UNIT 3 LABOR AND BIRTH COMPLICATIONS CHAPTER 17 Flashcards
Risk factors for preterm pregnancies?
- Spontaneous preterm birth: early initiation of labor
process - 75% induced preterm birth: resolve maternal or fetal
risk - Risk factors for spontaneous preterm birth
- History of spontaneous preterm birth (#1 risk)
- African-American race
- Genital tract infections
- Multifetal gestation
- Second trimester bleeding; bleed @ placental site
- Low pre-pregnancy weight
What are the indicated findings of preterm birth?
^Preterm labor: cervical changes, uterine contractions
occurring 20-36 completed weeks (36 6/7 weeks)
^Preterm birth: before 37 weeks of pregnancy
^Preterm birth, prematurity describes length of
gestation, not birth weight
^Low birth weight describes only birth weight: 2500 g
or <
* Easier to measure & less dangerous than preterm birth
* Intrauterine growth retardation (IUGR): inadequate fetal growth
Interventions to prevent pre term birth
Prevention
* Pre-pregnancy counseling
* Preventive strategies to address risk factors
* Prenatal care, health promotion; disease prevention
- Interventions to prevent spontaneous preterm birth
- Predicting spontaneous preterm labor, birth
- Fetal fibronectin-binder, vaginal swab 22-34 weeks
- Cervical length
Can bed rest assist with dealing preterm labor and cervical insufficiency?
A. No
B. Yes
B. Yes
Activity restriction-Limited work hours
* Restriction of sexual activity (not proven
effective)
* Home care
* Modified bed rest
Lifestyle modifications
Early recognition of Preterm labor?
Gestational age between 20 & 36 6/7 weeks
* Control of gestational & preexisting conditions
* Uterine activity (contractions)
* Progressive cervical change
* Effacement of 80%; Cervical dilation of 2 cm
or greater
Care management of Preterm labor, medications to slow down labor
Suppression of uterine activity
* Tocolytics
* Facilitates antenatal glucocorticoids
* Magnesium sulfate- slow down system
* Terbutaline
* Indomethacin
* Antenatal glucocorticoids: 24-34 weeks gestation
* National Institutes of Health (NIH) recommends for women at risk preterm; optional
benefit first 24 hrs.
* Single course of antenatal glucocorticoids
Non reassuring fetal heart rate
■ Bradycardia
■ Tachycardia
■ Late decelerations
■ Prolonged decelerations
■ Hypertonic uterine activity
■ Decreased or absent variability
■ Variable decelerations falling to less than 70 beats per
minute for longer than 60 seconds
What is the bishop score for
A. Bishop score (Table 24.2)
1. The Bishop score is used to determine maternal
readiness for labor and evaluates cervical status and fetal position.
What are Tocolytics
Tocolytics are medicines that are used to slow or stop the contractions of a woman’s uterus during pregnancy.
Indomethacin
Indomethacin—Nonsteroidal antiinamma- tory drug (NSAID); prevents the body from releasing prostaglandins and cytokines; as a result, delays preterm delivery when given at the onset of preterm labor
Magnesium Sulfate
Magnesium sulfate—Central nervous system depressant; relaxes smooth muscle, including the uterus; used to halt preterm labor contrac- tions; used for preeclamptic clients to prevent seizures
Keep calcium gluconate readily accessible (antidote)
Magnesium toxicity THE HIGHER THE MAGNESIUM - the slower the body systems move
- Respiratory depression, absent deep tendon reflexes, : weakness, nausea, dizziness, and confusion.
Why is the use of glucocortisterioiuds important for preterm pregnancies?
to promote lung health , and increase the protein (surfactant) in fetal lung maturity
Signs and symptoms of Premature labor
- Change in type of vaginal discharge(watery, mucus, or bloody)
- Increaseinamountofvaginaldischarge
- Pelvic or lower abdominal pressure
- Constant low,dull backache
- Mild abdominal cramps, with or without diarrhea
- Regular or frequent contractions or uterine tightening ,often painless ]
- \Ruptured membranes
Which of the following dilation of the cervix indicates an inevitable preterm birth?
A. 2.5cm
B. 2cm
C. 3cm
D. 4cm
D. 4cm
PPROM
Labor progressed: 4 cm likely inevitable
preterm birth
* Magnesium sulfate given to reduce or
prevent neonatal neurologic sequelae(those complications involving the brain that include cognitive, sensory, and motor deficits that may encompass emotional instability and seizure activity in the most severe cases)
* Malpresentation is common (oblique, breech, horizontal)
* Neonatal resuscitation
* Fetal and early neonatal loss
* Premature Rupture of Membranes
What is the difference bt=etween Rupture of Membranes and Preterm Pre mature Rupture of Membranes?
