L&D III Flashcards
Exam 2
What is the indication for external cephalic version?
Breech, shoulder, or oblique presentation
What is the indication for internal version?
Position of second twin in a vaginal birth
What are the contraindications for vaginal birth?
Uterine malformations, Previous cesarean birth, Placenta abnormalities, Third trimester bleeding, Cephalopelvic disproportion, Multifetal gestation, Oligohydramnios, Intrauterine growth restriction, Uteroplacental insufficiency, Engagement of fetal head into the pelvis
Are changes to fetal heart rate common during versions?
Yes
What are some serious risks to the fetus during versions?
Umbilical cord entanglement, fetal hypoxia, abruptio placentae
Can maternal sensitization to fetal blood type occur during versions?
Yes
What is external cephalic version?
Turning the baby from a breech position to a head-down position
Need to check:
Nonstress test (NST) to
bpp –
Determine gestational age beyond 37 weeks
Administer tocolytic drugs
Use ultrasound to guide manipulations Rho(D) immune globulin (RhoGAM) given
What is a nonstress test (NST) used for?
Evaluate fetal well-being
What is a bpp used for?
Determine if the baby is able to do the turn
Why is gestational age beyond 37 weeks important?
Determining if it is safe to perform external cephalic version
What is a tocolytic drug used for?
Relax the uterus
What is the role of ultrasound in external cephalic version?
Guide manipulations
What are some maternal indications for operative vaginal birth?
Exhaustion, inability to push effectively, infection, cardiac or pulmonary disease
What are some fetal indications for operative vaginal birth?
Failure of presenting part to descend in the pelvis, partial separation of the placenta, non-reassuring FHR patterns
What is the desired station for the baby for operative vaginal births?
Zero station
What is an operative vaginal birth?
Assisted delivery using instruments
What are the instruments used in operative vaginal birth?
Forceps and vacuum extractor
What are the contraindications for forceps or vacuum extraction?
Severe fetal compromise, acute maternal conditions, high fetal station, cephalopelvic disproportion
What are the risks of forceps and vacuum extraction?
Trauma to maternal and fetal tissues
What are the potential maternal complications of forceps and vacuum extraction?
Laceration and hematoma of the vagina, pelvic floor disorders, anal sphincter disruption, infection
What are the potential infant complications of forceps and vacuum extraction?
Ecchymoses, facial and scalp lacerations and abrasions, facial nerve surgery, cephalohematoma, subgaleal hemorrhage, intracranial hemorrhage, scalp edema
What is the technique used in forceps delivery?
Locking blades applied to fetal head
What is the technique used in vacuum extraction?
Cup attached to fetal head and traction applied
What nursing consideration should be observed for the mother after an operative vaginal birth?
Observe mother for trauma after birth
What is a sign of potential complications in the mother after an operative vaginal birth?
Bright red bleeding with firm fundus
What nursing consideration should be observed for the neonate after an operative vaginal birth?
Observe neonate for trauma after birth
What is a potential sign of trauma in the neonate after an operative vaginal birth?
Facial asymmetry
What are two different ways a tear can occur during childbirth?
Slanted or cut down
What are the indications for episiotomy during childbirth?
Shoulder dystocia, Vacuum or forceps-assisted births, Face presentation, Breech delivery, Macrosomic fetus
What are the risks associated with tears during childbirth?
Infection, Perineal pain, Extensive tearing (3rd or 4th degree)
What methods to promote gradual stretching of the perineum during the second stage of labor?
Perineal massage and ice packs
When should pushing during the second stage of labor be delayed until?
Until the urge is felt
What should be done during pushing during the second stage of labor?
Push with an open glottis
What complications should be observed for after childbirth?
Hematoma and edema
When is a cesarean birth necessary?
When complications make vaginal delivery unsafe or not possible.
What are some common reasons for a cesarean birth?
Dystocia
Cephalopelvic disproportion
Hypertension
Maternal diseases
Active genital herpes
Previous uterine surgical procedures
Persistent indeterminate or abnormal FHR patterns
Prolapsed umbilical cord
Fetal malpresentations
Hemorrhagic conditions
What is the purpose of preparation for a Cesarean birth?
Laboratory studies
Anesthesia
Time-out
Fetal surveillance
Prophylactic antibiotics
Skin prep
Foley catheter
What are the types of incisions used in Cesarean birth?
Low transverse, low vertical, classical
Which type of incision is associated with a better outcome for TOLAC?
