Nursing Management of Labor/Birth at Risk Flashcards
1
Q
Dystocia
A
abnormal or difficult labor
-slow abnormal progression of labor
2
Q
Hypertonic Uterine Dysfunction
A
occurs when the uterus never fully relaxes between contractions
-prolonged latent phase = stays at 2-3 cm and do NOT dilate as they should
3
Q
Hypotonic Uterine Dysfunction
A
occurs during active labor; dilation more than 5-6 cm; when contractions become poor in quality and lack sufficient intensity to dilate and efface cervix
4
Q
What factors are associated with Hypotonic Uterine Dysfunction?
A
Overstretching of the uterus Large fetus Multiple fetuses Hydramnios Multiple parity Bowel/bladder distention Excessive use of analgesia
5
Q
What is the major risk with Hypotonic Uterine Dysfunction after birth?
A
Hemorrhage after giving birth because the uterus cannot contract effectively to compress blood vessels
6
Q
Labor
A
refers to uterine contractions resulting in progressive dilation and effacement of cervix and accompanied by descent and expulsion of fetus
7
Q
Protracted Disorders
A
series of events including slower than normal rate if cervical dilation and delayed descent of fetus
8
Q
Arrest Disorders
A
complete cessation of progress
9
Q
Precipitate Labor
A
labor that is completes in less than 3 hours from the start of contractions to birth
10
Q
Maternal Trauma from Precipitate Labor
A
- Cervical lacerations
- Uterine rupture
11
Q
Potential Fetal complications from Precipitate Labor
A
Intracranial hemorrhage
Nerve damage
Hypoxia
12
Q
Problems with Powers
A
Hypertonic uterine dysfunction Hypotonic uterine dysfunction Protracted disorders Arrest disorders Precipitate labor
13
Q
Problems with Passenger
A
Occiput posterior position Breech presentation Multifetal pregnancy Macrosomia and CPD Structural abnormalities
14
Q
Occiput Posterior Position
A
- Most common malposition
- Presents slightly larger diameters to the maternal pelvis first
15
Q
External Cephalic Version
A
a procedure in which the fetus is rotated from breech to the cephalic presentation by manipulation through the mother’s abdominal wall
16
Q
Breech Position
A
Buttocks or feet presenting first
17
Q
Shoulder Dystocia
A
obstruction of fetal descent and birth by the axis of the fetal shoulders after the fetal head has been delivered
18
Q
Multifetal Pregnancy
A
twins, triplets, or more infants within a single pregnancy
19
Q
What is the most common maternal complication with multifetal pregnancies?
A
Postpartum hemorrhage resulting from uterine atony
20
Q
Macrosomia
A
Newborn weighs 8.81-9.92 lbs or more at birth
-result of change in body composition w/ an increase in percentage of fat and fat mass
21
Q
Macrosomia as been associated with what complications later in life?
A
Obesity
Diabetes
Cardiovascular disease
22
Q
Problems with Passageway
A
Pelvic contraction
Obstructions in maternal birth canal
23
Q
Contraction of the midpelvis is bad because it can cause what?
A
Arrest of fetal descent
24
Q
Obstructions of Maternal Birth Canal
A
Swelling of soft maternal tissue and cervix
Termed soft tissue dystocia
25
Problems with Psyche
Psychological distress
| -fear, anxiety, helplessness, isolation, and weariness
26
Nursing Management for Dystocia
```
History of risk factors
Maternal frame of mind
Vital Signs
Uterine contractions
FHR, fetal position
```
27
Nursing Management for Dystocia
Promoting labor progress
Providing physical and emotional comfort
Promoting empowerment
28
How often should you monitor the clients bladder for distention?
q 2hours
29
Preterm Labor
occurrence of regular uterine contractions accompanied by cervical effacement and dilation before the end of the 37th week of gestation
30
What is one of the most common obstetric complications?
Preterm labor
31
When is predicting the risk of preterm labor valuable?
When there is an available intervention that is likely to improve the situation
32
Tocolytic Drugs
No clear first-line drugs to manage preterm labor
| -may prolong pregnancy for 2-7 days while steroids can be given for fetal lung maturity
33
Antibiotics should be reserved for what?
For group B streptococcal prophylaxis in women in whom birth is imminent
34
Why are Corticosteroids recommended for all pregnant women?
significantly reduce the incidence and severity of neonatal respiratory distress syndrome
35
When are corticosteroids recommended to be given?
A pregnant women between 24-34 weeks of gestation who are at risk of preterm birth within 7 days
36
Nursing Assessment of Preterm Labor
Risk factors
Subtle signs
Contraction pattern
Laboratory and diagnostic testing
37
What are some signs of preterm labor?
