Test 2 Flashcards
1
Q
Four P’s of labor
A
-passageway
-passenger
-powers
-psyche
a problem in any area influences labor negatively
2
Q
passageway
A
-bony pelvis and soft tissue of the cervix and vagina
3
Q
false pelvis
A
- flared upper portion of the bony pelvis
- not part of the bony passageway
4
Q
true pelvis
A
- inner portion of the pelvis below the linea terminalis
- consists of the inlet, midpelvis, and outlet
5
Q
most favorable for a vaginal birth. rounded shape
A
gynecoid
6
Q
elongated shape
A
anthropoid
7
Q
heart shaped
A
android
8
Q
flat in its dimensions
A
platypelloid
9
Q
is considered the most important measurement of the inlet. to measure this the practitioner measures the diagonal conjugate, then subtract 1.5-2.0cm
A
obstetric conjugate
10
Q
ischial spine is level of
A
midpelvis
11
Q
if they are prominent and extend into the midpelvis they can ………………… and …………………..
A
reduce the diameter of the midpelvis, interfere with the journey of the fetus
12
Q
………….. and ………….. are soft tissue that form the part of the passageway known as the ……………….
A
cervix, vagina, birth canal
13
Q
cervix during early pregnancy …………………
A
firm, long and closed
14
Q
cervix at delivery
A
begins to soften, gets shorter and thinner in a process called effacement, dilatation occurs
15
Q
cervix during birth
A
rugae of the vaginal walls stretch and smooth out allowing for considerable expansion
16
Q
T or F : The gynecoid pelvis is the most favorable for a vaginal birth
A
True
Rationale: The gynecoid pelvis is most favorable for a vaginal birth.
17
Q
passenger refers to the
A
fetus
18
Q
size of the ……………….. and ………………. to the ……………… can significantly affect the labor process .
A
fetal skull, fetal accommodations, passageway
19
Q
the most important fetal structure in relation to labor and birth
A
fetal skull
- diameters must be small enough to allow the head to travel through the bony pelvis
- molding- the process where the cartilage between the bones allows the bones to overlap during labor.
- molding allows the fetal skull to elongate ultimately reducing the diameter of the head
20
Q
the long axis of the fetus is parallel to the long axis of the mother
A
longitudinal lie
21
Q
in between the two
A
oblique lie
22
Q
the long axis of the fetus is perpendicular to the long axis of the woman
A
transverse lie
23
Q
fetal presentation
A
the foremost part of the fetus that enters the pelvic inlet
24
Q
three main ways a fetus can present
A
- head
- feet or buttocks
- shoulder
25
cephalic presentation
head
26
breech presentation
feet or buttocks
27
shoulder presentation
shoulder
28
relationship of fetal parts to one another ...............
fetal attitude
29
fetal attitudes
- vertex
- military
- brow
- face
30
attitude most favorable for vaginal delivery
vertex
31
attitude with no flexion or extension
military
32
attitude with partial extension
brow
33
attitude with full extension
face
34
the relationship of the reference point on the presenting part to the quadrants of the maternal pelvis
fetal position
35
refers to the side of the pelvis in which the reference point is facing
first designation
| -R/L
36
reference point of the presenting part
second designation
| -O
37
Refers to the part of the pelvis (front, back, or side) in which the reference point is found
third designation
| -ATP
38
you want a baby to come out
OA
39
the relationship of the presenting part of the fetus to the ischial spines
fetal station
40
presenting part is at the level of the ischial spines
zero station
41
presenting part is above the ischial spines
minus station
42
presenting part is below the ischial spines
plus station
43
phases of involuntary uterine contraction
- increment
- acme
- decrement
- relaxation period
44
building up of the contraction - longest phase
increment
45
peak of the contraction
acme
46
letting up phase back to baseline
decrement
47
rest period between contraction
relaxation period
48
descriptors of contractions
- frequency
- duration
- intensity
49
how often the contractions are occurring. measured by counting the time interval from the beginning of one contraction to the beginning of the following contraction
frequency
50
the interval from the beginning of a contraction to its end
duration
51
the strength of the contraction
intensity
52
during a contraction blood vessels are ............. . this decreases the amount of ................ that flows to the fetus. .................... allows the vessels to fill with oxygen-rich blood to supply the uterus and placenta.
squeezed, oxygen, relaxation
53
Fetal attitude refers to the relationship of fetal parts to each other. Which fetal attitude is most favorable to a vaginal birth?
a. Extension
b. Flexion
c. Military
d. Hyperextension
b. Flexion
Rationale: The most common attitude, and the one that is most favorable for a vaginal birth, is an attitude of flexion, also called a vertex presentation.
