Labor and birth at risk: nursing mgmt

Question 1

Dystocia

Answer 1

-Abnormal progression of labor
-Slow and abnormal progression of labor
-Leading cause for C-section in US
-Associated w/ increase in postpartum hemorrhage, infections, perineal lacerations
-Admitting women too early to hospital while still in early latent phase of labor may increase dx of dystocia

Question 2

C-section indicators

Answer 2

-Labor dystocia
-Abnormal FHR tracing
-Fetal malpresentation
-Multiple gestation
-Suspected macrosomia

Question 3

Dystocia: problems w/ powers

Answer 3

-Hypertonic uterine dysfxn: uterus never fully relaxes btwn contractions
-Hypotonic uterine dysfxn: contraction become poor in quality and lack sufficient intensity to dilate cervix
-Protracted disorders: slower-than-normal rate of cervical dilation
-Arrest disorders: secondary arrest of dilation (no progress in cervical dilation in over 2 hrs), arrest of descent (fetal head does not descend for more than 30 min in multis and 1 hr in primis)
-Precipitate labor: labor completed in less than 3 hrs from start of contractions to birth

Question 4

Dystocia: problems w/ passenger

Answer 4

-Any presentation other than occiput anterior (head down and anterior facing)
-Common problems: occiput posterior, breech, multifetal, macrosomia, structural anomalies
-Shoulder dystocia: obstruction of fetal descent by the axis of the shoulders after head has been delivered (infant has greater shoulder-to-head and chest-to-head disproportions); McRoberts maneuver or suprapubic pressure can reduce severity of injuries; Immediately assess infant for signs of trauma such as fractured clavicle, erb palsy, neonatal asphyxia; assess mother for excessive vaginal bleeding and blood in urine from bladder trauma
-Multiple gestation
-Macrosomia: newborn weights 4,000-4,500 g (8.13-9.15 lb) at birth; d/t change in body comp in neonate w/ increase in fat and fat mass; associated w/ obesity, diabetes, cardiovascular disease, fetal abnormalities

Question 5

External cephalic version

Answer 5

-Procedure in which fetus is rotated from breech to cephalic presentation by manipulation thru mother’s abdominal wall at or near term
-Done during 36-38 weeks gestation
-Women w/ breech presentations are advised to have surgical births w/ no attempt to rotate fetal position

Question 6

Dystocia: problems w/ passageway

Answer 6

-Contraction of 1 or more of the 3 planes of maternal pelvis
-Contraction of midpelvis is more common
-Obstructions in maternal birth canal, such as swelling of soft maternal maternal tissue and cervix (soft tissue dystocia), can hamper feta descent

Question 7

Dystocia: problems w/ psyche

Answer 7

-Psychological stress
-Hormones released in response to anxiety
-Intense anxiety stimulates SNS
-NE and EPI leads to uncoordinated or increased uterine activity
-Anxiety reduces pain tolerances and decreases uterine contractility

Question 8

Dysotica: assessment

Answer 8

-Mother’s anxiety, stress, lack of support, pain
-Note elevated temp or changes in HR/BP (potential hypovolemia)
-Normal contraction patterns
-Leopold maneuvers

Question 9

Dystocia: mgmt

Answer 9

-Promote progression of labor: cervical dilation (1 cm/hr), observe for visible cord prolapse, fluid balance status, bowel status (full bladder impedes descent), administer oxytocin
-Provide physical and emotional comfort: blankets, backrub, warm shower, pillows, offer fluids to moisten mouth, food to replenish energy, change positions q30min
-Promoting empowerment

Question 10

Nontraditional families

Answer 10

-Complex childbearing decision
-Alternative methods of conceptions
-Insurance issues
-Negative attitudes from healthcare workers
-Appropriate language, identification, cultural representation

Question 11

Preterm labor

Answer 11

-Occurrence of regular uterine contractions accompanied by cervical dilation before end of 37th week of gestation
-If not halted, leads to preterm birth
-One of biggest contributors to perinatal morbidity
-Infant has cerebral palsy, intellectual impairment, vision defects, hearing loss, infections, congenital heart defects, thermoregulation problems, jaundice, hypoglycemia

