L&B/1 Gestational Disorders & Disease Considerations in Labor

Question 1

1) Meconium stained amniotic fluid
2) Meconium Aspiration Syndrome (MAS)
3) Tx via antibiotics, amnioinfusion, fetal nasal suction immediately after birth

Answer 1

Chorioamnionitis is more likely to occur when meconium-stained amniotic fluid (MSAF) is present. Meconium may enhance the growth of bacteria in amniotic fluid by serving as a growth factor, inhibiting bacteriostatic properties of amniotic fluid. Many adverse neonatal outcomes related to MSAF result from Meconium Aspiration Syndrome (MAS). MSAF is associated with both maternal and newborn infections. Antibiotics may be an effective option to reduce such morbidity.

Question 2

HELLP Syndrome

Answer 2

HELLP syndrome is a group of symptoms that occur in pregnant women who have:

H – hemolysis (the breakdown of red blood cells)
EL – elevated liver enzymes
LP – low platelet count

Question 3

HELLP Syndrome: Risks

Answer 3

Many women have high blood pressure and are diagnosed with preeclampsia before they develop HELLP syndrome. In some cases, HELLP symptoms are the first warning of preeclampsia and the condition can be misdiagnosed

Question 4

HELLP Syndrome: When can it occur?

Answer 4

Most often HELLP develops before the pregnancy is 37 weeks along. Sometimes it develops in the week after the baby is born.

Question 5

HELLP Syndrome:
1) Tx? (2)
2)

Answer 5

1a) The main treatment is to deliver the baby as soon as possible, even if the baby is premature. Problems with the liver and other complications of HELLP syndrome can quickly get worse and be harmful to both the mother and child.
1b) Your doctor may induce labor by giving you drugs to start labor, or may perform a C-section.

You may also receive:

A blood transfusion if bleeding problems become severe
Corticosteroid medications to help the baby’s lungs develop faster
Medications to treat high blood pressure

Question 6

Disseminated Intravascular Cougulation (DIC)

What is it?

Answer 6

Disseminated intravascular coagulation (DIC) is a serious disorder in which the proteins that control blood clotting become over active.

Question 7

Disseminated Intravascular Cougulation (DIC)

1) As the disease progresses what happens?
2) Risk factors

Answer 7

1) Over time, the clotting proteins in your blood are consumed or “used up.” When this happens, you have a high risk of serious bleeding, even from a minor injury or without injury. You may also have bleeding that starts spontaneously (on its own). The disease can also cause healthy red blood cells to break up when they travel through the small vessels that are filled with clots.
2) Pregnancy complications (such as placenta that is left behind after delivery)

Question 8

Idiopathic thrombocytopenic purpura (ITP)

1) What is it?
2) Risk factors

Answer 8

1) Idiopathic thrombocytopenic purpura (ITP) is a bleeding disorder in which the immune system destroys platelets, which are necessary for normal blood clotting. Persons with the disease have too few platelets in the blood.

ITP is sometimes called immune thrombocytopenic purpura or simply, immune thrombocytopenia.

2) pregnancy (plus more)

Question 9

What is umbilical cord prolapse?

Answer 9

Umbilical cord prolapse is a complication that occurs prior to or during delivery of the baby. In a prolapse, the umbilical cord drops (prolapses) through the open cervix into the vagina ahead of the baby. The cord can then become trapped against the baby’s body during delivery. Umbilical cord prolapse occurs in approximately one in every 300 births.
(ClevelandClinic.org)

Question 10

What causes an umbilical cord prolapse?

Answer 10

The most common cause of an umbilical cord prolapse is a premature rupture of the membranes that contain the amniotic fluid. Other causes include:

Premature delivery of the baby
Delivering more than one baby per pregnancy (twins, triplets, etc.)
Excessive amniotic fluid
Breech delivery (the baby comes through the birth canal feet first)
An umbilical cord that is longer than usual

Question 11

What are the consequences of umbilical cord prolapse?

Answer 11

An umbilical cord prolapse presents a great danger to the fetus. During the delivery, the fetus can put stress on the cord. This can result in a loss of oxygen to the fetus, and may even result in a stillbirth.

Question 12

How is an umbilical cord prolapse detected?

Answer 12

The doctor can diagnose a prolapsed umbilical cord in several ways. During delivery, the doctor will use a fetal heart monitor to measure the baby’s heart rate. If the umbilical cord has prolapsed, the baby may have bradycardia (a heart rate of less than 120 beats per minute). The doctor can also conduct a pelvic examination and may see the prolapsed cord, or palpate (feel) the cord with his or her fingers.

