Intrapartum Complications: Sherpath

Question 1

Types of Dysfunction Labor?

Answer 1

Prolonged Labor

Precipitate Labor

Question 2

Precipitate labor

Answer 2

occurs when delivery occurs within 3 hours of labor onset. Precipitate labor is not the same as a precipitate birth. A precipitate birth occurs when the infant is expelled more rapidly than usual after a labor of any length, in or out of the hospital or birth center and with or without a trained professional present to assist. Precipitate labor may result in a precipitate birth, but this is not always the case. Unusually brief labor often leads to a rapid delivery, while some women may have a brief labor resulting in a delivery that takes place at an expected pace.

Question 3

Prolonged Labor

Answer 3

the result of problems with one or more stages in the progression of labor.

Question 4

Dystocia

Answer 4

pathologic or difficult labor that may be caused by an obstruction or constriction of the birth passage or abnormal size, shape, position, or condition of the fetus.

Question 5

Risks for prolonged labor

Answer 5

Is a nullipara
Has a cervix that is not sufficiently dilated
Has weaker than usual uterine muscles
Has advanced maternal age
Has received sedatives or analgesics

Question 6

Risks for Precipitate labor

Answer 6

Efficient and strong uterine contractions
An extremely compliant birth canal
History of rapid labor
Maternal cocaine use (also may be associated with abruptio placentae in any labor)

Question 7

Prolonged Labor: Maternal Risks

Answer 7

Infection, intrapartum or postpartum
Exhaustion
Increased anxiety and fear during a subsequent labor
Higher risk for cesarean delivery

Question 8

Prolonged Labor: Fetal Risks

Answer 8

Exposure to thick meconium

Hypoxia

Question 9

Prolonged Labor: Neonatal Risks

Answer 9

Infection, which may be severe or fatal
Increased risk for requiring neonatal intensive care admission
Low Apgar scores (abnormal skin color, pulse, reflexes, activity, respiratory effort)

Question 10

Precipitate Labor: Neonatal Risks

Answer 10

Trauma, such as intracranial hemorrhage or nerve damage

Infection, if birth takes place in a nonsterile setting

Question 11

Precipitate Labor: Fetal Risks

Answer 11

Hypoxia

Aspiration of amniotic fluid

Question 12

Precipitate Labor: Maternal Risks

Answer 12

Trauma such as uterine rupture, cervical lacerations, or hematoma of the vagina or vulva
Increased risk of delivery outside a hospital or birthing center
Anxiety or emotional trauma
Postpartum hemorrhage
Retained placenta

Question 13

Types of Dysfunction: Hypotonic: Characteristics

Answer 13

Also known as secondary arrest.
Usually occurs during the active phase of labor.
Contractions are coordinated but too weak to be effective.
Fundus easily can be indented with fingertip pressure.

Question 14

Types of Dysfunction: Hypertonic: Characteristics

Answer 14

Usually occurs during the latent phase of labor.
Uncoordinated, erratic contractions that are powerful but ineffective.
Uterine blood flow is reduced by high muscle tone between contractions.

Question 15

Hypotonic Implications

Answer 15

Maternal fatigue and frustration

Increased risk of fetal complications

Question 16

Hypertonic Implications

Answer 16

Pain
Fetal hypoxia
Increased risk for abruptio placentae (premature separation of the normally implanted placenta)

Question 17

Causes of ineffective maternal pushing

Answer 17

Incorrect pushing techniques or inefficient pushing positions
Fear of injury because of pain and tearing sensations felt by the mother when she pushes
Minimal or absent urge to push
Maternal exhaustion
Regional block analgesia that may suppress the patient’s urge to push
Psychologic unreadiness to “let go” of the fetus

Question 18

Pelvic Problems

Answer 18

A small (contracted) or abnormally shaped pelvis can slow labor and obstruct fetal passage. The patient may experience poor contractions, slow dilation, slow fetal descent, and a long labor. The danger of uterine rupture (a tear in the uterine wall) is greater with thinning of the lower uterine segment, especially if contractions remain strong.

Question 19

Maternal Soft tissue obstruction

Answer 19

During labor, a full bladder is a common soft tissue obstruction. Bladder distention reduces available space in the pelvis and intensifies maternal discomfort. The patient should be assessed for bladder distention regularly and encouraged to void every 1 to 2 hours. Catheterization may be needed if she cannot urinate or if she receives regional block analgesia.

