Module 2 INTRAPARTUM - LECTURE 7

Question 1

DYSTOCIA

The abnormal progression of labor
Need to be able to define normal progression first
Diagnosed usually during the “active phase” of the 1st stage of labor.
“failure to progress”
Early detection for better outcomes

Answer 1

Normal Progression of Labor:

Normal labor is typically divided into three stages: the first stage, the second stage, and the third stage.
The first stage is further divided into latent and active phases. During the latent phase, the cervix begins to efface (thin) and dilate (open), and contractions become regular but less intense. The active phase follows, characterized by more rapid cervical dilation and stronger contractions.
The second stage begins when the cervix is fully dilated and ends with the birth of the baby. During this stage, the mother pushes to help the baby descend and be born.
The third stage involves the delivery of the placenta.
Dystocia:

Dystocia, or “failure to progress,” is diagnosed when labor deviates from this normal progression.
It is most commonly diagnosed during the active phase of the first stage of labor when cervical dilation slows down or stalls, or when contractions become ineffective in progressing labor.
Dystocia can result from various factors, including abnormalities in the baby’s position, issues with the maternal pelvis, or problems with uterine contractions.
Early detection of dystocia is crucial for better outcomes, as it allows healthcare providers to intervene and address the underlying causes promptly. Timely interventions may include changing the mother’s position, using oxytocin to augment contractions, or considering cesarean delivery if necessary.

Question 2

How many cesarean births occur each year in the
U.S.?

Answer 2

In 2020, 31.8% of live births were by cesarean section.

Primary cesarean sections were 21.9%

Induction of nulliparous patients who were induced after 37 weeks for nonmedical purposes, doubled their chances of having a cesarean birth.

Overall Cesarean Section Rate: In 2020, 31.8% of live births were delivered via cesarean section. This figure indicates that nearly one-third of all births that year were performed by C-section.

Primary Cesarean Sections: Of the total cesarean sections performed, 21.9% were primary cesarean sections. A primary cesarean section is the first C-section performed on an individual, often for medical reasons.

Induction and Cesarean Risk: Your statement highlights a key finding regarding the induction of nulliparous patients (those having their first baby) after 37 weeks for nonmedical reasons. It suggests that inducing nulliparous individuals for nonmedical purposes at or after 37 weeks of gestation doubled their chances of having a cesarean birth.

Question 3

The 5 P’s of Labor. Where can problems arise?

Answer 3

Power
Passageway
Passenger
Position
Psychological

Question 4

Problems with POWER. Hypertonic Uterus

Answer 4

Hypertonic uterine dysfunction –
1. uterus never fully relaxes
2. contractions ineffective
3. prolonged latent phase (2-3cm)
4. reduced placental profusion

Uterus Never Fully Relaxes: In this condition, the uterine muscles do not relax between contractions as they should. Normal contractions are characterized by a contraction phase (tightening of the uterine muscles) followed by a relaxation phase (muscles returning to a resting state). With hypertonic uterine dysfunction, the relaxation phase is inadequate or absent.

Contractions Ineffective: The contractions that do occur may be strong, but they are often ineffective in terms of cervical dilation and fetal descent. This can prolong the labor process because the cervix does not dilate as it should.

Prolonged Latent Phase: The latent phase of labor is the early stage where the cervix begins to dilate from 0 to about 3 centimeters. In cases of hypertonic uterine dysfunction, this phase can be excessively long, causing frustration and exhaustion for the mother.

Reduced Placental Perfusion: The constant, strong contractions can reduce blood flow to the placenta. This reduction in placental perfusion can affect the baby’s oxygen and nutrient supply, potentially leading to fetal distress.

Question 5

Problems with POWER. Nursing Management. Hypertonic

Answer 5

Bedrest
Monitor fetal wellbeing
Assess for maternal infection
Promote adequate hydration
Pain management
Educate

Question 6

Problems with POWER. Hypotonic uterus

Answer 6

Hypotonic uterine dysfunction
1. poor quality and intensity
2. arrest of dilation & effacement
3. active face of 1st stage (5-6cm)
4. at risk for PP hemorrhage

Poor Quality and Intensity of Contractions: In this condition, the contractions of the uterus are weak and lack the necessary intensity to effectively push the baby down the birth canal. These contractions are often described as “ineffective.”

Arrest of Dilation & Effacement: Contractions that are too weak may result in the arrest of cervical dilation (the cervix not opening further) and effacement (thinning of the cervix). This means that labor progress slows down or stops altogether.

Active Phase of 1st Stage (5-6cm): Hypotonic uterine dysfunction can often occur during the active phase of the first stage of labor, typically when the cervix is dilated to around 5-6 centimeters. This can be frustrating for the mother because labor has progressed significantly, but then it slows down.

At Risk for Postpartum Hemorrhage (PPH): After childbirth, a hypotonic uterus may not contract adequately to help stop bleeding from the placental site. This places the mother at higher risk for postpartum hemorrhage, a potentially serious complication.

Question 7

Problems with POWER. Nursing management
.Hypotonic

Answer 7

Administer oxytocin
Assist with amniotomy
Continuous EFM
Assess for maternal/fetal infection
Educate

Administer Oxytocin: Oxytocin is a hormone that can be used to augment and strengthen uterine contractions. Nursing staff may be responsible for administering oxytocin according to the healthcare provider’s orders. It’s important to closely monitor the mother’s response to oxytocin and adjust the dosage as needed to achieve effective contractions.

Assist with Amniotomy: Amniotomy is the artificial rupture of the amniotic sac (the “water breaking”) to help stimulate contractions and speed up labor. Nursing staff may assist the healthcare provider in performing this procedure safely.

Continuous Electronic Fetal Monitoring (EFM): Continuous EFM is essential to monitor the baby’s heart rate and assess fetal well-being during labor. Nurses should ensure that the EFM equipment is properly applied and that they are vigilant in recognizing any signs of fetal distress or changes in the heart rate pattern.

Assess for Maternal/Fetal Infection: Infections can contribute to uterine dysfunction and complicate labor. Nurses should monitor both the mother and the baby for signs of infection, such as fever, increased heart rate, or abnormal laboratory results. Promptly report any concerns to the healthcare provider.

Educate: Provide the mother with information about her condition, the progress of labor, and the interventions being used. Education should also cover potential risks, benefits, and alternatives to interventions like oxytocin administration and amniotomy. Informed decision-making is essential.

Question 8

Problems of POWER Precipitate labor

Answer 8

Precipitate labor
1. birth <3 hours from start of contractions
2. maternal injury
3. fetal traumatic & asphyxia insults

Precipitate labor, defined as labor that progresses extremely rapidly, can indeed present several problems for both the mother and the baby. Here are some of the issues associated with precipitate labor:

Maternal Injury: The rapid progression of labor can lead to maternal injuries, including tears and lacerations in the vaginal or perineal area. These injuries may require stitches and can be painful during the postpartum period.

Hemorrhage: Quick and forceful contractions can increase the risk of postpartum hemorrhage (excessive bleeding after childbirth) for the mother. The uterus may not have enough time to contract effectively after delivery, leading to excessive bleeding.

Psychological Distress: Rapid labor can be overwhelming for the mother, causing heightened anxiety and emotional distress due to the unexpected speed of the birth process.

Limited Pain Management: Mothers may not have sufficient time to receive pain relief options like epidurals, which can be a concern for those who had planned on using these methods to manage labor pain.

Fetal Distress: The rapid descent of the baby through the birth canal can sometimes lead to fetal distress. This occurs when the baby’s oxygen supply is compromised due to compression of the umbilical cord or other factors.

Neonatal Trauma: The speed of the delivery can result in neonatal trauma, including injuries such as head and shoulder trauma, as the baby is rapidly pushed through the birth canal.

Increased Risk of Postpartum Shock: The suddenness of precipitate labor can increase the risk of postpartum shock for the mother. Postpartum shock is a severe condition that can result from rapid blood loss and inadequate uterine contractions.

Unplanned Home Births: In some cases, precipitate labor may progress so rapidly that there’s no time to reach a healthcare facility, resulting in an unplanned home birth. This can be challenging if there are complications or medical assistance is needed.

Difficulty Monitoring: Healthcare providers may have difficulty monitoring the progress of labor and the baby’s well-being when labor progresses too quickly, making it challenging to intervene when necessary.