Question 13

How is an umbilical cord prolapse managed?

Answer 13

How is an umbilical cord prolapse managed?
Because of the risk of lack of oxygen to the fetus, an umbilical cord prolapse must be dealt with immediately. If the doctor finds a prolapsed cord, he or she can move the fetus away from the cord in order to reduce the risk of oxygen loss.

In some cases, the baby will have to be delivered immediately by cesarean section. If the problem with the prolapsed cord can be solved immediately, there may be no permanent injury. However, the longer the delay, the greater the chance of problems (such as brain damage or death) for the baby.

Question 14

Dystocia or Dysfunctional labor
What is it?
(ATI)

Answer 14

Dystocia, or dysfunctional labor, is a difficult or abnormal labor related to the five powers of labor (powers, passenger, passageway, psyche, and position).
Atypical uterine contraction patterns prevent the normal process of labor.

These contractions can be hypotonic (weak, inefficient, or completely absent) or hypertonic (excessively frequent, uncoordinated, and of strong intensity with inadequate uterine relaxation) with failure to efface and dilate the cervix for the progression of labor.

Question 15

Dystocia or Dysfunctional labor
Risk Factors
(ATI)

Answer 15

Risk factors for dysfunctional labor

Short stature, overweight status
Age greater than 40 years
Uterine abnormalities
Pelvic soft tissue obstructions or pelvic contracture
Cephalopelvic disproportion (fetal head is larger than maternal pelvis) Fetal macrosomia
Fetal malpresentation, malposition
Multifetal pregnancy
Hypertonic or hypotonic uterus
Maternal fatigue, fear, or dehydration
Inappropriate timing of anesthesia or analgesics

Question 16

Dystocia or Dysfunctional labor
Assessment
(ATI)

Answer 16

Assessment
● Objective Data
Physical assessment findings
■ Note a lack of progress in dilatation, effacement, or fetal descent during labor.
☐ A hypotonic uterus is easily indentable, even at peak of contractions.
☐ A hypertonic uterus cannot be indented, even between contractions.
■ Observe the client as having ineffective pushing with no voluntary urge to bear
down.
☐ Persistent occiput posterior presentation is when the fetal occiput is directed toward the posterior maternal pelvis rather than the anterior pelvis.
☐ Persistent occiput posterior position prolongs labor and the client has a great deal of back pain as the fetus presses against the maternal sacrum.

Question 17

Dystocia or Dysfunctional labor
Diagnostic Procedures (5)

Answer 17

Diagnostic Procedures
■ Ultrasound
■ Amniotomy or stripping of membranes if not ruptured
■ Oxytocin (Pitocin) infusion
■ Vacuum-assisted birth
■ Cesarean birth

Question 18

Dystocia or Dysfunctional labor

Nursing Care

Answer 18

Nursing Care Dysfunctional Labor
◯ Assist with the application of a fetal scalp electrode and/or intrauterine pressure
catheter.
◯ Assist with an amniotomy (artificial rupture of membranes).
◯ Encourage the client to engage in regular voiding to empty her bladder.
◯ Encourage position changes to aid in fetal descent or to open up the pelvic outlet.
◯ Encourage ambulation to enhance the progression of labor
◯ Encourage hydrotherapy and other relaxation techniques to aid in the progression of labor
◯ Assist the mother into a beneficial position for pushing and coaching her about how to bear down with contractions.
◯ Prepare for a possible forceps-assisted, vacuum-assisted, or cesarean birth.
◯ Continue assessing FHR in response to labor.
■ The client should be positioned on her hands and knees to help the fetus to rotate from a posterior to anterior position.
■ Counterpressure should be applied with the fist or heel of the hand to the sacral area. This technique can help to alleviate discomfort.

Question 19

Dystocia or Dysfunctional labor

1) Medications (1)
2) Therapeutic intent (1)
3) Nursing Considerations (1)

Answer 19

1) ● Medications
Oxytocin (Pitocin)

2) ■ Therapeutic intent
☐ Used to augment labor and strengthen uterine contractions

3) ■ Nursing considerations
☐ Administer oxytocin if prescribed to augment labor. Oxytocin is not administered for hypertonic contractions.