Question 20

Psychological Problems

Answer 20

Increasing glucose consumption, which reduces the energy available to the contracting uterus
Releasing catecholamines, which interfere with uterine contractility and reduce the placenta’s blood supply
Reducing the effectiveness of labor contractions and maternal pushing efforts, which must now overcome the resistance of tense abdominal and pelvic muscles
Increasing pain perception and reducing pain tolerance

Question 21

Fetal Complications

Answer 21

The macrosomic infant weighs more than 4000 g (8 lb, 13 oz) at birth, although some authorities define it as a weight of 4500 g (9 lb, 15 oz) or greater. The head or shoulders may not be able to adapt to the pelvis, known as cephalopelvic, or fetopelvic, disproportion. In addition, distention of the uterus by a large fetus can reduce the strength of contractions both during and after delivery.

Fetal presentation or position as the fetus descends through the pelvis is another important factor in terms of fetal size and maternal pelvic size and shape.

Question 22

Shoulder Dystocia

Answer 22

Delayed or difficult delivery of the shoulders can occur if the shoulders become impacted above the maternal symphysis pubis. As soon as the head is delivered, it retracts against the perineum, much like a turtle’s head drawing into its shell (“turtle sign”).

Shoulder dystocia is unpredictable and can occur with a baby of any weight. It requires urgent intervention by the health care provider because the umbilical cord is compressed, but compression of the fetal chest within the vagina prevents respiration.

Nursing interventions to help rotate the fetal head and promote descent may help prevent shoulder dystocia.

Question 23

Rotation Abnormalities

Answer 23

The occiput posterior (OP) or occiput transverse (OT) fetal position can contribute to dysfunctional labor and possible shoulder dystocia. These positions delay fetal descent and other mechanisms of labor (cardinal movements). Most fetuses in the OP position during early labor rotate spontaneously to an occiput anterior position, promoting normal extension and expulsion of the head. Some patients with a large pelvis relative to fetal size may be able to deliver their infants in the OP position.

Labor is usually longer and more uncomfortable when the fetus is in the OP or OT position, causing intense lower back or leg pain that is poorly relieved with analgesics. “Back labor” aptly describes the sensations a patient feels when her fetus is in the OP position.

Question 24

Deflexion Abnormalities

Answer 24

The poorly flexed fetal head presents a larger diameter to the pelvis than if the head were flexed with the chin on the chest.

In the face-up presentation, the head diameter is similar to that of the vertex presentation, but the maternal pelvis can be traversed only if the fetal chin (mentum) is anterior.

Question 25

Breech presentation

Answer 25

Fetal injury
A prolapsed umbilical cord
Low birth weight
Fetal anomalies, such as hydrocephalus
Complications caused by placenta previa (implantation of the placenta in the lower uterus, at or very near the cervical os)
Complications caused by cesarean delivery

Question 26

Fetal Anomalies

Answer 26

Fetal anomalies, such as hydrocephalus or a large fetal tumor, may prevent normal descent of the fetus. Abnormal presentations, such as breech or transverse lie, are also associated with fetal anomalies. These abnormalities may be discovered by ultrasound examination before labor. A cesarean delivery is scheduled unless presentation can be corrected.

Question 27

Assessment for Intrauterine Infection

Answer 27

Assess the fetal heart rate (FHR) and maternal vital signs for evidence of infection
FHR: Persistent fetal tachycardia (more than 160 beats/min for more than 10 minutes) is often an early sign of intrauterine infection and often occurs with maternal fever.
Maternal vital signs: temperature, pulse, respiration, and blood pressure. Maternal vital signs are usually displayed on the bedside monitor.
Assess amniotic fluid for a normal clear color and mild odor; small flecks of white vernix are normal.

Question 28

Signs of Intrapartum Infection

Answer 28

Fetal tachycardia (>160 beats/min for 10 minutes or longer)
Maternal fever (≥38° C [100.4° F])
Foul- or strong-smelling amniotic fluid
Cloudy or yellow amniotic fluid

Question 29

Reducing the Risk for Infection

Answer 29

Follow standard precautions by using gloves and other protective wear to prevent contact with potentially infectious secretions
Limit vaginal examinations to reduce transmission of vaginal organisms into the uterine cavity
Maintain aseptic technique during essential vaginal examinations
Keep underpads as dry as possible to reduce the moist, warm environment that favors bacterial growth
Periodically clean excessive secretions from the vaginal area in a front-to-back motion to limit fecal contamination and promote the mother’s comfort