54
factors impacting the psyche of a laboring woman
- current pregnancy experience
- previous birth experiences
- expectations for current birth experience
- preparation for birth
55
theories of labor onset
- progesterone-withdrawal theory: when it comes time for labor, progesterone drops
- oxytocin theory: oxytocin levels increase for contractions
- prostaglandin theory: helps soften cervix/tissue (Cytotec)
56
anticipatory signs of labor
- lightening or sense that the baby has "dropped"
- Braxton Hicks contractions (false labor pains)
- gastrointestinal disturbances
- expelling the mucous plug
- feeling a burst of energy
- ripening (softening) and effacement (thinning) of the cervix
57
this labor has an increase in Braxton Hicks contractions with NO cervical changes; can be uncomfortable .................
prodromal labor
58
this kind of labor is progressive dilation and effacement of cervix
true labor
59
cardinal movements of labor
- engagement
- descent
- flexion
- internal rotation
- extension
- external rotation
- expulsion
60
factors that may affect the progress of labor .
- agents to soften the cervix
- labor induction techniques
- type of anesthesia
61
how many stages of labor?
4
62
first stage of labor
Dilation
- early labor (latent phase)
- active labor (active phase)
- transition (transition phase)
63
second stage
birth
64
third stage
delivery of the placenta
65
fourth stage
recovery
66
dilation in cm for each phase in the first stage
- early: 0-3 cm
- active: 4-7 cm
- transition: 8-10 cm
67
Which stage of labor is birth?
a. First stage
b. Second stage
c. Third stage
d. Fourth stage
b. Second stage
Rationale: The second stage begins when the cervix is dilated fully and ends with the birth of the infant.
68
physiologic adaptation
-increased demand for oxygen during the first stage of labor
-increased cardiac output
-increased heart rate
-increased respiratory rate
-gastrointestinal and urinary systems are affected
blood pressure usually does not change
-usually women are only given clear liquids due to risk of aspiration.
-pressure on the urethra from presenting part may cause overfilling of the bladder, a decreased sensation to void and edema. May need in-and-out cath.
-stress of labor can cause elevated WBC
-urine specific gravity is high
-trace amount of urinary protein
69
physiologic adaptation by stage
- early stage of labor: excited and talkative
- active labor: more introverted, focusing her energies on coping with the stress of contractions
- transition: feel out of control
- pushing: more in control
- maternal responses to the birth vary widely
70
fetal adaptation to labor
- increased ICP
- placental blood flow temporarily interrupted during uterine contractions: stresses the cardiovascular system. results in a slowly decreasing pH throughout labor
- passing through the birth canal is beneficial in two ways
- stimulates surfactant production
- helps clear the respiratory passageways
- pressure on the fetus caused by progress through the birth canal may result in: ecchymosis, edema, caput succedaneum, cephalohematoma
71
pain is
- individual
- subjective
- sensory experience
72
many factors influence the way a client perceives pain
- physiological
- psychological
- emotional
- environmental
- sociocultural
73
uniqueness of labor and birth pain
- different from other types of pain
- increased intensity desired and positive outcome
- occurs in predictable pattern
74
first stage of labor pain
- pain from cervix and lower uterine segment
- characteristics like other abdominal pain
- diffuse in nature
- occurs in the lower abdomen
- may be referred to the lower back, buttocks, and thighs
75
second stage of labor pain
- pain from perineum and birth canal as the fetus descends
- described as most extreme pain
- "burning" pain in perineum
76
psychosocial influences
- level of fear and anxiety
- culture
- circumstances surrounding the birth experience
77
the level of pain necessary for an individual to perceive pain
pain threshold
78
the ability of an individual to withstand pain once it is recognized
pain tolerance
79
physiologic factors that affect pain
- the longer the labor
- obstructed or dysfunctional labor
- induced with pitocin
- back labor
80
variables that affect woman's perception
- younger age
- 1st time bearing children
- high levels of anxiety
- fear
81
The pain of labor and birth is unique to the woman giving birth. It is a multidimensional experience consisting of many factors. What is one of those factors?