PPROM(NOT EXPECTED)
* Membranes rupture before 37 weeks of gestation
* Approximately 10% of all preterm births
* Infection major risk factor
* Pathologic weakening of the amniotic membranes
* Inflammation
* Stress from uterine contractions
* Other factors
Rupture of Membranes(EXPECTED)
- Rupture amniotic sac/leak amniotic fluid @ least 1 hour before labor
- Presence of uid pooling in vaginal vault; nitra- zine test is positive.
- Amount, color, consistency, and odor of uid need to be assessed.
- Vital signs are monitored; an elevated tempera- ture may indicate infection.
- Fetal monitoring is necessary; tachycardia in the fetus may indicate maternal infection.
C. Interventions
Clinical findings of Chorioamnionitis
*Maternal fever
* Fetal tachycardia
* Uterine tenderness
* Foul odor of amniotic fluid
What is Chorioamnionitis
Bacterial infection of amniotic cavity
* Major cause of complications
* 1% to 5% of term births
* 25% of preterm births
What is Post term pregnancy?
Pregnancy that extends over 42 weeks gestation
Maternal risk for post term pregnancy
Maternal risks
* Dysfunctional labor(prolongation in the duration of labor, typically in the first stage of labor)
* Macrosomia-physical injury,
-hemorrhage,
- infection
Feta risk of Post term pregnancy
Fetal risks
* Abnormal fetal growth-macrosomia
* Aging placenta-oligohydramnios
* Most physicians induce at 41 weeks gestation
What is Dystocia?
dysfunctional labor
Defined as long, difficult, or abnormal labor
* Ineffective uterine contractions (powers)
* Alterations and pelvic structure (passage)
* Fetal causes (passenger)
* Maternal position during labor and birth
* Psychological response of woman
. Assessment for…
1. Excessive abdominal pain
2. Abnormal contraction pattern
3. Fetal distress
4. Maternal or fetal tachycardia
5. Lack of progress in labor
Supine Hypotension (Vena Cava Syndrome) assessment
- Pallor
- Faintness, dizziness, breathlessness
- Tachycardia, hypotension
- Sweating, cool and damp skin
- Fetal distress
What is Precipitous Labor
. Precipitous Labor and Delivery
A. Description: Labor lasting less than 3 hours
Complications of Precipitous Labor
Fetal: hypoxia, changes in FHR, Unnecessary CS
for FHR patterns
* Maternal: Pain,
Abruption,
Uterine rupture,
Postpartum hemorrhage
, infection,
peri-rectal injury
Complications Obesity
Obesity
* Increasingly serious problem for pregnant
women
* Likely to begin pregnancy with pre-existing
conditions
* Hypertension
* Diabetes
* Increased risk of postdate pregnancy &
complications
* Nursing care has many challenges
Should a woman be induced into labor with a Bishop score of 3
A. Yes
B. No
B. No
Elective induction > 39
weeks
* Bishop score 5 or less,
cervix not ripe
* Ripen cervix
* Chemical
* Mechanical & physical
* Amniotomy
Oxytocin & Augmentation of Labor
Requires careful monitoring of fetal wellbeing
Implement management of hypotonic uterine dysfunction
* Stimulation contractions/labor unsatisfactory progress
Should you use oxytocin to induce labor of your pt and the fetus is not engaged
NO
Contraindications of
Contraindications to use of oxytocin
* Unfavorable fetal presentation or floating (station) of fetus
* Contraindication to vaginal delivery (placenta previa, active herpes,
* macrosomia,
fetal distress,
early preterm labor)
* Maternal oliguria
What can adverse effects can Oxytocin do?
Hormone-posterior pituitary gland; stimulate contractions
- Induce or augment slow labor r/t poor uterine contractions
- Oxytocin—high alert medication; 1 mu/min:1 mL/hr.