Question 9

Problems of POWER Precipitate labor. Nursing Management

Answer 9

Closely monitor contractions & FHR
May administer tocolytics
Stay with patient
Inform Health Care Provider
Anticipate RN delivery

Closely monitor contractions & FHR (Fetal Heart Rate):

Monitor uterine contractions using a tocodynamometer or palpation to assess their frequency, duration, and strength.
Continuously monitor the fetal heart rate using electronic fetal monitoring (EFM) to detect any signs of distress or variability.
Document the findings regularly to track changes in labor progression and fetal status.
May administer tocolytics:

Tocolytics are medications that can slow down or stop contractions. In the case of precipitate labor, if contractions are excessively strong or frequent and pose a risk to the mother or baby, tocolytics may be administered.
Nursing responsibilities include preparing and administering the tocolytic medication as per the healthcare provider’s orders and monitoring the response.
Stay with the patient:

Provide continuous bedside support and reassurance to the mother, as precipitate labor can be overwhelming and frightening.
Observe for signs of maternal distress, such as anxiety, pain, or discomfort, and address her needs promptly.
Inform Health Care Provider:

Notify the healthcare provider immediately about the rapid progression of labor and any concerning findings, such as signs of fetal distress, excessive bleeding, or maternal discomfort.
Provide the healthcare provider with up-to-date information on contractions, fetal heart rate, and the mother’s condition.
Anticipate RN delivery:

Be prepared for the possibility of a rapid delivery. Gather necessary delivery equipment and supplies, including sterile gloves, towels, and a bulb syringe for newborn suctioning.
Position the mother for delivery and provide clear instructions on when to push during contractions if delivery is imminent.
If the delivery occurs before the healthcare provider arrives, assist with the birth, ensuring a safe and controlled delivery.

Question 10

Problems with PASSENGER/POSITION. Occiput Posterior Position

Answer 10

Occiput posterior – face up
1. Labor usually longer
2. Maternal exhaustion
3. Extensive caput (Extensive Caput: Caput succedaneum is the swelling of the baby’s head that occurs as it passes through the birth canal.)

Question 11

Problems with PASSENGER/POSITION. Nursing Management

Answer 11

Pain management
Intense back labor 1st stage
Encourage/Assist patient for position changes
Anticipate operative vaginal delivery
Educate

Pain Management:

Assess and monitor the mother’s pain levels regularly, especially if she is experiencing intense back labor during the first stage of labor.
Administer pain relief measures as prescribed, which may include epidurals, intravenous medications, or non-pharmacological pain management techniques such as relaxation exercises, breathing techniques, and massage.
Intense Back Labor in the First Stage:

Recognize the signs of back labor, where the pain is primarily located in the lower back. Provide comfort measures such as warm compresses or counter-pressure on the lower back to alleviate discomfort.
Encourage the mother to try different positions and movements that may relieve some of the back pain.
Encourage/Assist Patient for Position Changes:

Advocate for and encourage the mother to change positions frequently during labor. Position changes can help the baby rotate and descend, which may alleviate some of the issues associated with passenger/position problems.
Suggest positions such as hands and knees, side-lying, or sitting on a birthing ball to promote optimal fetal positioning.
Anticipate Operative Vaginal Delivery:

Recognize the signs that may indicate the need for an operative vaginal delivery, such as prolonged labor or fetal distress.
Prepare the patient for the possibility of an assisted delivery using forceps or vacuum extraction by explaining the procedure, obtaining informed consent, and ensuring that all necessary equipment is readily available.
Educate:

Provide patient education about the baby’s position and its potential impact on labor. Explain the benefits of position changes and movement to facilitate the baby’s rotation.
Offer information about the risks and benefits of interventions like operative vaginal delivery or cesarean section, ensuring that the patient can make informed decisions.
Discuss postpartum care and recovery, including potential issues related to caput succedaneum and pain management during the postpartum period.

Question 12

Problems with PASSENGER/POSITION. Face/Brow Presentation

Answer 12

Face/Brow present at cervix
1. Poor force against cervix
2. Very rare
3.Associated with fetal anomalies (anencephaly)

Poor Force Against Cervix:

In face or brow presentation, the baby’s head is not in an optimal position for engaging the cervix and descending through the birth canal. This can result in inefficient contractions and a slower progression of labor.
Very Rare:

Face or brow presentation is considered very rare, occurring in less than 1% of pregnancies. Because it is uncommon, healthcare providers may have limited experience managing this presentation, which can pose challenges in providing appropriate care.
Associated with Fetal Anomalies:

Face or brow presentation is sometimes associated with fetal anomalies or malformations, such as anencephaly (a severe neural tube defect where the baby is born without parts of the brain and skull). Fetal anomalies can complicate the labor and delivery process and may require special medical considerations.

Question 13

Problems with PASSENGER/POSITION. Face/Brow Presentation.
Nursing Management

Answer 13

Brow presentation prepare for cesarean birth
EFM for fetal wellbeing
Emotional help patient fetal demise
Educate

Prepare for Cesarean Birth:

Given the difficulties associated with face or brow presentation and the increased risk of complications during vaginal delivery, nursing staff should prepare the patient for a possible cesarean section (C-section). This includes explaining the need for a C-section, obtaining informed consent, and ensuring that all necessary pre-operative and post-operative preparations are in place.
Electronic Fetal Monitoring (EFM) for Fetal Wellbeing:

Continuous electronic fetal monitoring (EFM) is crucial to assess the well-being of the baby throughout labor. Monitor the fetal heart rate and uterine contractions to detect any signs of fetal distress.
Report any concerning changes in the fetal heart rate or patterns promptly to the healthcare provider.
Emotional Support for the Patient:

Face or brow presentation can be emotionally distressing for the patient, especially if there is a concern about fetal demise or complications. Provide emotional support, reassurance, and a safe space for the patient to express her feelings and concerns.
Offer information about the medical situation in a clear and empathetic manner, and involve the patient in decision-making as much as possible.
Educate the Patient:

Offer comprehensive education to the patient about the nature of face or brow presentation, the potential risks and complications, and the need for a C-section in some cases.
Explain the surgical procedure, anesthesia options, and what to expect before, during, and after the C-section.
Discuss post-operative care and recovery, including incision care and pain management.
Address any questions or concerns the patient may have, and provide written materials for reference.

Question 14

Problems with PASSENGER/POSITION. Breech Presentation. Nursing Management

Answer 14

Arrange U/S to confirm position
Assist with external cephalic version
Trial labor 4-6 hours for progress with unsuccessful version
Prepare for cesarean
Check with provider for Rhogam administration
Educate

Arrange U/S to Confirm Position:

When breech presentation is suspected or identified, the first step is to arrange an ultrasound (U/S) to confirm the baby’s position. Accurate positioning is crucial for making appropriate management decisions.
Assist with External Cephalic Version (ECV):

ECV is a procedure in which healthcare providers attempt to manually turn the baby into a head-down position. Nurses play a role in assisting during this procedure by providing support to the patient, monitoring fetal well-being, and documenting the outcomes of the ECV.
Trial Labor for Progress with Unsuccessful Version:

In some cases, if an ECV is unsuccessful or contraindicated, healthcare providers may opt for a trial of labor with careful monitoring. Nurses should assist in monitoring the progress of labor, fetal well-being, and the mother’s comfort during this period.
Prepare for Cesarean Section:

If ECV is unsuccessful, contraindicated, or if labor does not progress as expected, a cesarean section (C-section) may be necessary to safely deliver the baby. Nurses should prepare the patient for the possibility of a C-section by explaining the procedure, obtaining informed consent, and ensuring that all necessary pre-operative and post-operative preparations are in place.
Check with Provider for Rhogam Administration:

In cases of Rh-negative mothers with Rh-positive babies, Rhogam administration may be necessary to prevent Rh sensitization. Nurses should coordinate with the healthcare provider to ensure that Rhogam is administered according to the appropriate guidelines.
Educate:

Provide comprehensive education to the patient about breech presentation, the potential risks and benefits of interventions, and the importance of informed decision-making.
Explain the procedures involved in ECV, labor, and C-section in a clear and empathetic manner.
Discuss post-operative care and recovery if a C-section is planned.
Address any questions or concerns the patient may have and provide written materials for reference.

Question 15

Problems with PASSENGER/POSITION. Shoulder Dystocia.

Answer 15

Shoulder dystocia – axis of shoulders prevent fetal descent after delivery of the fetal head.
1. fetal injury
2. maternal injury
3. risk for PP hemorrhage

Shoulder dystocia is a childbirth complication that occurs when the shoulders of the baby become stuck behind the mother’s pelvic bone after the delivery of the fetal head. This situation can lead to several potential problems:

Fetal Injury:

Shoulder dystocia can result in fetal injuries, the most common of which is brachial plexus injury. The brachial plexus is a network of nerves controlling the arm and hand muscles. Excessive force during delivery can damage these nerves, causing weakness or paralysis of the baby’s arm (most commonly the upper arm or shoulder). In severe cases, other fetal injuries such as fractures or hypoxia (lack of oxygen) may occur.
Maternal Injury:

While the primary concern in shoulder dystocia is the baby’s well-being, the intense efforts to resolve the situation, which may involve significant maneuvers and force, can put the mother at risk of injury. Maternal injuries can include tears or lacerations of the vaginal or perineal tissues, and in some cases, uterine rupture or postpartum hemorrhage due to excessive bleeding during delivery.
Risk for Postpartum Hemorrhage (PPH):

Shoulder dystocia can increase the risk of postpartum hemorrhage (excessive bleeding after childbirth) for the mother. The prolonged and difficult delivery can cause trauma to the birth canal, potentially leading to bleeding. Prompt recognition and management of PPH are essential to minimize this risk.