Question 12

Preterm labor: medical mgmt

Answer 12

-No clear 1st line tocolytic drugs (drugs that promote uterine relaxation)
-Deferring birth to 39th week is not recommended if there is a medical indication for an earlier delivery
-Abx don’t appear to prolong gestation and should be reserved for GSB in women whom birth is imminent
-Tocolytic may prolong pregnancy for 2-7 days; during this time, steroids can be given to improve fetal lung maturity and woman can be transported to tertiary care center; usually given before 34th week
-Single course of corticosteroids for women at 24-34 weeks gestation who are at risk of preterm birth within 7 days; prenatal corticosteroids significantly reduce severity of neonatal respiratory distress syndrome; given 24-34 weeks; at least 24 hr for drugs to become effective
-Other meds: Mg sulfate, indomethacin, nifedipine, betamethasone

Question 13

Preterm labor: assessment

Answer 13

-Change or increase in vaginal discharge w/ mucus, water, or blood in it
-Pelvic pressure (pushing-down sensation
-Low, dull backache, cramping, UTIs, GI upset, aching in thighs, > 6 contractions per hr
-Contractions must be consistent, such that 4 contractions occur every 20 min
-Cervical effacement is 80% or greater and cervical dilation is greater than 1 cm

Question 14

Preterm labor: dx

Answer 14

-Fetal fibronectin: present in secretions up to 22 weeks and at end of last trimester; impending rupture in 7-14 weeks
-Cervical length measurement: transvaginal ultrasound; women w/ short cervical length of 2.5 cm during mid-trimester have greater risk prior to 35 weeks

Question 15

Preterm labor: nursing mgmt

Answer 15

-Primary prevention: smoking and substance use cessation, adequate nutrition, weight gain, progesterone therapy for at-risk women, treating infections, reducing stress
-Mg sulfate: adequate renal fxn; assess for drowsiness or hypotonia
-CC blockers: orally or sublingually q4-8h; monitor for hypotension and facial flushing
-Cyclooxygenase inhibitor (indomethacin): can cause oligohydramnios if used for more than 48 hrs; not for 32 weeks or more; initial loading dose is 50-100 mg orally or rectally

Question 16

Preterm labor: prevention education

Answer 16

-Avoid travelling long distances
-Avoid lifting heavy objects
-Avoid strenuous work
-Mild to moderate exercise is permitted such as walking daily
-Achieve appropriate prepregnancy weight
-Adequate Fe levels
-Wait at least 18 m between pregnancies
-Smoking cessation
-Curtail sexual activity after 37 weeks if experiencing preterm s/s
-Identify areas of stress in life

Question 17

Preterm labor: if experiencing any s/s education

Answer 17

-Stop what you are doing and rest for 1 hr
-Empty bladder
-Lie down on side
-Drink 2-3 glasses of water
-Note hardness of contraction; call HCP (mild: feels like tip of nose, moderate: feels like tip of chin, strong: feels like forehead

Question 18

Postterm pregnancy

Answer 18

-Full term is defined as 39-40 weeks and 6 days
-Postterm continues after end of 42nd week gestation or 294 days from 1st day of last menstrual period
-Incorrect dates account for majority of these cases: many women have irregular menses and thus cannot identify date of last menstrual period accurately
-Theory that may be d/t deficiency of estrogen and continued secretion of progesterone that prohibits uterus from contracting
-Intervention such as forceps or vacuum-assisted birth and labor induction w/ oxytocin may be necessary
-Maternal risk: infection, hemorrhage, birth trauma, dystocia
-Fetal risk: macrosomia, brachial plexus injuries, low apgar scores, postmaturity syndrome (loss of subq fat and muscle and meconium staining), placental insufficiency, oligohydramnios, hypoxia

Question 19

Postterm labor: assessment

Answer 19

-Date given from women w/ irregular menstrual cycle may be unreliable
-Daily fetal mvmt counts
-Nonstress tests
-Induction can be deferred until 42 weeks if fetal surveillance is reassuring
-Client’s understanding of fetal well-being tests, stress concerning prolonged pregnancy, support network

Question 20

Postterm labor: nursing mgmt

Answer 20

-Providing support: provide reassurance about expected time range for birth and well-being of fetus
-Educating woman and her partner: reasons for each test, possibility of induction if woman’s labor is not spontaneous or dysfunctional labor pattern occurs, prepare for surgical delivery if fetal distress occurs
-Providing care during intrapartum period: hydration status, fetal distress, amnioinfusion to dilute meconium concentration, monitor dysfxnal patterns

