Chapter 21:Management of Labor and Birth at Risk

Question 1

Umbilical Cord Prolaps

Answer 1

Positions used for a prolapsed cord: trendelenburg, knee chest position.
Steps used by the nurse for prolapsed cord: uses a sterile glove and places hand into the vagina and hold the presenting part off the umbilical cord until delivery
Risk for the fetus: fetus is oxygen deprived and will die if cord compression is not relieved

Question 2

Hypotonic uterine dysfunction

Answer 2

happens during active labor (dilation >4cm) contractions are poor in quality. Lack sufficient intensity to dilate.

Question 3

Fetopelvic disproportion

Answer 3

with lg fetus: a complication associated with dystocia r/t excessive fetal size.
Nursing: asses for inability of fetus to descend, anticipate need for vacuum and forceps assisted births, plan for a C-section

Question 4

dystocia

Answer 4

Dystocia is an abnormal difficult labor. Can’t be diagnosed until pt is in active labor (after 4cm), Lack of progressive cervical dilation, lack of descent of the head, or both. Causes: shoulder dystocia, breech, hydrocephalus more risks on pg 729

Question 5

hypertonic uterine dysfunction

Answer 5

uterus does not fully relax between contractions. Moms progress 2-3 cm prolonged latent phase, and don’t dilate like they should.
Dx: Characteristic hypertonicity of the contraction and the lack of labor progress.

Nursing: bed rest, sedation to promote relaxation and reduce pain, evaluate fetal tolerance to labor pattern, asses for signs of maternal infection, rule out disproportion and fetal malpresentation, epidural or IV analgesics, assist with amniotomy to augment labor, explain to woman/family about dysfunctional pattern, plan for C-section.

Question 6

Placental abruption

Answer 6

: is the premature separation of the placenta.
Risk factors: preeclampsia, gestational hypertension, seizure activity, uterine rupture, trauma, smoking, cocaine use, coagulation defects, previous hx of abruption, domestic violence, placental pathology.
Nursing: maintain cardio status of mom and developing a plan to deliver quickly.
Gestational hypertension: B/P higher than 140/90 on two separate occasion during pregnancy and six hours apart after 20 wks. gestation.
Seizure activity and Tx: Mother with severe preeclampsia it at risk for seizure activity, Tx given is parenteral magnesium sulfate.

Question 7

hypotonic contractions

Answer 7

Contractions relax too much
Major risks: hemorrhage after giving birth b/c uterus can’t contract.
When does it occur? During active labor
Meds used in L&D: oxytocin
What do contractions appear like on the strip? Infrequent and briefer.

Question 8

hypertonic contractions

Answer 8

Uterus never fully relaxes
Contraction pattern: ineffectual, erratic, uncoordinated,
State of the uterus: portion of the uterus is involved.
What is compromised? Placental perfusion

Question 9

Occiput posterior position

Answer 9

Poor uterine contractions, provide pain management, and provide a comfortable environment as well as relaxation and comfort for mom.

Question 10

Forceps and Vacuum

Answer 10

Forceps: stainless steel instruments that apply traction to the fetal head
Vacuum assisted birth: cup shaped instrument attached to a suction cup that is placed on the occiput of the fetal head.
Potential newborn traumas from forceps and vacuum assisted birth; cephalhematoma, caput succedaneum
Nursing responsibility for procedure: Reassure mom that NB head or face will have red marks that will go away within 2-3 days w/o Tx. Alerts staff to observe for any bleeding or infection r/t genital lacerations.

Question 11

Cervidil

Answer 11

Dinoprostone (Cervidil; insert; Prepidil gel) Provide emotional support, pain meds prn, asses degree of effacement and dilation, Headache, n/v, diarrhea monitor uterine contractions, v/s and FHR

Question 12

cytotech

Answer 12

Misoprostol (Cytotec) Instruct client about purpose and possible adverse effects of med, ensure informed consent is signed n/v, diarrhea, uterine hyperstimulation, category II and II FHR patterns Assess v/s, FHR, Initiate oxytocin for labor induction 4hrs after last dose was given.