- Placental abruption
- Uterine rupture
- Unnecessary cesarean birth
- Postpartum hemorrhage
- Infection
- Fetal hypoxemia and acidemia
Forcep use
Fetal indications:
Abnormal fetal heart rate
tracing
Certain abnormal
presentations/arrest of rotation
Delivery of head in a breech
presentation
Forceps-assisted birth
Vacuum Assisted Birth
Attachment of vacuum cup to
fetal head, using negative
pressure to assist birth of head
Prerequisites:
Completely dilated cervix
Vertex presentation/engaged
head
Ruptured membranes
No suspicion of CPD
Cesarean birth Verticle(Classical) vs Transabdominal(horizontal)
- Transabdominal incision of uterus
- Preserve life or health of mother and her
fetus - Elective cesarean birth
- Surgical techniques-Vertical/transverse
Cesarean Birth
Procedure
Cesarean Birth
Procedure
* Forced cesarean birth-confidential
information
* Complications & risks
* Anesthesia
* Scheduled cesarean birth
* Unplanned cesarean birth
* Prenatal preparation
* Preoperative care
* Immediate postoperative care
* Postoperative/postpartum care
Cesearean birth- Complication and risk
Major Abdominal Surgery
* Invasive procedure
* Anesthesia
* Regional
* General
* Less postpartum movement
* Foley catheter
* Pain
* Complication causing need for cesarean
* Emotional response
What to promote after Cesarean Birth
- Promote bonding & family comfort with education
- Safety alert: Mother may be drowsy; watch for baby safety
Vaginal birth after cesarean
(VBAC)
- Indications for primary cesarean birth such as dystocia, breech
presentation, or fetal distress often are nonrecurring - Biggest risk of uterine rupture
- Trial of labor (TOL)
- Observation woman, fetus to assess safety of vaginal birth
- Contraindications to VBAC: hx.
*Classical (vertical) incision in uterus,
*more than 3 previous cesarean deliveries, *complications present pregnancy, - previous uterine injury
Meconium- stained amniotic fluid
- Indicates fetus has passed first stool before
birth - Amniotic fluid thin, light green to thick
appearance of pea-soup - Place infant at risk for meconium aspiration
syndrome - Requires the team skilled in neonatal
resuscitation - Thick meconium or fetal compromise at birth-
delee suction before shoulder delivery,
intubate to suction meconium below cords
before first breath
Shoulder dystocia
Head is born, anterior shoulder
cannot pass under pubic arch.
Increased risk of birth injuries,
brachial plexus- nerve dysfunction
Shoulder dystocia
Interventions
MC Robert’s maneuver
* Pull legs back to shorten birth canal
* Bring pelvic arch back-Open pelvic outlet
Umbilical Cord Prolapse
- Cord lies below fetal
presenting part - Long cord (longer
than 100 cm) - Malpresentation-
Breech - Transverse lie
- Unengaged presenting part
Maternal positioning for
Cord Prolapse
- If out of a hospital setting or unable
- to immediately
- start emergent
- surgical delivery
Rupture of
uterus
-Multiple cesarean births-separation c/s scar
-Overdistended uterus-Multifetal-Macrosomia
-Augmented or induced labor-intense contractions
-No previous vaginal births
-Congenital uterine anomaly
-Uterine trauma
-Forceps deliveries
-Versions
-Infection
-Short interpregnancy interva
Signs and symptoms Rupture of uterus
Signs, symptoms
* Abnormal FHR & loss of contraction tracing
* Tetany of uterine muscle
* Loss of fetal station
* Abdominal pain/Shock
*Amniotic fluid embolism
(anaphylactoid syndrome
of pregnancy)
*Amniotic fluid containing particles of
debris
*Acute onset of hypotension, hypoxia,
cardiovascular collapse, and coagulopathy
*Maternal mortality to 61% or higher
*Neonatal outcome is poor
The nurse is performing an assessment on a client who has just been told that a pregnancy test is posi- tive. Which assessment nding indicates that the cli- ent is at risk for preterm labor?
1. The client is a 35-year-old primigravida.
2. The client has a history of cardiac disease.
3. The client’s hemoglobin level is 13.5 g/dL (135
mmol/L).
4. The client is a 20-year-old primigravida of average
weight and height.
- The client has a history of cardiac disease.
The nurse is monitoring a client who is in the active stage of labor. The nurse documents that the client is experiencing labor dystocia. The nurse determines which risk factors in the client’s history places the client at risk for this complication? Select all that apply.
1. Age 45 years
2. Body mass index of 28
3. Previous difculty with fertility
4. Administration of oxytocin for induction
5. Potassium level of 3.6 mEq/L (3.6 mmol/L)
- Age 45 years
- Body mass index of 28
- Previous difculty with fertility
Risk factors that increase a woman’s risk for dys- tocia include the following: advanced maternal age, being overweight, electrolyte imbalances, previous difficulty with fertility, uterine overstimulation with oxytocin, short stat- ure, prior version, masculine characteristics, uterine abnor- malities, malpresentations and position of the fetus, ceph- alopelvic disproportion, maternal fatigue, dehydration, fear, administration of an analgesic early in labor, and use of epidural analgesia.