Question 21

Women requiring labor induction and augmentation

Answer 21

-Labor induction: stimulation of uterine contraction by medical means before onset of spontaneous labor; increased risk of C-section
-Labor augmentation: stimulation of uterus w/ oxytocin to enhance ineffective contractions after labor has begun
-WHO recommendations: performed only for a clear medical indication, women being induced should not be left unattended, oxytocin use for delay in labor in women w/ an epidural is not recommended, only performed after cephalopelvic disproportion has been ruled out, not applied to women w/ abnormal fetal presentations, close monitoring of FHR and uterine contractions patterns
-Before labor induction is started, fetal maturity (dating, amniotic fluid studies) and cervical readiness (vaginal examination, bishop scoring) must be assessed; both need to be favorable

Question 22

Postterm labor: medical mgmt

Answer 22

-Ultrasound
-Pelvimetry to rule out fetopelvic disproportion
-Nonstress test to evaluate fetal well-being
-PG level to assess fetal lung maturity
-Confirmation of category 1 FHR pattern
-CBC and urinalysis to rule out infection
-Vaginal exam to eval cervix for inducibility
-Accurate dating of pregnancy

Question 23

Cervical ripening

Answer 23

-Cervix soften via breakdown of collagen, leading to elasticity
-Important variable when labor induction is being considered
-Necessary for cervical dilation
-Bishop score: identifies women who would be most likely to achieve a successful induction; over 8 = successful vaginal birth, less than 6 = cervical ripening method needed prior to induction
-CAM: primrose oil, black haw, blue cohosh, red raspberry leaves, castor oil, hot baths, enemas, sexual intercourse along w/ breast stimulation
-Mechanical methods: fole, hygroscopic dilators
-Surgical methods: amniotomy, stripping of membranes
-Meds: dinoprostone, misoprostol, oxytocin

Question 24

Oxytocin

Answer 24

-Used for both artificial induction and augmentation of labor
-Naturally produced by posterior pituitary gland and stimulates contractions of uterus
-For women w/ low bishop score, cervical ripening is initiated before oxytocin is used
-Most common adverse effect is uterine hyperstimulation, leading to fetal compromise and impaired oxygenation; watch for headache and vomiting, decreased urine flow (water intoxication)
-Administered via IVPB, 10 units to 1 L isotonic solution
-Uterus should relax between contraction
-If resting uterine tone remains above 20 mmHG, uteroplacental insufficiency and fetal hypoxia may occur
-Pros: potent and easy to titrate, short half-life (1-5 min), well tolerated
-Encourage mother to empty bladder q2h

Question 25

Postterm labor: education for labor induction

Answer 25

-Used for HTN, medical condition, prolonged pregnancy over 41 weeks, problems w/ fetus
-May strip membranes, break amniotic sac to release fluid, administer meds to soften cervix, administer oxytocin to stimulate contractions
-Provider may perform procedure to ripen cervix before induction
-During induction, contractions may feel stronger than usual, however, length of labor may be reduced

Question 26

Vaginal birth after C-section

Answer 26

-Giving birth vaginally after having at least 1 previous C-section
-Contraindications: prior classic uterine incision, prior transfundal uterine surgery (myomectomy), uterine scare (not from C-section), short maternal stature, macrosomia, maternal age (over 40 y), gestational diabetes, contracted pelvis, inadequate staff if emergency C-section is required

Question 27

Intrauterine fetal demise

Answer 27

-Fetal death that occurs after 20 weeks gestation but before birth
-Trauma in pregnancy one of major contributors
-Leading causes of obstetric trauma are MVA, IPV, falls, assault, gunshot
-Early pregnancy loss may be thru a spontaneous abortion (miscarriage), induced abortion (therapeutic abortion), or rupture ectopic pregnancy
-Once IUFD is confirmed, most women choose to immediately undergo induction of labor
-90% of women will go into spontaneous labor within 2 weeks of fetal death

Question 28

Order of grief following IUFD

Answer 28

1. accepting reality of loss
2. getting over suffering from loss
3. adapting to new environment w/o deceased
4. emotionally relocating deceased and proceeding w/ life

Question 29

IUFD: nursing assessment

Answer 29

-Recent absence of fetal mvmt
-No fetal heartbeat heard
-Ultrasound necessary to confirm absence of fetal cardiac activity

Question 30

IUFD: nursing mgmt

Answer 30

-Associated w/ PTSD and anxiety in subsequent pregnancy
-Aid in grieving process: reassure women is not cause for loss
-Encourage discussion of loss
-Allow unlimited time w/ stillborn infant after birth to validate the death
-Use appropriate touch such as holding a hand or touching a shoulder
-Inform chaplain or religious leader of family’s denomination abt death and request their presence