Question 13

Oxytocin

Answer 13

Oxytocin (Pitocin) Admin IV infusion via pump, determine frequency, duration, and strength of contractions Hyper stimulation of the uterus, impaired uterine blood flow leading to fetal hypoxia, rapid labor, water intoxication, headache, vomiting, hypotension, I&O, water intoxication, notify Dr of uterine hypertonicity or abnormal FHR

: Oxytocin has an antidiuretic effect that decreases urine flow leading to water intoxication.
How to administer oxytocin IV: via IV infusion pump piggybacked to the main IV line at the port most proximal to the insertion site.

Question 14

Uterine rupture

Answer 14

tearing of the uterus at the site of a previous scar into the abdominal cavity. Fetal distress, acute and continuous abdominal pain, vaginal bleeding, hematuria, irregular abdominal wall contour, loss of station in the fetal presenting part, and hypovolemic shock.
Nursing: monitor v/s, observe for tachycardia and hypotension, assist to prepare pt for a C-section, insert catheter, Ensure pt knows what is going on and remain calm for the pt.
Pt hx of substance abuse: crack cocaine use
Drugs known to abort fetus: Misoprostol (Cytotec)

Question 15

VBAC

Answer 15

Contraindications: a prior classic uterine incision, prior transfundal uterine Sx (Myomectomy), uterine scar or other transverse C-section scar, contracted pelvis, inadequate staff for an emergency Sx.
Consent: Fully informed consent is needed for a woman who wants a VBAC.
Role of nurse with VBAC: Inform pt of the risks and benefits of a VBAC, documentation, surveillance, and readiness for emergency. (756)

Question 16

Amnioinfusion

Answer 16

Warmed NaCl or LR is introduced into the uterus through IUPC Purpose: to increase fluid volume when oligohydramnios is present, to release cord compression, postmaturity or ROM, and thick meconium fluid
Contraindications: vaginal bleeding, umbilical cord prolapse, amnionitis, uterine hypertonicity, and severe fetal distress.
Risk: overdistention of the uterus
Pre-procedure pt teaching: Explain need for the procedure, mother to be on bed rest, prepare for a C-section if FHR does not improve.

Question 17

Cervical Ripening

Answer 17

: a process by which the cervix softens via breakdown of collagen fibrils.
What is considered a ripe cervix? The cervix is shortened, centered (anterior), softened, and partially dilated
Scoring system: the Bishop score; score over 8 is a successful vaginal birth, Bishop score of less than 6 need meds to ripen the cervix.
Drugs used how and why: (drugs on chart 21.2) they are used to ripen the cervix or induce labor; given intravaginally or po.

Question 18

Magnesium Sulfate

Answer 18

reduces the muscles ability to contract (tocolytic therapy)
Actions used for:
preterm labor: arrest uterine contractions for preterm labor
preeclampsia: tx of seizures in preeclampsia pts
Nursing implications: Admin IV w/ a loading dose of 4-6g over 15-30 min, asses v/s and deep tendon reflexes, LOC, I&O, FHR, RR, asses for mg toxicity: decreased LOC, depressed respirations, DTR’s, slurred speech, weakness. Ca gluconate reverses toxicity.

Question 19

Post term labor

Answer 19

: term pregnancy lasting 38-42 wks.
Nursing assessment for accurate gestational dates: determine estimated due date, date of LMP, and ultrasound
Antepartum assessment: daily fetal movements, nonstress tests twice a wk, amniotic fluid assessments, and weekly cervical exams to evaluate for ripening.
Nursing: determine plan to deliver the baby then labor induction is initiated or if mom want to wait then fetal surveillance is necessary.
Care for a intra-partum period: asses monitor FHR, hydration status, placental perfusion, ROM asses fluid, prepare for prevention of meconium aspiration.

Question 20

C section

Answer 20

(mother and as a couple of the infant) asses v/v q15min for first hr., then every 4 hrs. if stable, assist and instruct with perineal care, inspect abdominal dressing, asses LOC, check for abdominal distention, safety precautions.
Nursing responsibilities: focus is on the women, and family, provide education and minimize separation of the mom, father and NB, provide couple w/ a positive birth experience.