Question 16

Problems with PASSENGER/POSITION. Shoulder Dystocia.
Nursing Management

Answer 16

Recognize and intervene immediately
McRobert maneuver along with suprapubic pressure
Call for help, OR notified
Patient position changes
Educate

Recognize and Intervene Immediately:

Early recognition of shoulder dystocia is essential. Nurses should be vigilant during labor and delivery, continuously monitoring for signs of this complication, such as difficulty delivering the baby’s shoulders after the head.
If shoulder dystocia is suspected or confirmed, nurses should promptly alert the healthcare provider and initiate interventions.
McRobert Maneuver along with Suprapubic Pressure:

Nurses may assist the healthcare provider in performing the McRobert maneuver, which involves flexing the mother’s thighs sharply against her abdomen to widen the pelvic outlet.
Simultaneously, nurses can apply suprapubic pressure just above the mother’s pubic bone to help dislodge the baby’s anterior shoulder and facilitate delivery.
Call for Help, Notify the Operating Room (OR):

In cases of shoulder dystocia, additional help and expertise may be needed. Nurses should call for additional healthcare providers, such as obstetricians, neonatologists, or pediatricians, as appropriate.
If the situation does not resolve quickly, nurses should notify the operating room (OR) or the appropriate personnel to be on standby for a potential C-section.
Patient Position Changes:

Nurses can assist with patient position changes to help alleviate shoulder dystocia. For example, they may help the mother change her position to hands and knees, which can sometimes facilitate the delivery of the baby’s shoulders.
Nurses should be prepared to assist with different maneuvers and techniques as directed by the healthcare provider to resolve the shoulder dystocia.
Educate:

After the resolution of the emergency, provide education and support to the mother and her family. Explain what happened during the delivery, the actions taken to address the issue, and the well-being of the baby.
Offer emotional support to the mother, as shoulder dystocia can be a traumatic experience.

Question 17

How many births in the U.S. result in shoulder dystocia?

Answer 17

1. 3%
2. 5,000 new cases of permanent “brachial plexus palsy” a year.

Question 18

Problems with PASSENGER. Multiple Gestation

Answer 18

More than one fetus
1. higher perinatal mortality rate
2. uterine overdistention
3. Fetal hypoxia
4. Presenting fetus must be in vertex position

Higher Perinatal Mortality Rate:

Multiple gestation pregnancies are associated with a higher risk of perinatal mortality, which includes fetal deaths that occur in the perinatal period, typically defined as from the 20th week of gestation to the 28th day after birth. The increased risk is often attributed to a higher likelihood of preterm birth and other complications.
Uterine Overdistention:

Carrying more than one fetus can lead to uterine overdistention, which means the uterus becomes stretched beyond its normal capacity. This can increase the risk of complications such as preterm labor, preeclampsia, and uterine dysfunction.
Fetal Hypoxia:

Uterine overdistention and other factors related to multiple gestation pregnancies can increase the risk of fetal hypoxia, where the fetuses may not receive an adequate oxygen supply. This can lead to various complications, including fetal distress and growth restriction.
Presenting Fetus Must Be in Vertex Position:

In cases of multiple gestation pregnancies, especially when both fetuses are expected to be delivered vaginally, it is generally preferred that the presenting (first) fetus is in the vertex (head-first) position. This is because delivering a breech (bottom-first) presenting fetus in a multiple gestation pregnancy can be more complicated and riskier.

Question 19

Problems with PASSENGER. Multiple Gestation
Nursing Management

Answer 19

EFM for contraction pattern, assess for hypotonia
Confirm gestational age
Notify OR of possible cesarean
Notify NICU of multiple gestation birth
Educate

Question 20

What percentage of births are multiple gestation?

Answer 20

1.4%

2. 2/3s dizygotic and 1/3 monozygotic

Question 21

Problems with PASSENGER. Macrosomia

Answer 21

Macrosomia – neonate weight > 4,000 mg
1. fetopelvic disproportion
2, overdistended uterus
3. fetal injury
4. maternal injury
5. maternal fatigue

Question 22

Problems with PASSENGER. Macrosomia. Nursing Management

Answer 22

Fetal wellbeing
Pain management
Inadequate contraction pattern/strength
Anticipate vaginal operative delivery
Educate

Question 23

Problems with PASSAGEWAY. Pelvic or Canal Disproportion

Answer 23

Contraction of any 3 of the pelvic planes or swelling of soft tissues or placenta issues.
Failure to descend with adequate contractions
Obstruction of the birth canal

Question 24

Problems with PASSAGEWAY. Pelvic or Canal Disproportion. Nursing Mnagement

Answer 24

Assess for contraction pattern, cervical dilation
Evaluate for bladder distention
Evaluate for fecal interference
Plan for cesarean birth
Educate

Assess for Contraction Pattern and Cervical Dilation:

Continuously monitor the mother’s contraction pattern, strength, and frequency.
Assess cervical dilation and effacement to gauge the progress of labor.
Document findings and report any abnormalities or deviations from the expected labor progression to the healthcare provider.
Evaluate for Bladder Distention:

Frequent bladder assessment is essential, as a distended bladder can impede fetal descent and cause discomfort.
Encourage the mother to empty her bladder regularly, especially if an epidural is in place, as the sensation of a full bladder may be diminished.
Evaluate for Fecal Incontinence:

Assess for fecal interference, as it can indicate that the baby’s head is putting pressure on the rectum.
Provide appropriate perineal care and assist the mother with maintaining cleanliness and comfort.
Plan for Cesarean Birth:

Collaborate with the healthcare provider in making the decision to perform a cesarean section if pelvic disproportion is confirmed or if labor is not progressing despite interventions.
Prepare the patient both physically and emotionally for the cesarean section, explaining the procedure, risks, and benefits.
Educate the Mother:

Provide thorough education about the need for a cesarean birth if it becomes necessary, ensuring the mother understands the reasons and what to expect during and after the surgery.
Offer emotional support to address any concerns or anxieties the mother may have.
Educate the mother on postoperative care, including pain management, wound care, and breastfeeding techniques.

Question 25

Problems with PSYCHE. Psyche Dystocia.

Answer 25

Sympathetic nervous system releases hormones.
1. catecholamines can create myometrium dysfunction
2. norepinephrine and epinephrine can lead to uncoordinated or increased uterine activity
3. increased fear & tension can reduce pain tolerance

Question 26

Problems with PSYCHE. Psyche Dystocia. Nursing Management

Answer 26

Environment control
Encourage partner participation
Keep patient informed
Encourage relaxation & comfort techniques
Educate

Question 27

All patients

Answer 27

Monitor vital signs
EFM
Assess fluid balance
Provide physical & emotional comfort
Empower your patient

Monitor Vital Signs:

Regularly assess and record vital signs, including blood pressure, heart rate, respiratory rate, and temperature. Monitoring vital signs helps in early detection of any changes in a patient’s condition.
EFM (Electronic Fetal Monitoring):

Electronic Fetal Monitoring is primarily used during labor and delivery to monitor the fetal heart rate and uterine contractions. It ensures the well-being of both the mother and the baby.
Continuous monitoring helps identify signs of fetal distress or complications, allowing for prompt intervention if needed.
Assess Fluid Balance:

Evaluate a patient’s fluid balance by monitoring input and output (I&O).
Assess for signs of dehydration or fluid overload, such as changes in urine output, skin turgor, and mucous membrane moisture.
Adjust fluid therapy as per the patient’s medical condition and physician’s orders.
Provide Physical & Emotional Comfort:

Offer physical comfort measures such as pain management, positioning, and wound care.
Address the patient’s emotional well-being by providing emotional support, active listening, and empathetic communication.
Create a comfortable and reassuring environment to promote healing and reduce stress.
Empower Your Patient:

Encourage patients to actively participate in their care decisions and treatment plans.
Provide information and education to help patients understand their condition, treatment options, and self-care strategies.
Foster patient autonomy and involve them in goal-setting and care planning.