Question 30

Maternal Exhaustion

Answer 30

Verbal expression of tiredness, fatigue, or exhaustion
Verbal expression of frustration with a prolonged, unproductive labor (“I can’t go on any longer. Why doesn’t the doctor just take the baby?”)
Ineffectiveness of or inability to use coping techniques (e.g., patterned breathing) that she previously used effectively
Increases or decreases in pulse, respiration, and blood pressure

Question 31

Conserving Maternal Energy

Answer 31

Reduce factors that interfere with the patient’s ability to relax.
Reduce light and noise.
Silence the electronic fetal monitor (EFM) if she prefers.
Maintain a comfortable maternal body temperature with blankets or a fan.
Offer the patient a warm shower or bath.
Support the patient with pillows to reduce muscle strain and added fatigue.
Help the patient change positions regularly (about every 30 minutes) to reduce muscle tension from constant pressure.
Administer intravenous (IV) fluids at the rate ordered to maintain fluid and electrolyte balances, and occasionally, to provide glucose.
Assess intake and output to identify dehydration, which may accompany prolonged labor and may cause maternal fever, often preceded by fetal tachycardia.

Question 32

Promoting Coping

Answer 32

When medical therapy or position changes are used to enhance labor, explain their purposes and expected benefits.
Encourage the patient to visualize her baby passing downward smoothly through her pelvis as a result of her efforts.
Provide the patient with mental images that allow her to “see” herself giving birth.
Encourage the patient to use skills, such as breathing techniques, and praise her when she does so.
Motivate the patient by telling her she is making progress, if this is true.

Question 33

Multifetal Pregnancy

Answer 33

During labor, each fetus’s FHR is monitored separately. The patient should remain in bed, in a lateral position, to promote placental blood flow. Assessment of each FHR continues until delivery. The nurse observes for signs of hypotonic dysfunction throughout labor and for uterine atony, often related to the overdistended uterus, after delivery.

Whether delivery is vaginal or cesarean, the neonatal care staff must be prepared for the care and possible resuscitation of multiple infants. Cord clamps, bulb syringes, radiant warmers, and resuscitation equipment must be prepared for each infant. A neonatal care team of nurses, a neonatal nurse practitioner, and a pediatrician or a neonatologist should be available for each infant, with another nurse caring for the mother.

Question 34

A patient in prolonged labor expresses frustration when changing positions and states, “I didn’t have to move around so much last time I had a baby.” Which nursing intervention is most appropriate for this patient?

Answer 34

Inform the patient that repositioning is necessary to promote progress of labor

Question 35

A patient whose labor was complicated by shoulder dystocia reports that one of her infant’s arms is “floppy.” The nurse examines the infant and finds flaccid muscle tone on one side. Which is the most appropriate nursing education for this patient?

Answer 35

“Your health care provider will likely recommend physical therapy to treat this injury.”

Question 36

The antepartum nurse is caring for a patient carrying twins. While educating the patient about what to expect during labor, the patient states, “I thought all twins were delivered by C-section.” Which response from the nurse is appropriate?

Answer 36

“There is a very realistic possibility that the twins may be delivered vaginally.”

Question 37

Risk Factors for prolapsed umbilical cord

Answer 37

A fetus that remains at a high station
A very small fetus
Breech presentation (The footling breech presentation is more likely to be complicated by a prolapsed cord because the feet and legs are small and do not fill the pelvis well.)
Transverse lie
Hydramnios (excess accumulation of amniotic fluid), often associated with abnormal presentations (The unusually large amount of fluid exerts more pressure to push the cord out.)

Question 38

Manifestations of prolapsed umbilical cord

Answer 38

Prolapse may be complete, with the cord visible at the vaginal opening. A prolapsed cord may not be visible but may be palpated on vaginal examination as it pulsates synchronously with the fetal heart. Introduction of a speculum may allow visualization of the cord. An occult prolapse of the cord is one in which the cord slips alongside the fetal head or shoulders. The prolapse cannot be palpated or seen but is suspected because of changes in the FHR, such as bradycardia or variable decelerations.