Low transverse
Does the risk of Cesarean birth increase with the number of previous c-sections?
Yes
What is the recommended practice for internal incision during a cesarean section?
Low transverse
Would a low lying placenta previa be a reason to opt for a classical incision?
yes
If a woman has previously had a cesarean section, what type of incision is most likely to be repeated?
The same cut
What are some nursing considerations for Cesarean birth?
Emotional support, teaching, postoperative care
What is labor dystocia?
Failure to progress
What is tachysystole?
More than 5 contractions in ten minutes
What are abnormal presentations or positions?
OP (baby looking up) or OT (baby transverse)
What is CPD?
when a baby’s head is too large to fit through the mother’s pelvis
What are the problems with the passenger?
Multi-fetal pregnancy or fetal anomalies
What soft tissue and skeleton obstruction can contribute to dysfunctional labor?
Bladder and pelvis shape
What are some psychological problems that can occur in dysfunctional labor?
Pain, fear, lack of privacy, anxiety, etc.
How is abnormal labor duration defined?
Prolonged - longer than 1.2-1.5 cm/hr of cervical dilation in active phase and/or 1-2 cm descent into cervix/vaginal canal
What is the higher risk associated with prolonged labor?
Infection
What is precipitatous labor?
Occurs within 3 hrs of onset with or without a provider
What is precipatous birth?
No provider present
What is considered prolonged pregnancy?
Longer than 42 weeks
What are the complications associated with prolonged pregnancy?
Insufficient placental exchange, Oligohydramnios, Cord and oxygen problems, Meconium aspiration, Large baby, Increased risk of CPD
What is the therapeutic management for prolonged pregnancy?
Determine gestational age, Determine fetal status, Induce
What are the concerns for a mom who comes in without prenatal care?
Increased risk for complications
What are intrapartum emergencies?
Emergencies that occur during labor and delivery
What is umbilical cord prolapse?
When the umbilical cord slips through the cervix ahead of the baby
What is placental abruption?
Premature separation of the placenta from the uterine wall
What is placenta accreta?
Implanted into the uterine wall or too deep in wall
What is placenta increta?
Chorionic villi invade the myometrium
What is placenta percreta?
Perforation through uterine musculature and onto organs
How much blood loss would be considered abnormal for the mother?
5 L
Replace blood and do a type and screen. Blood products for replacement should be available, and two large-bore IV lines should be started for replacement of fluid if indicated.
What is uterine inversion?
Uterus turning inside out
What causes uterine inversion?
Delivery of the placenta
How is uterine inversion managed?
Manual replacement, surgical intervention
What is a risk factor for fundal inversion?
Pulling too hard or anything in abdomen that has extra pressure or pushing on the fundus
What are some causes of fundal inversion?
Excessive traction on cord, fundal pressure during birth, fundal pressure on incompletely contracted uterus after birth, increased intraabdominal pressure, abnormal adherent placenta, congenital weakness of uterine wall, fundal placenta implantation
What are some signs and symptoms of fundal inversion?
Absent or depressed fundal area, interior uterus seen through cervix or protruding in vagina, massive hemorrhage, shock, severe pain
What is the therapeutic management for uterine inversion?
Quick identification, provider replacement of uterus through the vagina or surgical replacement
What are the nursing considerations for uterine inversion?
Maintain blood volume, Frequent fundal assessments, Observe vital signs and oxygen saturation, Monitor for shock/cardiac dysrhythmias, Foley catheter, intake and output, NPO until stable
What is uterine rupture?
Separation through the thickness of the uterine wall
When can uterine rupture occur?
Prepartum, intrapartum, or postpartum
What are some causes of uterine rupture?
Prior cesarean section, especially with a classic incision or abdominal surgery; thin uterine wall
What are the common effects of uterine rupture?
Bleeding in mom, lack of oxygen to baby
When is uterine rupture most likely to happen?
During labor but can occur antepartum and postpartum
What are the signs and symptoms of uterine rupture?
Chest and shoulder pain, tender abdomen, low fetal heart rate
What is the management for uterine rupture?
Stabilize for cesarean, possible hysterectomy, blood and blood products
What are the signs and symptoms presented during uterine rupture?
Abdominal pain and tenderness
Chest/shoulder pain
Hypovolemic shock
Impaired fetal oxygenation
Absent FHR
Cessation of contractions
Palpation of fetus outside of uterus
Loss of station
What are some reasons for an emergency C-section?
