Variations of Spontaneous Labor Flashcards
What are some indications for labor induction?
PROM, preeclampsia, GHTN, infection, fetal demise, postterm pregnancy, fetal compromise, mild abruptio placentae, logistics
What are some contraindications for induction of labor?
Breech/transverse, severe HTN, significant heart dz, umbilical cord prolapse, hx of uterine surgery, vasa previa, complete placenta previa, active genital herpes
What is Bishop’s score?
Group of 5 factors to determine favorability of induction based on cervical ripeness & probability of success of induction
What is a favorable Bishop score?
> 6
What is an unfavorable Bishop score?
<5
What Bishop score indicates likelihood of vaginal birth similar to spontaneous labor?
> 8
What are the 5 factors included in the Bishop score?
Position, consistency, effacement, dilation, fetal station
*All scored 0-3
What are risks associated w/ induction?
Uterine tachysystole/hyperstimulation, uterine rupture, maternal water intoxication, greater risk for chorioamnionitis and/or C-section
How might induction lead to maternal water intoxication?
Oxytocin has an antidiuretic effect
What is problematic about uterine tachysystole?
Can reduce placental perfusion & fetal oxygenation due to excess frequency/duration/intensity of contractions or insufficient relaxation between contractions
What might be done if a birthing person is to be induced but their Bishop score is too low?
Prostaglandins to promote ripening
What positions are included in the Bishop score?
Posterior, midposition, anterior
What consistencies are included in the Bishop score?
Firm, medium, soft
What is the purpose of cervical ripening?
To increase cervical readiness for labor by promoting softening, dilation, & effacement
Techniques for cervical ripening
Prostaglandins, mechanical
What are advantages of cervical ripening?
Reduce dose or eliminate need for oxytocin
*Low dose oxytocin is used for cervical priming
What are some mechanical techniques of cervical ripening?
Balloon catheter in the intracervical canal (inflated w/ 30 cc saline)
Osmotic/hygroscopic dilators absorb body fluids and expand (e.g. seaweed (laminaria tents), Mg sulfate-based)
Disadvantage of balloon catheters
Causes pressure on the cervix
Disadvantage of osmotic dilators
Increased infection risk
Advantages of mechanical methods
Low cost, stable at room temp, reduced risk of uterine tachysystole
How are PGs administered?
Oral, vaginal suppository/gel
Cytotec
Misoprostol (PE1)
Cervidil
Dinoprostone (PE2)
Prepidil
PG gel
Complications of cervical ripening
Uterine tachysystole, fetal distress
Nursing action for uterine tachysystole
Subq terbutaline
Nursing actions for fetal distress
O2 via face mask at 10 L/min
Left side-lying position
Increase rate of V fluid admin
Notify provider
Nursing actions for cervical ripening
Assess for urinary retention, rupture of membranes, uterine tenderness/pain, contractions, vaginal bleeding, fetal distress
Nursing interventions for cervical ripening
Informed consent Baseline fetal and maternal data Void before procedure Document number of dilators used Side-lying position Assist w/ procedure Monitor FHR, uterine activity Notify provider of complications Monitor for AEs (N/V/D, fever, tachysystole)
Maternal precaution conditions w/ PG use
Asthma - known hypersensitivity
Glaucoma
Ischemic heart disease
Pulmonary, hepatic, renal disease
PG mechanism of action
PGE2 sensitizes to PGF2 which sensitizes myometrium to endo-/exogenous oxytocin & ripens cervix
*Used in conjunction w/ oxytocin
PG contraindications
Known allergy Fetal distress w/o imminent delivery Unexplained bleeding Cephalopelvic disproportion CI of oxytocic drugs Prior C-section, major uterine surgery Prior IV oxytocic admin Multipara w/ 6+ prior term pregnancies
Non-pharmacologic methods of induction
Membrane stripping, amniotomy, nipple stimulation, intercourse?
What gestational age is required for elective induction?
39 weeks
Induction indications
Postterm pregnancy (>42 weeks) Dystocia Prolonged ROM IUGR Maternal medical complications - Rh isoimmunization, DM, pulm dz, GHTN Fetal demise Chorioamnionitis (infection)
What is membrane stripping?
Provider inserts finger into internal cervical os & rotates 360 degrees twice
Requirement for membrane stripping
Cervical dilation >1 cm
Benefit of membrane stripping
Increases PGF/PGE release from membranes and cervix
What fetal engagement and station are required before oxytocin admin?