Question 20

Dystocia or Dysfunctional labor

1) Nursing Care for Hypertonic Contractions (3)
2) Medications (1)
3) Client outcomes (1)

Answer 20

1) ● Nursing Care for Hypertonic Contractions
◯ Maintain hydration.
◯ Promote rest and relaxation and provide comfort measures between contractions.
◯ Place the client in a lateral position and provide oxygen by mask.

2) ● Medications
◯ Administer analgesics if prescribed (for rest from hypertonic contractions).

3) ● Client Outcomes
◯ The client will experience labor without complications or injury.

Question 21

Hypotonic contractions:

1) What are they?
2) How to Tx?

Answer 21

1) These contractions can be hypotonic (weak, inefficient, or completely absent)
2) Oxytocin (? check this)

Question 22

Hypertonic Contractions

1) What are they?
2) How to Tx?
3) DO NOT Tx with?

Administer analgesics if prescribed (for rest from hypertonic contractions).

Answer 22

1) These contractions can be hypertonic (excessively frequent, uncoordinated, and of strong intensity with inadequate uterine relaxation) with failure to efface and dilate the cervix for the progression of labor.
2) ?
3) Oxytocin is not administered for hypertonic contractions.

Question 23

What kind of labor would require these interventions?

• The client should be positioned on her hands and knees to help the fetus to rotate from a posterior to anterior position.
• Counterpressure should be applied with the fist or heel of the hand to the sacral area. This technique can help to alleviate discomfort.

Answer 23

Dystocia or Dysfunctional labor

ATI

Question 24

Umbilical Prolapse: Risk Factors

Answer 24

Rupture●of●amniotic●membranes
◯● It●is●necessary●to●check●FHR●immediately●following●rupture●of●membranes. Abnormal●fetal●presentation●is●any●presentation●other●than●vertex●(occiput●is●the●
presenting●part)●is●abnormal.
Transverse●lie
◯● The●presenting●part●is●high●in●the●pelvis●and●not●yet●engaged●when●the●membranes● rupture.●This●leaves●room●for●the●cord●to●descend●and●precede●the●presenting●part.
Small-for-gestational-age●newborn Unusually●long●umbilical●cord Multifetal●pregnancy
Cephalopelvic disproportion
◯ This can result in a loose fit between fetal presenting part and maternal pelvis, leaving
room for the cord to slip down.
● Placenta previa
● Intrauterine tumor preventing the presenting part from engaging.
● Hydramnios or polyhydramnios
◯ Hydramnios or polyhydramnios is excessive amniotic fluid of more than 2,000 mL. ● Oligohydramnios
◯ Oligohydramnios is a decreased amount of amniotic fluid of less than 300 mL.

Question 25

Umbilical Prolapse: Assessment
Subjective (1)
Objective (3)

Answer 25

Subjective Data
◯ The client states that she can feel something coming through her vagina.
● Objective Data
◯ Physical assessment findings
■ Visualization or palpation of the umbilical cord protruding from the introitus
■ Assessment that shows FHR to have variable or prolonged decelerations
■ Extreme increase in fetal activity that occurs and then ceases; suggestive of severe fetal hypoxia

Question 26

What condition has this finding?

Assessment that shows FHR to have variable or prolonged decelerations

Answer 26

Umbilical Prolapse

ATI

Question 27

Severe fetal hypoxia can be indicated by (Fetal Activity)

Answer 27

Extreme increase in fetal activity that occurs and then ceases; suggestive of severe fetal hypoxia.
e.g. Umbilical Prolapse

Question 28

Umbilical Prolapse: Collaborative/ Nursing Care (10)

Answer 28

Nursing Care
■ Call for assistance immediately.
■ Notify the primary care provider of the prolapsed cord.
■ Position the client’s hips higher than her head.
■ Reposition the client in a knee-chest, Trendelenburg, or a side-lying position with a rolled towel under the client’s right or left hip to relieve pressure on the cord.
■ Use a sterile-gloved hand, insert two fingers into the vagina, and apply finger pressure on either side of the cord to the fetal presenting part to elevate it off of the cord.
■ Apply a sterile saline-soaked towel to the cord to prevent drying and to maintain blood flow if it is protruding from the vaginal introitus.
■ Closely monitor the FHR with an electronic fetal monitor for variable decelerations, which are indicative of fetal asphyxia and hypoxia from cord compression.
Administer oxygen at 8 to 10 L via a face mask. This will improve fetal oxygenation.
■ Initiate IV infusion or administer a bolus.
■ Prepare the client for a cesarean birth if other measures fail.
■ Inform and educate the client and her support person about the interventions.

(ATI)