a. The number of generations in the woman's family who are living
b. The significant other's ability to cope
c. The woman's culture
d. The societal association of the significant other's family
Rationale: Many factors influence the pain of labor and birth, making it a multidimensional experience. Examples of psychosocial influences include the level of the woman's fear and anxiety, her culture, and the circumstances surrounding the birth experience, such as whether the pregnancy is planned or unplanned, the child is wanted or unwanted, the birth is preterm or term, and the fetus is living or dead.
82
pain management during labor should be
- planned
| - implemented
83
principles of pain relief during labor
- women are more satisfied when they have control over the pain experience
- caregivers commonly underrate the severity of pain
- women who are prepared for labor usually report a more satisfying experience than do women who are not prepared
84
non-pharmacologic pain interventions
- continuous labor support
- comfort measures
- relaxation techniques: patterned breathing, attention focusing (imagery), movement and positioning, touch and massage, water therapy, hypnosis, intradermal water injections, acupressure (noninvasive form of massage), acupuncture (Use of needles)
85
advantages and disadvantages of non-pharmacologic interventions
- advantages: noninvasive, address emotional and spiritual aspects of birth, promote women's sense of control over pain.
- disadvantages: many of the interventions require special training and/or practice before birth, these methods are not effective for every woman.
86
analgesia and sedation
- the use of medication to reduce the sensation of pain
- sedatives given to promote sedation and relaxation
- opioids given to provide analgesia during labor
87
anesthesia
- the use of medication to partially or totally block all sensation to an area of the body
- local, regional, general
88
advantages and disadvantages of opioid administration
-advantages: an increased ability for a woman to cope with labor, the medications may be nurse-administered. Examples: Meperidine (demerol) and fentanyl (sublimaze)
-disadvantages: frequent occurrence of uncomfortable side effects, such as nausea and vomiting, pruritus, drowsiness, can cross the placenta and cause fetal heart tone changes and neonatal depression. pain is not eliminated completely
Can ultimately cause maternal death by aspiration, inadequate ventilation and overdosage.
89
used to numb the perineum just before birth to allow for episiotomy and repair
local anesthesia
90
involves blocking a group of sensory nerves that supply a particular organ or area of the body
regional anesthesia
91
not used frequently in obstetrics because of the risks involved
general anesthesia
92
types of regional anesthesia
- pudendal block
- paracervical block
- epidural anesthesia
- intrathecal anesthesia
93
pudendal block
- given just before the baby is born to provide pain relief for the birth.
- physician injects a local anesthetic bilaterally into the vaginal wall to block pain sensations to the pudendal nerve.
- helpful for instrument-assisted deliveries and repair of an episiotomy.
94
paracervical block
- involves injection of a local anesthetic in the area close to the cervix.
- can't be used once the cervix is completely dilated and has a short duration of action.
- advantage: it does not block sensation and movement in the lower extremities.
95
epidural anesthesia
- provides excellent pain relief, often completely blocking pain sensation.
- placed by anesthesiologist or CRNA.
- intrathecal injection (spinal block)- a one-time dose of medication is placed into the spinal fluid.
- combined epidural/intrathecal allows pain relief until the epidural begins to work because the intrathecal works immediately
96
complication with epidural and spinal anesthesia
- hypotension
- maternal fever
- shivering
- pruritus (Itching)
- inadvertent injection into the blood stream
- spinal headache
- fetal distress
97
general anesthesia ..................
- not used frequently
- risk of aspiration
- general anesthetic agents cross the placenta and can result in the birth of a severely depressed neonate who requires full resuscitation.
98
life threatening complications occurring with general anesthesia
- failed intubation
| - malignant hyperthermia
99
T or F: Malignant Hyperthermia is a potential complication of general anesthesia that has genetic origins.
True
Rationale: Malignant hyperthermia is a rare, but potentially life-threatening complication of general anesthesia. It is an inherited condition that causes sustained muscle contractions in the presence of certain anesthetic agents.