Placental abruption, umbilical cord prolapse, fetal distress, etc.
What are the signs of a prolapsed cord?
Complete with visible cord or occult (cord slips alongside fetal head or shoulders)
Changes in FHR (bradycardia, variable decelerations, prolonged decelerations)
What are the management techniques for a prolapsed cord?
Position hips higher than head, maintain vaginal elevation, avoid manual palpation, Ultrasound or doppler, Cesarean Section
Why should you avoid touching or moving the prolapsed cord?
Can cause a vagal response
What is the increased risk for prolapsed cord?
Increase inductions
What is the recommended intervention for a prolapsed cord?
Don’t touch cord – push baby off the cord – Trendelenburg the bed – call for help need to do a c section
What is the pathophysiology of Amniotic Fluid Embolus (AFE)?
Amniotic fluid enters maternal circulation triggering immune maternal reaction
What are the diagnostic criteria for Amniotic Fluid Embolus (AFE)?
Sudden onset of cardiopulmonary arrest, hypotension and respiratory compromise
- DIC
- Onset of labor or within 30 mins of placental delivery
- afebrile during labor
What is the morbidity and mortality rate of Amniotic Fluid Embolus (AFE)?
High morbidity and mortaltiy for client and fetus/newborn
When does Amniotic Fluid Embolus (AFE) typically occur?
Occurs at or close to the time of birth
What is the connection between Amniotic Fluid Embolus (AFE) and DIC?
Amniotic Fluid Embolus (AFE) can lead to Disseminated Intravascular Coagulation (DIC)
Is fever a symptom of AFE?
No, Afebrile during labor
What is the clinical management for Amniotic Fluid Embolus (AFE)/ Anaphylactoid Syndrome of Pregnancy?
Rapid, coordinated emergent care
What position should the patient be placed in during the management of AFE?
Left lateral position
What intervention may be considered in AFE to potentially save the life of the mother?
Perimortem cesarean section
What additional medical team should be involved in the management of AFE?
Neonatal team and neonatal resuscitation
What kind of IV access is preferred during the management of AFE?
Large-bore IV access
What protocol may be required for the administration of blood products in AFE?
Blood transfusion protocol
What are the symptoms and treatment for DIC?
Hemorrhage and bleeding out; transfuse blood products
Phase 3 of Amniotic Fluid Embolus (AFE)/ Anaphylactoid Syndrome of Pregnancy and progression to DIC…
DIC – problems with clotting – hemorrhage and bleeding out in all different places and this is the third phase want to be prepared to for transfusing blood products
What happens in Phase 1 of Amniotic Fluid Embolus (AFE)/ Anaphylactoid Syndrome of Pregnancy?
Amniotic fluid enters circulation, right-sided ventricular failure
How do you manage Phase 1 of DIC?
Immediate CPR, consider immediate delivery, avoid excessive fluid resuscitation
What happens in Phase 2 of Amniotic Fluid Embolus (AFE)/ Anaphylactoid Syndrome of Pregnancy?
Release of inflammatory mediators, pulmonary edema, left ventricular failure
What are the symptoms of Phase 2 of Amniotic Fluid Embolus (AFE)/ Anaphylactoid Syndrome of Pregnancy?
Hypotension, acute renal failure, cardiac failure, shock, lung injury, neurologic changes
How do you manage Phase 2 of Amniotic Fluid Embolus (AFE)/ Anaphylactoid Syndrome of Pregnancy?
Use inotropes (dobutamine or norepinephrine), avoid excessive fluid administration
What happens in Phase 3 of Amniotic Fluid Embolus (AFE)/ Anaphylactoid Syndrome of Pregnancy?
Overwhelming coagulopathy; profound bleeding, disseminated intravascular coagulation
How do you manage Phase 3 of Amniotic Fluid Embolus (AFE)/ Anaphylactoid Syndrome of Pregnancy?
Activate massive blood transfusion protocol, treat uterine atony
What are the causes of indeterminate FHR?
Umbilical cord prolapse, umbilical cord compression, uteroplacental insufficiency
What is shoulder dystocia?
Baby’s shoulder gets stuck during delivery
What is the ‘Turtle Sign’?
Baby’s head retracts back into the birth canal after delivery of the shoulders
What can fetal hypoxia indicate?
Lack of oxygen to the baby
What are some interventions for shoulder dystocia?