Question 39

Therapeutic Management of Prolapsed Umbilical Cord

Answer 39

Summon help and have others call the health care provider
Prepare for delivery and have the care team prepare for neonatal resuscitation
The nurse does not leave patient, nor does he or she remove his or her hands from the vaginal canal, but continues to apply pressure to the fetal head to keep pressure off the cord as much as possible.
Regardless of the severity of the prolapse, prompt delivery of the viable fetus remains the priority. A tocolytic drug with a rapid onset of action may be ordered to cause relaxation of the uterus, thus inhibiting contractions, increasing placental blood flow, and reducing intermittent pressure on the pelvis and cord.

Question 40

Nursing Care for Patients with Umbilical Cord Prolapse

Answer 40

Avoid or minimize manual palpation or handling of the cord because vasospasm of or trauma to cord vessels may further reduce umbilical blood flow to and from the fetus
Vigilant assessment of FHR is necessary to determine whether interventions are effective.
If cesarean delivery is delayed, application of warm saline-solution-moistened towels will slow cooling and drying of the cord that protrudes from the vagina. Cooling causes vasospasm within the cord.

Question 41

A nurse is caring for a laboring patient with hydramnios. After the patient’s membranes rupture, the fetal heart rate is 100 beats/min for longer than 90 seconds. The nurse suspects cord compression. Which action should the nurse perform first?

Answer 41

Reposition the patient on her hands and knees with the head lowered

Question 42

The nurse is preparing a patient for cesarean delivery because of umbilical cord prolapse. Which is the nurse’s most appropriate action?

Answer 42

Monitor fetal heart rate (FHR) continuously

Question 43

While performing a vaginal examination on a patient in active labor, which finding would prompt the nurse to call the health care provider immediately?

Answer 43

Palpable pulse that beats synchronously with fetal heart monitor

Question 44

The nurse is caring for a patient experiencing prolonged labor. The patient reports intense back pain that radiates down to the leg. Which is the appropriate nursing intervention for this patient?

Answer 44

Reposition the patient onto her hands and knees.
Back pain that radiates to the leg is also called “back labor”, and it is often a sign of a fetus in the occiput posterior (OP) position. Repositioning the patient onto her hands and knees helps facilitate fetal rotation.

Question 45

A patient in labor is in visible distress and reports fear of pushing too hard and “tearing something.” Which response from the nurse is appropriate?

Answer 45

“The team can’t guarantee that you won’t have some tearing, but your body will stretch to accommodate the baby.”

It is not certain that stretching will prevent tearing, but stretching is sure to occur and will greatly reduce the tearing that would occur if the patient’s perineal tissues could not stretch.

Question 46

The nurse is caring for a patient who has just been admitted to the labor and delivery unit. The patient suddenly grips the side rails and yells loudly, and the nurse can see the infant rapidly crowning. Which action should the nurse take first?

Answer 46

Reposition the patient to a side-lying position.
A patient experiencing precipitate birth should remain in a side-lying position to slow the descent of the infant and prevent perineal lacerations. Repositioning the patient to a side-lying position is the first action the nurse should take because this is an independent nursing action that directly addresses the patient’s priority health problem. This intervention can be performed rapidly, ensuring that other aspects of care are not delayed.

Question 47

The labor and delivery nurse is monitoring a laboring patient and notes the presence of variable decelerations on the fetal monitor tracing. Which finding should the nurse expect based on this observation?

Answer 47

Umbilical cord compression

Variable decelerations present on a fetal heart monitor suggest umbilical cord compression.

Question 48

While waiting for a cesarean delivery because of cord prolapse, a patient in the Trendelenburg position reports discomfort and asks for her head to be lifted up. The nurse offers to reposition her onto her side with pillows supporting her hips. Which is the nursing rationale for this action?

Answer 48

Pillows maintain elevation of the hips.
Using pillows to elevate the hips in a side-lying position helps maintain fetal oxygenation by relieving pressure on the umbilical cord.

Question 49

The nurse is caring for a patient in labor and has identified a severe deceleration in fetal heart rate. The health care provider has subsequently diagnosed a cord prolapse. Which actions should the nurse perform?

Answer 49

Continue assessing fetal heart rate.
Assessing fetal heart rate allows the nurse to ensure that pressure on the cord is minimized.
Correct

Assess the patient’s level of anxiety.
The nurse should assess the patient’s anxiety and provide education to address the patient’s concerns.
Correct

Ensure that the patient’s hips are elevated above the head.
Ensuring that the patient’s hips are elevated above the head helps maintain relief of cord compression and ensure fetal oxygenation

Evaluate the family’s understanding of the need for immediate delivery.
The nurse should include the family in education as much as possible and evaluate the family’s understanding of the patient’s condition.