Engagement in birth canal & minimum station of 0
Maternal assessments w/ oxytocin
BP, HR, RR q30-60mins & w/ dose change
FHR monitoring w/ oxytocin
1st stage - q15mins
2nd stage - q5mins
Every dose change
Maintain dose of oxytocin when contraction…
Frequency - 2-3 min Duration - 80-90 sec Intensity - 40-90 mmHg/strong Uterine resting tone - 10-15 mmHg Dilation - 1 cm/hr Reassuring FHR 110-160 bpm
Clinical findings of uterine tachysystole
Frequency <2 min Duration >90 sec Intensity >90 mmHg Resting tone >20 mmHg No relaxation between contractions
Characteristics of nonreassuring FHR
Abnormal baseline <110 or >160 bpm
Loss of variability
Late/prolonged decelerations
Define amniotomy
Artificial rupture of membranes (AROM)
Indications for AROM/amniotomy
Labor induction, stimulation, internal electronic fetal monitoring
Major risks of amniotomy/AROM
Umbilical cord prolapse
Chorioamnionitis
Placental abruption
How is amniotomy performed?
Amnihook perforates amniotic sac
Amniotomy considerations
Fetal engagement to prevent cord prolapse
Monitor FHR before & after
Assess/document fluid characteristics
Amniotomy nursing interventions
Document time or rupture
Obtain temp q2hrs
Comfort measures
Amniotomy contraindications
Fetal presenting part high in pelvis
Non-cephalic presentation
How do nipple stimulation & sex promote labor?
Nipple stim releases oxytocin
Semen has PGs in it
Orgasms could stimulate contractions
Oxytocin (Pitocin) administration
IV piggyback
Inserted into primary line at closest port to patient
Start at low dose, increase q20-30mins until regular contractions
Continuous FHR & contraction monitoring (chart q15mins in 1st stage, q5mins in 2nd stage)
What should you never use Pitocin w/o?
IV pump
Pitocin risks
Tachysystole Hypertonic uterus/increased resting tone Uterine rupture Non-reassuring FHR Increased risk of uterine atony PP
Non-reassuring FHR nursing interventions
Reduce/stop Pitocin Increase IV fluids to 200 mL/hr Side-lying position 100% O2 at 8-10 L/min via face mask Continue assessing FHR, contractions Monitor maternal BP, HR q30mins Administer subq terbutaline
Caput succedaneum
Newborn scalp swelling, resolves in 3-5 days
C-section indications
Malpresentation (breech) Cephalopelvic disproportion Dystocia Non-reassuring FHR Placental abnormalities Placenta previa Abruptio placentae Prior C-section Multiple gestations Maternal and/or fetal distress Umbilical cord prolapse Failed induction Macrosomia Congenital malformations Maternal cardiac/respiratory dz High risk pregnancy - HIV+, HTN (preeclampsia, eclampsia), DM, active genital herpes
C-section risks
Infection Hemorrhage UTI, UT trauma VTE Ileus Atelectasis Anesthesia complications Transient newborn tachypnea Persistent pulm HTN of newborn Newborn injury (lac, bruising, fracture)
C-section pre-op nursing interventions
Last oral intake Allergies Current meds & last dose Informed consent Labs - CBC, blood type/Rh Pre-op teaching Start IV and bolus Clip abdominal hair Administer GI meds - Bicitra, pepcid Insert catheter Assist pt onto table, hip wedge Grounding pad for electrocautery Sterile prep of abdomen Fetal monitoring
Types of assisted deliveries
Vacuum, Forceps
Assisted delivery indications
Need shortened 2nd stage Exhaustion Ineffective pushing Cardiac, pulm dz Infection Fetal cord compression Premature placental separation Non-reassuring FHR
Assisted delivery risks
Maternal - lac, vaginal hematoma, perineum, large episiotomy
Fetal - ecchymoses, facial/scalp lacs, facial nerve palsy, cephalohematoma, intracranial hemorrhage
Assisted delivery nursing considerations
Empty bladder (straight catheter) Assess FHR (report <100 bpm) Assess for trauma of mom/baby Cold application to perineum/vagina for 12 hours after Fundus tone
Fetal assessment - skin breaks, facial asymmetry, seizures, scalp edema, facial bruising