100
role of LPN during labor and delivery
- recognize and manage complications that may arise during the process
- give intensive support to the laboring woman and her partner or coach
- facilitate the labor process and ensure safe passage of the laboring woman and fetus through the event
101
nurse's role during admission
- immediate assessments: birth imminence, fetal and maternal status, risk factors.
- additional assessments if birth is not imminent: maternal health history and physical assessment, status of labor, labor and birth preferences
102
components of the admission health history
- obstetric history
- current status
- med-surg history
- social history
- desires/plans for labor and birth
- desires/plans for newborn
103
labor status
- assess contraction pattern
- determine fetal lie, presentation, attitude using Leopold's maneuver
- determine cervical dilatation/effacement and fetal position and station with vaginal examination
104
birth plans usually include request regarding
- mobility
- IV fluids
- episiotomy
- presence of friends/family
- fetal monitoring
- pain management
105
routine admission orders
- perineal shave prep
- fleet enema in membranes are intact
- fetal/uterine monitoring
- IV access
- lab work
106
admission labs ................
- CBC
- blood type and Rh factor
- serologic studies, such as VDRL or RPR to test for syphilis
- rubella titer (not done if prenatal record indicates the woman is immune)
- ELISA to detect HIV antibodies (requires informed consent)
- vaginal or cervical cultures
- urinalysis (clean-catch specimen)
107
Mrs. Jones , a G4 P3, has just come in to the labor and delivery suite. She tells the admission nurse that her water broke 2 hours ago and she feels like pushing. What is the first assessment the nurse should make?
a. Maternal vital signs
b. Imminence of birth
c. Take an obstetric history
d. Find a good vein and start an IV
b. Imminence of birth
Rationale: Nursing assessment for signs that birth is imminent begins from the moment the woman arrives in the labor and delivery unit. If the woman is introverted and stops to breathe or pant with each contraction, you can infer that she is in an advanced stage of labor. In addition, if the woman makes statements such as, "I feel a lot of pressure," or "The baby is coming," or "I want to have a bowel movement," it is likely the woman is in the second stage of labor, and the baby will be born soon.
108
monitoring uterine contractions : external methods
- palpation to evaluate the contraction pattern: mild contraction- fundus feels like the tip of your nose at the peak of a contraction. moderate contraction-fundus feels like touching your chin. strong contraction- feels like you are pushing on your forehead.
- toco measures contraction frequency and duration
109
monitoring uterine contractions : external methods ................
-intrauterine pressure catheter: catheter tip placed above presenting part. connected to fetal monitor. records frequency, duration, and intensity of contractions.
110
intermittent auscultation of FHR ..................
- acceptable method in low-risk pregnancy
- most common practice: place external fetal monitor for 20 minutes to get baseline data
- if pattern is reassuring, then fetoscope or external monitor used intermittently
- auscultate fetal heart rate
- any concerns: attach continuous EFM
111
advantages of internal auscultation FHR.
- woman has more freedom to move about
- nurses are encouraged to focus on the laboring woman and her support person, rather than on the technology
- associated with fewer medical interventions and fewer surgical deliveries
112
disadvantages of internal auscultation FHR
- takes more time
- requires higher nurse staffing levels
- many practitioners unaccustomed to using IA fear the potential of missing an ominous FHR pattern.
113
external EFM : indirect
- most common way to assess fetal status during labor
- works on the principle of ultrasound
- characteristics of the fetal heart rate pattern can then be monitored continuously via a video display and/or a continuous printout
- toco monitors the contraction pattern
- helps screen for signs of fetal compromise
- sometimes it is difficult to get a consistent tracing if the fetus is small or extremely active, or if the woman is obese
- uncomfortable
- some manufacturers of fetal monitors have developed telemetry units
114
internal EFM
- invasive procedure
- spiral electrode is attached to the presenting part just under the skin
- records a graphic representation of FHR
- easier to obtain consistent tracing
- increases the risk of maternal and fetal infection and injury
115
baseline FHR
- measured between uterine contractions during a 10-minute period
- normally accepted baseline rate is between 110 beats per minute (bpm) and 160 bpm
- baseline variability: fluctuations of the FHR from the baseline rate
116
fetal tachycardia
greater than 160
117
fetal bradycardia
below 110
118
three major deviations form a normal FHR baseline
-tachycardia: greater than 160
-bradycardia: below 110 bpm
-absent or minimal: non reassuring pattern
MUST CONTINUE FOR ATLEAST 2 MINS
119
.......................... are variations in the FHR pattern that occur in conjunction with uterine contractions .