Question 28

Nontraditional Families

Answer 28

LGBTQI families are navigating a system set up around heterosexual couples.
Barriers
1. Insurance
2. Healthcare worker attitudes
3. Uncertain legal rights
4. Identification language

Question 29

Preterm Labor

Answer 29

Regular contractions causing cervical change at < 37 weeks gestation.
Sequelaeofcomplications
Lifelong disabilities for many

Question 30

Preterm Labor. Nursing Management

Prediction and prevention
Administering Tocolytics – oral or IV
Administering Antibiotics for presumed or confirmed infections
Corticosteroids
Lab work
Educate

Answer 30

Prediction and Prevention:

Identify individuals at risk for preterm labor through thorough assessment and prenatal history.
Provide education on the signs and symptoms of preterm labor to help individuals recognize warning signs early.
Offer guidance on lifestyle modifications and strategies to reduce risk factors, such as smoking cessation and stress management.
Encourage adherence to prenatal care and appointments for close monitoring.
Administering Tocolytics (Oral or IV):

Tocolytics are medications that can be used to temporarily halt uterine contractions and delay preterm birth.
Nurses may administer tocolytics as prescribed and monitor the patient’s response, vital signs, and side effects.
Educate the patient about the purpose, potential side effects, and importance of compliance with tocolytic therapy.
Administering Antibiotics for Presumed or Confirmed Infections:

Infections, especially those of the reproductive tract, can contribute to preterm labor.
Nurses may administer antibiotics as prescribed to treat or prevent infections, particularly if there are signs or symptoms suggestive of an infection.
Monitor the patient for allergic reactions or adverse effects related to antibiotics.
Corticosteroids:

Corticosteroids (e.g., betamethasone or dexamethasone) are given to promote fetal lung maturity when preterm birth is anticipated.
Nurses may be responsible for administering corticosteroids, monitoring maternal and fetal responses, and educating the patient on the purpose and potential benefits for the baby.
Lab Work:

Order and monitor lab work as directed by healthcare providers, which may include blood tests, cultures, or other diagnostic studies to assess the patient’s condition.
Collaborate with the healthcare team to interpret lab results and implement appropriate interventions.
Educate:

Education is a vital component of nursing care for preterm labor. Provide thorough education on:
Signs and symptoms of preterm labor.
Medications, including tocolytics and corticosteroids.
Activity restrictions and bed rest if prescribed.
Self-monitoring techniques, such as counting fetal movements.
Importance of seeking immediate medical attention if symptoms worsen.
Emotional support and coping strategies for managing stress and anxiety.

Question 31

Post-Term Pregnancy.

Pregnancy lasting > 42 weeks gestation
Unknown etiology
Incorrect dating
Maternal injury
Fetal injury
Hypoxia
oligohydramnios

Answer 31

Definition: A post-term pregnancy is defined as one that has extended beyond 42 weeks of gestation, which is considered beyond the normal 40-week full-term duration.

Unknown Etiology: The exact cause of post-term pregnancy is often unknown. While many pregnancies naturally reach term (around 40 weeks), some continue beyond that point.

Incorrect Dating: In some cases, post-term pregnancies occur because the estimated due date was incorrectly calculated. Accurate dating of the pregnancy is essential to determine the gestational age.

Maternal Injury: Maternal injury or complications may contribute to post-term pregnancy. In some instances, an injury or health condition in the mother may result in the pregnancy continuing beyond the expected due date.

Fetal Injury: Similarly, fetal injury or complications can play a role in post-term pregnancies. These may include conditions that affect fetal well-being, leading to a delay in labor.

Hypoxia: Prolonged pregnancy can increase the risk of fetal hypoxia, which is a condition characterized by insufficient oxygen supply to the fetus. This can occur when the placenta’s function declines as the pregnancy progresses.

Oligohydramnios: Oligohydramnios is a condition characterized by a lower-than-normal level of amniotic fluid in the womb. It can be associated with post-term pregnancy and may raise concerns about fetal well-being due to reduced cushioning and protection for the baby.

Question 32

Post-term. Nursing Management

Answer 32

EFM Fetal wellbeing
BPP
Assessing maternal coping
Anticipate induction
Educate

Electronic Fetal Monitoring (EFM) for Fetal Well-Being:

Continuously monitor the fetal heart rate using EFM to assess fetal well-being.
Report any abnormalities in fetal heart rate patterns promptly to the healthcare provider.
Biophysical Profile (BPP):

A Biophysical Profile is a prenatal ultrasound evaluation that assesses fetal well-being by examining various fetal parameters, including fetal movements, breathing, muscle tone, amniotic fluid volume, and heart rate.
Nurses may assist in coordinating and facilitating BPP tests as ordered by healthcare providers.
Assessing Maternal Coping:

Recognize and assess maternal emotional and psychological well-being. Post-term pregnancies can be emotionally challenging for expectant mothers.
Provide emotional support, active listening, and counseling to help mothers cope with anxiety or concerns related to the extended pregnancy.
Anticipate Induction of Labor:

Collaborate with the healthcare team to anticipate the need for labor induction if the pregnancy exceeds a certain point beyond the due date or if there are concerns about fetal well-being.
Prepare the patient for the induction process, explain the reasons for induction, and address any questions or concerns.
Educate:

Provide comprehensive education to the patient about the potential risks and benefits of post-term pregnancy, induction of labor, and the monitoring process.
Ensure that the patient understands the importance of monitoring fetal movements and promptly reporting any changes or concerns.
Educate the patient on the signs of labor and when to contact healthcare providers if labor begins or if there are any concerns.

Question 33

Labor Induction or Augmentation. Induction

Stimulation of uterine contractions by medical or surgical means before onset of labor.
Maternal injury
Fetal injury
Medical reasons only

Answer 33

Stimulation of Uterine Contractions:

Labor induction involves initiating contractions of the uterine muscles before they begin naturally. This can be achieved through various methods, including medications, artificial rupture of membranes (amniotomy), or mechanical methods like cervical ripening with a Foley catheter or the use of a synthetic prostaglandin.
Medical or Surgical Means:

Labor induction can be accomplished using medical or surgical techniques, depending on the patient’s condition and the healthcare provider’s recommendations. Medications are the most common method, but surgical methods may be used in certain situations.
Before Onset of Labor:

Labor induction is typically performed when the woman has not gone into labor spontaneously or when labor has not progressed as expected.
Maternal Injury:

While labor induction is generally considered safe when performed under appropriate medical supervision, there can be risks and potential complications for the mother. These may include uterine hyperstimulation (excessive contractions), uterine rupture (rare but serious), infection, or other adverse reactions to medications used for induction.
Fetal Injury:

There are potential risks to the fetus when labor is induced, such as fetal distress due to uterine hyperstimulation, changes in fetal heart rate, or the need for operative interventions like forceps or vacuum extraction during delivery.
Medical Reasons Only:

Labor induction is not performed solely for convenience. It is reserved for situations where there are medical indications or reasons that make it safer for the mother or baby to deliver than to continue the pregnancy. Common medical reasons for induction include post-term pregnancy, preeclampsia, gestational diabetes, intrauterine growth restriction, and other maternal or fetal health concerns.

Question 34

Labor Induction or Augmentation. Induction. Nursing management

U/S fetal/placental positioning
Non-stress test (EFM)
Lab work
Cervical exam (Bishop scoring)
Non-pharmacological
Cervidil or misoprostol
Oxytocin IV
Pain management
Confirm gestational age
Educate
Informed consent

Answer 34

U/S Fetal/Placental Positioning:

Perform an ultrasound to assess fetal position and the location of the placenta. This information helps determine the safest approach for induction.
Non-Stress Test (EFM - Electronic Fetal Monitoring):

Initiate electronic fetal monitoring (EFM) to continuously assess fetal heart rate and uterine contractions, ensuring the baby’s well-being throughout the induction process.
Lab Work:

Order and monitor necessary lab work, such as blood tests, to assess the patient’s overall health and baseline values before induction.
Cervical Exam (Bishop Scoring):

Perform a cervical examination to assess the cervix’s readiness for labor induction. The Bishop scoring system helps determine the likelihood of a successful induction.
Non-Pharmacological Techniques:

Offer non-pharmacological pain relief methods, such as relaxation techniques, breathing exercises, and position changes to help the patient cope with contractions and discomfort.
Cervidil or Misoprostol:

Administer cervical ripening agents, such as Cervidil or misoprostol, if the cervix is not yet favorable for induction. These medications help soften and prepare the cervix for labor.
Oxytocin IV:

Initiate an intravenous (IV) infusion of oxytocin (Pitocin) to induce or augment labor. This medication stimulates uterine contractions.
Pain Management:

Provide pain management options, which may include epidural anesthesia, intramuscular or intravenous pain medications, or other techniques to relieve pain and discomfort during labor.
Confirm Gestational Age:

Verify the gestational age of the fetus through ultrasound or other methods to ensure that the induction is appropriate for the stage of pregnancy.
Educate:

Offer comprehensive education to the patient about the induction process, what to expect during labor, and potential interventions or complications.
Provide information about the expected course of labor, pain management choices, and the importance of fetal monitoring.
Informed Consent:

Obtain informed consent from the patient, ensuring she understands the risks, benefits, and alternatives associated with labor induction.
Ensure the patient has the opportunity to ask questions and make informed decisions regarding her care.