The nurse in a birthing room is monitoring a cli- ent with dystocia for signs of fetal or maternal com- promise. Which assessment nding would alert the nurse to a compromise?
1. Maternal fatigue
2. Coordinated uterine contractions
3. Progressive changes in the cervix
4. Persistent nonreassuring fetal heart rate
- Persistent nonreassuring fetal heart rate
Thenurseinalaborroomispreparingtocareforacli- ent with hypertonic uterine contractions. The nurse is told that the client is experiencing uncoordinated con- tractions that are erratic in their frequency, duration, and intensity. What is the priority nursing action?
1. Provide pain relief measures.
2. Prepare the client for an amniotomy.
3. Promote ambulation every 30 minutes. 4. Monitor the oxytocin infusion closely.
- Provide pain relief measures.
Hypertonic uterine contractions are painful, occur frequently, and are uncoordinated. Management of hypertonic labor depends on the cause. Relief of pain is the primary inter- vention to promote a normal labor pattern. An amniotomy and oxytocin infusion are not treatment measures for hyper- tonic contractions; however, these treatments may be used in clients with hypotonic dysfunction. A client with hypertonic uterine contractions would not be encouraged to ambulate every 30 minutes but would be encouraged to rest.
The nurse is reviewing the primary health care pro- vider’s (PHCP’s) prescriptions for a client admitted for premature rupture of the membranes. Gestational age of the fetus is determined to be 37 weeks. Which prescription would the nurse question?
1. Monitor fetal heart rate continuously.
2. Monitor maternal vital signs frequently.
3. Perform a vaginal examination every shift.
4. Administer an antibiotic per prescription and per
agency protocol.
- Perform a vaginal examination every shift.
Rationale: Vaginal examinations should not be done rou- tinely on a client with premature rupture of the membranes because of the risk of infection. The nurse would expect to monitor fetal heart rate,
The nurse has created a plan of care for a client ex- periencing dystocia and includes several nursing ac- tions in the plan of care. What is the priority nursing action?
1. Providing comfort measures
2. Monitoring the fetal heart rate
3. Changing the client’s position frequently
4. Keeping the signicant other informed of the pro-
gress of the labor
- Monitoring the fetal heart rate
Dystocia is difficult labor that is prolonged or more painful than expected. The priority is to monitor the fetal heart rate. Although providing comfort measures, chang- ing the client’s position frequently, and keeping the significant other informed of the progress of the labor are components of the plan of care, the fetal status would be the priority.
Fetal distress is occurring with a laboring client. As the nurse prepares the client for a cesarean birth, what is the most important nursing action?
1. Slow the intravenous ow rate.
2. Continue the oxytocin drip if infusing.
3. Place the client in a high Fowler’s position.
4. Administer oxygen, 8 to 10 L/minute, via face
mask.
- Administer oxygen, 8 to 10 L/minute, via face
mask.
Oxygen is administered, 8 to 10 L/minute, via face mask to optimize oxygenation of the circulating blood. Option 1 is incorrect, because the intravenous infusion needs to be increased (per primary health care provider prescription) to increase the maternal blood volume. Option 2 is incorrect, because oxytocin stimulation of the uterus is discontinued if fetal heart rate patterns change for any reason. Option 3 is incorrect because the client is placed in the lateral position
- The nurse in a labor room is performing a vaginal assessment on a pregnant client in labor. The nurse notes the presence of the umbilical cord protruding from the vagina. What is the rst nursing action with this nding?
- Gently push the cord into the vagina.
- Place the client in Trendelenburg’s position.
- Find the closest telephone and page the primary
health care provider stat. - Call the delivery room to notify the staff that the
client will be transported immediately.
- Place the client in Trendelenburg’s position.
When cord prolapse occurs, prompt actions are taken to relieve cord compression and increase fetal oxygen- ation. The client would be positioned with the hips higher than the head to shift the fetal presenting part toward the dia- phragm. The nurse would push the call light to summon help, and other staff members would call the primary health care
provider and notify the delivery room. If the cord is protrud- ing from the vagina, no attempt is made to replace it because to do so could traumatize it and reduce blood flow further. Also as a first action, the examiner would place a gloved hand into the vagina and hold the presenting part off the umbilical cord. Oxygen, 8 to 10 L/minute, by face mask is administered to the client to increase fetal oxygenation.
Also remember that the cord would not be pushed back into the vagina.