periodic changes
120
............................. are variations in the FHR pattern NOT associated with uterine contractions .
episodic changes
121
reassuring periodic changes
accelerations above the baseline by at least 15 bpm for at least 15 seconds (15 x 15 window)
122
benign periodic changes
early decelerations
123
non reassuring periodic changes
- variable decelerations indicating some type of acute umbilical cord compression
- late decelerations indicating uteroplacental insufficiency
124
measures used to clarify nonreassuring FHR patterns
- fetal stimulation: acoustic vibrator, scalp stimulation
- fetal scalp sampling: small blood sample obtained from scalp
- fetal scalp pulse oximetry: sensor placed next to fetal cheek or temple
125
T or F : Early decelerations are benign periodic changes.
True
Rationale: Sometimes instead of accelerations, there is a slowing of the FHR. If the dip in the FHR tracing occurs in conjunction with and mirrors a uterine contraction, it is an early deceleration. As long as the baseline remains within normal limits and the variability is good, early decelerations are benign.
126
nursing process during first stage of labor : dilation
- focus is on assessment
- providing physical care to the mother and fetus
- providing psychological care to the mother
- keep the practitioner informed about labor progress
127
interventions during the latent phase (early labor)
ASSESSMENT
- FHR and contractions at least once every hour
- maternal status
- status of fetal membranes
- the woman's psychosocial state
128
nursing diagnosis during the latent phase
- risk of injury (fetal and maternal) related to possible complications of labor
- anxiety related to uncertainty of labor onset and insecurity regarding ability to cope
- acute pain related to contractions
- deficient Knowledge of labor process related to inadequate preparation for delivery or unexpected circumstances of labor
129
outcome identification and planning during latent phase ..
- primary goals are maternal and fetal safety
| - other goals and interventions are planned according to the individual needs of the laboring woman and her partner
130
implementation during latent phase
- preventing fetal and maternal injury
- relieving anxiety
- promoting comfort
- providing patient teaching
131
goals and expected outcomes of the latent phase
- woman and fetus remain free from injury
- anxiety is reduced
- pain is manageable
- woman and her partner have adequate knowledge of the labor process
132
When planning care for a client in the latent phase of labor what is one primary goal?
a. Mother's pain is adequately controlled
b. Mother's anxiety is controlled
c. Mother has adequate knowledge of labor process
d. Mother is safe
d. Mother is safe
Rationale: Maintaining the safety of the laboring woman and her fetus throughout the latent phase of the first stage of labor are primary goals when planning care.
133
assessment during active labor
- psychosocial state
- labor progress
- fetal status
- maternal status
134
nursing diagnosis during active labor
- risk for trauma to the woman or fetus related to intrapartum complications or a full bladder
- acute pain related to the process of labor
- anxiety related to fear of losing control
- ineffective coping related to situational crisis of labor
- ineffective breathing pattern: hyperventilation related to anxiety and/or inappropriate application of breathing techniques
- impaired oral mucous membrane related to dehydration and/or mouth breathing
- risk for infection related to invasive procedures (e.g., vaginal examinations) and/or rupture of amniotic membranes
135
outcome identification and planning during active labor
primary goal remains maintaining maternal and fetal safety
136
implementation during active labor
- preventing trauma during labor
- providing pain management
- reducing anxiety
- promoting effective coping strategies
- promoting effective breathing patterns
- maintaining integrity of the oral mucosa
- preventing infection
137
assessment during transition phase of labor
- signs woman has reached transition phase
- woman's ability to cope
- maternal status
- fetal status
138
nursing diagnosis during transition phase of labor
- acute pain related to frequent, intense uterine contractions and pressure of the descending fetal head
- ineffective breathing pattern: hyperventilation related to intense uterine contraction pattern and loss of control of breathing techniques
- powerlessness related to intensity of the labor process
- fatigue related to energy expended coping with the intense labor
139
goals during transition phase of labor
- woman's pain will be manageable
- she will exhibit effective breathing patterns
- maintain a sense of control
- rest between uterine contractions.