- Change/increase in vaginal discharge
- Pelvic pressure
- Low-dull backache
- Menstrual like cramps
- UTI symptoms
- GI upset: N/V and diarrhea
- General sense of discomfort/unease
- Heaviness or aching in thighs
38
Labs/Diagnostic testing of Preterm Labor
CBC, urinalysis, amniotic fluid analysis, fetal fibronectin, cervical length via transvaginal ultrasound, salivary estriol, home uterine activity monitoring
39
How early can a Fetal fibronectin test detect ROM?
1-2 weeks before
40
What medications are commonly used for Tocolytic administration?
Magnesium Sulfate
Indomethacin
Atosiban
Nifedipine
41
What should you monitor for after administering Magnesium sulfate?
Flushing, N/V, dry mouth, lethargy, blurred vision, headache, and hypotension
42
Educating the Client Preterm
```
Harmful lifestyles
Signs of genitourinary infections and preterm labor
Appropriate response
How to palpate and time contractions
Importance of prenatal care
```
43
Postterm Labor
pregnancy that continues past the end of the 42 week of gestation
44
Postterm Labor Maternal Risks
```
Increased risk of cesarean birth
Dystocia
Birth trauma
Postpartum Hemorrhage
Infection
```
45
Postterm Labor Fetal Risks
```
Macrosomia
Shoulder Dystocia
Brachial plexus injuries
Low APGAR scores
Post-maturity syndrome
Cephalopelvic disproportion
```
46
What can happen as amniotic fluid begins to decline after 38 weeks?
Oligohydramnios resulting in fetal hypoxia and an increased risk of cord compression
47
Hypoxia and Oligohydramnios predispose the fetus to what?
Aspiration of meconium
48
Nursing Assessment for Postterm Pregnancy
- Estimated date of birth
- Fetal movement counts
- Non-stress test twice weekly
- Amniotic fluid analysis
- Weekly cervical exams
- Client understanding
49
Nursing Management for Postterm Labor
Fetal Surveillance
Decision for labor induction
Support/Education
Intrapartal care
50
Intrauterine Fetal Demise (IUFD)
Fetal death that occurs after 20 weeks gestation, but before birth
-Numerous causes
51
Nursing Assessment of IUFD
Inability to obtain fetal heart sounds
Ultrasound to confirm absence of fetal activity
Labor induction
52
Nursing Management IUFD
Assistance w/ grieving process
| Referrals
53
What risks are considered obstetric emergencies?
- Umbilical cord prolapse
- Placental abruption
- Uterine rupture
- Amniotic fluid embolism
54
Umbilical Cord Prolapse
protrusion of the umbilical cord ahead of the presenting part of the fetus
55
What is key to managing umbilical cord prolapse?
Prevention by identifying clients at risk
56
What pregnancies would be considered most at risk for umbilical cord prolapse?
```
Malpresentation (breech)
Growth restriction
Prematurity
ROM w/ fetus at high station
Hydramnios
Grandmultiparity
Multiple gestations
```
57
What is often the first sign of umbilical cord prolapse?
Sudden fetal bradycardia or recurrent variable decelerations that become progressively more severe
58
Nursing Management for Umbilical Cord Prolapse
Prompt recognition
| Measures to relieve compression
59
What measures would the nurse take to relieve compression of cord during umbilical cord prolapse?
- Call for help ASAP
- Do NOT leave mom
- Place sterile gloved hand into the vagina and holds the presenting part off the umbilical cord until delivery
60
What can you change mom's position to during umbilical cord prolapse to help relieve compression?
- modified Sims (all 4's)
- Trendelenburg
- Knee-chest position
61
Placental Abruption
premature separation of a normally implanted placental from the maternal myometrium
62
What are the risk factors for Placental Abruption?
```
Preeclampsia
Gestational hypertension
Seizures
Advanced maternal age
Uterine rupture
Uterine Trauma
Smoking/Cocaine
Coagulation defects
Chorioamnionitis
PROM
Hydramnios
```
63
Management for Placental Abruption depends on what?
Gestational age
Extent of hemorrhage
Maternal-fetal oxygen perfusion
64
What is typically the main focus once diagnosis of Placental Abruption is confirmed?
Maintaining the cardiovascular status of mom
| Developing plan to deliver fetus quickly
65
If the fetus is still alive during placental abruption what type of birth typically happens?
emergency c/s
66
If Fetal Demise happens during placental abruption how will the mother give birth?