Question 35

Oxytocin Administration

Side effects – water intoxication, hypotension, & uterine hypertonicity
Short half-life (1-5) minutes, works well for titration
Use facility protocol
Does not cross the placental barrier.
Continuous EFM – document every 15” during active phase and every 5” during2nd stage
Fluid balance assessment

Answer 35

Side Effects:

Oxytocin administration can lead to side effects, including:
Water Intoxication: Excessive oxytocin can cause water retention, leading to water intoxication, which can be harmful.
Hypotension: Oxytocin can cause a drop in blood pressure, especially if administered too quickly or at high doses.
Uterine Hypertonicity: Excessive uterine contractions (hypertonicity) can occur, potentially compromising fetal oxygenation. Proper dosing and monitoring are crucial to prevent this.
Short Half-Life:

Oxytocin has a short half-life, typically ranging from 1 to 5 minutes. This short duration of action makes it suitable for titration, allowing healthcare providers to adjust the dose as needed to achieve the desired uterine contractions.
Facility Protocol:

Oxytocin administration should follow the facility’s established protocols and guidelines. Protocols outline the appropriate dosing, monitoring, and safety measures to ensure the well-being of both the mother and the baby.
Does Not Cross the Placental Barrier:

One advantage of oxytocin is that it does not cross the placental barrier. This means that it does not directly affect the fetus, making it a safer option for labor induction or augmentation.
Continuous Electronic Fetal Monitoring (EFM):

When oxytocin is used, continuous electronic fetal monitoring (EFM) is typically employed to assess the fetal heart rate and uterine contractions.
During the active phase of labor, the fetal heart rate and uterine contractions are often documented every 15 minutes.
In the second stage of labor (when the baby is descending), monitoring becomes more frequent, with documentation every 5 minutes to closely observe fetal well-being.
Fluid Balance Assessment:

Monitoring the patient’s fluid balance is essential when oxytocin is administered.
Assess urine output and input, as excessive fluid retention can lead to water intoxication.
Maintain appropriate fluid administration, and be cautious about overhydration.

Question 36

VBAC

Vaginal birth after cesarean birth
Contraindicated if they had a classic incision
Why did they need a cesarean?
Contraindications
Uterine rupture

Answer 36

VBAC Definition: VBAC is a planned vaginal delivery for individuals who have had a previous C-section. It is an alternative to having a repeat C-section for subsequent pregnancies.

Contraindication for Classic Incision: VBAC is generally contraindicated if the individual had a “classic” uterine incision during their previous C-section. A classic incision is a vertical incision on the uterus, which carries a higher risk of uterine rupture during a trial of labor.

Reason for Previous C-Section: The reason for the previous C-section plays a significant role in determining whether a person is a suitable candidate for VBAC. If the previous C-section was due to a specific medical condition or complication, the healthcare provider will consider this when assessing the eligibility for VBAC.

Contraindications: While VBAC can be a safe and successful option for many individuals, there are contraindications and factors that may make it less suitable or even risky. Some contraindications to VBAC include:

Prior classic uterine incision.
Multiple prior C-sections.
Certain medical conditions or pregnancy complications.
An unresolved reason for the previous C-section that still exists in the current pregnancy.
Uterine Rupture: One of the most significant risks associated with VBAC is uterine rupture. Uterine rupture is a rare but potentially life-threatening complication where the uterine scar from the previous C-section tears during labor, which can lead to severe bleeding and harm to the baby. This risk is higher in individuals with a classic uterine incision and other specific factors.

Question 37

VBAC. Nursing Management

Answer 37

Continuous EFM
Pain management
Consent form signed
Advise OR, Anesthesia of VBAC
Educate

Question 38

Intrauterine Fetal Demise. IUFD

Fetal death occurring > 20weeks but before birth
Maternal injury
Shock
Induction wanted by most women

Answer 38

Induction wanted by most women

Definition: IUFD is the medical term used to describe fetal death that occurs after the 20th week of pregnancy but before the baby is born. It is also sometimes referred to as stillbirth.

Maternal Injury and Shock: While IUFD is primarily a fetal condition, the emotional and psychological impact on the mother can be significant. Experiencing the loss of a baby can lead to intense grief and emotional distress, which may have physical manifestations like shock or profound sadness.

Induction: In many cases of IUFD, labor induction is recommended. Induction involves using medications or other medical interventions to initiate labor and deliver the baby. Induction is often wanted by most women who have experienced IUFD because it offers a way to bring closure, physically and emotionally, to the pregnancy.

Induction may involve the use of medications like oxytocin to stimulate contractions or other methods to ripen the cervix and prepare it for labor.
The timing of induction is typically determined based on various factors, including the mother’s health, the cause of IUFD, and the gestational age at which the fetal demise occurred.

Question 39

Intrauterine Fetal Demise. IUFD. Nursing Management

EFM for contractions only
Recovery care
Environment
Allow grieving
Allow unlimited time with stillborn
Provide baby mementos
Follow facility guidelines
Educate – support groups

Answer 39

Electronic Fetal Monitoring (EFM) for Contractions Only:

While continuous EFM for fetal heart rate may not be necessary, monitor contractions to assess uterine activity during labor induction or if the mother experiences contractions.
Recovery Care:

Assist with recovery care following the delivery, which may include monitoring vital signs, checking for postpartum hemorrhage, and assessing the mother’s physical condition.
Environment:

Create a sensitive and supportive environment in the labor and delivery suite that respects the emotional needs of the parents and family.
Ensure privacy and comfort for the grieving family.
Allow Grieving:

Encourage parents to express their emotions, including grief, anger, sadness, and confusion. Offer a compassionate and nonjudgmental presence.
Listen actively to their feelings and concerns.
Allow Unlimited Time with Stillborn Baby:

Give the parents the option to spend as much time as they need with their stillborn baby. This allows for bonding, saying goodbye, and creating lasting memories.
Provide Baby Mementos:

Offer keepsakes and mementos, such as handprints, footprints, locks of hair, or photographs, to help the parents remember their baby.
Follow Facility Guidelines:

Follow the facility’s established protocols for handling IUFD cases and providing bereavement support. Ensure that legal and ethical requirements are met.
Educate and Offer Support Groups:

Educate the parents about the grieving process and available support resources, including bereavement support groups, counseling, and community services.
Provide information on the options available for memorial services or ceremonies.
Continued Support:

Continue to offer emotional support to the parents during their hospital stay and provide contact information for support resources after discharge.
Respect Cultural and Religious Preferences:

Be aware of and respect the cultural and religious preferences of the parents, which may influence their grieving process and rituals.

Question 40

Obstetric Emergencies

Umbilical cord prolapse
Placenta Previa, Placenta Abruption
Uterine Rupture

Answer 40

Obstetric emergencies are critical situations that can occur during pregnancy, labor, or delivery, requiring immediate medical attention and intervention. Here are three obstetric emergencies:

Umbilical Cord Prolapse:

Umbilical cord prolapse is a rare but serious emergency where the umbilical cord slips through the cervix ahead of the baby’s head. This can lead to compression or occlusion of the cord, potentially compromising the baby’s oxygen supply.
Signs and symptoms may include variable fetal heart rate decelerations, a visible or palpable cord in the vaginal canal, and maternal and fetal distress.
Immediate actions include calling for help, positioning the mother with hips elevated and knees to chest to relieve cord compression, and providing continuous fetal monitoring.
Emergency cesarean delivery is often necessary.
Placenta Previa:

Placenta previa is a condition where the placenta partially or completely covers the cervix. This can lead to painless vaginal bleeding in the second or third trimester.
Signs and symptoms include bright red vaginal bleeding, often without pain, during the later stages of pregnancy.
Immediate management includes bed rest, monitoring the mother and baby, and avoiding vaginal exams.
Delivery may be scheduled by cesarean section, depending on the severity and location of the placenta.
Placental Abruption:

Placental abruption occurs when the placenta prematurely separates from the uterine wall before delivery, causing bleeding behind the placenta.
Signs and symptoms may include sudden and severe abdominal pain, vaginal bleeding, uterine tenderness, and fetal distress.
Immediate actions include stabilizing the mother’s vital signs, providing blood transfusions if necessary, and delivering the baby, often via cesarean section.
Placental abruption is a life-threatening emergency requiring prompt intervention.
Uterine Rupture:

Uterine rupture is a rare but critical event where the uterine wall tears, potentially leading to severe maternal and fetal complications.
Signs and symptoms include sudden, intense abdominal pain, abnormal fetal heart rate patterns, and signs of shock in the mother.
Immediate surgical intervention, typically via emergency cesarean section, is necessary to repair the uterine rupture and deliver the baby.