140
implementation during transition phase of labor
- managing pain
- promoting effective breathing patterns
- promoting a sense of control
- supporting the woman through fatigue
- preparing the room for delivery
141
T or F : Your patient is in the transition phase of labor. One of your nursing interventions will be supporting the woman's coach through the woman's fatigue.
False
Rationale: Relaxing with contractions may be almost impossible; assist the woman to achieve relaxation or even sleep between contractions. Help her to find a comfortable position. Support her position with pillows. Placing a cool cloth to her forehead or giving her a back rub may help her relax between contractions.
142
assessment during second stage of labor : expulsion of fetus
- monitor the blood pressure, pulse, and respirations every 15 to 30 minutes
- assess the contraction pattern every 15 minutes
- assess the woman's report of an uncontrollable urge to push
- check the FHR every 15 minutes for the low-risk woman and every 5 minutes for the woman who is at risk for labor complications
143
nursing diagnoses second stage of labor
- fatigue related to length of labor and pushing efforts
| - risk for trauma related to pushing techniques and positioning for delivery
144
goals for second stage of labor
- the woman will push effectively despite fatigue
| - she will give birth with minimal or no trauma to the fetus or herself
145
implementation for second stage of labor
- promoting effective pushing despite fatigue
- reducing the risk of trauma using effective pushing techniques and positions
- preparing for delivery of the newborn
146
assessment for third stage of labor : delivery of placenta
- assess the woman's psychosocial state after she gives birth
- monitor for signs of placental separation
147
nursing diagnoses for delivery of placenta
- risk of deficient fluid volume related to blood loss in the intrapartum period
- risk of trauma: hemorrhage, amniotic fluid embolism, retained placenta, or uterine inversion related to delivery of the placenta
148
goals during delivery of placenta
- the new mother will maintain adequate fluid volume
| - she will remain free of trauma.
149
implementation during delivery of placenta
- preventing fluid loss
| - maintaining safety and preventing trauma
150
assessment during fourth stage of labor : recovery
- continue to assess the woman for hemorrhage
- assess the lochia (vaginal discharge after birth)
- signs of infection
- monitor for suprapubic distention
- woman's comfort level
- mother's psychosocial state during the fourth stage.
- initial bonding behaviors of the new family.
151
nursing diagnoses during recovery
- risk of impaired parent-infant attachment related to disappointment regarding the gender of the newborn or an unwanted pregnancy
- risk of deficient fluid volume related to the possibility of hemorrhage from the former site of placenta attachment
- risk of infection related to invasive procedures and vaginal examinations during labor
- impaired urinary elimination related to perineal trauma during delivery
- acute pain related to episiotomy, birth trauma, and/or after pains
- fatigue related to energy expended during labor
goals of
152
goal of recovery
- parents will begin a positive bonding process with their newborn
- woman will : maintain adequate fluid volume, no signs of infection, maintain adequate voiding patterns, not become extremely fatigued, have her pain adequately managed
153
implementation during recovery
- providing care immediately after delivery
- promoting parent-newborn attachment
- maintaining adequate fluid volume
- preventing infection
- promoting urinary elimination
- minimizing pain
- reducing fatigue
154
where physician and woman choose to induce labor without medical cause. major cause of increase in number of induced labors
elective induction
155
elective inductions often result in
- more interventions
- longer labors
- higher costs
- possible cesarean birth
156
indications for induced labor
- postdate pregnancy
- premature rupture of membranes (PROM)
- spontaneous rupture of membranes (SROM) without the onset of spontaneous labor
- chorioamnionitis
- pregnancy-induced hypertension
- preeclampsia
- severe intrauterine fetal growth restriction
- maternal medical conditions
157
contraindications for induced labor
```
maternal
-complete placenta previa
-history of a classical uterine incision
-structural abnormalities of the pelvis
-invasive cervical cancer
-medical conditions such as active genital herpes
fetal
-certain anomalies, such as hydrocephalus
-certain fetal malpresentations
-fetal compromise
```
158
prerequisite for induced labor
'ripe cervix'
159
........................ often used to determine readiness for labor
bishop score
- 5 factors evaluated
- each factor scored 0 to 3
- score of 8 or greater associated with successful oxytocin-induced labor
- 5 or less indicates cervix is not ripe: associated with unsuccessful induction of labor
160
transvaginal ultrasound
- relatively new
| - cervix 27 mm or less is a predictor of successful induction of labor despite Bishop score
161
measurement of fetal fibronectin levels
labor readiness
- newer
- presence in cervical secretions is associated with labor readiness
- more often used as a predictor of preterm labor risk
162
fetus should be
mature
163
several ways to assess fetal maturity
- at least 38 weeks' gestation considered mature
- date fetal heart tones first heard
- other pregnancy milestones
- fetal lung maturity is the major point of consideration
- measure L/S ratio by amniocentesis
164
methods of cervical ripening
- mechanical: membrane stripping, inserting a catheter into the cervix and inflating the balloon, cervical dilators (laminaria)
- pharmacologic: prostaglandin E2 (dinoprostone), prostaglandin E1 (misoprostol)
- artificial rupture of membranes (AROM) : also called amniotomy causes the body to release prostaglandins, which enhances labor.