McRobert’s maneuver, suprapubic pressure, changing to supine position
What is the importance of counting time between head and baby being delivered?
Determining if there is a risk of fetal hypoxia
What are some potential complications if a baby’s shoulder gets stuck on the pelvic bone during delivery?
Cerebral palsy or developmental delays
What is the purpose of the McRoberts maneuver?
To move the knees back to the shoulders and encourage pushing the legs out in a supine position
What is PROM?
Rupture of amniotic sac before true labor
What is pPROM?
< 37 weeks premature rupture of the membranes
What should be assessed for in PROM?
Infection
What should be tested in PROM?
Fluid
What should not be done if preterm and there are no contractions?
SVE (Sterile Vaginal Examination)
What is the time frame for induction in PROM?
24-hour window
What should be considered in preterm pregnancies for induction?
Risk vs benefit
What should be given in PROM?
Antibiotics
What assessments should be done in PROM?
VS (Vital Signs) + FHR (Fetal Heart Rate) + CTX (Contractions)
What tests should be done in PROM?
NSTs (Non-Stress Tests), BPPs (Biophysical Profile)
What should be avoided in PROM?
Breast stimulation
What other activity should be restricted in PROM?
Activity restrictions
What is the biggest concern in a sterile vag exam?
Infection
What are the symptoms of infection in a mom after a sterile vag exam?
Fever, yellow foul smelling discharge
What is considered preterm labor?
Before the start of week 37
What weeks are considered term?
Weeks 37-41
At what point is a pregnancy considered nonviable?
Before 24 weeks
What are some associated factors for preterm labor?
Infections, GDM, smoking, drug abuse, no prenatal care, previous preterm birth, IVF
What are some signs and symptoms of preterm labor?
Constant low back pain, cramping, pelvic pressure
What is the benefit of mom not having to dilate the entire way? preterm
No need for a lengthy labor
What are some risk factors for preterm labor?
Smoking
How can prenatal care help prevent preterm birth?
Access to care
Identify risk factors
Adequate nutrition
What can be done to predict preterm labor?
Cervical length, fFN
lets them know they are going to go into labor in next two week and it is a protein detected in fetus – don’t want to do sve) infection
How can preterm labor be identified?
Frequent visits, ultrasound, screenings
What are some methods to stop preterm labor?
Stopping (before 3 cm) – easier when they are 3 cm to stop labor : based on cause
Treat infection, limit activity, hydrate, Tocolytics
How can fetal lung maturity be accelerated in preterm labor cases?
Corticosteroids
What do oxytocic drugs do?
Stimulate contractions
What should you monitor for when using oxytocic drugs?
Tachysystole
What type of monitoring should be done when using oxytocic drugs?
Continuous FHR monitoring
What is another benefit of using oxytocic drugs?
Prevent hemorrhage
Misoprostol (Cytotec)
Cervical ripening: 25mcg (1/4 tab), PO or intravaginal
Hemorrhage:1000 mcg, rectal
What are oxytocic drugs?
Drugs that stimulate contractions of the uterus
10-40 Units/L of D5LR
Start low and slow at 2 mU/min. No benefit after 40.
What are tocolytics used for?
Delaying labor
At what gestational age are tocolytics most likely to be used?
<34 weeks
What is the most effective cervical dilation for tocolytics?
<3cm
Magnesium sulfate
Slows CTX, neuroprotector (prevents CP)
Loading dose followed by maintenance dose
Not for long term use (<72 hours)
Remember: calcium gluconate antidote
What is the potential side effect of nifedipine (Procardia) [Calcium antagonists]?
Flushing of face, headache, hypotension, temporary HR increase
may be taken throughout pregnancy
What is the potential side effect of indomethacin (Indocin)?
None major unless used >48-72 hours
reduces amniotic fluid
What is the purpose of corticosteroids?
Accelerate Fetal Lung Maturity
When should corticosteroids be given?
At least 24 hours before birth is best
What are the recommended drugs for corticosteroid administration?
Betamethasone (Celestone) and dexamethasone (Decadron)
What is the dosage regimen for corticosteroids?
12mg IM x1, repeat in 24 hours
What gestational age range is appropriate for corticosteroid administration?
24 - 34 weeks
When is a single course of corticosteroids recommended?
34-37 weeks
Does corticosteroid administration have any benefits if given less than 24 hours before birth?
<24 hours some benefits