Question 41

Umbilical Cord Prolapse (to fall down” or “to slip forth.)

Umbilical cord is either visualized or is palpated with cervical exam.
Hypoxia for fetuscan lead to asphyxia and death.
50% mortality rate
Cesarean birth

Answer 41

Umbilical cord prolapse is a rare but serious obstetric emergency that occurs when the umbilical cord descends through the cervix ahead of the presenting part of the fetus. This can result in compression or occlusion of the cord, which can compromise the baby’s oxygen supply. Here are some key points to understand about umbilical cord prolapse:

Identification: Umbilical cord prolapse can be identified when the umbilical cord is either visualized or palpated during a cervical examination. It is considered an obstetric emergency that requires immediate medical attention.

Hypoxia and Asphyxia: Umbilical cord prolapse poses a significant risk to the fetus. When the cord is compressed or blocked, it can lead to reduced blood flow and oxygen supply to the baby. This can result in fetal hypoxia (oxygen deficiency) and, if left unaddressed, can progress to fetal asphyxia, which is a life-threatening condition.

Mortality Rate: Umbilical cord prolapse is associated with a high risk of fetal mortality. The severity of the outcome can vary depending on factors such as the duration of cord compression, the baby’s gestational age, and the promptness of medical intervention. The reported mortality rate is approximately 50%.

Cesarean Birth: In most cases of umbilical cord prolapse, a cesarean section (C-section) is the recommended mode of delivery. A C-section can be performed more quickly than a vaginal delivery in such emergencies and can help ensure the baby’s safe and rapid delivery.

Question 42

Umbilical Cord Prolapse. Nursing Management

Assessing EFM
Keep fingers in between cervix and head
Call for help
Trendelenburg or hands/knee position
Immediate cesarean
Educate

Answer 42

Assessing Electronic Fetal Monitoring (EFM):

Continuously monitor the fetal heart rate (EFM) to assess for signs of fetal distress, such as variable decelerations or bradycardia, which may indicate cord compression.
Keep Fingers in Between Cervix and Head:

If you can safely do so, gently insert sterile, gloved fingers into the vagina to create a protective barrier between the baby’s presenting part (usually the head) and the umbilical cord. This may help alleviate cord compression temporarily.
Call for Help:

Immediately call for assistance from the healthcare provider, obstetric team, or emergency response team. Timely intervention is crucial in managing umbilical cord prolapse.
Trendelenburg or Hands/Knees Position:

Position the mother to help alleviate cord compression. The Trendelenburg position or the hands-and-knees position may be used to encourage the baby’s head to move away from the prolapsed cord, reducing pressure and compression.
Immediate Cesarean Section:

In most cases of umbilical cord prolapse, an emergency cesarean section (C-section) is indicated. Prepare the mother for surgery, ensuring that she understands the urgency of the situation.
Educate:

After the immediate crisis has been managed, provide education to the mother and her support system about what occurred and why an emergency C-section was necessary. Offer emotional support and address any questions or concerns they may have.

Question 43

Placenta Previa

Complete or partial covering of the internal os by the placenta
Placental separation with cervical dilation
Hemorrhage/hysterectomy
Fetal hypoxia and/or death
Vaginal bleeding > 24 weeks gestation
Vaginal U/S increase the accuracy of diagnosis,all placentas covering part of the cervix are placenta previa, those close to cervix are termed low-lying

Answer 43

Definition: Placenta previa is characterized by the placement of the placenta in such a way that it partially or completely obstructs the cervical opening, making it low-lying or covering the cervix.

Placental Separation and Hemorrhage: Placenta previa can increase the risk of placental separation from the uterine wall, especially during labor. This separation can lead to significant vaginal bleeding, which can be life-threatening for both the mother and the baby. In severe cases, a hysterectomy may be necessary to control bleeding.

Fetal Hypoxia and Death: The obstruction of the cervix by the placenta can potentially lead to fetal hypoxia (oxygen deficiency) due to compromised blood flow. Severe cases of placenta previa can result in fetal distress and even fetal death if not managed promptly.

Vaginal Bleeding: Vaginal bleeding is a hallmark symptom of placenta previa and often occurs after 24 weeks of gestation. The bleeding may be painless, but it is usually bright red and can be profuse.

Diagnosis: Diagnosis of placenta previa is typically confirmed through ultrasound (U/S) imaging. Transvaginal ultrasound is especially useful in assessing the exact location of the placenta and whether it covers or is close to the cervical os.

Types of Placenta Previa: Placenta previa can be categorized into different types based on the proximity of the placenta to the cervical os:

Complete Placenta Previa: The placenta completely covers the cervical os.
Partial Placenta Previa: The placenta partially covers the cervical os.
Low-Lying Placenta: In some cases, the placenta may be located near the cervix but not directly covering it. This is referred to as a low-lying placenta.

Question 44

Placenta Previa. Nursing Management

Partial – bedrest, EFM
Measure blood loss
Possible blood transfusion
Check for sepsis
Plan for cesarean delivery
U/S for confirmation
Administer Rhogam if indicated
Administer steroids if indicated
Educate

Answer 44

Partial Hysterectomy: A partial hysterectomy involves the removal of the upper part of the uterus while leaving the cervix intact.

Bedrest and Monitoring:

After surgery, the patient will typically require bedrest to facilitate healing and recovery.
Continuously monitor vital signs, including blood pressure, heart rate, and respiratory rate.
Utilize electronic fetal monitoring (EFM) to assess the fetal heart rate if the patient is pregnant.
Blood Loss Measurement:

Accurately measure and document any postoperative vaginal bleeding to monitor for excessive bleeding.
Blood Transfusion:

In cases of significant blood loss, a blood transfusion may be necessary. Ensure compatibility and monitor the patient’s response closely.
Infection Prevention:

Carefully assess the surgical site for signs of infection, such as redness, swelling, or drainage. Promptly report any signs of infection.
Monitor for signs and symptoms of sepsis, a serious infection that can occur after surgery.
Cesarean Delivery Planning:

If the patient is pregnant and requires a partial hysterectomy, plan for a cesarean section (C-section) if it hasn’t already been performed.
Ultrasound (U/S) Confirmation:

Utilize ultrasound to confirm the success of the partial hysterectomy and assess the postoperative condition of the patient.
Rhogam Administration:

Administer Rhogam, an immunoglobulin, if indicated and the patient is Rh-negative and the baby is Rh-positive. This helps prevent Rh sensitization in future pregnancies.
Steroid Administration:

Administer steroids if indicated, particularly if the patient is at risk of preterm birth. Steroids help mature the baby’s lungs to improve outcomes if delivery is necessary.

Question 45

Uterine Rupture.

Catastrophic tearing of the uterus at a previous scar.
Sudden fetal bradycardia
Constantabdominal pain, vaginal bleeding, loss of fetal station,maternalhypovolemic shock
Fetalmorbidity or mortality

Answer 45

Causes: Uterine rupture typically occurs at a previous scar site on the uterus, often where a previous cesarean section incision or other uterine surgery has taken place. It can also occur in cases of uterine trauma or weakness.

Signs and Symptoms:

Sudden Fetal Bradycardia: One of the hallmark signs of uterine rupture is a sudden and severe drop in the fetal heart rate (bradycardia), indicating fetal distress.
Constant Abdominal Pain: The mother may experience intense, constant abdominal pain, which can be localized or diffuse.
Vaginal Bleeding: Vaginal bleeding is often present, and it can range from moderate to severe.
Loss of Fetal Station: The fetus may no longer be palpable through the abdominal wall or may change position, indicating a shift in the uterine contents.
Maternal Hypovolemic Shock: Due to significant blood loss from uterine rupture and vaginal bleeding, the mother may develop hypovolemic shock, a life-threatening condition characterized by low blood pressure, rapid heart rate, and inadequate organ perfusion.
Complications: Uterine rupture is associated with fetal morbidity and mortality. The baby may experience oxygen deprivation and other complications due to the disruption in blood flow. Maternal complications can include severe hemorrhage, shock, and the need for emergency surgery.

Diagnosis: Diagnosis of uterine rupture is based on clinical signs and symptoms, fetal heart rate monitoring, and imaging studies, such as ultrasound or MRI.