Question 31

Umbilical cord prolapse

Answer 31

-Cord precedes the fetus out
-Risk increased when presenting part does not fill lower uterine segment, as is the case w/ incomplete breech presentations, premature infants, hydramnios, and multiparous women
-50% perinatal mortality rate
-Fetal perfusion deteriorates rapidly
-Dx by seeing or palpating

Question 32

Umbilical cord prolapse: nursing assessment

Answer 32

-More common in pregnancies involving malpresentation, growth restriction, prematurity, ruptured membranes w/ fetus at high station, hydramnios, grand multiparity, multiple gestation
-When presenting part does not fully occupy pelvic inlet, prolapse is more likely to occur

Question 33

Umbilical cord prolapse: nursing mgmt

Answer 33

-Reduce risk of fetal hypoxia
-1st sign is fetal brady or recurrent variable decelerations that become more severe
-Call for help immediately and do not leave the woman
-When membranes are artificially ruptured, assist w/ verifying that the present part is well applied to the cervix and engaged into the pelvis
-Changing woman’s position to modified sims, trendelenburg, or knee-chest position also helps cord pressure

Question 34

Placenta previa

Answer 34

-Complete or partial covering of uterine internal os of cervix w/ placenta, typically during 2nd or 3rd trimester
-Results in spontaneous placental separation and subsequent hemorrhage
-Most common cause of bleeding in 2nd half of pregnancy, and should be suspected in any woman beyond 24 weeks
-Dx w/ transvaginal ultrasonography
-Risk increased w/ prior C-sections, probably d/t uterine scarring

Question 35

Placenta previa: nursing assessment

Answer 35

-Sudden, painless bleeding, anemia, pallor, hypoxia, hypotension, tachycardia, soft and nontender uterus, rapid but weak pulse
-Bleeding may be episodic
-Can be asymptomatic

Question 36

Placenta previa: nursing mgmt

Answer 36

-Vaginal delivery possible when bleeding is minimal, previa is marginal, or labor is rapid
-Pregnancy termination, early birth by C-section, or hysterectomy may be necessary to control severe bleeding, especially for those w/ complete previa
-Fetal prognosis r/t amt of blood loss
-Monitor for sepsis
-Administer IV fluids, packed RBC, frozen plasma, Rho(D) if client is RH-neg, oxytocin to induce labor, tocolytics to inhibit contractions, corticosteroids to enhance fetal lung maturity
-Women are then monitored at home after discharge

Question 37

Placental abruption

Answer 37

-Premature separation of placenta from myometrium
-Underlying conditions may force blood into underlayer of placenta, causing it to detach

Question 38

Placental abruption: nursing mgmt

Answer 38

-Focus on maintaining cardiovascular status of mother
-C-section may take place if fetus is still alive w/ only a partial abruption
-Vaginal birth may take place if there is a fetal demise 2ndary to a complete abruption

Question 39

Uterine rupture

Answer 39

-High incidence of fetal and maternal morbidity
-Tearing of uterus at site of previous scar into abdominal cavity
-Marked by sudden fetal bradycardia
-Tx requires rapid surgery for good prognosis
-Fetal morbidity occurs 2ndary to hemorrhage, anoxia (total depletion of O2, or both

Question 40

Uterine rupture: nursing assessment

Answer 40

-Ask about uterine scars, prior C-sections, prior rupture, trauma, prior invasive molar pregnancy, crack cocaine use, forceps delivery
-Most reliable s/s is sudden fetal distress
-Other s/s include acute or continuous abdominal pain w/ or w/o epidural, vaginal bleeding, hematuria, irregular abdominal wall contour, loss of station in fetal presenting part, hypovolemic shock in woman, fetus, or both
-When excessive bleeding occurs during childbirth and it persists w/ bruising or petechiae, DIC should be suspected

Question 41

Uterine rupture: nursing mgmt

Answer 41

-Urgent C-section
-Monitor for hypovolemic shock (hypotension w/ tachycardia)
-Insert indwelling urinary catheter
-Outcome depends on speed of surgery

Question 42

Anaphylactoid syndrome of pregnancy (ASP)

Answer 42

-AKA amniotic fluid embolism
-Significant maternal and newborn mortality
-Sudden onset of hypotension, cardiopulmonary collapse, hypoxia, coagulopathy
-Amniotic fluid containing particles of debris (hair, skin, vernix, meconium) enters maternal circulation and obstructs pulmonary vessels, causing respiratory distress and circulatory collapse
-Timely recognition and response is critical in saving woman’s life

