of collagen fibrils
- cervix will become shortened and anterior, softened
Bishop scoring system score of 6 and score of 8
- score of 6 means cervical ripening method should be used prior to induction
- score of 8 usually means a successful vaginal birth
CAM methods of cervical ripening
- herbs
- hot baths, enemas
- sexual intercourse and breast stimulation
Mechanical methods cervical ripening
-hygroscopic dilators and osmotic dilators
surgical methods of cervical ripening
- stripping the membrane
- amniotomy (amniohook used to rupture membrane)
when using surgical cervical ripening, what to remember
- assess amniotic fluid for blood, meconium, or infection
- monitor FHR
Pharmacological methods of cervical ripening
- prostaglandin (can induce excessive contractions)
- Dinoprostone (cervidil)
- misoprostol (can cause uterine tetany, uterine rupture, and amniotic fluid embolism. contraindicated for women with uterine scars)
uterotonic agent used for both augmentation and induction of labor
Oxytocin
When to use oxytocin
women with low bishop score and after initiation of cervical ripening
does oxytocin cross the placenta
No
Nursing assessment for induction and augemntaiton
- assess fetal status and ability of fetus and client to withstand labor contractions
- evaluate cervical status, dilation, effacement, and station
- bishop score
Nurse interventions
- ensure consent, educate
- bishop score before proceeding
- pain management (reposition, nonpharmacological measures, medications
Vaginal birth after having at least one cesarean birth
vaginal birth after cesarean birth
contraindication for VBAC
- uterine incision
- myomectomy
- uterine scar that is not low-transverse cesarean scar
- contracted pelvis
- inadequate staff
- cant use cervical ripening agents
special focus for VBAC
- Consent
- documentation
- surveillance
- Readiness for emergency
fetal death that occurs after 20 weeks but before birth
Intrauterine fetal demise
grief accompanying the loss of a fetus proceeds which order
- accepting reality of loss
- getting over suffering
- adapting to new environment
- moving on
Nursing managements for IUFD
- mementos and pictures
- unlimited time with stillborn
- assist in funeral arrangements
obstetrical emergency that occurs when the cord precedes the fetus out
umbilical cord prolapse
umbilical cord prolapse is more common in
malpresentation
- growth restriction
- ruptured membrane with high fetal station
- hydramnios
- multiple gestation
Nursing management of cord prolapse
what positions?
- recognize fetal bradycardia and variable decelerations as early sign and call for help, stay with patient
- change position to sims, trendelberg or knee chest position
- do not replace the cord in terus
- monitor FHR, bed rest and oxygen if ordered.
in abruptio placenta, when to de caesarean and when to do vaginal birth
caesarean birth is done with partial abruption and viable fetus
vaginal is done with a complete abruption and fetal demise
tearing of uterus into abdominal cavity
uterine rupture
risks for uterine rupture
- uterine scars, prior cesarean birth
- prior rupture and trauma
- prior invasive molar pregnancies
- percreta and increta history
- malpresentation
- excessive uterine stimulation
- crocaine use
nursing assessment for uterine rupture
- fetal bradycardia and fetal distress
- abdominal pain
- vaginal bleed
- shock
nursing management for uterine rupture
- only 10 to 30 minutes are available before clinically significant fetal morbidity occurs
- urgent cesarean birth
- monitor vital signs and signs of shock
- foley catheter is placed
Amniotic fluid containing particles of debris (e.g., hair, skin, vernix, or meconium) enters the maternal circulation and obstructs the pulmonary vessels, causing respiratory distress and circulatory collapse
Amniotic fluid embolism
Nursing assessment for amniotic fluid embolism
- difficulty breathing
- hypotension, tachycardia
- cyanosis and hypoxia
- seizures
- DIC
Nursing management for amniotic fluid embolism
- oxygen (100%)
- IV and correct DIC (plasma)
- seizure precaution
- steroids to control inflammatory response
a volume of warmed, sterile, normal saline or Ringer lactate solution is introduced into the uterus transcervically through an intrauterine pressure catheter to increase the volume of fluid when oligohydramnios is present.
Amnioinfusion
Indication of Amnioinfusion
- severe variable decelerations, cord compression
- oligohydramnios
- PPROM
- Thick meconium fluid
Contraindications for Amnioinfusion
- vaginal bleed of unknown origin
- umbilical cord prolaps
- amnionitis, fetal distress
Nursing intervention for amnioinfusion
- if FHR does not improve
- what would you teach the patient
- Concent
- then vaginal exam
- warm infusion of fluid
- educate( remain in bedrest for the procedure)
- monitor vital signs, FHR, contractions
- if FHR does not improve, prep for cesarean birth
Why would forceps or suction be used
- apply traction to fetal head that will help in rotation
- prolonged second stage
- Distress FHR
- failure to rotate
- maternal heart disease,maternal fatigue
criteria to use forceps or vaccum
membrane rupture
cervix completely dilated
fetus is in vertex position and engaged
adequate maternal pelvic size
Ways to prevent the need for forceps and vaccum
- frequent reposition and ambulation
- frequent emptying bladder
- adequate hydration
surgical birth of the fetus through an incision in the abdomen and uterine wall and is the most commonly performed surgery in the United States
cesarean birth (classic vertical or low transverse)
indications of cesarean birth
- active genital herpes
- fetal macrosomia
- pelvic disproportion
- umbilical cord prolapse
- uterine scar or incision
- gestational hypertension, diabetes
- HIV
Nursing management for cesarean birth
- educate and support
- informed consent
- teach the use of incentive spirometer, deep breathing techniques, leg exercises, and splinting
- foley cath
For postop
- Assess vital signs and lochia flow every 15 minutes for the first hour, then every 30 minutes for the next hour, and then every 4 hours if stable
- check IV, LOC, bowel sounds
- perineal care
- early ambulation
Which forceps are used for breech
Pipers
Occurs when the uterus completely or partly turns inside out.
Uterine inversion (usually occur in 3rd stage of labor) replace ASAP