Treatment: Uterine rupture is a medical emergency, and prompt intervention is essential. Treatment options may include:

Immediate cesarean section to deliver the baby and repair the uterine rupture.
Blood transfusions to address maternal hemorrhage.
Additional surgical procedures to manage complications.
Prevention: Uterine rupture prevention may involve careful monitoring of patients with uterine scars, especially during labor. The mode of delivery (vaginal birth after cesarean or repeat cesarean section) should be determined based on the individual’s medical history and the risk of uterine rupture.

Question 46

Uterine Rupture. Nursing Management

Answer 46

Assess maternal history
EFM
Alert OR, anesthesia VBAC is being attempted
Immediate cesarean/hysterectomy
IV fluids for volume replacement
Educate

Question 47

Uterine Inversion part 1

Uterine inversion occurs when the uterine fundus collapses into the endometrial cavity, turning the uterus partially or completely inside out. It is a rare complication of vaginal or cesarean delivery
●1stdegree (also called incomplete) – The fundus is within the endometrial cavity
●2nddegree (also called complete) – The fundus protrudes through the cervical os
●3rddegree (also called prolapsed) – The fundus protrudes to or beyond the introitus
●4thdegree (also called total) – Both the uterus and vagina are inverted.

Answer 47

Uterine inversion is a rare but serious obstetric complication in which the uterine fundus collapses into the endometrial cavity, essentially turning the uterus partially or completely inside out. This condition can occur as a result of various factors, including trauma during childbirth. Uterine inversion is classified into different degrees based on the extent of the inversion, ranging from first-degree to fourth-degree. Here is an overview of the degrees of uterine inversion:

First-Degree Uterine Inversion (Incomplete):

In a first-degree uterine inversion, the uterine fundus remains within the endometrial cavity but begins to turn inward.
This is the mildest form of uterine inversion, and the uterus is not protruding through the cervical os.
Second-Degree Uterine Inversion (Complete):

In a second-degree uterine inversion, the uterine fundus continues to collapse and protrudes through the cervical os.
The uterus is partially inverted, with part of it extending outside the cervix into the vaginal canal.
Third-Degree Uterine Inversion (Prolapsed):

A third-degree uterine inversion is characterized by the uterine fundus protruding to or beyond the vaginal introitus.
This degree of inversion is more severe, with a significant portion of the uterus outside the body.
Fourth-Degree Uterine Inversion (Total):

In a fourth-degree uterine inversion, both the uterus and the vagina are inverted.
This is the most severe form of uterine inversion, and the entire uterus and vagina are turned inside out.

Question 48

Uterine Inversion part 2

Discontinue uterotonic drugs
Call for immediate assistance
Establish adequate intravenous access and aggressive fluid/blood product resuscitation
Do not remove the placenta
Immediately attempt to manually replace the inverted uterus
Give uterine relaxants
Prepare for surgical repair if the above interventions do not work.
Oxygen
Blood transfusions

Answer 48

Discontinue Uterotonic Drugs: If uterine inversion occurs during or after childbirth, immediately discontinue any uterotonic drugs that may have been administered, as these drugs can exacerbate uterine contractions and worsen the inversion.

Call for Immediate Assistance: Uterine inversion is a medical emergency. Notify the healthcare team and call for immediate assistance, including obstetricians, surgeons, and anesthesia providers.

Establish Adequate Intravenous Access: Start an intravenous (IV) line to provide aggressive fluid and blood product resuscitation. This helps address any blood loss and maintain hemodynamic stability.

Do Not Remove the Placenta: It is essential not to remove the placenta before addressing the uterine inversion. Removing the placenta first can exacerbate the condition and make it more challenging to correct.

Attempt Manual Replacement: The primary intervention is to attempt manual replacement of the inverted uterus. This is typically done by a skilled healthcare provider, such as an obstetrician. The goal is to gently manipulate the uterus back to its normal position.

Give Uterine Relaxants: Uterine relaxants or tocolytic medications may be administered to help relax the uterine muscles and facilitate the manual replacement of the uterus. Common medications include terbutaline or nitroglycerin.

Prepare for Surgical Repair: If attempts at manual replacement are unsuccessful or if the uterine inversion is severe, surgical repair may be necessary. Preparations for surgery should be made promptly.

Oxygen: Administer oxygen to the mother to ensure adequate oxygenation and support her respiratory function during the emergency.

Blood Transfusions: Depending on the extent of blood loss and the patient’s hemodynamic status, blood transfusions may be required to address anemia and maintain adequate blood volume.

Continuous Monitoring: Continuously monitor the mother’s vital signs, including blood pressure, heart rate, respiratory rate, and oxygen saturation, to assess her overall condition and response to interventions.

Question 49

Anaphylactoid Syndrome of Pregnancy

Amniotic fluid containing fetal particles enters maternal blood stream blocks pulmonary vessels.
a.k.a. “amniotic fluid emboli”.
Rare and often fatal
1 in 40,000 births with 20% mortality rate (50% in the 1st hour)
Fetal & Maternal hypoxicneurologicdamage

Answer 49

Anaphylactoid Syndrome of Pregnancy (ASP), also known as “amniotic fluid embolism” (AFE), is a rare but life-threatening obstetric emergency that can occur during pregnancy, labor, or immediately following childbirth. ASP involves the entry of amniotic fluid containing fetal cells and debris into the maternal bloodstream, which can lead to severe and rapid complications. Here are key points to understand about ASP:

Mechanism of Occurrence: ASP typically occurs when there is a rupture or disruption of the fetal membranes (amniotic sac) or placenta, allowing amniotic fluid, fetal cells, and other material to enter the maternal bloodstream. This can happen during labor, childbirth, or certain medical procedures, but the exact cause is not always clear.

Presentation: The syndrome can manifest with a wide range of symptoms, including sudden and severe respiratory distress, cardiovascular collapse, hypotension (low blood pressure), hypoxia (oxygen deficiency), coagulation abnormalities, and neurologic symptoms.

Incidence: ASP is extremely rare, occurring in approximately 1 in 40,000 births. Despite its rarity, it is associated with a high mortality rate, with about 20% of cases resulting in maternal death. A significant portion of these deaths occurs within the first hour after the onset of symptoms.

Fetal and Maternal Complications: ASP can lead to both fetal and maternal complications. Fetal complications may include hypoxia and neurologic damage, while maternal complications can involve cardiovascular collapse, hemorrhage, and organ failure.

Management: ASP is a medical emergency, and management involves prompt and coordinated efforts to stabilize the patient. Treatment may include cardiopulmonary resuscitation (CPR), administration of oxygen, blood transfusions, medications to support blood pressure, and interventions to correct coagulation abnormalities.

Prevention: Since the exact cause of ASP is often unclear, prevention strategies are limited. Healthcare providers should be vigilant in monitoring patients during labor and childbirth, especially those at high risk, and be prepared to respond rapidly to any signs or symptoms of the syndrome.

Question 50

Anaphylactoid Syndrome of Pregnancy. Nursing Management

Recognize symptoms – sudden onset of hypotension, cardiac collapse, and respiratory distress.
Resuscitation,100% oxygen
IV fluids to maintain cardiac output/B/P
Hemorrhage control
Steroids for inflammatory process
Seizureprecautions
Transfer to ICU
Educate

Answer 50

Recognition of Symptoms: Nurses should be vigilant in recognizing the early signs and symptoms of ASP, which may include a sudden onset of hypotension, cardiac collapse, respiratory distress, and other systemic manifestations. Early recognition is essential for prompt intervention.

Resuscitation and Oxygen: Initiate immediate resuscitation measures, including cardiopulmonary resuscitation (CPR) if necessary. Administer 100% oxygen to support oxygenation and address hypoxia, as respiratory distress is a hallmark feature of ASP.

Intravenous (IV) Fluids: Establish and maintain intravenous access to provide fluids and medications. IV fluids are essential for maintaining cardiac output and blood pressure, as hypotension is a common manifestation of ASP. Monitor the patient’s hemodynamic status closely and adjust fluid administration accordingly.

Hemorrhage Control: ASP can lead to coagulation abnormalities and bleeding. Assess for signs of hemorrhage and implement measures to control bleeding, such as uterine massage and administration of blood products if needed.

Steroids: Administer steroids as prescribed by the healthcare provider. Steroids may be given to address the inflammatory response associated with ASP and help mitigate its effects.

Seizure Precautions: Due to the potential for neurologic symptoms and seizures in ASP, take precautions to ensure the safety of the patient. This may include maintaining a safe environment, using padded side rails, and having appropriate seizure medications readily available.

Transfer to ICU: Following initial stabilization, transfer the patient to the intensive care unit (ICU) or a high-level care setting for continued monitoring and management. ASP is a complex and potentially life-threatening condition that requires close observation and expert care.

Patient and Family Education: While the immediate focus is on stabilizing the patient, provide information and support to the patient and their family. Keep them informed about the patient’s condition, treatment, and progress. Offer emotional support during this challenging time.