Vaginally
67
Uterine Rupture
catastrophic tearing of the uterus at the site of previous scar into the abdominal cavity
68
The onset of Uterine Rupture is typically marked only by?
Sudden fetal bradycardia
69
How much time from diagnosis to delivery is there to still have a living baby?
10-30 minutes
70
Risk Factors of Uterine Rupture
```
Uterine scars
Prior c/s
Prior rupture
Trauma
Prior invasive molar pregnancy
History of placental percreta or increta
Congenital uterine anomalies
Multiparity
Previous uterine myomectomy
Malpresentation
Cocaine use
Labor induction w/ excessive uterine stimulation
```
71
What is the first and most reliable symptom of uterine rupture?
Sudden fetal distress
72
Signs of Uterine Rupture
Sudden fetal distress
Acute-continuous abdominal pain w/ or w/o epidural
Vaginal bleeding
Hematuria
Irregular abdominal wall contour
Loss of station in fetal presenting part
Hypovolemic shock of women, baby, or both
73
Nursing Management of Uterine Rupture
Prepare for urgent c/s
| Continuous maternal and fetal monitoring
74
Hypotension and tachycardia may indicate what?
Hypovolemic shock
75
Amniotic Fluid Embolism
amniotic fluid containing particles of debris enters the maternal circulation and obstructs the pulmonary vessels causing respiratory distress and circulatory collapse
76
Amniotic Fluid Embolisms are characterized by what?
Sudden onset of hypotension, hypoxia, and coagulopathy
77
Amniotic Fluid Embolism causes what?
Respiratory distress and circulatory collapse
78
What are some predisposing factors for Amniotic Fluid Embolism?
```
Placental Abruption
Uterine over distention
Fetal demise
Uterine trauma
Oxytocin-stimulated labor
Amnioinfusion
Multi-parity
Advanced maternal age
ROM
```
79
Signs/Symptoms of Amniotic Fluid Embolism
```
Difficulty breathing
Hypotension
Cyanosis
Hypoxemia
Uterine atony w/ or w/o subsequent hemorrhage
seizures
tachycardia
coagulation failure
DIC
Pulmonary edema
ARDS
Cardiac arrest
```
80
Upon recognition of Amniotic Fluid Embolism what supportive measures should be implemented?
- maintain oxygenation and circulation function
| - Correct and control hemorrhage and coagulopathy
81
How would you manage DIC if it was to occur?
replacement with packed red blood cells or fresh frozen plasma
82
What can be used to address uterine atony?
Oxytocin infusions and prostaglandin analogs
83
Labor Induction
stimulation of uterine contractions by medical or surgical means before the onset of spontaneous labor
84
What is the most common reason to have labor induced?
prolonged gestation
85
Indications for Labor Induction
```
Prolonged gestation
PPROM
Gestation hypertension
Cardiac or Renal disease
Chorioamnionitis
Dystocia
Intrauterine fetal demise
Isoimmunization
Diabetes
```
86
A Bishop score less than 6 typically indicates what?
Indicates that a cervical ripening method should be used prior to induction
87
What does a Bishop score greater than 8 indicate?
A successful vaginal birth
88
Bishop Score
Most commonly used scoring system to determine cervical ripeness
-indicates who is likely to have a successful induction
89
What herbal agents are believed to induce labor?
```
Cabbage leaves
Evening primrose oil
Black haw
Black and blue cohosh
Red raspberry leaves
```
90
What home remedies are believed to induce labor?
Castor oil, hot baths, enemas, sexual intercourse with breast stimulation
91
How can sexual intercourse induce labor?
Promotes the release of oxytocin which stimulates uterine contractions
Human semen is a biologic source of prostaglandins
92
What are the risks of using mechanical methods of induction?
infection
bleeding
ROM
placental disruption
93
Mechanism of action for Mechanical method of induction
Application of local pressure stimulates the release of prostaglandins to ripen the cervix
94
Advantages of Mechanical Methods
Simplicity or preservation of the cervical tissue or structure, lower cost, and fewer side effects
95
Labor Augmentation
enhancing ineffective contractions after labor has begun
96
What are the 2 surgical methods of inducing labor?
Stripping of membranes
| Amniotomy
97
Stripping of Membranes
inserting a finger through the internal cervical os and moving in circular direction causing membranes to detach
98
Amniotomy
inserting cervical hook through the cervical os to deliberately rupture the membranes
99
What will an amniotomy promote?
Pressure of the presenting part on the cervix and stimulating an increase in the activity of prostaglandins
100
What are the risks associated with Surgical methods of induction?