- oxytocin induction: IV oxytocin (Pitocin) most common agent used for labor induction, infusion pump required, starting dose usually 1 milliunit/minute, titrated upward by 1-2 milliunits/minute until adequate contraction pattern established
165
potential complications of oxytocin inductions
- high risk of C-section
- hyperstimulation of uterus
- water intoxication: hyponatremia, confusion, convulsions, coma
166
LPN's role during induction depends upon the procedure
- assist with pelvic exam in mechanical ripening of cervix or amniotomy
- document fetal heart rate before and after amniotomy
- suprapubic or fundal pressure during the procedure if trained
- RN responsible for monitoring mother and baby during pharmacologic ripening of cervix
167
T or F : There are two types of prostaglandin approved by the Food and Drug Administration for the induction of labor.
False
Rationale: There are two main preparations, but the only substance approved by the United States Food and Drug Administration (FDA) for this purpose is prostaglandin E2 gel or vaginal inserts (dinoprostone). Prostaglandin E1 (misoprostol) is used frequently for cervical ripening, although it is not approved for this use.
168
a surgical incision is made into the perineum to enlarge the vaginal opening
episiotomy
169
methods to minimize the need for episiotomy
- Kegel exercises during pregnancy to strengthen perineal muscles
- using natural pushing techniques, particularly in the side-lying position
- patience with the delivery process
- protection of the perineum immediately before birth to avoid uncontrolled delivery of the fetal head
170
a suction cup is placed on the fetus's head; suction is applied and used to guide the delivery of the infant
vacuum-assisted delivery
171
vacuum delivery can be hazardous to infant because
-scalp trauma
-subgaleal and intracranial hemorrhage
pressures should not exceed 600 mmHg. should mot be more than 3-4 pop-offs. vacuum should not be applied for longer than 20 to 30 minutes
172
instruments with curved, blunted blades are placed around the head of the fetus to facilitate delivery
forceps
173
.................... and .................... forceps are more common than are midforceps .
low, outlet
174
.................... are most often used to assist the fetus to rotate to an anterior position.
midforceps
175
maternal indications for forceps
- fatigue
- certain chronic conditions such as heart or lung disease and
- prolonged second stage of labor
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complications of operative vaginal delivery
- neonatal cephalhematoma
- retinal, subdural, and subgaleal hemorrhage occur more frequently with vacuum extraction than with forceps.
- facial bruising
- facial nerve injury
- skull fractures
- seizures are more common with forceps.
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maternal complications of operative vagina delivery
- extension of episiotomy into anal sphincter
- uterine rupture
- perineal pain
- lacerations
- hematomas
- urinary retention
- anemia
- rehospitalization
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nursing care during an assisted delivery
- obtain needed equipment and supplies
- monitor maternal and fetal status before, during, and after the procedure
- assist the birth attendant
- provide support for the woman
- document the type of procedure
- document maternal and fetal response to the procedure
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An episiotomy is a surgical incision made in the perineum of a laboring woman to assist in the passage of the fetus at birth. What is a possible maternal complication of an episiotomy?
a. Loss of bladder control
b. Anemia
c. Bowel retention
d. Shoulder dystocia of the fetus
b. Anemia
Rationale: The woman is at higher risk to have episiotomy and for extension of episiotomy into the anal sphincter with operative vaginal delivery. Other maternal complications include uterine rupture, perineal pain, lacerations, hematomas, urinary retention, anemia, and rehospitalization (Ross & Beall, 2007; Wegner & Bernstein, 2007).