Question 43

ASP: nursing assessment

Answer 43

-No lab tests for dx
-Team response is necessary
-Cardinal signs: respiratory failure, altered mental status, hypotension, DIC
-Most women transferred to ICU

Question 44

ASP: nursing mgmt

Answer 44

-Resuscitation and 100% O2 (endotracheal intubation and mechanical ventilation), circulation (IV fluids, inotropic agents), control of hemorrhage and coagulopathy (oxytocic agents), seizure precautions, steroids
-Monitor for s/s of coagulopathy (vaginal bleeding, bleeding from IV site, bleeding from gums)
-Mgmt of DIC such as packed RBCs or frozen plasma
-Oxytocin infusions and prostaglandin analogs to address uterine atony

Question 45

Women requiring birth-related procedures

Answer 45

-Forceps-assisted,
-Vacuum-assisted
-C-section
-Episiotomy
-VBAC

Question 46

Forceps-assisted birth

Answer 46

-Forceps are stainless steel instruments, similar to tongs, w/ rounded edges to fit around fetal head
-Outlet forceps used when fetal head is crowning
-Low forceps used when fetal head is at +2 station or lower but is not yet crowning
-All forceps have a locking mechanism that prevents blades from compressing fetal skull
-Forceps rarely used in practice

Question 47

Vacuum-assisted birth

Answer 47

-Cup-shaped instrument attached to a suction pump used for extraction of the fetal head
-Suction cup is placed against occiput of fetal head
-Pump is used to create negative pressure aka suction (50-60 mmHg)

Question 48

Forceps or vacuum-assisted birth: indications

Answer 48

-Prolonged 2nd stage of labor
-Distressed FHR pattern
-Failure of presenting part to fully rotate and descend into pelvis
-Limited sensation and inability to push effectively d/t regional anesthesia
-Presumed fetal jeopardy or distress
-Maternal complications
-Vacuum preferred over forceps
-Potential newborn trauma such as ecchymoses, facial and scalp lacerations, facial nerve injury, cephalohematoma, caput succedaneum
-Criteria: membranes ruptured, cervix completely dilated, fetus vertex and engaged, adequate maternal pelvis size

Question 49

Forceps or vacuum-assisted birth: nursing mgmt

Answer 49

-Change positions frequently
-Encourage ambulation
-Remind pt to empty bladder
-Reassure mother that any marks or swelling on newborn’s head or face will disappear w/o tx in 2-3 days
-Observe for bleeding or infection r/t genital lacerations

Question 50

C-section

Answer 50

-Surgical birth of fetus thru incision in abdomen and uterine wall
-Most common surgery in US
-1/3 of births
-Increased use d/t external fetal monitoring, reduced # of forceps-assisted birth, older maternal age and reduced parity, maternal obesity, convenience to client and doctor, increase in malpractice suits
-Leading indications: previous C-section, breech, dystocia, fetal distress
-Once woman has C-section, she has a 90% chance of having another one
-Major risks: infection, hemorrhage, aspiration, pulmonary embolism, urinary tract trauma, thrombophlebitis, paralytic ileus, atelectasis, fetal injury, transient tachypnea
-Spinal, epidural, or general anesthesia used
-Epidural poses least risks and most women wish to be awake during birth experience

Question 51

C-section: nursing assessment

Answer 51

-Woman who requests C-section must be aware of risks and benefits for current and any subsequent births
-Maternal indications: genital herpes, fetal macrosomia, fetopelvic disproportion, prolapsed umbilical cord, placental abnormality, previous C-section, gestational HTN, DM, HIV, dystocia
-Fetal indications: malpresentation, congenital anomalies, fetal distress

Question 52

C-section: nursing mgmt

Answer 52

-Dx tests: CBC, urinalysis to rule out infection, blood type and cross-match for blood transfusion PRN, ultrasound to determine fetal position and placental location, amniocentesis to determine fetal lung maturity
-Center care on woman and family

Question 53

C-section: pre-op care

Answer 53

-Encourage woman to report any pain
-Pain meds can be provided during procedure
-Document time and description of last food/drink
-Demonstrate use of IS and deep breathing and leg exercises
-Instruct woman on how to splint her incision
-Start IV infusion
-Insert indwelling catheter (remains in place for 24 hrs)