Question 51

Birth-related Procedures

Forceps
Vacuum
Cesarean Birth

Answer 51

Birth-related procedures are medical interventions that may be employed during labor and childbirth to assist in the safe delivery of a baby or in the management of specific obstetric situations. Here are three common birth-related procedures:

Forceps Delivery:

Description: Forceps are specialized surgical instruments that resemble large spoons or tongs. They are carefully applied to the baby’s head to assist in guiding the baby through the birth canal during a vaginal delivery.
Indications: Forceps may be used when there is a need to expedite delivery due to concerns about the baby’s well-being, maternal exhaustion, or specific fetal positions that make delivery challenging.
Procedure: The healthcare provider applies forceps to the baby’s head and uses them to gently guide the baby’s descent through the birth canal during contractions.
Considerations: Forceps deliveries require expertise, and the procedure is typically performed by an obstetrician skilled in operative vaginal deliveries. It is important to assess the baby’s position and the mother’s pelvis before attempting a forceps delivery.
Vacuum Extraction:

Description: Vacuum extraction, also known as vacuum-assisted delivery, involves the use of a vacuum device attached to the baby’s head to facilitate delivery during a vaginal birth.
Indications: Vacuum extraction may be used when there is a need to assist with the baby’s birth, similar to forceps delivery, but the choice between vacuum and forceps often depends on provider preference and clinical circumstances.
Procedure: A soft cup is attached to the baby’s head, and suction is applied. During contractions, the healthcare provider gently guides and assists the baby’s descent through the birth canal.
Considerations: As with forceps, vacuum extraction requires skill and experience. Careful assessment of the baby’s position and maternal pelvis is crucial. Vacuum extraction is often preferred for certain clinical scenarios, such as fetal distress or maternal fatigue.
Cesarean Birth (C-Section):

Description: A cesarean birth, commonly known as a C-section, is a surgical procedure in which the baby is delivered through an incision made in the mother’s abdomen and uterus.
Indications: Cesarean births are performed for various medical reasons, including fetal distress, breech presentation, placenta previa, previous C-section scar, or maternal health concerns.
Procedure: The mother is typically administered anesthesia (either spinal, epidural, or general) before a surgical incision is made. The baby is then carefully delivered through the incision.
Considerations: Cesarean births are major surgical procedures and are performed when the health and well-being of the mother or baby are at risk. Recovery after a C-section may take longer compared to a vaginal birth.

Question 52

Forceps.

Metal instruments look like large tongs
Lock so as not to crush fetal skull
Outlet forceps & Low forceps
Fetal injury

Answer 52

Forceps are specialized metal instruments that resemble large tongs and are used in obstetrics to assist in the vaginal delivery of a baby. These instruments are designed to safely grip the baby’s head and provide guidance during the final stages of labor. Forceps can be a valuable tool when used by skilled healthcare providers but must be employed with caution due to the potential for both fetal and maternal complications. Here are some key points to understand about forceps:

Instrument Design: Forceps are designed with two curved blades that come together to form a controlled grip on the baby’s head. The blades lock in place to ensure a secure hold without crushing the fetal skull.

Types of Forceps: There are different types of forceps, including:

Outlet Forceps: These are used when the baby’s head is visible at the vaginal opening (crowning) and is typically low in the birth canal. Outlet forceps are used in the later stages of labor.
Low Forceps: Low forceps are used when the baby’s head is higher in the birth canal and may not be visible at the vaginal opening. They are applied when the baby is engaged in the pelvis but has not descended as far as in outlet forceps deliveries.
Indications: Forceps may be indicated in various situations, including maternal exhaustion, prolonged second-stage labor, concerns about fetal distress, and specific fetal positions that make delivery challenging.

Fetal Injury Risk: While forceps can be a valuable tool, there is a risk of fetal injury, especially if the procedure is not performed correctly or if excessive force is applied. Common fetal injuries associated with forceps deliveries include bruising or molding of the baby’s head.

Maternal Injury Risk: Maternal injuries during forceps deliveries are rare but can occur. These injuries may include vaginal lacerations or tears, perineal trauma, and discomfort during the recovery period.

Skill and Experience: The use of forceps requires skill and experience. Obstetricians and healthcare providers who are trained in operative vaginal deliveries are typically the ones who use forceps.

Informed Consent: Before performing a forceps delivery, healthcare providers should obtain informed consent from the mother, explaining the reasons for the procedure, its risks and benefits, and alternative delivery options.
Maternal Injury

Question 53

Forceps. Nursing Management

Answer 53

EFM
Mark application time, and amount of time for each pull. (work with contractions).
Assess maternal tissues for damage & hemorrhage
Assess fetalface and skull for soft tissue damage
Educate

Question 54

Check video slide 36 - 38- 40

Question 55

Vacuum Extractor

Soft cup placed on the occiput with negative pressure
Fetal Injury
Maternal Injury
2 types

Answer 55

Soft Cup Placement: A vacuum extractor typically includes a soft, flexible cup that is placed on the baby’s head. The cup is carefully positioned on the occiput, which is the back of the baby’s head.

Negative Pressure: Negative pressure is created within the cup, which causes it to grip the baby’s head securely. The vacuum pressure assists in the baby’s descent during contractions.

Types of Vacuum Extractors: There are two main types of vacuum extractors:

Mains-Powered Vacuum Extractor: This type of vacuum extractor is powered by an electrical source and provides consistent suction force. It is less common and typically used in specialized settings.
Manual Vacuum Extractor: The manual vacuum extractor is hand-operated, allowing the healthcare provider to control the level of suction. It is the more commonly used type of vacuum extractor.

Question 56

Vacuum Extractor. Nursing Management

Answer 56

EFM
Mark application time, and amountof time for each pull. (work withcontractions).
Mark pop-offs
Assess forneonate injury
Assess for maternal injury
Educate

Question 57

Cesarean Birth. Cesarean

Answer 57

Neonate born through an incision of the abdomen and uterine walls.
Most common surgery in theU.S.
Maternal complications
Fetal injury

Question 58

Cesarean Birth. Nursing Management

Preoperative blood work and education
EFM
Type & Cross Blood
U/S for fetal & placental lie
Informed consent
Educate partner
Post-operative care – policy protocol
Educate

Answer 58

Nursing management plays a crucial role in ensuring the safety and well-being of the mother and baby during a Cesarean birth (C-section) and in the postoperative period. Here are key nursing interventions and considerations for C-section nursing management:

Preoperative Preparation:

Blood Work: Ensure that preoperative blood work is completed as required by the facility’s protocols. This may include a complete blood count (CBC) and blood type and Rh factor testing.
Education: Provide thorough preoperative education to the mother regarding the C-section procedure, what to expect before, during, and after surgery, and postoperative care instructions.
Electronic Fetal Monitoring (EFM): Continuously monitor the fetal heart rate using electronic fetal monitoring to assess the baby’s well-being before and during the surgery.

Type and Cross Blood: Ensure that type and crossmatch blood is available in case it is needed during or after the surgery. This is a precautionary measure to address potential hemorrhage.

Ultrasound (U/S): Conduct an ultrasound to confirm the fetal and placental lie to guide the surgical incision placement and ensure the baby’s safe delivery.

Informed Consent: Verify that informed consent has been obtained from the mother. Ensure that she understands the reasons for the C-section, the surgical procedure, potential risks and complications, and alternative options. Answer any questions or concerns the mother may have.

Educate Partner or Support Person: If the mother has a partner or support person present, provide them with information about their role during the C-section, what to expect, and how to support the mother emotionally and physically.

Postoperative Care: Following the C-section, adhere to the facility’s postoperative care policy and protocol. Monitor the mother’s vital signs, assess the incision site for signs of infection or complications, and administer pain relief as prescribed.

Neonatal Care: Depending on the facility’s policies, neonatal care may involve immediate assessment, stabilization, and bonding between the mother and baby after the surgery.

Emotional Support: Offer emotional support to the mother and her support person. A C-section can be emotionally challenging, and providing reassurance and empathy is important.

Breastfeeding Support: Encourage and assist with breastfeeding initiation if the mother desires and is medically able to do so. Address any breastfeeding questions or concerns.

Pain Management: Administer pain medication as prescribed to manage postoperative pain. Educate the mother on pain management techniques and when to request pain relief.

Assessment and Documentation: Continuously assess and document the mother’s condition, including vital signs, incision site, uterine tone, and any complications or concerns.

Postoperative Education: Provide postoperative education to the mother, including instructions on incision care, wound healing, and signs of infection or complications to watch for after discharge.

Question 59

Brachial plexus palsy, also known as brachial plexus injury, is a condition that can occur during childbirth when there is damage to the network of nerves controlling the arm and hand muscles

Answer 59

caused by shoulder dystocia