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indications of cesarean birth
- history of previous cesarean birth
- labor dystocia (failure to progress in labor)
- non-reassuring fetal status
- fetal malpresentation
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incidence of cesarean birth
- from 5% to 31% between 1970 and 2007.
| - in 2010, 32.8% of births were by c-section, the highest rate ever reported in the US
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risks of cesarean birth
- major surgery that carries with it all the risks associated with surgery combined with the risks of birth itself
- 3 times more likely to die
- normal physiologic changes of pregnancy amplify some surgical risk factors
- inadvertent delivery of a premature fetus
- increases the incidence of neonatal respiratory distress
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maternal complications of cesarean birth
- laceration of the uterine artery, bladder, ureter, or bowel
- hemorrhage requiring blood transfusion
- hysterectomy
- infection
- pneumonia
- postpartum hemorrhage, thrombophlebitis, and other surgical-related complications
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fetal complications of cesarean birth
- most common is unintended delivery of an immature fetus because of miscalculation of dates and respiratory distress because of retained lung fluid
- depressed fetal respiratory drive, due to anesthesia, makes it difficult for the newborn to take his or her first breath
- fetal injury can occur
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incision types
abdominal
-vertical approach: done in the midline of the lower abdomen
-Pfannenstiel's incision- (bikini cut) low transverse
uterine
-classical incision: (used during emergencies)
-low cervical vertical incision
-low cervical transverse incision (preferred method)
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steps in a cesarean delivery
- preoperative phase: team approach, sometimes referred to as collaborative management
- intraoperative phase: LPN acts as a scrub nurse
- postoperative phase: LPN can assume care of woman after she has sufficiently recovered from anesthesia
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nursing care in cesarean birth
planned cesarean birth
-focus on education to prepare the family for the birth
emergency cesarean birth
-focus on supportive behaviors: explaining procedures as they are done, providing appropriate reassurance
providing care in immediate postoperative period
-many contributing factors
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A cesarean delivery is a major surgery and requires a team approach to caring for the pregnant woman. During the intraoperative period of a cesarean delivery, what is the role of the LVN/LPN?
a. Take vital signs every 15 minutes
b. Provide reassurance to the mother and significant other
c. Act as a scrub nurse if trained appropriately
d. Take the infant for assessment at birth
c. Act as a scrub nurse if trained appropriately
Rationale: The specially trained LPN/LVN may function as the scrub nurse if a cesarean becomes necessary.
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prerequisites ACOG recommendations for vaginal birth after cesarean
- adequate pelvis
- no previous uterine ruptures
- personnel and facilities available to perform an immediate cesarean delivery
- no more than one previous, low transverse uterine scar
- signed informed consent that lists benefits and risks
- surgeon, anesthesia provider, and operating room personnel in the hospital
- practitioner who can read and interpret EFM tracings and recognize the signs and symptoms of uterine rupture
190
VBAC contraindications
- previous classic C-section uterine scar
- placenta previa
- history of previous uterine rupture
- lack of facilities or equipment to perform an immediate emergency cesarean
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risks and benefits of VBAC
-greatest concern is uterine rupture
(Risk amplified when prostaglandins are used to ripen the cervix before induction with oxytocin)
-history of more than one cesarean
-short interval between pregnancies
-history of infection with the previous cesarean
-benefit: not a major surgery
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signs of uterine rupture
- dramatic onset of fetal bradycardia or deep variable decelerations
- reports by the woman of a "popping" sensation in her abdomen
- excessive maternal pain
- unrelenting uterine contraction followed by a disorganized uterine pattern
- increased fetal station felt upon vaginal examination
- easily palpable fetal parts through the abdominal wall
- signs of maternal shock
193
nursing care VBAC
- outside the scope of practice for the LPN/LVN to care for a laboring woman who has a history of a previous cesarean delivery
- the specially trained LPN/LVN may function as the scrub nurse if a cesarean becomes necessary
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placenta is only good for
41 weeks