```
Umbilical cord prolapse or compression
Maternal or neonatal infections
FHR decelerations
Bleeding
Client discomfort
```
101
What should be monitored closely after surgical induction?
FHR pattern and amniotic fluid characteristics
102
What are the 2 pharmacological agents used to induce labor?
Prostaglandin analogs and Oxytocin
103
Advantages of using prostaglandins to induce labor:
Promotes both cervical ripening and uterine contractility
104
What is the disadvantage of using prostaglandins?
Their ability to induce excessive uterine contractions which can increase maternal and perinatal morbidity
105
What Prostaglandin analogs are often used for induction?
Prepidil, Cervidil, Cytotec
106
Oxytocin
used to stimulate uterine contractions
107
What is typically done before oxytocin is introduced?
Cervical ripening is initiated before oxytocin by using a prostaglandin analog
108
What is the most common effect of oxytocin?
Uterine hyperstimulation leading to fetal compromise and impaired oxygenation
109
What other type of effect does oxytocin have on the body?
Antidiuretic effect resulting in decreased urine flow that may lead to water intoxication
110
What symptoms should be watched for with water intoxication?
Headaches and vomiting
111
Side effects of Oxytocin
Water intoxication
Hypotension
Uterine hypertonicity
Uterine hyperstimulation
112
Nursing Assessment for Induction/Augmentation
- Review history for relative indications for induction/augmentation
- Assist w/ determining gestational age
- Assess fetal and maternal status
- Bishop Score
113
Amnioinfusion
a volume of warmed, sterile normal saline or LR is introduced into the uterus transcervically through an intrauterine pressure catheter
114
What is an Amnioinfusion typically indicated for?
- Severe variable decelerations due to cord compression
- Oligohydramnios due to placental insufficiency
- Post-maturity or ROM
- Preterm labor w/ PROM
- Thick meconium fluid
115
Nursing Management for Amnioinfusion
Teaching
Maternal and fetal assessment
Prep for possible c/s
116
Vacuum Extractor
cup-shaped instrument attached to a suction pump used for the extraction of the fetal head
117
What part of the fetal head is the vacuum extractor applied to?
Occiput
118
Forceps
stainless steel instruments with rounded edges that fit around the fetal head
119
When is the use of the vacuum extractor/forceps indicated?
Prolonged second stage of labor, non-reassuring FHR pattern, failure of presenting part to fully rotate and descend, limited sensation or inability to push effectively, fetal distress, maternal heart disease, acute pulmonary edema, intrapartum infection, maternal fatigue, infection
120
What are the risks of using vacuum/forceps?
Risk of tissue trauma to mom and baby
121
Maternal trauma from Vacuum/forceps
lacerations of cervix, vagina, or perineum
hematoma
extension of episiotomy incision into the anus
hemorrhage
infection
122
Newborn trauma from vacuum/forceps
```
ecchymoses
facial and scalp lacerations
facial nerve injury
cephalhematoma
caput succedaneum
```
123
What can be done to try and prevent the use of vacuum/forceps?
Frequent position changes
Ambulation if permitted
Frequent reminding to empty bladder
Providing adequate hydration
124
Cesarean Birth
surgical birth of the fetus through an incision in the abdomen and uterine wall
-classic (vertical) or low transverse (horizontal)
125
Which c/s incision is more common today?
Low transverse
126
Risks from c/s
```
infection
hemorrhage
aspiration
pulmonary embolism
urinary tract trauma
thrombophlebitis
paralytic ileus
atelectasis
fetal injury and transient tachypnea
```
127
Nursing Assessment for C/S
History and physical exam for maternal and fetal indications
128
Preoperative care for C/S
- Ascertain family understanding of procedure
- Explain what to expect postop
- Explain incentive spirometer and leg exercises
- Prep surgical site
- Start IV fluids; foley catheter
- Administer any preop meds
129
Postoperative care for C/S
- Vitals/ Lochia flow
- Perineal care
- Assess abdominal dressing
- Assess uterine tone
- Assess woman's LOC
- Assess for evidence of abdominal distention and auscultate bowel sounds
- Early ambulation
- Cough, deep breathing, incentive spirometer
- Encourage bonding
130
Vaginal Birth after C/S (VBAC)
a women who gives birth vaginally after having at least one previous c/s
131
Contraindications for VBAC
- prior uterine incision
- prior uterine surgery
- uterine scar
- contracted pelvis
- inadequate staff/facility
132
Special areas of focus for VBAC
Consent
Documentation
Surveillance
Readiness for emergency
